We need a better National Mental Health System. Alongside stronger regulation and governance, we especially need a body that can commission services to better mental health standards, and to help develop a workforce better able to serve New Zealanders. To do this, we need a better standards framework alongside a workforce development strategy to meet these standards.
There are welcome developments in He Ara Oranga : the report of the Government Inquiry into Mental Health and Addiction. The inclusion of voices of those with lived experience is an important development. However, the report is light on the role of the established and developing evidence-base and how services are commissioned.
When mental health workers try to help people, often they generate new solutions or ways of working where best-practice guidelines already exist. This may be driven by several factors, including a lack of awareness or viable options or resource constraints. Often, it can be impelled by the idea that each and every geographical district is distinctly different and needs to do things their own way. Although there are definite advantages to locally-tailored solutions, we cannot afford to remake the wheel every time a knowledgeable member of staff leaves, or a new provider wins the contract to deliver a service.
How should we intervene to align professional standards and guidelines across the country to deliver better outcomes based on effective best-practice on well–researched protocols from across the globe?
In the UK, The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health. NICE was established in an attempt to end the so-called postcode lottery of healthcare in England and Wales, where treatments that were available depended upon the NHS Health Authority area in which the patient happened to live, but it has since acquired a high reputation internationally as a role model for the development of clinical guidelines.
NICE publishes guidelines in four areas including clinical practice: guidance on the appropriate treatment and care of people with specific diseases and conditions. These appraisals are based primarily on evaluations of efficacy and cost–effectiveness in various circumstances. NICE also provides a service called Clinical Knowledge Summaries which provides primary care practitioners with a readily accessible summary of the current evidence base and practical guidance – extremely important to keep all stakeholders informed with best practice.
How would this work in New Zealand?
The New Zealand Guidelines Group was an independent, not-for-profit organisation, set up in 1999 to promote the use of evidence in the delivery of health and disability services. The NZGG went into ‘voluntary liquidation’ in mid-2012. We could look at re-constituting a similar body. However, we are fortunate in that we already have an existing operations model which could be used as a proto-template for this body: PHARMAC.
PHARMAC makes its decisions around medicines through their Factors for Consideration. These Factors cover four dimensions: need, health benefits, costs and savings, and suitability. I don’t think it is a huge leap to apply a combination of the NICE and PHARMAC models to mental health care in New Zealand. We have too many ad-hoc decisions meaning that funding doesn’t necessarily flow to the right treatment protocols, and people aren’t getting access to the best treatments for their conditions. We can do better than this, and models exist to help us deliver this.
A commissioning structure that works more closely with the centre can also take advantage of closer coordination with those agencies that have influence on social determinants such as housing, meaningful and adequately paid employment and education that influence mental health.
We have a workforce with varying levels of training all over New Zealand. One of the issues that I have talked with people about is that this results in a lack of confidence in the consistency of quality of the services offered in the mental health sector. Furthermore, because of the lack of nationally agreed standards and what services should be commissioned to improve mental health and wellbeing outcomes, there is a lack of drive and curriculum base upon which to train our social and mental health and wellbeing care workers, volunteers and other providers.
If we don’t know what we are training for, is it any wonder that providers may feel under-prepared, and community members start to lack confidence in the competence of those providers?
We should aim to support the development of the workforce in accordance with the approaches, methods and techniques recommended for various disorders and outcomes by a NZ-equivalent of NICE. This would mean working with training programmes such as medical training providers, clinical psychology, nursing, social work, psychotherapy and counselling, and community development making sure that they are delivering training according to a skills and knowledge framework developed by this NZ body.
Service users can then be confident that they are getting the best treatment that exists and is available in New Zealand, delivered to transparent best-practice protocols and treatment recommendations.
Part of the reform work for mental health services is underway. Much of how we decide which services will be commissioned about the workforce will be trained to ensure equity of access for all New Zealanders is yet to be finalised.
I believe that a focus on a National Mental Health System will bring a much needed focus on better nationally agreed standards for intervention, improved commissioning for services in line with these standards, and a workforce trained to be able to meet them.