Early Intervention and Prevention in New Zealand
The key to any future development of Early Intervention and Prevention
Programmes (EIPP's) in this country lies with the appointment of a Special
Project Group (SPG) whose members will drive all aspects of the process and
take responsibility for the overall implementation and monitoring of these
programmes.
Mental Health Commission
Early Intervention and Prevention Group Workshop
Dunedin
June 1997
Table of contents
Introduction
Background
Workforce development
Service co-ordination
Funding/Resources
Appendices (as listed)
Early Intervention and Prevention Workshop
May 28th - 29th 1997
Dunedin
Introduction
This workshop was sponsored by the New Zealand Mental Health Commission.
Participants
The Mental Health Commission would like to thank the following people for their
input into the workshop and acknowledge their employers in agreeing to support
participants to attend.
Cath Allan, Manager, PACT, 28 London Street, Dunedin
Marilyn Bartlett, Team Leader, Community Mental Health Team, Psychiatric
Services Centre, Dunedin Hospital, Great King Street, Dunedin
David Barthgate, Consultant Psychiatrist, Community Mental Health Team,
Psychiatric Services Centre, Dunedin Hospital, Great King Street, Dunedin
Jim Crowe, National President Schizophrenia Fellowship (NZ), Dunedin
Pauline Hinds (facilitator), Advisory Board Member, Mental Health Commission,
Dunedin
Alison Masters, Community Psychiatrist, Central Community Mental Health
Team, Capital Coast Health, 100 Tory Street, Wellington.
Aroha Noema, Te Orangaronu Tonga, Waikaeri, Helensburgh House, Dunedin.
Sue Thompson, Senior Lecturer, Nursing and Midwifery Department, Otago
Polytechnic, Private Bag 1910, Dunedin.
Workshop scribe and report writer:
Chris Walsh, Senior Lecturer, Co ordinator, Advanced Programme in Mental
Health Nursing, Department of Nursing and Midwifery, Victoria University, Private
Bag 600, Wellington.
Terms of reference
Participants at the workshop were asked to come up with a consensus statement
on early intervention that would meet the needs of the New Zealand population.
The overall aim of the workshop was to produce a source document on early
intervention mental health services for the Mental Health Commission. This
document would assist the commission in its work, especially on projects such as
the Blueprint for mental health services and the strategy for workforce
development.
The three main areas covered in this report are workforce development, service
co ordination and funding/resources. Attention to these three areas is seen as
central to any discussion and implementation of Early Intervention and
Prevention Programmes (EIPP's) in this country.
Scope and definition of early intervention
Early intervention is multi faceted and should take account of people who are
accessing the service for the first time, those who have relapsed since first
contact with the mental health service and those who are living in smaller and
sometimes isolated communities. Furthermore early intervention must consider
not only the changing needs of the population but also the changing needs of the
workforce who are assigned the task of meeting those needs. For the purpose of
this workshop there was a clear distinction made between people presenting for
the first time with a mental illness and people who have presented previously
with a mental illness and have subsequently relapsed. The issues and ongoing
treatment of these presentations are quite different. However there is a demand
for early intervention services and strategies to deal with both types of
presentation. To keep this distinction intact the group decided that the term Early
Intervention and Prevention Programme (EIPP) would address both concepts
and so this term is used throughout this report.
Background
The benefits of early intervention are well documented both here in New Zealand
and internationally. So too are the problems, short term and ongoing, associated
with delayed recognition and treatment (see appendix one for information on
early intervention, the Mason Report).
Consensus statement on early intervention for psychotic illness
A recent early intervention initiative in this country has been the work of a New
Zealand group of people with a wide range of perspectives who came together at
a consensus conference in Auckland late last year. These people had a shared
concern about early intervention improving outcomes for people developing
psychosis and a belief that effective quality early intervention services needed to
be developed throughout this country. Some of this group had attended the Early
Psychosis Prevention and Intervention Centre (EPPIC) conference held in
Melbourne earlier in 1996 and saw the need for a similar initiative here. Despite
the fact that the focus of the New Zealand consensus group has been on
psychotic illness, the values and philosophy outlined in the consensus statement
were seen to be in line with the approach needed to deliver EIPP's generically.
Furthermore, the discussion about aims, assessment, treatment, location/setting,
resources/staff, liaison, evaluation/outcomes and services for Maori in relation to
early intervention were seen as being congruent with an overall approach to early
intervention. In the consensus statement the service for Maori is discussed with
emphasis on consultation, "Issues regarding whether early intervention for Maori
should be provided from within mainstream Early Intervention Services or by
specialist services for Maori by Maori must be resolved as part of local
consultation processes" (NZ Early Intervention Interest Group, 1996, p 12). The
service should also be user friendly to Maori and take account of the principles of
the Treaty of Waitangi.
