Review of the
Continuum of Mental Health
Services Funded by the District
Health Boards
in the
Auckland Region
December 2002
Foreword
In April 2002 the Minister of Health, the Hon Annette King approved the terms of
reference for the Mental Health Commission to undertake an independent review of
mental health services in metropolitan Auckland. The Review covered the three
District Health Boards, Auckland, Counties Manukau and Waitemata.
The
Commission engaged a review team to undertake the work and used a reference group
as a sounding board in the early stages of the process.
There have been high expectations that the Review would solve most of the problems
in the mental health sector. It will not do that. What it does do is provide a way
forward for Auckland which involves a change in the arrangements for planning and
co-ordinating service delivery, an immediate relief from the pressure on acute
inpatient beds and a longer term commitment to addressing the funding path and the
contracts and service specification framework.
The Review Team listened to over 400 people, many of them staff who do the real
work day in and day out and many of them consumers and families who must be the
final arbiters as to whether we have a mental health system in Auckland that works.
The Review Team received a strong message from staff that despite some pockets of
real innovation they had no sense of being part of a co-ordinated system with a
coherent and consistent vision and were frustrated that their work was not as effective
as it might be. For families and service users their experience was often of a system
under pressure more intent on deciding why they did not fit than on meeting their
needs.
The Review Team also analysed all the major reports on Auckland services over the
years and considered all the reports provided by management. It was the voices of
staff and service users that provided the most compelling case for change.
The action plan that was generated by the Review was refined in consultation with the
three DHB Chairs and their CEOs. The Commission is confident that the six actions
provide the basis for dealing with the problems that are adversely impacting the
delivery of an effective mental health service in Auckland. The Commission is also
confident there is the will and the capacity within the sector in Auckland to embrace
the recommendations and move forward.
We wish to acknowledge the work of the Review Team and in particular thank the
many people who willingly provided advice, guidance and information during the
Review.
Jan Dowland
Chair
Bob Henare
Commissioner
Mary O’Hagan
Commissioner
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the
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Contents
FOREWORD ................................................................................................................. 2
CONTENTS ................................................................................................................ 3
GLOSSARY .................................................................................................................. 5
EXECUTIVE SUMMARY ................................................................................................ 8
RECOMMENDATIONS AND ACTION PLAN .................................................................. 11
1.
INTRODUCTION ................................................................................................. 14
1.1 The review process ......................................................................................... 15
1.2 Outline of this report ...................................................................................... 16
2. THE AUCKLAND REGION CONTEXT .................................................................. 17
2.1 Demographic environment............................................................................. 17
2.2 Current structure of mental health delivery................................................... 19
2.3 Other government agencies providing services to people with mental illness
.............................................................................................................................. 20
3. WHAT IS HAPPENING IN THE AUCKLAND REGION .............................................. 21
3.1 People cannot move freely between the services they need ........................... 21
3.1.1 Primary care ............................................................................................... 22
3.2 Gaps and under supply in the provision of mental health services ............... 23
3.2.1 Gaps after discharge from acute inpatient units......................................... 24
3.2.2 Capped and uncapped services ................................................................... 26
3.2.3 Specialist services ...................................................................................... 26
3.2.4 The ‘three percent rule’ .............................................................................. 27
3.3 Access difficulties created by the standard of service provision ................... 27
3.3.1 Monitoring .................................................................................................. 28
3.4 A demoralised workforce ............................................................................... 29
3.5 Access difficulties for particular age groups ................................................. 29
3.5.1 Children and at risk youth .......................................................................... 29
3.5.2 Older people................................................................................................ 30
3.6 People with mental illness and drug and alcohol dependency ...................... 30
3.7 Issues for Maori ............................................................................................. 30
3.8 Pacific Peoples............................................................................................... 31
3.8.1 Co-ordination and access ........................................................................... 31
3.8.2 Service responsiveness ................................................................................ 31
3.8.3 Resourcing .................................................................................................. 32
3.8.4 The Pacific mental health workforce .......................................................... 32
4. WHY THERE ARE PROBLEMS.............................................................................. 34
4.1 Leadership and shared vision ........................................................................ 34
4.2 Funding constraints and uneven distribution of resources............................ 35
4.3 Workforce capacity and capability ................................................................ 35
4.4 Planning, funding and contracting processes ................................................ 36
4.4.1 Services needed ........................................................................................... 36
4.4.2 Communication between funders, providers and other stakeholders ......... 37
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the
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4.4.3 Communication between funders and providers regarding contracting .... 37
4.4.4 Communication and co-operation between providers ................................ 37
4.4.5 Clarity about the role of NGO providers .................................................... 38
4.4.6 Effectiveness of the NDSA ........................................................................... 38
4.5 Operational systems and procedures in provider organisations ................... 38
5. PATHWAYS TO IMPROVEMENT .......................................................................... 40
5.1
Action (1): Appoint a General Manager, Regional Mental Health
Services and establish an Auckland Regional Mental Health Service Coalition to
co-ordinate services within and across the three DHBs in Auckland. ................ 41
5.2
Action (2): Provide additional capacity for accommodation with intensive
support and crisis respite services. ...................................................................... 42
5.3
Action (3): Allocate adequate funding to the three Auckland DHBs to
provide the required service. ............................................................................... 43
5.4
Action (4): Ensure all contracts and service specifications support the
implementation of an integrated continuum of services. ..................................... 43
5.5
Action (5): Ensure primary care practitioners are integrated into the
mental health continuum of services, through the implementation of the Primary
Health Strategy. ................................................................................................... 44
5.6
Action (6): Establish policy and service linkages between government
agencies at national and local levels. .................................................................. 44
REFERENCES ............................................................................................................. 46
APPENDIX 1: TERMS OF REFERENCE ......................................................................... 47
APPENDIX 2: MEMBERS OF THE REVIEW TEAM:........................................................ 48
APPENDIX 3: LETTER OF RESPONSE FROM CHIEF EXECUTIVES, AUCKLAND REGION
DISTRICT HEALTH BOARDS (3): ................................................................................ 49
APPENDIX 4: LIST OF MEETINGS HELD BY THE AUCKLAND REVIEW TEAM: ............. 57
APPENDIX 5: REFERENCE GROUP .............................................................................. 63
APPENDIX 7: HISTORY OF THE DELIVERY OF MENTAL HEALTH SERVICES .................. 71
APPENDIX 8: EXPENDITURE CURRENT AND GUIDELINE BY DHB, AS AT 30/6/2002 .. 74
APPENDIX 9: REVISED METROPOLITAN AUCKLAND MENTAL HEALTH STRUCTURES
AND RELATIONSHIPS ................................................................................................. 75
APPENDIX 10: MENTAL HEALTH STRUCTURES AND RELATIONSHIPS ........................ 76
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the
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Glossary
Acute Inpatient Services
Mental health services for people with severe and acute
symptoms who need 24 hour care in a safe environment.
BPFP
By Pacific For Pacific
Capped Services
Services contracted to provide care for a set number of
people, these are usually specialist services. They have
well-defined entry criteria.
CATT
Community Assessment and Treatment Team
Community Mental Health
Services
Services that are day or residential, located outside of a
hospital setting.
Community Mental Health
Team
A team of health professional and support workers that
provides assessment, treatment and support for people
with mental illness.
Crisis Respite
Home based or other community-based service for
people in crisis as an alternative to admission to an
acute inpatient service.
Crisis Team
Specialised clinical services providing emergency
assessment, stabilisation, treatment and referral to other
services.
CYF
Child, Youth and Family
DAPs
District Annual Plans
DHBs
District Health Boards
GPs
General Practitioners
HFA
Health Funding Authority
HHS
Health and Hospital Services
HNZC
Housing New Zealand Corporation
Kaupapa Maori Services
Maori centred services offered within a Maori cultural
context.
Level 3 Services
Full time support for people living in homes run by
residential providers.
Level 4 Services
Residential intensive long term support.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the
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MHC
Mental Health Commission
MoH
Ministry of Health
National Mental Health
Standards
A set of standards developed by the Ministry of Health
for use by mental health service providers to improve
quality of services and ensure consistency for people
who use them.
National Mental Health
Strategy
An overall strategy for mental health covering the
Government’s goals, principles and objectives for
mental health services. The strategy is set out in two
documents – Looking Forward: Strategic Directions for
Mental Health Services (1994) and Moving Forward:
The National Mental Health Plan for More and Better
Services (1997).
NDSA
Northern DHB Support Agency Ltd – responsible for
regional co-ordination of planning and funding of
mental health issues.
Needs Assessment
Comprehensive assessment of the requirements for
individuals in their recovery. The assessment includes
housing, vocational, income and general support needs.
NGOs
Non Government Organisations
Primary Health Care
Services
The first point of contact with health services, e.g. GPs.
These services are also responsible for services for
people with milder mental illness.
RCS
Regional Co-ordination Service – responsible for the
co-ordination of all levels 3 and 4 accommodation and
rehabilitation placements across Auckland.
Recovery
Living well in the presence or absence of mental illness.
Residential Intensive Long
Term Support
Services that provide a structured closely supervised
environment and assistance with behaviour problems,
and where residents may live indefinitely.
RHA
Regional Health Authority
Secondary Health Care
Services
Specialist services that people can access when their
needs cannot be met by primary care services.
Service Provider
Organisation or individual that provides direct treatment
or support to the individual or their family.
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Service User
A person who experiences, or who has experienced,
mental illness, and who uses or has used mental health
services.
Support Worker
Non-clinicians who work with people with mental
illness.
Uncapped Services
Services with no caseload limit. These are usually core
services.
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Executive Summary
Mental Health services in the Auckland region are characterised by a large number of
very committed people working hard to provide the best possible assessment,
treatment, care and support for those who experience mental health problems.
Nevertheless, the Review of Auckland mental health services has found that there are
significant issues demanding attention. (See Appendices 1 and 2 for the Review’s
Terms of Reference and Members of the Review Team).
The planning, funding, delivery and monitoring of mental health services are not
satisfactory and must be modified to better suit the complicated environment that is
Auckland. Both within and across the three District Health Boards (DHBs) the range
of services required do not match service users’ needs as they proceed through their
different stages of recovery. While there are regional mechanisms directed to regional
planning and service provision, they do not appear to adequately address the
metropolitan issues. Within the DHBs themselves, funding and planning activities do
not adequately take into account input from service providers and other stakeholders.
There is lack of integration among service providers, not only across the three DHBs,
but also across the range of services delivered within a single DHB. The funding and
delivery of mental health services in discrete service units exacerbates problems of
service access and uneven investment by DHBs in some services.
Providers cannot collectively deliver a continuum of services to meet the needs of
service users and their families. The continuum of services is compromised by:
 Poor co-ordination between services, so that service users cannot move freely
between the services they need
 Gaps in the provision of services – some services for which there is a demand
do not exist, and other services cannot cope with the numbers seeking the
service.
Like some other regions, Auckland has not got the funding commensurate with its
population needs. However, while funding constraints must be acknowledged, a
shortfall in funding is not the only problem, or even perhaps the most critical problem
at this point. Problems arising from under funding are made all the more acute by an
uneven distribution of resources. Auckland region should be doing better with the
level of funding it has. While it must also be acknowledged that additional funding
will be necessary for the Auckland DHBs, extra funding is not in itself sufficient to
resolve the systemic problems in the Auckland region.
The symptoms of a system under stress are numerous:
 There is poor service integration, evidenced by gaps in services and lack of
continuity for service users, who need to be able to move between services and
levels of service to get the care they need at any stage.
 Access to services is rationed through the use of a ‘3%’ rule, without adequate
assessment being undertaken. In some circumstances, when individuals cannot
get the care they need, they go to the emergency department of the hospital, or
are picked up by the Police.
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 There is lack of information on services, including the nature and range of
services available, criteria for entry or referral, and the point of contact for
service users and their families. Lack of such critical information forms a
barrier, not only for access of service users and their families, but also for
liaison and referral between service providers.
 Some services, particularly acute inpatient services, are overwhelmed. They
have very little flexibility in how they manage fluctuating case loads. There is
evidence that pressures are being transferred to community teams.
 There are tensions between various services, including between:
o Capped and un-capped services, which is affecting the resourcing of
some core services and the employment choices of workers.
o Support services and clinical services, including perceptions amongst
support workers that they are under-valued by health professionals. On
the other hand, some clinicians express concern about the quality of
services provided by non-government organisations (NGOs).
o General Practitioners (GPs) and DHBs – many GPs consider that
DHBs do not see them as partners in the continuum of services and
express frustration in dealing with DHB services.
o Acute and long-term supported care – there is a lack of accommodation
with intensive support (providing more intensive support than level 3
and 4 services), and providers are concerned about having to take
people whose needs are outside of their contracted service.
o Acute and crisis respite services – there are insufficient respite
services, which means that service users are forced to access the acute
system.
 The role of the so-called ‘non-contracted’ accommodation providers is unclear
and the quality of services they provide variable.
 There is limited contact between regional planning mechanisms such as the
Northern District Support Agency (NDSA) and the Regional Co-ordination
Service (RCS), and providers.
 There is some disagreement amongst DHBs on how to manage the complexity
and fragmentation in the planning, funding and provision of services
 There is a lack of leadership and a shared vision on how DHBs and providers
can work together effectively.
 Distress, frustration and cynicism are evident amongst service users and
families.
 Stress, low morale and concern about their ability to effectively perform under
current conditions are evident amongst a large number of mental health
workers.
Some sections of the Auckland population experience particular impacts of a troubled
mental health system. Maori, Pacific people, and new migrant and refugee
populations are particularly vulnerable. Especially affected are those who move
frequently, who wish to use kaupapa Maori or Pacific services, or who have a limited
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choice of services in their local areas. In addition, children, young people, older
people and those with drug and alcohol problems are not adequately catered for in the
present configuration of services.
A number of impediments stand in the way of settling problems in the Auckland
region. One issue is the failure of DHBs to co-operate with one another at the
planning and funding levels, as well as at the service end in a way that delivers an
integrated continuum of services. However, it must be recognised that underpinning
problems of co-ordination between DHBs, are the significant differences within the
practices of the DHBs themselves. The main issues are:
 Resource allocation, funding and planning decisions are being undertaken by
the DHBs without proper engagement with the DHBs’ own service delivery
arms, and other service providers. The knowledge that service providers can
bring to ensure cost-effective and well-targeted resource deployment is too
often not taken into account.
 A lack of procedures that make services work and ensure that those in need
can access them. In particular, there is a lack of procedures for co-ordinating
the care of individual service users across the service spectrum. The
procedures and criteria for assessment, service admission and discharge are
not transparent.
There needs to be, within and across the DHBs, a commitment to establish continuity
of services directed to recovery outcomes. Despite the complex and entrenched nature
of the problems, many of them steeped in history, there is a way forward. The action
plan proposes a way forward which includes:

appointing a General Manager, Regional Mental Health Services and
establishing a Service Coalition to manage the contracting and co-ordination
of mental health services across the three Auckland DHBs (Action1)

providing immediate relief from the pressure on acute beds through providing
additional packages of care (Action 2)

allocating adequate funding to the three Auckland DHBs (Action 3)

ensuring all contracts and service specifications support the implementation of
an integrated continuum of services (Action 4)

integrating primary care practitioners into the continuum of mental health
services (Action 5)

establishing better policy and service linkages across governmental agencies
(Action 6).
There are strongly committed people working within the sector in the Auckland
region and a strong commitment among service users to assist DHBs to move
forward.
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Recommendations and Action Plan
The terms of reference required the development of an action plan. It was, therefore,
important that the actions proposed addressed the problems identified by the Review
and were accepted by the Auckland DHBs as achievable. The process of finalising
the action plan involved a number of steps as follows:

Initial actions developed by the Review were submitted in draft to the Chief
Executives of the three DHBs for comment (see Appendix 3 : Letter of
Response from Chief Executives , Auckland Region District Health Boards).

