Working for better health care in New Zealand

The Association of Salaried Medical Specialists (ASMS) is the professional association and union uniting doctors and dentists in New Zealand.

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Hopes high for positive change following mental health and addictions review

12 December 2018 Wellington forensic psychiatrist - Justin Barry-Walsh

The Mental Health and Addiction inquiry report released this month by Health Minister David Clark is the most significant review of the sector since the 1990s and looks set to lead to an overhaul of services. It’s prompted discussion about the role of the state and health professionals in an issue with wide social and community drivers. In an article for ASMS, Wellington forensic psychiatrist Justin Barry-Walsh argues both for broad social change and an immediate increase in resources to deal with pressures in the sector. 

For the first time in my career in psychiatry, the sector appears likely to undergo large-scale change.

Seeing for myself the work of the mental health and addiction inquiry panel, led by Professor Ron Paterson, it’s clear its members have taken seriously the need to grapple with and understand the immense complexity of the problem. Its rigour reflects the Government’s decision to deal with a long-neglected service.

We are not meeting the demands of our population. There are too few beds, too few psychiatrists, too few allied health workers, and too little money going into community and primary care.

There are too few psychiatrists in virtually all sub-specialties; at present 59% of the psychiatrist workforce is overseas-trained doctors, a high proportion even by New Zealand standards.

Further, a New Zealand study has revealed a 56% work-related burnout rate among psychiatrists.

Local training programmes could be expanded if the necessary funding is available.

There is a crisis in the psychiatrist workforce in district health boards with 56% suffering work-related burnout.

Mental health has historically been dubbed the Cinderella of health services, and it remains so.

Despite public campaigns, and the exponential growth in people seeking mental health services, the stigma around it does not seem to have changed.

Stigma is a deep societal problem and health professionals themselves are not immune from showing stigma.

Just why demand has grown so much – including a 62% increase in new referrals to mental health triage teams over five years – is not well understood and flags the need for alternative approaches and models of care.

This is a big and somewhat abstract problem for our community, and it is to be hoped the inquiry and the discussion that will now follow will further our understanding and empathy.

The reasons for its Cinderella status are complex and societal, and lack of resourcing is really a symptom rather than a cause.

By contrast, dealing with the resourcing shortfall seems simple.  In my sub-specialty, forensics (dealing with the law), patients are sometimes shifted into the prison system for relatively minor offending because of inadequate resources to facilitate diversion back into mental health.

As successive governments introduced punitive justice policies, the prison muster increased massively, as did the numbers of prisoners with mental health issues.

More than 90% of prisoners have addiction or mental health issues.

When it was established in the early 1990s, the forensic service was adequately resourced.

The Royal Australian and New Zealand College of Psychiatrists, in our inquiry submission, called for far-reaching measures to reduce the prison muster, and an immediate increase in resources to cope with demand.

We contend the money being spent on building new prisons should be diverted to social programmes that improve people’s health and life chances.

Implementing social programmes will take a generation before showing positive outcomes, and that’s why both long-term and short-term remedies are necessary.

Our college has made what some might view as a predictable call for more hospital-level funding, but we are also calling for an increase in GP and community funding.

At present just 2% of the overall mental health budget goes to primary care. There is too little money for talking therapies and an over-reliance on pharmaceutical prescribing.

The disparate parts of mental health sector, including GPs and Iwi, should be brought together with a strategy emphasising the “no wrong door” concept. This is the idea that a patient’s entry point to the system, nor their primary diagnosis (for instance, addiction rather than a mental health disorder), makes no difference to the care received.

One area where we are especially keen to see new ideas and initiatives is Maori mental health, as the current models have not always worked.

Psychiatrists are criticised for over-medicalisation of mental health, and while critics over-state the problem, it is a valid debate.

The profession encourages change and new initiatives, but it must be tempered by the need for evidence.

With a government seemingly committed to an overdue rethink of the sector, this is an ideal time for new thinking.