The work to date of this group (The New Zealand Early Intervention Interest
Group) in producing a consensus statement on) early intervention services for
people developing psychotic illnesses (appendix two) was fully endorsed by
members of this workshop.
Workforce Development
A major area of concern was the importance of workforce development to EIPP's.
There was much discussion about both the current training and education
available currently and the overall planning and co ordination of these courses.
In particular, there was concern expressed by group members that there are
different skills needed to work with first time presenters as opposed to those with
persistent enduring mental illness.
Aside from this the differences in service delivery of EIPP's in urban and rural
areas was seen as an area needing focussed and specific attention. The fact that
larger urban areas were more likely to be able initiate and sustain EIPP's (as
some urban areas are currently doing) was encouraging. It was however
acknowledged that service delivery to more isolated areas was going to be an
ongoing challenge for mental health providers. Nevertheless the demand for
EIPP's in more rural isolated areas was something that service providers should
not overlook or earmark into the "too hard" basket.
Service and education
Service providers need opportunities to work with local communities to develop
innovative programmes which will address the needs of EIPP's. To develop any
partnership between service providers and the mental health workforce requires
an understanding of the roles and responsibilities of all parties concerned and a
commitment to negotiating desired outcomes in education and training.
Under the present Regional Health Authority (RHA) contracting system there is
little incentive for health providers to take responsibility for or be involved in
education in the mental health service. Currently education is seen to be outside
of the core business directives of health providers. A fundamental shift in
philosophy is needed so that these health providers, under Ministerial direction,
are obliged to provide comprehensive education and training to their workforce.
This would be enhanced through a more co operative approach involving the
combined expertise of educational and clinical staff working together to provide
the best possible education and training for the mental health workforce.
Furthermore, the performance of these health providers needs to be assessed,
monitored and audited over a period of time.
Although Nursing comprises the bulk of the workforce in mental health services
the following groups were identified as needing ongoing training and up skilling:
Nursing:
institutional
current community
new graduates
non government organisations primary health nurses (practice & public)
students
educators
policy/ministry nurses
managers/service leaders
GP's:
vocational programme
current practitioners
college of GP's
Psychiatrists:
private
CHE based
other
Social workers
Occupational therapists
Clinical psychologists
Maori mental health workers
Cultural workers
Support workers/caregivers
Consumers
Employees/advocates
Lawyers
Planning the needs of the workforce
Identifying the specific training needs of these groups was seen to be essential to
the implementation of EIPP's. Service providers should check out the skill level of
their workforce and identify further training needs. For example, nurses who have
been working in institutions need to learn strategies for working in the community
which take account of the changing and diverse needs of the consumer, family
members, caregivers and other health professionals. Further to this, student
nurses require quality mental health clinical placements and supervision by
suitably qualified and credible nursing lecturers. The training needs of
psychiatrists should take account of changing treatment modalities and family
intervention programmes. Family members and caregivers may need education
about how to handle different behaviours of their loved one, as well as
information about accessing services and information about specific mental
health problems. Finally, community mental health carers may need education
and training in how to work with people who have mental illness in a community
setting (see appendix three which gives an example of one of the many types of
courses provided for carers).
There are a number of programmes for early intervention currently working well
in this country and overseas (see appendix four for an Australian home based
treatment programme for early psychosis that has received positive recognition).
Staff working in the area of early intervention would benefit from visiting and
working in a proven programme and be well placed to bring their new knowledge
and skills to New Zealand.
The following recommendations have been made taking into account the
changing needs of the workforce, funding/resources and the role of service
providers.
Recommendations:
•That people with the right attitudes, knowledge and skills work alongside the
philosophy of EIPP's.
•That training of this workforce should be properly planned, resourced and
recognised as a priority by all parties concerned. Staff should be given the
opportunity to do exchange visits both locally and internationally to investigate
and train in service delivery models that could be developed in New Zealand.
•That the concept of primary health care is recognised by people working in this
area as pivotal to the success of EIPP's, therefore it is imperative that the first
two recommendations are implemented.
•That a clear distinction is made between the skills needed to work effectively
with EIPP's for people with first onset presentation and those with persisting
enduring mental illness. Consequently, the recognition of this should lead to
targeting both up skilling and redevelopment of the workforce in both areas.
•That appropriate funding and resources should be targeted to new initiatives in
EIPP's and that current initiatives and funding continue.
•That contractual obligations between employers and employees incorporate
ongoing training responsibilities of both parties.
•That institutions responsible for training and education of health care providers
are assessed for programmes congruent with EIPP philosophy. Furthermore,
there should be strategies in place to allow for funding which builds on existing
successful programmes and a system whereby information about such
programmes is easily accessed allowing for a more co ordinated approach.