A draft report including a proposed action plan was submitted to the Minister
of Health.

The three Auckland DHBs were invited by the Minister to respond to the draft
report and the proposed action plan.

A response was received from the three Auckland DHB Chairs “generally
supporting Actions 2 through 6” but offering an alternative framework for coordinating and managing services across the three DHBs.

Further discussion involving the Ministry of Health, the Mental Health
Commission and the three Auckland DHBs resulted in a reworked Action 1
that was acceptable to all parties. Initially Action 1, as recommended by the
Review, involved the establishment of a Mental Health Agency as a separate
legal entity to manage the contracting and co-ordination of mental health
services across the three DHBs in Auckland. Concerns expressed by the
Auckland DHBs about creating a new structure and a belief that modifications
to existing arrangements would achieve the desired outcomes were taken on
board and are reflected in the final action plan.
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Action Plan for Auckland Mental Health Services
Action (1): Appoint a General Manager, Regional Mental Health Services and establish an Auckland
Regional Mental Health Service Coalition to co-ordinate services within and across the three DHBs in
Auckland.
Responsibility: Three DHBs through Board of DHB Shared Service Agency and the Ministry of
Health.
Task
Timeframe
Develop job description for General Manager, Immediately
Regional Mental Health Services
Recruit General Manger, Regional Mental Health Within two months
Services
Develop Terms of Reference for Coalition and Within two months
establish Coalition
Review existing contracts and services
March 2003
Develop plan to further relieve blocks in the
March 2003
acute services (to include respite and intensive
rehab options)
Confirm Regional Plan
April 2003
Integrate the proposed actions in the action plan
April 2003
for Maori (Appendix 6) into the Regional Plan
Develop an action plan that specifically addresses April 2003
mental health issues for Pacific people.
Action (2): Provide additional capacity for accommodation with intensive support and crisis respite
services
Responsibility: Initially three DHBs and later General Manager, Regional Mental Health Services
Task
Timeframe
Immediate implementation of a limited number Immediately
of accommodation with intensive support and
crisis respite services
Plan additional accommodation with intensive By March 2003 for 2003/04 implementation
support and crisis respite services
Action (3): Allocate adequate funding to the three Auckland DHBs to provide the required services
Responsibility: Ministry of Health
Task
Timeframe
Review and revise present funding plans for 1 April 2003
mental health in the Auckland region
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Action (4): Ensure all contracts and service specifications support the implementation of an
integrated continuum of services.
Responsibility: Ministry of Health, General Manager Regional Mental Health Services
Task
Timeframe
Review contracts and service specifications
March 2003
Establish and operationalise care pathways
5 care pathways* to be implemented by June
2003
Establish monitoring process to ensure that June 2003
contracted services are provided
Mental health needs assessment and review of September 2003
international clinical best practice to meet
identified needs
* Care pathways are to be defined and developed, but are likely to include those for older people,
young people, those who are new to mental health services, and those with alcohol and drug addictions.
Action (5): Ensure primary care practitioners are integrated into the mental health continuum of
services, through the implementation of the Primary Health Strategy
Responsibility: General Manager Regional Mental Health Services
Task
Timeframe
Assess
opportunities for
primary care Medium term
practitioners to be integrated into the mental
health continuum of services
Action (6): Establish policy and service linkages between government agencies at national and local
levels
Responsibility: Ministry of Health and General Manager Regional Mental Health Services
Timeframe
Task
Establish policy and service linkages between Medium to longer term
governmental agencies at national and local
levels.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the
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1.
Introduction
This report presents the Mental Health Commission’s review of the continuum of services1
funded by the three District Health Boards (DHBs) in the Auckland region, Waitemata,
Auckland and Counties Manukau DHBs (see Appendix 1 for Terms of Reference and
Appendix 2 for members of the Review Team).
The Review was called because of a number of serious issues affecting mental health services
in the Auckland Region. A major and urgent problem is the pressure on beds in acute patient
services, access to those services, and provision of intensive support after discharge from
acute services. Further, there are serious systemic issues regarding the planning, funding,
delivery and monitoring of services across the whole continuum of services. These issues
include: access to and quality of mental health service delivery, gaps in services, the
relationship between funders and providers, relationships amongst providers, and the overall
co-ordination of services. An effective mental health system requires a well functioning
continuum of services that has good working relationships between funders and providers,
and strong linkages between services throughout the continuum.
The Review has focussed on what is needed to achieve an effective and responsive
continuum of services, so that the broad changes needed in the mental health sector in
Auckland can be put in place. The Review has not focussed on financial management, as the
Ministry of Health and Mental Health Commission are undertaking a review of the
application of mental health funding to mental health services (the ‘Ringfence Project’). Nor
has the Review focussed on the specific types of services needed, or the quality of particular
services (although quality issues around access to services have been identified). Focusing on
deficiencies in the provision or quality of particular services would merely provide a
springboard for a round of reallocation of resources within a system ill prepared to deliver
services in the complex environment that is Auckland.
The Review concludes that there is a fundamental need to redesign the model of funding
mental health services in Auckland so that providers deliver a continuum of services to
proactively meet the needs of service users and their families, as well as meeting the
aspirations of the people working within the mental health system. Once an effective
continuum of services is in place, matters concerning the range and quality of services can be
addressed by the General Manager, Regional Mental Health.
Up until the time of the last ‘Mason’ inquiry there were as many as 67 inquiries into some
aspect of mental health services in New Zealand. In the course of this Review, it was not
uncommon to hear statements such as “not another review”, or, “why should we think your
review will make it better?” Consequently there is some scepticism that another review will
really make a difference. Nevertheless, a large number of people made efforts to contact the
Review Team. People wanted to be heard, and did really care about the mental health
services in Auckland. Many suggestions were made for positive and forward looking
initiatives. Mindful of the wide ranging concerns expressed, the Review has identified
fundamental systemic issues that must be addressed, and developed a package of
While the Review Terms of Reference uses the term ‘continuum of care’, the Review uses the term continuum
of services to reflect an emphasis on a whole of system approach, where care is part of services. Particular
aspects of care are covered in the review’s consideration of access and assessment issues.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland 14
Region
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recommended actions that focuses on developing and maintaining an integrated continuum of
services for service users.
The Review has found serious systemic issues in service planning, delivery and monitoring.
The result is that the principle of the continuum of services is lost. The continuum of services
has become compromised by a labyrinth of specifications and contracts that have inhibited
the establishment of collaborative and trusting relationships and behaviours. Furthermore,
there are inadequate operational systems and procedures to support service users in accessing
and moving between the services they need.
Without doubt there is a funding shortfall in mental health services in the Auckland region.
This has a major impact, both in terms of service quality and establishing and maintaining an
integrated continuum of services. There have also been increasing expectations that mental
health services will manage a wider range of conditions than they had previously managed.
While funding constraints must be acknowledged, a shortfall in funding is not the only
problem in the Auckland region, or the most critical problem at this point. Problems arising
from under funding are made all the more acute by an uneven distribution of resources, both
within the Auckland region, and between Auckland and the rest of the country. The systemic
problems in the Auckland region must be resolved so that better use can be made of current
resources.
1.1 The review process
Many individual interviews and group meetings were conducted in order to understand the
factors impacting positively and negatively on the continuum of services. Those interviews
were structured around three questions:
 What is working well for mental health in Auckland?
 What is not working for mental health in Auckland?
 How can mental health services in Auckland be improved?
The Review commenced on the 30th and 31st of May 2002 with meetings of introduction to
the Chairs and Chief Executives of each of the three DHBs in the Auckland region. During
the course of the Review, the Chief Executives were briefed on two separate occasions on
progress, findings and possible actions.
A large number of interviews and meetings took place in June, July and August 2002. The
Review Team met with over 450 people, including:

Service users

General Practitioners (GPs) and Independent Practice Associations (IPAs)

Families and their support networks

DHB Chairs, Chief Executives and Managers of Mental Health Services

Funders and planners

Contracted service providers - DHBs and Non-government organisations (NGOs)

Non-contracted providers

Maori and Pacific communities and services
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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
Mental health service staff


Unions
Government agencies such as Police, Coroners, Housing New Zealand Corporation,
Work and Income and education providers
Ministry of Health and the Mental Health Commission.

A full list of individuals and organisations consulted as part of the Review are set out in
Appendix 4.
The Review Team also hosted two forums. The first was a workshop of 65 people. The
second was a smaller forum of 25 key people made up of service users, families, unions,
providers, planners, funders, Maori, Pacific peoples and NGOs. This forum was convened
for the purpose of presenting the draft findings of the Review and discussing possible ways
forward.
The Review Team benefited from the guidance of a Reference Group (see Appendix 5 for
detail on its composition). The Reference Group met with the Review Team three times and
provided valuable perspectives.
1.2 Outline of this report
Section 2 of this report describes the demographic context in which the three Auckland DHBs
operate, and outlines the current structure of mental health funding and delivery.
Section 3 presents the key findings of the Review. It provides an overview of the main areas
where the continuum of services is breaking down and there is evidence of a system under
considerable strain. In particular:

People cannot move freely between services they need

There are gaps in services

There are significant access difficulties for some groups including Maori, Pacific,
children, young people, older people, and those with drug and alcohol problems

There are access difficulties created by the standard of service provision

There is low staff morale.
Section 4 considers the multiple causes that have resulted in disjunctures in the continuum of
mental health care in the Auckland region. The Review has identified the following key
issues:

Leadership and shared vision

Funding constraints and an uneven distribution of resources

Workforce capacity and capability

Planning and contracting processes

Operational systems and procedures.
Section 5 sets out the proposed actions to address the systemic issues facing the mental health
sector in the Auckland region.
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2.
The Auckland Region Context
The current mix of mental health services in Auckland has developed within the context of
the demographic environment, and changes in mental health service delivery in the past
twenty-five years. This section provides a brief overview of the demographic context, and
outlines the current structure of mental health funding and delivery.
2.1 Demographic environment
The three Auckland DHBs fund and provide mental health services for large proportions of
New Zealand’s population. Waitemata has the largest population of all DHBs, at 11.5% of
the national population. Counties Manukau has 10% and Auckland DHB 9.8% of the national
population. Auckland DHB is one of only three DHBs with a sizeable population on islands
(including Waiheke, Great Barrier and islands of the Hauraki Gulf).2
Table 1 shows the ethnic diversity, both within and between the three DHB areas. Across the
three DHBs, the highest proportions of Maori and Pacific peoples are found in Counties
Manukau DHB, at 16% and 18% of the population respectively. The highest proportion of
Asian people is found in the Auckland DHB area, at 17%.
Table 1: Auckland Region DHBs: ethnic composition and age groups
Auckland
Number
Information
Ethnicity:
Pakeha
Maori
Pacific Island
Asian
Other
Not Specified
Total
%
DHB
Waitemata
Number
%
Counties/Manukau
Number
%
206457
29139
43638
63240
5169
20097
367740
56%
8%
12%
17%
1%
5%
100%
300103
39684
26622
40350
4461
18525
429745
70%
9%
6%
9%
1%
4%
100%
179802
61395
69054
42501
3264
19518
375534
48%
16%
18%
11%
1%
5%
100%
72423
37935
20%
10%
97239
46353
23%
11%
99945
32646
27%
9%
9036
951
31%
3%
14754
867
37%
2%
23964
1971
39%
3%
PI 0-14 years
PI 65+ years
14475
2133
33%
5%
9276
909
35%
3%
25476
2382
37%
3%
Asian 0-14 years
Asian 65+ years
12834
2598
20%
4%
9639
1467
24%
4%
10464
1938
25%
5%
European 0-14 years
European 65+ years
31512
29493
15%
14%
58974
40407
20%
13%
35100
24474
20%
14%
Age by region
ethnicity
All 0-14 years
All 65 + years
Maori 0-14 years
Maori 65+ years
and
Source: 2001 Census, data prepared for the Ministry of Health
Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.
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17
The Maori population has increased 21% between 1991 and 2001. One quarter of people of
Maori ethnicity live in the Auckland region3. Although the Auckland region DHBs have
lower relative proportions of Maori population compared to some other DHBs, nevertheless
they include a substantial number of Maori.
The 2001 census shows dramatic changes in the Auckland region population over the last 10
years for Pacific peoples, who make up 11% of the region’s population4. There has been a
39% percent increase in the Pacific population since the 1991 census - two in every three
people of Pacific ethnicity live in the Auckland region. The Auckland region DHBs are
among the DHBs with the highest numbers and proportions of Pacific peoples. Manukau City
has the largest proportion of Pacific peoples, with one in four residents in that city of Pacific
ethnicity. In Auckland and Waitakere cities, one in seven people are of Pacific ethnicity.
The Asian population includes many ethnic groups with distinct characteristics, although
44% identify with the Chinese ethnic group. The rapidly growing Asian population rose to
6.6% of the population in 2001. Almost two thirds of the Asian population live in the
Auckland urban area, with the majority living in central and southern Auckland. The three
Auckland region DHBs have the highest concentrations of Asian populations, with Auckland
DHB the highest5.
Table 1 shows that the Maori and Pacific populations are relatively youthful, compared to the
total populations within each of the three Auckland region DHB. The proportion of the Asian
population in the 0 – 14 years age group is similar to that of the total population in each DHB
area. However, compared to the total New Zealand population, the Maori, Pacific and Asian
populations are all relatively youthful. The median age of the Maori population in 2001 was
22 years, and three in eight were aged under 15 years. In 2001, the median age of Pacific
people in the Auckland region was 21 years. Nearly two in five people (44%), of Pacific
ethnicity are under the age of 15 years. In 2001 21% of the Asian population was in the 15 –
24 years age group, compared with 14% of the total New Zealand population.
The demographic data point to three substantial, and growing, populations with different age
structures and associated needs, experiencing different socio-economic conditions, and
having specific cultural requirements of mental health services. The mental health workforce
needs to reflect the ethnically diverse populations of Auckland, and service providers need to
ensure that planning, resource allocation and service development all take into account
cultural needs. In the case of Maori and Pacific peoples, there are disproportionate numbers
of young people who may need mental health services. Currently, there are kaupapa Maori
services, but many are small and scattered throughout the region. There is no effective
regional mental health strategy to eliminate health disparities for Maori. There is also an
urgent need to increase the number and quality of the Pacific mental health workforce. In
addition, the Asian population must rely on mainstream services as there is only one Asian
psychiatrist and a small number of Asian staff employed within services. Further detail on
Maori perspectives on mental health are contained in Appendix 6, which presents an action
plan for Maori mental health services in the Auckland metropolitan area. Pacific issues are
covered in Section 3.
3
Auckland region refers to the regional council area. Source of data: Statistics New Zealand: 2001 Census
Snapshot 4 Maori; Ministry of Health 2002 Atlas of New Zealand’s District Health Boards.
4
Statistics New Zealand: 2001 Census Snapshot 6 Pacific Peoples; Ministry of Health 2002 Atlas of New
Zealand’s District Health Boards.
5
Statistics New Zealand: 2001 Census Snapshot 15 Asian People; Ministry of Health 2002 Atlas of New
Zealand’s District Health Boards.
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2.2 Current structure of mental health delivery
Appendix 7 discusses some key changes that have occurred in the organisation, funding,
planning and delivery of mental health services in the Auckland region. A primary driver of
change has been deinstitutionalisation. Twenty-five years ago the majority of mental health
services in the Auckland region were delivered from hospitals that provided inpatient
facilities and attached outpatient clinics. The move away from residential care in large
psychiatric hospitals brought considerable benefits to service users. However, there is
evidence that deinstitutionalisation in Auckland also precipitated wide ranging and on-going
funding problems. Furthermore, longer-term service users who had previously lived in a
psychiatric hospital have experienced particular difficulties with the move to communitybased services. The types of accommodation provided for service users have seen
considerable change. Service users have had to rely on additional support through the benefit
system for services that were formerly free. Accessing and negotiating such support places
particular stresses on those with multiple problems.
The current structure of mental health service delivery in the Auckland region is undertaken
within the framework of the NZ Public Health and Disability Act 2000, which requires DHBs
to manage the funding and service provision roles within a single accountability arrangement.
Each DHB has the fundamental role of securing the best health gain that it can for its
population consistent with Government policy and within the constraints of the resources
available to it.
The present Service Coverage document (which is the means by which the Ministry of Health
on behalf of the Government, prescribes what the public should have access to) and its
associated National Service Framework, have service descriptions for 8 components with 97
service specifications in total for mental health services. These comprise service
specifications for alcohol and drug services (14), adult services (45), forensic (8), child
adolescent and youth (16), and kaupapa Maori services (14). All these service specifications
are applicable to the Auckland region DHBs, and add to the complexity and detail of what
must be provided.
The three DHBs fund mental health services from 73 providers for an extensive range of
services. Both the service delivery arms of the DHBs and NGOs provide, under contract,
mental health services. DHBs provide most of the acute and community mental health
services. NGOs predominantly provide, under contracts, residential care and supporting
services. In addition to services provided within each DHB area, there are regional services
funded and provided by the three DHBs. Regional services include Forensic, Alcohol and
Drug and Eating Disorders. There are also a number of organisations that are not contracted
by the DHBs providing accommodation services to people who have a mental illness.
There are two regional co-ordination services operating in the Auckland region:

The Northern DHB Support Agency Ltd (NDSA) is responsible for regional coordination of planning and funding of mental health services.

The Regional Co-ordination Service (RCS) is responsible for the co-ordination of all level
3 and 46 accommodation and rehabilitation placements across Auckland.
6
Level 3 services provide full time support for people living in homes run by residential providers, and level 4
services provide residential intensive long term support – see service descriptions in Mental Health Commission
1998 Blueprint for Mental Health Services in New Zealand, p.38.
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Region
2.3 Other government agencies providing services to people with mental
illness
Many Government agencies either directly provide services for people with mental illness, or
are involved with service users. The main agencies are:
 Child, Youth and Family (CYF) provides care and protection and youth justice
services to children, young people and their families. CYF interfaces closely with
mental health services in providing support and care for children and young people
with mental health issues.
 Work and Income provides various services for service users including income
support and employment search.
 Police often become involved with service users when they cannot access crisis teams
in a timely manner for appropriate treatment.
 Housing New Zealand Corporation (HNZC) provides rental properties for community
groups contracted to provide accommodation services to people with specialist
housing needs, such as service users.
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3.
What is happening in the Auckland region
This section presents the key findings of the Review. It provides an overview of the main
areas where the integrated continuum of services is breaking down.
The integrated continuum of services is a system where service users can move freely from
service to service and get the quality of care they need for their particular stage of recovery.
For a continuum to work effectively:

The full range of services required by people with mental illness must be available

Individuals must be able to access those services

Services need to be of the appropriate quality.
The development of pathways through a continuum of services is crucial to ensure the needs
of service users are met.
The Review has found a system under considerable strain. This is evidenced by the
following:

People cannot move freely between services they need

There are gaps in services

There are access difficulties created by the standard of service provision

There is low staff morale

There are significant access difficulties for some groups including Maori, Pacific,
children, young people, older people, and those with drug and alcohol problems.
3.1 People cannot move freely between the services they need
Clear care pathways that span the services of a number of providers are needed in the
Auckland region. Care pathways are made up of connected services that provide specific
treatment, care and support for people with particular types of mental illness, so that they can
move through different services as required by the nature of their illness and their stage of
recovery. Examples of care pathways that need to be developed include those for older
people, young people, those who are new to mental health services, and those with drug and
alcohol addictions.
The development of care pathways is crucial for:

Overcoming the lack of shared vision in Auckland’s mental health sector

Developing consistency in procedures to smooth the transition between services

Ensuring that providers talk to each other

Ensuring the diverse and changing needs of service users are met

Ensuring that service users know what to expect from services.
Although the three DHBs have a regional approach to the planning and funding of mental
health services, it does not appear to be effective. Service users who move across Auckland
for whatever reason, are not always able to access the same range of services in each of the
DHBs because the service configuration, access and discharge criteria, and management
practices, are different. Service users and families experience problems in getting ongoing
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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support when a service user living in one DHB area returns to the family home in another
DHB area after hospital discharge. There appears to be little liaison across teams in different
DHBs. Within DHBs, there are also problems in service users accessing the service they need
when they need it.
Examples of the lack of a continuum of services, both within DHBs and across DHBs
include:

Widespread lack of knowledge across DHB specialist services and NGO services
regarding the nature of each service, the criteria for referral or entry, and the point of
contact for families and service users. Lack of this critical information impedes the access
of service users and their families, and also limits engagement, liaison and transfer of
service users amongst service providers.

In circumstances where the service user ‘doesn’t fit’ the criteria for access to a service,
often referrals are not made or assistance to access other services is not given. In
desperation the service user may then seek help from the emergency department of the
public hospital, or alternatively, the Police become involved.

People with various drug induced psychoses are neither catered for by acute inpatient
services, nor by the regional drug and alcohol services.

Some DHBs are reluctant to contribute funding for regional services, believing that they
can more efficiently provide that particular service within the DHB.
It is common for service users to be told "that's not the way we work in our service” when
they try to explain their situation and the assistance they need for their distress.
A number of service users described the difficulties they have in adjusting to a new service
provider when they move between different services. Service users find that they must learn
their current service provider’s model of service delivery and ‘package’ their needs in a way
acceptable to the provider before they can benefit from the service. If service users move
between several services over time they might be confronted with having to ‘re-package’
their needs in three or four different ways to fit the service. Different service providers may
need to have different emphases in their approach or treatment modalities. But it appears that
service providers have no shared understanding of these differences, or procedures to smooth
the transition between services. Service users should not have to continually adjust to the
providers, and “re-package” their distress before they receive the treatment and support they
need.
Many service providers find the lack of continuity between services a major impediment to
delivering the best care they can for service users. Providers find it impossible to see where
their service fits into the broader context. Providers want to feel that they are part of a whole,
and that the work they do is validated and seen as important, not only within the organisation
they work, but also within the wider health sector, and society.
3.1.1 Primary care
There are opportunities to strengthen the continuum of services through improving links
between GPs and mental health services. Meetings with GPs, both as individual practitioners
and as part of their IPA, confirmed that an integrated continuum of services must include
access to suitable primary health care services. While the “NZ Primary Care Strategy” makes
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appropriate provision to acknowledge this intent, the reality for service users is quite
different.
Many GPs consulted as part of the Review consider that they are not seen as partners by
DHBs in the continuum of services. GPs expressed continued frustration in dealing with
DHB services. In particular, they identified problems in accessing information about patients
from mental health services.
GPs’ comments included:
“As a GP with a keen interest in caring for persons with mental illness in -----, I am appalled
at the limited funding for health workers and the poor systems in place. We get so little
information from mental health services as to when a patient is seen, what medications they
take, when there is a follow up appointment, who is their case manager, the ‘passing the
buck’ attitude of staff whenever a GP requests such information and hiding behind privacy
issues”.
“GP access to outpatient notes and treatment is very poor. Little by way of written
correspondence about patients – except from consultants. Privacy seems to override common
sense”.
A critical issue is the need to remove the financial barriers to primary care that service users
experience. One example of a useful approach is the ‘Procare’ initiative developed by an
Auckland IPA. Funded by savings from other parts of their operation, Procare ensures
responsive assessment, referral and treatment for service users. Procare considers that mental
health services in Auckland would be assisted if there were:
 Specific and targeted funding for primary mental health
 Recognition of the efficacy of primary mental health care
 Recognition of GP willingness to offer expertise and strengthen their contribution to
mental health.
3.2 Gaps and under supply in the provision of mental health services
Gaps in mental health services become evident when service users cannot get the types of
services and supports they need. This may be due to a lack of a particular service, or an under
supply of a service. Gaps in services are not only evident in mental health and other healthrelated services, but also in the employment, accommodation and social services that service
users need. The gaps in services experienced by particular groups are discussed in Sections
3.5 – 3.8 below.
The most mentioned gaps or under supply in services were in:

Acute and intensive inpatient services

Crisis respite services

Medium and extended accommodation with intensive support, preferably in a community
setting.
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Gaps at the more intensive end of the services continuum are often exacerbated by:

"Capped" services that are contracted to provide care for a specific caseload and
consequently cannot meet demand