•That a group is set up to co ordinate/liaise with workforce development and to
gain an overall picture of training and education in EIPP's. This group should
then have the capacity to provide information regionally about national training
strategies and appropriate programmes currently underway both locally and
internationally.
•That EIPP's should be resourced and financed immediately nationwide.
Service Co-ordination
Nowadays there are a number of agencies that in some way are involved in
mental health service delivery. The Ministry of Health, the Police, the Justice
Department, the Department of Social Welfare, the Ministry of Education,
Treasury, RHAs, CHEs, Non Government Organisations and the Mental Health
Commission are some of these agencies.
One of the ongoing issues with service delivery is the challenge of trying to co
ordinate services so there is minimal unnecessary duplication and maximum use
of resources. New Zealand is a small country with a population that has diverse
needs and limited funding/resources for mental health. It is therefore imperative
that mental health service delivery is well co ordinated, planned and monitored
so that agencies involved in mental health service delivery are aware of how their
service intersects with other services and what their role is in relation to these
service providers.
Recommendations:
•That the Mental Health Commission strongly recommends to the Minister that
the Commission appoints a Special Projects Group (SPG) that has a mandate to
implement EIPP's in mental health services throughout New Zealand.
•It is essential that the SPG consist of appropriate people with experience, skills
and knowledge in the education, policy, practice and research areas of mental
health.
•That this SPG has a commitment to working collaboratively towards the
successful implementation of EIPP's.
•That the implementation needs to include attention to co ordination, planning,
management, evaluation, accountability, consultancy, consistency and
accessibility of EIPP's.
Funding/Resources
A further concern about EIPP's is the acknowledged high financial cost of such
programmes. What is often lost in considering monetary outputs is the high cost
not only to the person who has, a mental illness but also to their families, friends
and to the wider community. The future of the mental health service lies in the
very notion of early diagnosis, treatment and further prevention.
The following recommendations relate specifically to budgeting allocations for
workforce development, the SPG and to mental health services.
Workforce development
Recommendations:
•That there is an immediate assessment and identification of the skill needs of
the workforce carried out.
•That budget allocations target the training of primary health care providers (eg.
General Practitioners).
•That support continues for existing training and there is a commitment made to
develop new EIPP's.
•That staff contracts include ongoing appropriately funded training which is
monitored, assessed and has accountability structures set in place.
Special Project Group (SPG)
Recommendation:
•That the cost of instigating a SPG is investigated and a budget is established
accordingly.
Services
Recommendations:
•That the funding level reflects the outcomes of service contracts with EIPP's.
•That the start up costs are acknowledged as having resource and budget
implications.
•That funding takes into account the costs of developing and implementing
research that contributes toward service development.
•That funding takes into account the cost of ongoing evaluation and auditing of
services that maintains stated standards.
The relationship between standards and evaluation/auditing of these standards
has more significance now since the recent development of the National Mental
Health Standards for New Zealand Mental Health Services. The preparation of
these standards, co ordinated by the Ministry of Health Mental Health Services,
specify criteria that will serve as guidelines for meeting the mental health needs
of New Zealanders. Service providers now have a set of national standards by
which they will be able to evaluate their service. The challenge for service
providers will be to not only target resources that comply with these standards
but also to audit their own performance in meeting these standards.
Service providers, responding to public demand, must seriously consider how
EIPP's will become part of the service that they provide to the community. EIPP's
do not come cheaply and mental health service providers must understand and
acknowledge this. While initial costs to set up and maintain such a service may
be high the long term benefits have the potential to save not only in terms of
financial cost but also the cost to human life.
Finally, a word from Jim Crowe, National Chair of the Schizophrenia Fellowship:
"I hope that this report will not be lost in the 'system' like so many other previous
reports on mental health services in this country. I suggest that the
recommendations of this workshop be adopted and supported by the Mental
Health Commission and Regional Authorities"'.
List of Appendices (in order of appearance)
Appendix one (264k PDF file)
Mason, K & Johnston, J & Crowe, J (1996) Early Intervention, in Inquiry Under
Section 47 of the Health and Disability Services Act 1993 in Respect of Certain
Mental Health Services, Report of the Ministerial Inquiry to the Minister of Health
Hon Jenny Shipley, Wellington, New Zealand.
Appendix two (Not available on-line - only available on hard copy)
New Zealand Early Intervention Group (1997) Consensus Statement-Early
Intervention Services for People Developing Psychotic Illnesses, New Zealand.
Appendix three (46k PDF file)
Nursing and Midwifery Department (1997) Community Mental
Health/intellectually Disabled Carers Course,Otago Polytechnic, Dunedin.
Appendix four (538k PDF file)
Kulkarni, J (1996) Home Orientated Management of Early Psychosis,
Dandenong Hospital, Department of Psychiatry, Melbourne, Australia.
© Mental Health Commission, 1997