Some specialist services that cannot meet demand

The use of a ‘3% rule’ to ration access.
Service users and family members were concerned about the difficulty of accessing services
when needed, rather than having to wait until the person became seriously ill.
"I know when I'm getting sick. However, I seem to have to get really crazy before they do
anything to help me".
Service providers highlighted various gaps in the Auckland region, but the most mentioned
gap affecting the continuum of service is the gap in provision of accommodation with
intensive support. There was a widespread view among providers that this gap continues to
be a major problem. Service providers also spoke of deficiencies in core clinical services, i.e.
acute general psychiatry, both inpatient and community facilities. Providers find it difficult to
refer service users to services that would offer them most benefit, at the time when needed.
There was a concern expressed “that if Police are seen to be too accommodating they will
get to carry more of the problem”.
The Police commented that they often become involved when individuals cannot access acute
mental services, whether inpatient services or crisis teams. As a consequence, police cells are
regularly used to contain people who have not offended, but who are in crisis. The Police
expect mental health services to be accessible and responsive, without the need to rely on the
criminal justice system to provide alternative accommodation. Nevertheless, there is
considerable goodwill at a local level between the Police and mental health services.
It is considered that the General Manager Regional Mental Health Services, should undertake
a mental health needs assessment and a review of international clinical best practice to meet
identified needs (Action 4). This exercise would confirm those gaps in services identified in
this Review, and identify any new components required for an integrated continuum of
services for Auckland.
3.2.1 Gaps after discharge from acute inpatient units
The occupancy rates for acute inpatient services for each of the DHBs is very high. Table 2
presents occupancy rates for the year ended 30 June 2002.
Table 2: Occupancy rates for acute inpatient services, year end 30 June 2002
DHB
Waitemata
Auckland
Counties Manukau
Occupancy rate (%)
96.8
88.3
97.7
Source: Auckland region DHBs
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These rates clearly demonstrate that acute inpatient services have very little flexibility in how
they manage the fluctuating nature of their caseloads. This has significant implications for the
management of accommodation with intensive support. At any one time, all acute wards have
service users that could be discharged if there were an appropriate facility available. The
Regional Co-ordination Service (RCS), which is responsible for the co-ordination of all level
3 and 4 placements across Auckland, reported in July 2002 that 61 people were waiting for
placements in level 3 and 4 housing. An additional 20 people were waiting for other intensive
rehabilitation options. Thirteen of those 20 were in acute inpatient units. Seven weeks later 24
people were waiting in acute units for placement to residential or rehabilitation options.
A nurse in an acute ward said “the number of acute beds is not the problem – it’s the need
for and access to supplementary services such as rehab and supported accommodation”.
Frequently the acute inpatient service is confronted with the difficult decision of whether to
discharge a person into supported accommodation, who is considered too unwell even though
he/she may be stable enough not to require inpatient treatment. These particular service users
often tend to be young, with a major mental illness complicated by substance abuse and a
diagnosis of personality disorder. Some have rapidly relapsed shortly after a previous
discharge, due to severe drug abuse. This group of service users has increased, both in
severity and numbers in recent years.
The Review was given several examples of patients who were inappropriately discharged:
One patient was discharged to a respite facility to create a bed at short notice, although still
acutely unwell. A couple of days later the patient was urgently readmitted following an
incident in the middle of a very busy main road in the early evening.
Assessment indicated that inpatient care was the preferred treatment venue for one patient.
Nevertheless, the patient was placed into respite at a rest home due to bed shortage in the
inpatient unit. During a follow up visit a week later by a nurse, the patient picked up a
carving knife, and self-inflicted wounds. Police and ambulance were called and the patient
was admitted to hospital.
In acute inpatient services there is intense pressure on beds from new referrals and very
limited options for other placements. In order to free an acute bed, service users are
discharged into supported accommodation, although their needs are more complex than the
provider is contracted to support. The lack of fit between the service and the specific needs of
a service user impacts on everyone: the service user, the staff and other service users within
the residence.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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NGO providers said:
“RCS talk about a match, we talk about a fit”.
“There is something missing in the design of services”.
One NGO Manager, when asked why they accepted “inappropriate” referrals stated that “if
you don’t take someone, then you don’t get referrals. We waited 11 weeks to fill a vacancy in
one house”.
Although there are questions about the quality of service of some non-contracted providers
they nevertheless fill a gap in accommodation. The Review heard that some service users
who are described as “having burned their bridges” with contracted supported
accommodation providers or as “difficult,” find a home with these non-contracted providers.
There needs to be more medium term and extended accommodation with intensive support,
preferably in a community setting, for people who need more on-going structured support and
safety than can be provided by current supported accommodation options. Action 2 addresses
this problem.
There have also been instances where service users have not received adequate assessment
and treatment before discharge. The system must be robust enough to ensure that service
users are properly assessed. If such requirements need legislative change, this matter should
be addressed by the proposed General Manager Regional Mental Health Services in Action 4.
3.2.2 Capped and uncapped services
On the whole, the Review found that capped services, with their well-defined entry criteria
and a specified caseload, tend to work well. Services that are contracted to provide care for a
set number of people can regulate and define their workload. Specialist services tend to be
capped, while core services are un-capped.
There appear to be considerable tensions between core services and specialist services, both
locally and regionally, because of the practice of directing new money to specialist (and
usually capped) services, while core services remain relatively poorly resourced. People who
continue to work in the core services see, because of the population growth in Auckland, a
rising demand for their services. Over time there has been a tendency for people working in
the core uncapped services to want to work in specialist capped services where they do not
have to face the pressures of unlimited demand.
3.2.3 Specialist services
A number of specialist services such as the Early Intervention Services and Intensive
Community Teams appear to work extremely well. However, not all the specialist services
are doing well. For example, the Regional Eating Disorders Service, which is uncapped, is
severely under resourced. People with eating disorders cannot access inpatient and
community support because of very high demands on those uncapped services.
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3.2.4 The ‘three percent rule’
The Review came across comments such as “doesn’t fit the 3%” and “not ours”.
Even if there are services available, service users may not be able to access those services
when needed. In particular, service users reported experiencing considerable difficulties in
accessing help that would enable them to stay out of hospital. It appears that a policy based
on the National Mental Health Strategy guideline that funding should target the 3% of the
population who at any given time are most severely affected by mental illness, is being used
to ration access.
While it may be possible for such guidelines to be used to manage high demands on an
uncapped service, this is not what the National Mental Health Strategy intended. The
Blueprint makes it clear that development of this percentage was done primarily for national
and regional planning, and any translation of these figures for requirements at a local level
must take into account the local population and its needs. 7 Targeting solely on the basis of
3% without adequate and appropriate assessment prejudices people’s access to services. It is
clearly not acceptable to the service user.
3.3 Access difficulties created by the standard of service provision
Concern about standards of service creates problems of access for service users. There are
quality issues, both in relation to particular services and across the continuum of services.
Even though some services may be of high quality, the overall quality of service is
compromised if there are gaps in the continuum, or access is difficult. Service users, families
and clinicians expressed concern about the quality of services provided by some NGOs and
DHBs. Some service users were satisfied with the level of service they were receiving but
considered that their experience could change if their clinician moved on. Service users and
family members reiterated concerns about the pervasive use of a medical model, rather than a
holistic view of the circumstances and needs of service users.
"[the psychiatrist is] only interested in whether I am taking my tablets or not, not how I am
doing".
A service user response to a call by clinicians for more “beds” was that, mental health
services should be designed to “keep it okay for me to be in my own bed”.
Service users pointed to problems in accessing DHB crisis services. For example, they
reported that some crisis teams do not return calls, particularly when they know there are
other staff available. There were many comments from service users and families, about
having to be in a great deal of distress before they could access either their key worker or
Community Assessment and Treatment Team (CATT). Refugee hostel staff reported that
they have been told by crisis teams to take people to the emergency department of the
hospital, or phone the Police. Families’ main concern was that their views and potential input
were often ignored by services.
7
Mental Health Commission Blueprint for Mental Health Services in New Zealand p.vii
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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Concerns were raised about the difficulties in accessing CATT between 2300 and 0700 hours
when calls are redirected to acute inpatient staff who respond unhelpfully; e.g. “have a hot
bath – I’m awfully busy”.
While some clinicians are attempting to meet the National Mental Health Sector Standard
through identifying early warning signs and developing relapse plans with the participation of
service users and families, the reality is that key workers and psychiatrists in a number of
teams are unable to respond as planned. The Review is aware of a call management service
being piloted by the Healthline project in Hutt, Capital Coast and Waikato DHBs. The
Healthline pilot may provide a more reliable means of helping to manage the acute caseload,
which can be introduced in other DHB areas.
The quality of service delivered by different community based NGOs varies considerably.
This diversity feeds the distrust of clinicians, is reflected on the whole NGO sector and thus
fuels the tension between DHBs and NGOs in some areas. Many DHB clinical staff
expressed deep concern about the quality of services provided by NGOs and a reluctance to
refer individuals to them. Currently there appears to be no process in place to address quality
issues, nor to provide feedback on performance to providers. However, it must be
acknowledged that many providers have joined Platform, the national association of support
and community development in mental health, and appear to be working collaboratively to
improve quality of services provided to service users.
The Review found that a number of people currently accommodated by non-contracted
providers are receiving inadequate mental health services. The mental health service in
Auckland is heavily dependent on non-contracted accommodation providers that house
people who are not currently able to be, or choose not to be, accommodated within the
contracted supported accommodation. The standard of non-contracted accommodation
appears to vary, with indications that it can be poor in some cases. Planning for the diverse
housing requirements of service users needs to happen through on-going dialogue between
health and housing agencies, and with the involvement of service users, so that the changing
requirements of this group are addressed.
3.3.1 Monitoring
Monitoring the quality of service provision, and understanding what is required in the
standards, appear to be variable. It is essential to an integrated continuum of services that all
providers meet the requirements of all relevant standards.
While the 1997 National Mental Health Standards were required to be implemented in
Hospital and Health Services (HHSs) by July 2000 and by NGOs in December 2000, the
Health Funding Authority (HFA) and Ministry of Health monitoring processes did not ensure
that all providers understood the intent of each standard and implemented them. Two of the
three Auckland DHB services have been accredited by Quality Health NZ, while the third
DHB is undergoing an audit process co-ordinated by another external agency.
Some of the NGOs have either sought, or are seeking external certification or accreditation of
their services, but many will struggle to meet the revised National Mental Health Sector
Standard and certification by October 2004. Smaller NGOs report that they do not have the
infrastructure and resourcing to undertake certification successfully.
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3.4 A demoralised workforce
In the course of the Review, many staff expressed a strong desire to have an effective mental
health system that clearly added value. However, for many staff working in mental health,
frequent reorganisations of the sector have dampened any enthusiasm to aspire to a whole of
system approach.
Large number of interviews showed that many staff working in mental health services receive
little job or professional satisfaction, although there are a few exceptions. While many staff,
both individually and in teams, demonstrated a very strong commitment to the needs of
service users, they are working very hard and feel under considerable stress. Across the
system there is widespread frustration and low morale.
Community teams are angry when they know the next call could be about a young person
who is too old for Starship, too young for the acute ward, too unwell for the inpatient unit
and not able to be placed through Child, Youth and Family.
Psychiatrists watch daily, with mixed feelings, their colleagues who are ‘getting out’. One
psychiatrist said, “being a psychiatrist is like playing Russian roulette except that all the
chambers have a bullet.”
Senior nurses watch new staff come into the workplace and ‘burn out’.
Staff do not feel that they are involved in a worthwhile and valued enterprise. One
psychiatrist commented, “you can’t look families in the eye knowing that you cannot provide
what is needed – the case load is overwhelming”.
Demoralisation has significant implications for staff recruitment and retention. It is hard to
recruit to a job that is seen as fighting for survival and even harder to get people to feel
willing to stay when they see little reward or sense of job satisfaction. This situation also has
implications for achieving and maintaining a quality service.
3.5 Access difficulties for particular age groups
In Auckland those at both ends of the age spectrum – younger people and older people – are
particularly vulnerable to missing out on the specific care and support they need. Services are
just not available for them.
3.5.1 Children and at risk youth
CYF has experienced a significant reduction in resources to provide residential placements
for at risk adolescents and children. At risk youth with both care and protection needs and
mental health issues are not being adequately catered for in either the mental health or the
care and protection sectors. At times this situation has resulted in considerable tension
between mental health and CYF staff in the Auckland region.
DHB teams identified that 15-19 year olds often cannot find services appropriate to their age
group or particular needs. For some, the insular silos in both health and other social agencies
that deliver specific categories of service are a major blockage to young people receiving help
when it is needed. Other groups whose needs are not met include:
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
Children and young people with mental illness who also have a head injury or an
intellectual disability

Young people with both substance abuse and mental health issues.
Access criteria for specialist teams such as dual diagnosis, early psychosis or mobile
intensive teams exclude young people. As a result their needs are not met.
3.5.2 Older people
The service specification and contracting framework make it difficult to provide the range of
services that older people need. A particular example is the difficulties for older people
accessing home support services as such services are for people with age-related physical
disability and not for people with ongoing mental ill health who have reached the age of 65.
3.6 People with mental illness and drug and alcohol dependency
Co-existing mental illness and drug and alcohol dependency is very common, but many
service users in this category cannot access services that are equipped to help them with both
problems. Organisations such as Salvation Army, City Mission and other church based relief
services, commented that people with drug and alcohol dependency who also have mental
illness, and who are transient, tend to slip through the gaps in mental health services.
There are inadequate detoxification services in Auckland. These were meant to be provided
when the Summary Proceedings Act was passed into law removing the ability of Police to
detain those found intoxicated in public places for 24 hours. Police consider that the lack of
accessible assessment services for people with alcohol and substance abuse means that by
default Police become the detoxification service.
3.7 Issues for Maori
A plan specifically for Maori mental health services has been prepared and is attached as
Appendix 6. The plan points out that Maori are much higher users of crisis, acute and
forensic services than non-Maori, and are more likely to suffer from alcohol and drug
disorders. Consultation with key Maori stakeholders identified that there are many small
fragmented and stressed kaupapa Maori services scattered throughout the Auckland region.
There are many gaps in services, and strong support from Maori for a more strongly
preventative model of mental health services that focuses on primary health services. There is
a need for Maori provider workforce development.
There is further work to be done in planning mental health services for Maori, particularly in
respect to:

Building effective relationships with key stakeholders in the Maori community

Establishing a comprehensive ten year regional mental health strategy for Maori

Over time, planning and funding local Maori mental health care continuums

Developing fiscally prudent objectives and long term plans for investing in kaupapa
Maori services.
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3.8 Pacific Peoples
All By Pacific For Pacific (BPFP) services that were interviewed expressed optimism and
enthusiasm. There was a common view that the BPFP models of service delivery are working
well in each of the DHBs. While staff, elders and service users associated with these services
all had some reservations, they were adamant that these services shared the following
strengths:
 BPFP services were receiving good support from their respective DHBs
 Good networks were developing between the BPFP services
 There was an increasing level of acceptance of BPFP services by most of the
‘mainstream’ providers
 BPFP services were beginning to develop positive links with various NGOs
 The two most consistent benefits these services felt they contributed to mental health
care for Pacific people were:

The delivery of culturally appropriate services

The ability to offer choice to Pacific service users and their families.
Despite these positive statements; Pacific service providers, service users and their families
voiced a number of significant areas of frustration, including service co-ordination,
accessibility, responsiveness and resourcing. Another critical issue is Pacific workforce
development.
3.8.1 Co-ordination and access
Although better links are being established between some services, there was also a sense that
poor regional planning, co-ordination and collaboration have made it harder and more
expensive to deliver services to the Pacific community. Effective co-ordination is particularly
hard to achieve, given the patterns of transience and mobility of the Pacific population.
Services have to work very hard to ensure that service users do not “fall through the cracks in
the system”.
One person summed up the general view that “the boundaries between DHBs do not take into
account the movement of people”.
3.8.2 Service responsiveness
Despite positive initiatives at individual and local levels, there is also a view that there are
poor links and communication between support services and clinical services. BPFP services
feel undervalued and in some instances are treated with considerable discourtesy by health
professionals in the clinical services.
Pacific mental health workers said that their cultural expertise is disregarded, and that the
“mainstream view of Pacific providers is paternalistic”.
There is some evidence to suggest that Pacific people under-use mental health services
because of cultural understandings of mental illness and the appropriate interventions. For
many Pacific people, odd behaviour may be explained in terms of spirit possession, curses or
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visits from one’s ancestors. The tendency of health professionals to diminish these practices
as superstition is simply ethnocentric arrogance, and does nothing to break down the cultural
barriers to Pacific people using mental health services.
3.8.3 Resourcing
While there is optimism and commitment in BPFP support services, there is also a strong
sense that these same services are inadequately resourced for the size of the task confronting
them, and there is not a well-developed or coherent infrastructure to support them.
“Pacific people are over represented in first episode psychosis admissions. Three quarters of
first episode clients are Pacific”
“Pacific clients present too late with high acuity”.
Perceived shortcomings in the range of services were highlighted:

Considerable disquiet was expressed about the lack of specific Pacific options for fulltime
support for people living in homes run by residential providers, and for accommodation
with intensive support.

A lack of early intervention and prevention services was identified.

There is a lack of supported employment options, and no or low youth services and drug
and alcohol capacity.

There are examples of Pacific health and social services that are not contracted to provide
mental health services, but nevertheless are asked to ‘step into the breach’. Apart from the
obvious contractual inequity, these services do not have sufficiently or appropriately
skilled staff to take on mental health care.
3.8.4 The Pacific mental health workforce
“Pacific health professionals are under pressure, feel isolated and unsupported by DHBs”.
Discussion about the Pacific workforce raised major issues. Firstly, the majority of people
who spoke about Pacific workforce issues see a high need for capacity and capability
development to increase the number and quality of the Pacific workforce. There are limited
resources for staff development and limited opportunities to increase contracted FTEs in
order to effectively address demand. The present workforce feels overwhelmed by the size of
the task it is being asked to address. This in itself becomes a disincentive to recruiting more
Pacific health professionals into the field of mental health.
Secondly, there are un-addressed tensions in relationships and accountabilities between
mainstream clinical staff and Pacific non-clinical staff leading to ‘patch-protecting’
behaviours that deflect attention from the main task of providing quality services. There is a
view that the quality of the service provided by Pacific services are clinically inadequate.
There is little research on the effectiveness of Pacific models of care. Furthermore, there is a
lack of national and regional strategic leadership and direction for Pacific mental health, and
the current approach to Pacific workforce development is flawed.
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There needs to be much more investment in Pacific workforce development at all levels.
Clearly, if the DHBs see BPFP as the most appropriate way to address the mental health
needs of Pacific service users and their communities, then there has to be a commitment to
make sure they are sufficiently resourced to do the job. It is unacceptable to set up these
services and then marginalise them. They must be an integrated part of the overall system.
It is proposed that the General Manager Regional Mental Health Services (Action 1) take
responsibility for the development of an action plan that specifically addresses issues for
Pacific peoples mental health services.
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4.
Why there are problems
There are multiple causes of the failure to provide a continuum of mental health services in
the Auckland region. The issues identified in Section 3 not only reflect some of those diverse
causes, but also in turn contribute to further fragmentation of services. It is clear that the
integrated continuum of services has not only broken down with co-ordination failure at the
regional level, but there are also practices and processes within the DHBs that are
unsatisfactory. The Review has identified the following key areas affecting the development
and maintenance of an effective and integrated continuum of services:

Leadership and shared vision

Funding constraints and an uneven distribution of resources

Workforce capacity and capability

Planning, funding and contracting processes

Operational systems and procedures.
4.1 Leadership and shared vision
A large number of people spoken to in the course of the Review highlighted the lack of any
shared vision for mental health in the Auckland region. The lack of leadership and a shared
vision are considered to be a critical cause of a range of problems besetting the continuum of
services. For example, the lack of leadership and a shared vision are seen to be key drivers of:

Low workforce morale and difficulties with recruitment and retention

Differences in the way services have been planned for, funded, and contracted

The development of a number of "internally focussed services"

Lack of linkages and communication between services.
The need for a shared vision is recognised by most people in the sector. However, one of the
impediments to a shared vision is the existence of three DHBs in the Auckland region and the
legislative requirements that each has to meet the needs of its own community.
While clearly there is leadership at the local service level, there is no single ‘metropolitan
Auckland’ leadership. A number of senior clinicians with whom the Review Team met
believed that leadership is as much a national issue as it is a regional or district matter. There
was comment that mental health is made up of a large number of disparate groups with few
connections across the system. People argued persuasively for clear mandated direction and
authority at the national level, as well as for the Auckland region, especially in the planning
of specialist services and the development of models of good practice.
It is expected that the appointment of a General Manager, Regional Mental Health Services
and the requirement to review existing specifications (Action 4) and develop care pathways
(Action 4) will provide a sense of shared vision and leadership.
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4.2 Funding constraints and uneven distribution of resources
There has been a 125% increase in nominal funding for mental health services in New
Zealand over the period 1994/95 to 2002/038. This investment is redressing the historical
legacy of under funding, but it is estimated that this increase accounts for 65% of the
resourcing necessary to reach the Blueprint target across the country. The northern DHBs
(comprising Northland, Waitemata, Auckland and Counties Manukau) are estimated to be
funded to 58% of Blueprint requirements. Across the three Auckland DHBs there is variation
in funding, with Auckland DHB funded at 67% of Blueprint target, Waitemata at 64% and
Counties Manukau at 42%. The variation may be due to the distribution and local allocation
arrangements between the DHBs for regional services. Overall, the Auckland region DHBs
face considerable challenge and continue to be compromised in their ability to deal with the
demand for services, both in the short and longer term. Consequently, a review of present
funding plans for the three DHBs is recommended (Action 3). That review must be informed
by the findings of the Ring-fence Project.
The Review has also found that funders and providers have misinterpreted Blueprint funding,
believing it can only be applied to new services, not for additional capacity of existing
services. It is unclear why this interpretation exists as it is not national policy. The capacity
of the clinical base of acute inpatient services and community mental health teams has been
jeopardised by this interpretation, which has favoured the development of new capped
services. While ‘capped’ services are capably managing the caseload, ‘uncapped’ services are
overwhelmed and in some cases have to manage in circumstances that are clearly
unacceptable.
It appears that funding constraints and an uneven distribution of resources result in a short
term focus on service provision and act as a disincentive to innovate or improve service
delivery. Funding constraints have also impacted on the ability of funders to build an
integrated continuum of services because funding has not been applied evenly across the
continuum.
4.3 Workforce capacity and capability
An issue underlying many of the systemic problems is the development of the capacity and
capability of the mental health workforce. It is difficult to develop and maintain an integrated
continuum of services if there are problems in recruitment and retention of workers. Low
morale is pervasive among workers in the sector.
Both the quality and the quantity of the workforce need to be increased. There is a need for
more people in specific occupations such as psychiatrists. The workforce also needs to be
educated in using a recovery approach in their work, with a holistic approach to service
provision, cultural responsiveness, developing the personal resourcefulness of service users
and keeping service users linked to their families and communities.
The Maori and Pacific mental health workforces experience particular issues with regard to
work-related stress, upskilling workers, requirements for workers in specialised areas, and
supports for Maori and Pacific-based services.
8
Ministry of Health August 2002 Advice to the Incoming Minister of Health: Background Briefing Papers p.65.
Mental Health Commission data on current and guideline expenditure by the three DHBs vis a vis Blueprint
guidelines, and compared with all DHBs, is presented in Appendix 8.
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People with experience of mental illness also have important roles to play in the mental
health workforce, e.g. as advisors, in support roles and clinical roles. The workforce
development needs of this group have been neglected. There is very little training and
development for service users in advisory or support roles.
4.4 Planning, funding and contracting processes
A wide variety of issues demonstrate deficiencies in planning, funding and contracting
systems and procedures. The complexity of getting the right range, quality, variety and
volume of services that fit together cannot be underestimated. There are many examples of
fragmentation in how mental health services are currently planned, funded, and provided.
Providers of mental health services in Auckland are not confident that the existing planning,
funding and contracting arrangements are as informed as they need to be.
More dialogue at the planning and funding level is necessary if progress is to be made.
Dialogue needs to happen between the Ministry of Health and the DHBs, as well as between
the DHBs, providers and other stakeholders, including service users. There should also be
opportunities to engage other government agencies in planning for mental health services, as
there are significant interface issues with such agencies as the Police, CYF, HNZC and Work
and Income that need to be addressed.
Contracting arrangements and supporting service specifications for mental health services do
not seem to support a ‘whole of system’ approach to an integrated continuum of services. The
National Service Framework does not support the need for an integrated continuum of
services for people with a mental illness. Furthermore, the present contracting framework
would seem to inhibit a regional ‘whole of system’ approach to the management of mental
health services.
Current planning, funding and contracting issues are inhibiting:

The identification and development of the full range of services that are needed

Communication between funders and providers and other stakeholders

Communication and co-operation between providers

Clarity about the roles of NGOs

Effectiveness of the NDSA.
These issues are outlined below.
4.4.1 Services needed
With the shift to a contracting model in the early 1990s, contracts with existing organisations
that had previously delivered services through the Department of Social Welfare and
Community Funding Agency were ‘rolled over’ through the new arrangements. Since that
time, continued ‘roll over’ of contracts has become a consistent feature. The Review was told
that some providers have contracts that are not considered to be appropriate to meet current
needs but it is too hard for the funders to exit them.
Furthermore, the Review has found that formal contracts have been used extensively by
funders as the vehicle to prescribe the nature of the service. The National Service Framework
produces a consistent approach but also results in one-size fits all. The effect is that the
contract reflects neither the specifics of the service nor the outcomes for service users.
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4.4.2 Communication between funders, providers and other stakeholders
Both the former RHA and HFA produced strategic plans for mental health using public
consultative processes. These are the 1995 North Health Strategic Plan for Mental Health in
2010 and the HFA Strategic Plan for the Northern Region 1998-2003. It is unclear whether
either of these documents continues to influence decision making on funding.
Unlike the earlier plans, the Regional Mental Health Plan 2002 - 03 has had little input from
significant mental health stakeholders who now feel marginalised. Maori, Pacific Island,
NGOs, DHB provider arms, GPs, service users and families have little confidence that the
planning is inclusive, informed and relevant. During the time of the Review local and
regional stakeholder networks were being set up. It is expected that these groups would have
some input into future planning processes.
4.4.3 Communication between funders and providers regarding
contracting
The relationship between those who fund the service and those who deliver it appears to be
tenuous. Providers spoke of frustration at the lack of contact and interest from funders in the
work of providers, and despair at the hoops and levels within the new bureaucracy. The
Review heard from providers that had not been contacted by the funder in many years. The
lack of relationship between the funder and the NGO providers contributes to the scepticism
that the DHB funders will favour their DHB provider arm. Such scepticism is fuelled by the
fact that funders have not invited NGOs to tender for any new contracts. NGO providers
disputed the accuracy of NGO contract data provided by some DHBs to the Review. NGO
providers said the information did not accurately reflect the contracts they had with the DHB,
in terms of the nature of the services provided.
The providers also expressed dissatisfaction that there is no monitoring, feedback or research
that establishes whether or not the services being funded are making a difference. Most of the
providers and other stakeholders interviewed in the course of the Review have not been
consulted about what they think works or does not work. Their vast experience and specialist
knowledge in mental health is not considered or used by planners.
4.4.4 Communication and co-operation between providers
The previous contracting culture of the RHA and HFA operated within a competitive and
commercial environment. That has led to tension between the providers of services and has
created barriers, which still impede the relationships between the NGO and the DHB
providers. The present contracting arrangements with supporting service specifications have
also led to the emergence of service ‘silos’ that are inward looking and concentrate on
delivering only what is exactly specified.
Workers at the coalface are told "your role is to meet our contractual requirements and if it
is outside our contract we don't do it".
“We spend more time deciding on who we won’t see than seeing those that we are contracted
to see”.
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The emphasis on service prescription has been at the expense of building an integrated
continuum of services with clearly defined points of access for service users. The emphasis
appears to have been on the purchasing of components without resourcing the “glue” to
integrate services. The present arrangements, together with the legacy of the competitive
environment, have inhibited integration and collaboration between providers.
4.4.5 Clarity about the role of NGO providers
With the latest restructuring of health funding to the DHBs, the NGO sector was expected to
participate in the regional networks recommended in Mental Health Commission advice to
the sector in 2000. However, there has been no clarity about the future of NGO services. The
removal of a community networking position to facilitate the development of community
networks builds on the concern of the Auckland NGOs that they will continue to be excluded.
At the NGO forum attended by the Review Team, NGOs described how they feel
marginalised and patronised by the DHB system, yet some of the most innovative service
delivery is occurring in the NGO sector.
4.4.6 Effectiveness of the NDSA
The complex arrangements of the NDSA, DHB Planning and Funding Teams, and Boards do
not make it clear to NGO providers and other stakeholders exactly which organisation has the
ultimate responsibility to contract services.
The Review has considered whether the NDSA should take a greater role in the overall coordination of mental health services, as it has a planning and funding skill set relevant to
mental health. The presence of the NDSA and its role in the planning and funding of mental
health services is an attempt by the three CEOs to address systemic issues across the entire
service profile of Auckland collectively. The action plan builds on the intent to address
matters collectively and provides for a service coalition to oversee service co-ordination and
to inform the planning process across the three Auckland DHBs.
4.5 Operational systems and procedures in provider organisations
A number of shortcomings in operational systems and procedures have made it difficult to
establish and maintain a successful, functional and integrated continuum of services. Areas
that need to be addressed include:

The inappropriate use of a 3% threshold instead of assessment to determine access to
particular services

Needs assessment for individual service users

Co-ordination mechanisms

Criteria for discharge

Protocols for the transfer of individuals from one service to another

Quality control mechanisms

Staff supervision procedures.
It is clear that the operational procedures of many providers are not developed to take account
of their contribution to the continuum of services. There are several examples of this:

One rehabilitation service received a call from the funder stating that a new contract had
been let for 15 residential intensive long term support beds and they were directed to start
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using them. The rehabilitation service had no idea of the model the provider used, what
services would actually be provided, or what the provider’s linkages were as no one in the
service had heard of this particular provider.

At times, in order to manage their caseload, teams change their admission and discharge
criteria with little apparent regard for the consequential effect on other services.

Some services appear to have little or inadequate knowledge of other mental health
services or of other social supports available in the community that make up the
continuum. Such lack of information and rigorous management of entry leaves service
users and families desperate at times.
The Review also found little evidence of effective co-ordination and operating protocols
between mental health services and government agencies. This issue was raised in particular
by Police.
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5.
Pathways to improvement
Despite the problems identified in this Review, there is a strong base from which to address
the systemic issues facing the Auckland region mental health services. However, it will
require focussed leadership, energy and passion. There are many committed people working
within the mental health sector in the Auckland region, and a strong commitment among
service users to assist DHBs to improve their service provision. Many staff have good
collegial contact within their teams and often across agencies. The Review believes that it is
within the capacity of people involved in mental health services in Auckland to fix the
problems.
To enable this to happen there needs to be:

A single accountability for the overall direction and leadership of Auckland services

A more inclusive and widely informed approach to the planning, funding and provision of
mental health services in the Auckland region

Better operational systems and procedures to ensure that service users can access and
move between services when they need to

Attention to workforce recruitment, retention and morale

Adequate funding to provide the required services

More collaboration between providers, whether they be DHBs or NGOs, and with other
government agencies

More recognition of the contribution of primary care to mental health services.
This report recommends the following actions, which are expanded in more detail below:
 Action 1: Appointing a General Manager, Regional Mental Health Services and
establishing a Mental Health Services Coalition to better manage the contracting and
co-ordination of mental health services and inform the planning across the three
DHBs in Auckland
 Action 2: Providing additional capacity for accommodation with intensive support
and crisis respite services
 Action 3: Allocating adequate funding to the three Auckland DHBs to provide the
required services
 Action 4: Ensuring all contracts and service specifications support the implementation
of an integrated ‘continuum of services’
 Action 5: Ensuring primary care practitioners are integrated into the mental health
continuum of services, through the implementation of the Primary Health Strategy
 Action 6: Establishing policy and service linkages between government agencies at
national and local levels.
The package of actions reflects a desire to work within existing arrangements. There were
persuasive arguments to establish a separate DHB specifically for mental health in Auckland.
There was also some support for one of the three DHBs to take overall responsibility for
mental health. However, another structural reconfiguration of services is not the preferred
option at this time.
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The process of finalising the action plan involved a number of steps as follows:

Initial actions developed by the Review were submitted in draft to the Chief
Executives of the three DHBs for comment (see Appendix 3 : Letter of Response
from Chief Executives , Auckland Region District Health Boards).

A draft report including a proposed action plan was submitted to the Minister of
Health.

The three Auckland DHBs were invited by the Minister to respond to the draft report
and the proposed action plan.

A response was received from the three Auckland DHB Chairs “generally supporting
Actions 2 through 6” but offering an alternative framework for co-ordinating and
managing services across the three DHBs.

Further discussion involving the Ministry of Health, the Mental Health Commission
and the three Auckland DHBs resulted in a reworked Action 1 that was acceptable to
all parties. Initially Action 1, as recommended by the Review, involved the
establishment of a Mental Health Agency as a separate legal entity to manage the
contracting and co-ordination of mental health services across the three DHBs in
Auckland. Concerns expressed by the Auckland DHBs about creating a new structure
and a belief that modifications to existing arrangements would achieve the desired
outcomes were taken on board and are reflected in the final action plan.
It is recommended that:
5.1
Action (1): Appoint a General Manager, Regional Mental Health
Services and establish an Auckland Regional Mental Health Service
Coalition to co-ordinate services within and across the three DHBs in
Auckland.
The Review has established that there is no coherent and co-ordinated system of
accountability for the provision of mental health services across metropolitan Auckland. This
has led to many providers not being able to function as effectively for service users as they
should. For service users it often leads to a sense that there is not a responsive “system”
willing and able to help. Without the appointment of a General Manager, Regional Mental
Health Services with the authority and accountability for overall service co-ordination and the
establishment of an Auckland Regional Mental Health Service Coalition, it is likely that
problems with service integration and fragmentation will continue.
The purpose of the proposed new role and the establishment of the Auckland Regional
Mental Health Service Coalition is to achieve maximum integration and co-ordination of
services within and across all three DHB mental health services in Auckland. It is also to
ensure a direct voice and active participation in regional funding decisions from the providers
and other important stakeholders in services, and to ensure that contracts are reviewed,
managed and delivered to achieve maximum integration of services for the service user.
The Auckland Regional General Manager Mental Health will report directly to the three
DHB CEOs. The General Manager will be a member of the Board of the DHB Shared
Service Agency and have overall delegated responsibility for the planning and funding of
mental health services in the Auckland region and the integration and co-ordination of service
delivery. This includes:
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
Reviewing existing contracts and services

Managing and monitoring contracts

Ensuring the delivery of a co-ordinated and recovery focussed continuum of services.

Ensuring the quality of services

Balancing the distribution of resources to ease pressure points, address service priorities
and respond to any shortfall in provider capacity.

Managing the implementation of regional plans and ensuring a consistent and coordinated approach to service development.

Managing the interface between primary, secondary and tertiary mental health services

Playing a significant role in workforce planning, including input to staff recruitment,
retention and training across the sector.
The General Manager, Regional Mental Health Services will also provide overall clinical
direction, leadership and oversight of the Auckland regional services.
The Auckland Regional Mental Health Service Coalition will have a suggested membership
from the three DHB Mental Health Service Managers, three NGO providers, three clinical
directors, two union representatives, three consumers, an alcohol and other drugs service
provider, and a primary health care representative. There will be someone employed in the
NDSA to provide organisational leadership and support to the Coalition.
The purpose of the Coalition is to promote an integrated continuum of services in
metropolitan Auckland. The General Manager, Regional Mental Health Services will use the
expertise of the Coalition to inform and provide oversight of all tasks required to achieve
service integration and co-ordination.
The Coalition will directly influence the work of the Regional Mental Health Funding and
Planning Team, through regular meetings and through their employed “leader”.
Appendix 9 presents a diagram of the proposed mental health structure and relationships.
Appendix 10 provides more detail as to the proposed responsibilities of the General Manager
and Service Coalition.
5.2
Action (2): Provide additional capacity for accommodation with
intensive support and crisis respite services.
The immediate task of the three Auckland DHBs will be to establish additional
accommodation with intensive support and crisis respite services. The Review confirms that
the provision of intensive accommodation and crisis respite services is inadequate for the
demand. This gap impacts on the capacity of acute services to manage the acute caseload.
Either DHB or NGO intensive accommodation services, or a mix of both, are needed. There
is also inadequate provision of crisis respite options, which can also place strain on acute
services. These options could include acute home-based treatment services and crisis respite
houses.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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If additional capacity for intensive accommodation and crisis respite services is not provided,
acute services will continue to be placed under an intolerable burden that will threaten their
sustainability. Residual goodwill between acute and other services will disintegrate, and
service users will not get the care they need.
Timeframe
The establishment and commission of more intensive accommodation and crisis respite
services should be a 2 stage process:
 Stage 1: the three Auckland DHBs should commission the provision of at least 20
packages of additional services, with either NGOs or DHBs. This work should start
immediately.
 Stage 2: General Manager, Regional Mental Health Services to commence planning
for additional accommodation with intensive support and crisis respite services for
implementation in 2003 – 04.
Costs
Subject to confirmation from the ringfence project, unspent money from 2001 – 02 (should
that be a finding of the ringfence project), along with Blueprint money for 2002 – 03, will be
allocated to funding the urgent intensive accommodation and crisis respite services. An
indicative cost is given by the DHBs in their reply to the Review’s draft actions (see
Appendix 3). The three Auckland DHBs should examine the funding requirements, taking
into account the findings of the ringfence project.
5.3
Action (3): Allocate adequate funding to the three Auckland DHBs to
provide the required service.
The current funding level has compromised the ability of the three Auckland DHBs to deal
with the demand for services, both in the short and longer term. The three DHBs and the
Ministry of Health must review and revise the present funding plans for mental health
services in the Auckland region. The Ministry of Health must then release the funding
necessary to provide the required services. The General Manager, Regional Mental Health
Services should be involved in any review of funding arrangements. The funding review
should address both short-term imperatives and the medium to long-term funding path.
Failure to address the funding will compromise the proposed continuum of services, with
continuing fragmentation of services, service gaps, and declining workforce morale.
5.4
Action (4): Ensure all contracts and service specifications support the
implementation of an integrated continuum of services.
Current contracts and their associated service specifications, together with the contracting
processes, inhibit integration, innovation and collaboration between providers. The lack of
regular service reviews, quality monitoring and the persistent rolling over of contracts
without review of the effectiveness of outcomes for service users has also contributed to
increasingly fragmented services.
It will be necessary to examine all contracts to ensure that services are properly linked to
secure an integrated continuum of services.
Specific tasks include:
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Region
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 Review of contracts and service specifications, including identification of
impediments to proper assessment, treatment and recovery.
 Establish and operationalise care pathways, likely to include pathways for older
people, young people, those who are new to mental health services, and those with
drug and alcohol addictions.
 A needs assessment to identify the best mix of components necessary to meet the
needs of people in Auckland with a serious mental illness.
 Establishment of an effective monitoring process to ensure that contracted services –
including quality and recovery requirements – are actually provided.
The Ministry of Health should assist the General Manager, Regional Mental Health Services
and his/her Funding and Planning Team with this action because of the implications for the
National Service Framework for mental health. It is a substantial piece of work in the
medium to long-term that will require dedicated resources.
5.5
Action (5): Ensure primary care practitioners are integrated into the
mental health continuum of services, through the implementation of
the Primary Health Strategy.
There are financial barriers to the development of sustainable primary mental health care
effectively linked to specialist mental health services as it contributes to an integrated
continuum of services. The planning process of the DHBs needs to more effectively engage
with primary health care providers and mental health services to ensure that primary mental
health services are developed and integrated with secondary and tertiary services in the
Auckland region. The General Manager, Regional Mental Health Services needs to establish
closer relationships between primary and secondary mental health services to support the
integrated continuum of services. A primary care practitioner needs to be included on the
Service Coalition.
The risks of not integrating primary care practitioners into the mental health continuum of
services are that secondary and tertiary services will continue to receive inappropriate and
unnecessary referrals that will lead to continued de-skilling of the primary care workforce.
Costs will increase as more secondary, and in some cases tertiary, services are required to
deal with those who could and should have been assessed as part of primary care. Service
users and families will continue to experience barriers to accessing timely and appropriate
mental health and general practice care.
This Action is planned for the medium term. The 2003/04 District Annual Plans (DAPs) for
the three DHBs should demonstrate progress on this matter.
5.6
Action (6): Establish policy and service linkages between government
agencies at national and local levels.
There is a significant gap in joint policy development and/or linkages across the various
government agencies that contribute to policy and planning for mental health services at both
the national and local levels. These agencies include the Police, CYF, HNZC, Work and
Income, and Immigration Service
If effective co-ordination among agencies is not established and maintained, policy and
planning inconsistencies will continue to prejudice the integrated continuum of services.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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Poorly co-ordinated policy development will continue to impact on service users and their
families.
The Mental Health Commission needs to incorporate into its monitoring evidence that DHBs
are maintaining local service linkages with these government agencies. The Ministry of
Health needs to ensure that any advice to Government by these government agencies must
include potential impact on mental health policy and services.
This Action is planned for the medium to longer term.
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Region
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References
Ministry of Health 2002-11-20
Atlas of New Zealand’s District Health Boards
Occasional Bulletin 13
Public Health Intelligence Group, Public Health
Directorate, Ministry of Health - Wellington
The Audit Office 1993
Report of the Controller and Auditor-General on
Community Care for People with Mental Illness,
The Audit Office - Wellington
Statistics New Zealand
2001 Census Snapshot 4 Maori, Statistics New
Zealand – Wellington
Statistics New Zealand
2001 Census Snapshot 6 Pacific Peoples,
Statistics New Zealand – Wellington
Statistics New Zealand
2001 Census Snapshot 15 Asian People,
Statistics New Zealand – Wellington
Mental Health Commission
1998 Blueprint for Mental Health Services in
New Zealand, Mental Health Commission –
Wellington
Ministry of Health
August 2002 Advice to the Incoming Minister of
Health; Background Briefing Papers, Ministry
of Health – Wellington
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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Appendix 1: Terms of Reference
The Minister has directed that this review look at the continuum of care for those with mental
illness – from primary and community interventions, through to in-patient mental health
services and provision of long term care in residential or community settings.
The Terms of Reference are:
1. The Mental Health Commission will undertake an independent review of the
continuum of care and services mix as funded by DHBs in the Auckland region
(particularly Waitemata, Auckland and Counties Manukau DHBs), which will inform
the Minister of Health on the actions that the Ministry of Health and the DHBs in the
Auckland region, whether collectively or independently, can take urgently to
significantly improve mental health care, over the medium and long term, to achieve
the standards set out in the National Mental Health Strategy, the Blueprint and the
National Mental Health Sector Standard.
2. As well as other factors influencing the continuum of care and services mix in the
Auckland region, the Review will consider:
 Governance and management (including financial management)
 Clinical practice
 Regional co-ordination of planning, funding and service delivery.
3. The Mental Health Commission will provide to the Minister:
 A report on progress with the Review by 30th June 2002 (which may include
recommendations for changes to District Annual Plans for 2002/03)
 A draft action plan by 30th August 2002
 A final action plan and Review report by 30th September 2002.
 The Mental Health Commission work with the support of the Ministry and
District Health Boards to achieve the outcomes required of the Review.
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Region
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Appendix 2: Members of the Review Team:
John Ayling
Project Leader
Dr Anthony Duncan
Deputy Director of Mental Health - Ministry of Health
Marion Blake
CEO – Platform
Wi Keelan
Chief Advisor, Maori Health - Ministry of Health
Margie Hamilton
Community Liaison Officer - Lakes DHB
Dr Margaret Southwick
Head of Pacific Studies – Whitireia Polytechnic
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Appendix 3: Letter of response from Chief Executives, Auckland
Region District Health Boards (3):
30 September 2002
John Ayling
MHC Review Team
Mental Health Commission
PO Box 12 479
Thorndon
WELLINGTON
Dear John
REVIEW OF AUCKLAND MENTAL HEALTH SERVICES
DRAFT ACTION PLAN
Thank you for the opportunity to review the Draft 7-Point Action Plan, and provide our
comments, these are outlined in appendix 1.
During discussions between the DHBs and the Review Team, you have signaled that the
Review Team will provide the DHBs with the draft report for comment, prior to its
submission to the Minister.
We look forward to receiving the draft report. We have prepared our own summary of key
messages we would, from our discussions with you, be expecting to be reflected in the body
of the report and have enclosed this document for your information.
As requested in a meeting between the review team and us the three Auckland Metro DHBs
have prepared a high level response to inform the MHC Action Plan. Included is a reference
to key regional projects (some currently in train) and additional initiatives and their estimated
value that could be implemented during the coming nine months to address the immediate
crisis (Appendix 2). We would anticipate wider consultation around these, and negotiation
with the Ministry of Health about their exact nature where additional funding to be made
available.
Key Messages
The Terms of Reference of the MHC review required the identification of “actions that the
Ministry of Health and DHBs in the Auckland region, whether collectively or independently,
can take urgently to significantly improve mental health care, over the medium and long term
to achieve the standards set out in the National Mental Health Strategy, the Blueprint and the
National Mental Health Sector Standards”.
The three Auckland Metro DHBs have agreed the following key messages which must be
made explicit in the body of the review report, and be reflected in any proposed Action Plan.
a) The key themes that have been identified as a result of this review reflect issues found
nationwide within the mental health sector
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b) The most significant issue that differentiates Auckland is the inequity of funding
against Blueprint benchmarks
c) An explicit funding path to equity is required and should be indicated in the Report
along with accompanying timeline
d) While we remain so far behind Blueprint Benchmarks the region does not support
changes to our current planning documents (Regional Mental Health Plan 2002/03,
local DHB strategic plans), or a reconfiguration of existing resources. Regional and
District plans for 02/03 arose out of careful consideration of the need to re-orient the
sector to a community model over time. This requires a long-term steady effort paced
to match the resources available.
e) There is a need to continue to strengthen regional funding and planning approaches
for the allocation of any new and additional funding, service development and
capacity building.
f) Stakeholder communication, engagement, and participation is actively supported,
with a commitment to build the capacity of the regional and local stakeholder
networks.
We look forward to receiving the draft report for comment.
Yours sincerely
SIGNED
SIGNED
SIGNED
Graeme Edmond
CEO ADHB
Stephen McKernan
CEO CMDHB
Dwayne Crombie
CEO WDHB
Copies to:
GM Funders
Mental Health Manager – NDSA
Mental Health Funding and Planning Managers – ADHB, CMDHB, WDHB
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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Appendix 1
Feedback on the MHC Draft Action Plan 20/09/02
The MHC has identified the following seven Action points in their draft action plan. The
Auckland DHBs have reviewed this draft and provide the following comments. The
following comments indicate proposed changes to the content of certain action points, and the
rationale for these.
Action 1:
To manage the fragmentation of mental health services by establishing across the three
DHBs a consortium of providers of mental health services for the effective management
and coordination of an integrated continuum of care.





We support reducing fragmentation in the sector,
If a new structure is proposed, the role, function, and mandate of such a structure would
need further clarification
The structure would need to have a limited lifespan and lines of accountability clearly
identified.
In order to further avoid duplication and fragmentation we would see such a structure
needing to be positioned as a workstream under the Regional Stakeholder Network who
hold a regional brief for input into planning and funding. Their brief could expand to
include overseeing a continuum of care within Auckland through the consortium.
We consider enhancing the existing structures to be the preferred option.
Action 2:
To make immediate arrangements to provide additional capacity in the provision of subacute rehabilitation services.


It is not explicit where any additional funding would come from for such services; - the
review team need to state explicitly in Action 2 that there is no current resource for these
services and that this matter is covered under Action 3.
DHBs are willing to work with the MoH to apply any additional funding to build service
capacity according to identified local and Regional DHB priorities as outlined in the
Regional Mental Health Plan and targeted at addressing Blueprint benchmark gaps
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Action 3:
To ensure that the three Auckland DHBs receive the funding necessary to provide the
required services



The wording of this action is open to misinterpretation.
We suggest a need to strengthen this action point to specifically state that there is an issue
re historical inequity of funding, and that additional funding from Government will be
needed to address the funding and equity issue.
It is important that there is no inference that this can be achieved through reallocation of
existing funds, but rather that a clear statement is made regarding the need for additional
funding as part of a clearly defined 3-5 year funding path to address historical inequity.
Action 4:
For there to be more effective provision of the core clinical community mental health
services (crisis, community and continuing care mental health teams) in Auckland.



We support this Action point, however, ask that the term “more effective provision of
services” is clearly defined in the Action Plan
That the Action Plan specifically recognises and outlines the need to build infrastructure
capacity to support service growth (e.g. quality monitoring, workforce development etc)
‘Rationale’ in Action Point 4. The statement is incorrect, we suggest that it be reworded
to accurately reflect DHB practice i.e. Blueprint funding is applied to new and additional
services to increase service capacity and to further develop the continuum of care.
Action 5:
To examine all contracts and service specifications for the purposes of ensuring that their
terms and conditions support the implementation of an integrated “continuum of care”

We support the approach and seek no amendment. This is a matter on which the MOH
should take leadership, with active engagement and participation from DHBs
Action 6:
To assess opportunities within implementation of the Primary Health Strategy for
primary care practitioners to be integrated into the mental health continuum of care.

We support the assessment of opportunities to improve integration with primary care
practitioners in line with the Primary Health Strategy and Primary Mental Health –
Review of Opportunities document.
Action 7:
To establish policy and service linkages by which Health, Housing, Police, Corrections
and other Crown Agencies such as Child, Youth and Family and Immigration,
communicate at regional and local levels.

We support this action and will actively encourage linkages with local and regional
stakeholder networks.
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Appendix 2
Current and Proposed Regional Actions
Auckland Metro DHBs Immediate Actions (July 02 – June 03)
The Northern Regional Mental Health Funding Team (NRMHFT) met with the sector
prepared a paper to the Regional Funding Forum (RFF) proposing that CCPS funding
underspend be applied to some one-off initiatives aimed at reducing some of the pressures
being experienced. The agreed actions are contained in Table One below.
It is important to note that these initiatives have been funded from 2001/02 “one-off”
underspend as an emergency response, and are time-limited. As a result there is no
sustainable funding pathway to allow the region to continue funding these initiatives. Any
continued delivery of these services will result in increased DHB deficit.
Table One: Immediate Service Actions
Activity/Service







DHB Location
Annual
ongoing cost
3 level iv rehabilitation packages of CMDHB
care
Additional Respite, Respite Coordination and Community based
services
$730k
Additional resources to acute ADHB
services
community mental health services
services and respite
$750k
Establishment of pre-assessment unit WDHB
for acute admissions,
additional resources to respite, crisis
team and inpatient nurses (general
and acute mental health)
$700k
Project worker to identify and 1 FTE to
develop options for accommodation Auckland
on discharge from Acute services, DHBS
link closely with Acute and Support
service reviews
cover One off
Metro nil ongoing
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Auckland Metro DHBs Proposed Short-term actions (July 02- June 03)
Seek a sustainable Mental Health funding path, identifying key issues in both the Review of
Acute Services and Mental Health ring fence review.
New services have been identified in the Northern Regional Mental Health Plan as part of the
2002/03 Blueprint funding allocation.
The identified service developments are the highest priority for the Auckland region
currently, and target those clients with the highest and most complex needs. Auckland DHBs
are committed to establishing these services as soon as Blueprint funding is received.
Immediate service developments
While most of the immediate focus is on building capacity within adult Community-based
clinical teams, there is still a need to invest in more Acute, Sub Acute and Intensive Support
Rehabilitation services that have a community focus or are community based. This is
consistent with points 2-4 of the Draft Action Plan and will strengthen the continuum of care.
Table 2 below outlines key additional services that could be purchased and operational in the
Northern region within a 6-9 month timeframe, should additional resource become available.
The three DHBs will ensure, as is with current practice, any additional resource would be
applied to the priorities identified and agreed to in the Regional Mental Health Plan, continue
to target Blueprint benchmark gaps, and are consistent with the regionally agreed principles
for funding and planning.
Table Two: Additional service options
Service/Activity



DHB location
Indicative
Funding
(annual)
New
required
– $2,000,000
4 additional ICU beds – Connoly ADHB
Unit. As part of the re-building regional access
programme, there will be extra
capacity to provide these beds,
but
currently no
funding
available to resource this.
5
Intensive
support
Rehabilitation beds, Pacific focus
(Proposed ADHB & NGO joint
venture)
Flexible packages of care for
people unable to leave inpatient
units but no longer requiring
inpatient care
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Service/Activity







DHB location
Reconfiguration of existing high WDHB
support services (19 beds to
subacute level)
Flexible packages of care for
people unable to leave inpatient
units but no longer requiring
inpatient care
Enhanced Crisis response
Continued funding of 5 Acute CMDHB
Inpatient beds existing but no
sustainable funding
4 additional sub-acute beds
Enhanced Crisis response
Flexible packages of care for people
unable to leave inpatient units but no
longer requiring inpatient care
Indicative
New
Funding
required
(annual)
$2,000,000
$2,000,000
Summary
Table 3 below summarises the total level of additional funding that would ensure
sustainability of current short term measures aimed at addressing the immediate problems
within Metro Auckland (see Table 1 above) and would allow implementation of the proposed
additional services (see Table 2 above).
Table 3 Summary of additional funding needed
DHB
Annualised ongoing funding Indicative
new Annualised
for existing one off services funding required Total
(Table 1)
for
proposed
additional service
options (Table 2)
ADHB
WDHB
CMDHB
$750K
$700k
$730K
$2,000,000
$2,000,000
$2,000,000
$2,750,00
$2,700,00
$2,730,00
Total
$2,180,000
$6,000,000
$8,180,00
In the 2002/03 financial year the cost of the additional services is likely to be less than the
amount shown in Table 3 above, since it will be part year costs only and since some CCPS
underspend has already been allocated.
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Key Projects
In addition to a number of potential service options as identified above, the Northern region
DHBs are committed to building a sustainable and robust mental health infrastructure via a
number of strategic regional and local projects. These projects will support the development
of a continuum of care, improved service delivery models, and provide for a more inclusive
and informed approach to the planning and provision of mental health services.
Auckland Metro DHBs Proposed Medium-term actions (July 03- June 04)
DHBs will continue to build on and invest in Local and Regional stakeholder networks to
ensure a robust process is developed to maintain active community engagement in funding
and service planning issues.
Within this context we aim to:










Implement Regional Mental Health Action Plan (seek early draw down on 03/04
Blueprint funding to apply to service and infrastructure development).
Revisit Blueprint targets in line with current levels of service provision, and
population needs, and align with 2001 census data.
Use this information to plan for 2003/04 Blueprint funding allocation (from MoH:
indicative Northern region allocation is in the $8 million range).
Implement Regional Maori Mental Health Action Plan
Implement Regional Pacific Mental Health Action Plan
Implement Regional Workforce Mental Health Action Plan
Move towards equity of funding and service levels in line with national Blueprint
benchmarks
Retain Mental Health Funding ringfence
Plan for the application of Future Funding Track (FFT) to ensure existing mental
health services are sustainable, within the context of deficit management
Reconfigure services to ensure they are being purchased on the most cost effective
and efficient manner (eg. Implementation of the recommendations from the National
Support Services Review)
Summary
This Work Plan goes some way to outlining regionally supported actions that will alleviate
pressure on Auckland’s adult mental health services in the short-to medium term if additional
funding is made available.
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Appendix 4: List of Meetings Held by the Auckland Review Team:
Organisation
Meeting held with
Acquired Brain Injury
Max Cavitt
Louise Armstrong
ADHD Association
Susan Hamp
Auckland Central Police
John Palmer (Acting Dist Commander standing in for Sup. Int Howard
Broad)
Graham Edmond, Chief Executive Officer
Roger Mysliwiec, Clinical Director, Eating Disorders
CAT Teams
RC Managers
Clinical Directors Mental Health Services (MHS) plus key staff
Barry Bublitz, Manager Maori Mental Health Services
Te Puea Winiata, Maori Advisor
Fionnagh Dougan, Manager MHS
Lorrima Cranstoun, Acting Manager Pacific Island MHS
Auckland District Health Board
Deirdre Mulligan, Manager Funding and Planning for MHS
Nick Argyle, Severe Personality Disorders
Eileen Swann & Dr Helen Cooney, Maternal MHS
Conolly Unit
Buchanan Clinic
Brenda Strathern, Kari Centre
Annette Shea, Taylor Centre
Auckland Hospital
Greg Funnicane
Awahitia Te Whanau Pani Trust (Bi cultural services – nurses)
Tarati Burkes
South Auckland Bipolar Support Group
12 members
Central Auckland Forum for Mental Health
Provider Forum
CEOs of the 3 DHBs
Stephen McKernan
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Organisation
Meeting held with
Dwayne Crombie
Graeme Edmond
Challenge Trust
Lina Samu
Consumer Strategy Group South Auckland / Counties Manukau
Child Youth and Family
Alan Newman
Mike Munnelly
Chinese speaking Psychiatrist
Dr Sai Wong
Clinician
David Cordye
Comprehensive Health Services
Dr Julian Roberts, Chairperson & Hugh Kininmonth, CEO
Auckland Consumer Network
Consumers from wider Auckland region - approximately 50 persons
Coroners Office
2 Coroners
Counties Manukau DHB
Ron Pearceson , Acting Chief Executive Officer
Ross Keenan, Chairperson
Debbie Sorrenson
Sue Hallwright
Dr Lyndy Matthews, Clinical Leadership Group / GP Liaison
Kelly Johnstone,
Dr David Hughes
Dr Margaret Aimer,
Dr Sylvia Van Altvorst,
Dr Michael Rimm,
Dr Verity Humberstone,
Dr Siale Foliaki,
Dr John Cosgriff
Hui at Tiaho Mai
ICT team representatives
Tricia Dore and 3 others
Management Group
Sylvia van Altvorst & Sharon McFarland, Maori Clinical Team
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Organisation
Meeting held with
Ian McKenzie, General Manager , MHS
Dr Murray Patton, Clinical Director, MHS
Staff forum
Shirley Frear and team, Maternal Mental Health Services
Counties Manukau Police
Superintendent Ted Cox and senior officers
District Inspector
Phil Recordon plus 2 non contracted providers
EastHealth (IPA)
Paul Cressey & Michael Clarke
Eating Disorders
Carol Drew
Elderly Persons Mental Services (3 DHBs)
Jill Calverly and others from 3 DHBs
Framework Trust
Jeff Radford
General Managers Mental Health Services for the three DHBs
Dave Davies, Ian McKenzie and Fionnagh Dougan
GP – Ex Physic Registrar
Neville Geary
Hapai Te Hauora Tapui Ltd
Regional Maori Consumer Network
Housing NZ – Community Housing
Paula Comerford, Blair Badcock and Rosemary Simpson
Integrated Primary Care Services
Alan Greenslade (GM)
Dr Lannes Johnson (Chair)
Korean Counsellor
Hyeeun Kim
Lotofale Mental Health Service, Auckland DHB
Lita Foliaki, Maliaga Erick, Ita Martin, and Peti Tevi
Malologa Trust
Leu Manea
Manaaki House, Auckland DHB
Maori Mental Health Forum
Leith Carter, Manager
20+ people
Mason Clinic – Forensic Unit, Waitemata DHB
Epa Auimatangi, Samoan Social Worker
Bruce Talbot
Charles Joe
Mason Clinic – Regional Forensic Services, Waitemata DHB
Sandy Simpson
Dave Davies
Mental Health Foundation – Youth Mental Health Network
Steering Committee (12 members)
Mind and Body Consultancy
Auckland DHB Consumer Advisor
Ministry of Health
Te Puea Winiata (plus others) Hui Te Atea Narino
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Organisation
Meeting held with
David Chaplow
Todd Kreible
Gina Lomax
Ana Long
Linda Jacobs
Janice Wilson
Kristan Johnson
NDSA – Regional Mental Health Team
Frank Tracey
Russell Graham
Deirdre Mulligan
Lindsay
Sue Hallwright
Pete Carter
Bram Kukler
North Shore / Waitakere / Rodney Police
Super Intendent Roger Carson, District Commander and senior officers
Northern DHB Support Agency Ltd (NDSA)
William Grainger, General Manager
Frank Tracey
Northern Region NGO Provider Groups – CEO Meeting
20+ people
Northern Regional CA and Reps Groups
50 + Consumer Advisors and consumer representatives
NZ Police, National Headquarters
Catherine Coates
Odyssey House
John Challis
Olders Person Mental Health Services
Lorrima Cranstoun and Representatives of the DHBs
Open Forum
Approximately 75 people
Order of St John
Peter Tranter (Director of Ambulance Operations and 3 operational managers
Others
David King
Pacificare
Kuresa Faleseuga
Pathways
Paul Ingle (GM)
Procare (IPA)
Dr Tom Marshall (Chair)
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Organisation
Meeting held with
Mark Wills (CEO), William Fergusson (Clinical), Mark Vela (GM MHS)
Professional Advisors / Leaders – 3 x DHBs
12 people
PSA
Richard Wagstaff and regional delegates – 30 people
Raukura Hauora o Tanui
Tanui Mapo
Winston Maniapoto
Di Moss
Refugees as Survivors
Patrick Jackson
Regional Alcohol & Drug Service, Waitemata DHB
Frances Agnew plus 8 people
SF Auckland
Mike Loveman
Field Workers
25 family members
SFWU
Duane Leo and 10 members
Starship
Michael Gudex + senior members of his team
Stewart Centre
Denis Denton
Tamaki Oranga, Counties Manukau DHB
Wayne Hussey
Te Ara Hou Mental Health Services
Breakfast meeting with NGO sector
Te Korowai Aroha
Barbara Anderson
Alistair Russell
Barbara Anderson
Carol Seymour
Te Kotuku Ki Te Rangi
Tipa Compain
Tihi Ora Maho
Temiha Cookson
UNITEC Institute of Technology School of Health Science
Ruth de Souza
Waipareira Trust
Reg Ratahi
Nelda Taurua
Mental Health Services
Manager of Wai Health & Social Services
Waitemata DHB
Dwayne Crombie, Chief Executive Officer
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Organisation
Meeting held with
Kay McKelvie, Chairperson
15 Consultant Psychiatrists
Pauline Hinds, Consumer Advisor
Vaoita Turituri & Dave Davies, Isa Lei
Timoti George & Dave Davies, Maori Mental Health Services
Paula Huxley, Maternal Mental Health
Senior Nurses
Professional Advisors
District Mental Health Services
Regional Alcohol and Drug Services
Regional Coordination Service
Regional Coordination Service
 Marcus Wells
 John Hopkins
 Amanda Bleckmann
 Mirella Allen
 Pauline Hinds
 Dave Davies
West Auckland Family Start Programme
Mary Watts
WINZ
Barry Fisk, Regional Commissioner
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland Region
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Appendix 5: Reference Group
Monica Cartner
Maxine Gay
John Tovey
Professor Graham Mellsop
Cindi Wallace
Kate Prebble
Robyn Priest
Fuimaono Karl Pulotu-Endemann
Kay Saville-Smith
Mental Health Commission
Bob Henare
Mary O’Hagan
Jan Dowland
Mark Jacobs
Sue Ellis
The Reference Group met three times during the review. Once at the early stages to provide
advice as to the review approach and twice to receive and comment on the initial findings of
the Review team. Once the draft report was submitted to the Minister of Health the
Reference Group had no further involvement in the process. The advice of the Reference
Group was not sought on the content of the final report or details of the action plan.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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Appendix 6: Briefing Paper – Maori Perspective
Review Of Mental Health Services
In Auckland Metropolitan Area
MENTAL HEALTH COMMISSION REVIEW TEAM
September 2002
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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Recommendation
It is recommended that: the Review team include the objectives allocated to: District Health
Board Funders and Maori Co-Purchasers, the Northern District Support Agency, and
Provider Services in the Action Plan for Maori, into the overall Action Plan for the Review of
Mental Health Services in Auckland Metropolitan Area.
1.
Introduction
The purpose of the briefing paper is to summarise the information in the Action Plan for
Maori, from the review of mental health services in Auckland metro. It will inform the
Mental Health Commission and the District Health Boards about the needs and aspirations of
Maori, as identified by key stakeholders in the Maori community.
2.
Background
A Review team has been established by the Mental Health Commission to undertake a review
of the care provided to those with mental illness by District Health Boards in the Auckland
metropolitan area. Maori quality and safety issues were not raised specifically during
instigation by the Public Service Association, however such issues are included in the
Commission’s brief to the Review team and this is entirely appropriate in view of the
significant Maori population in Auckland metro, as well, it is thought, the prevalence of
mental illness may be higher amongst Maori. It is well known that patterns of mental illness
are different for Maori9 and that since 1995, Maori rates of mental illness have increased,
while rates for Maori in a number of primary health problems such as heart disease and infant
mortality have declined10. It is known, Maori have much higher rates of presentation to crisis,
acute and forensic services than non-Maori and they are much more likely to suffer from
alcohol and drug disorders11.
3.
Current Situation
Auckland metro contains the highest concentration of Maori in the country, accounting for
12% of population (144,078). Current data analysis shows a disproportionately high use of
almost all District Health Boards, both local and regional mental health services, by Maori.
For example in Waitemata, Maori, 9.6% of the population, use: (44%) forensic, (35%)
regional co-ordination and (22%) of acute services12. In Auckland central, Maori, 9% of the
population, use (30%) and (89%) of intensive rehabilitation services at Buchanan clinic and
Manawanui respectively, and (23%) of acute services13. At Counties Manukau, Maori, 18%
of the population, use over (50%) of intensive care team resources, (30%) of secure long-term
rehabilitation and 24% of acute services14.
Te Puni Kokiri, Ministry of Maori Development, 1996. Nga Ia o Te Oranga Maori – Trends in Maori Mental
Health, 1984 – 1993, Wellington.
10
Durie M. 1997. Puahou: A five Point Plan for Improving Maori Mental Health. Maori Mental Health Summit.
11
MHC. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington:
Mental Health Commission.
12
Mental Health Information Service, Waitemata District Health Board, July 2001-June 2002.
13
Mental Health Information Service, Auckland District Health Board, July 2001-June 2002.
14
Mental Health Information Service, Counties Manukau District Health Board, July-August 2002.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland 65
Region
9
Maori suffer a greater burden of disease than non-Maori, even after eliminating variations by
age, gender, and socio-economic deprivation, they experience higher prevalence in most
disease groups, all these factors major predictors for greater use of mental health services15.
The development of mental health services for Maori by Maori has proceeded to the point
where there are now 16 contracted kaupapa Maori services in the area. Iwi relationships are
progressing with District Health Boards and Maori co-purchasers are in place to represent the
Treaty partnership. However, there are many gaps in services, and much work needs to be
accomplished by District Health Boards with their Treaty partners in appropriately leading
and planning mental health service for Maori, particularly with respect to:
4.

Building effective relationships with key stakeholders in the Maori community;

Establishing a comprehensive ten-year regional mental health strategy for Maori;

Over time, planning and purchasing local Maori mental health care continuums; and

Developing fiscally prudent objectives and long term plans for investing in kaupapa
Maori services.
Consultation
The Action Plan was developed in partnership with key Maori stakeholders represented in the
Te Kotahitanga Maori Mental Health Network and the Maori Advisory Group. Other
individuals and groups from regional and local funding and provision services of the District
Health Boards participated in the review, as did many non-government organisations.
5.
Implications For Maori
Currently, the Maori population structure is much younger than non-Maori. In 1996, the
Pakeha 0-14 cohort accounted for 18.2% of their total population as opposed to 37.5% for
Maori aged 0-14 years. Over the next 20 years Auckland metro will experience the largest
growth in Maori up 61,200 or 46% on 1996 census figures. This means that District Health
Boards will require an effective regional mental health strategy, to eliminate health disparities
for Maori.
What resource is required to build an effective mental health service continuum for all people
in Auckland metro? Difficult to answer at this time, particularly for Maori, because a module
for them has yet to be been determined, and having accomplished that, we will still need to
identify, how the module sits inside a generic mental health care continuum.
Mental health services do not appear to have been purchased using a comprehensive quality
continuum of care approach. Instead, much of the focus for purchasing services has been in
accordance with the “Blueprint.” benchmark of 3%, for those with serious mental illness. For
Maori, this has resulted in many small fragmented and stressed kaupapa Maori services,
scattered throughout Auckland metro. It is the Review teams contention that, continuing
topping up toward 3% without proper regard for constructing an appropriate and effective
mental health care continuum, would be throwing good money after bad!
There was a suggestion that there is too much emphasis on the 3% with serious mental illness
and not enough on the 17% who currently use ineffective primary health services. This was
described as “ the ambulance at the bottom of the cliff”. There is strong support by Maori for
15
Ministry of Health 2000. Social Inequalities in Health: New Zealand 1999. Wellington. P 12.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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a more preventive model and a suggestion that the wide-ranging inter-sectoral services
similar to Wai-Health be closely looked at as their preferred model for future Maori primary
health organisations.
It should be noted there is nothing new or outside of what would be regarded as core business
for the District Health Boards requested in the Action Plan for it is based on current
Government policy. These are all actions that they should be carrying out already with
respect to providing effective services for Maori.
There is an expectation that the Ministry if Health will fund and then monitor the Action Plan
for a minimum of two years and that all District Health Boards in Auckland metro will
include the actions in their regional mental health plan.
6.
Maori Needs and Aspirations
Throughout the review Maori people voiced their needs and aspirations for the future. They
said, District Health Boards need to:
7.

Recognise and acknowledge the principles of the Treaty and incorporate them into all
aspects of mental health service planning, funding, provision and evaluation;

Recognise that in order to diminish inequalities in mental health it is imperative that
Maori are given opportunities to lead, plan, and monitor services for Maori;

Enable Maori co- purchasers and Maori communities to develop and implement
whanau strategies for health improvement and Maori provider workforce
development.

Support Maori co-purchasers and Maori providers in the development of appropriate
outcome measures for whaiora and whanau health and well being.

Develop fiscally prudent objectives and long term plans for investing in kaupapa
Maori services.
The Action Plan for Maori
The Action Plan is framed to identify, allocate and timeline accountabilities to the
organisations who have responsibility for funding and providing mental health services.
7.1
District Health Boards Funders and Maori Co-Purchasers
The planning and funding mental health managers employed within individual District Health
Boards are responsible, alongside Maori co-purchasers, for the planning and funding local
mental health services. In order to carry out the role effectively, they must:
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7.1.1 Building Capability and Capacity
(Timelines are indicative only, as Auckland metro District Health Boards will have to
consider these actions alongside their existing regional mental health plan).
Objective
Year 1 Milestone
With, Maori co-purchaser develop and
implement Treaty of Waitangi
Responsiveness framework in all planning,
funding services of the District Health
Boards.
April 2003
With, Maori co-purchaser develop plan for
improving accuracy and appropriateness of
collection of Maori health information.
May 2003
Cost
With Maori co-purchaser develop explicit
quality requirements including clinical and
cultural outcome measures for all kaupapa
Maori contracts and mainstream contracts
involving the provision of care to Maori
whanau.
Year 2 Milestone
July 2004
With Maori co-purchaser establish a
managed and regular programme for
monitoring and evaluating mainstream and
Maori provider effectiveness in meeting
Maori needs.
August 2004
With Maori co-purchaser Commission an
independent review of the capacity and
capability of Maori co-Purchaser to
provide appropriate planning, funding and
contracting processes for all kaupapa
Maori services.
October 2004
With Maori co- Purchaser develop fiscally
prudent objectives and long term plans for
investing in kaupapa Maori services.
November 2004
7.2
Cost
Northern District Support Agency
The Agency is responsible for funding mental health services. In this role it co-ordinates,
analyses and project manages for the range of processes that require regional collaboration.
Its work is central to improving Maori mental health gain.
7.2.1 Building Capability and Capacity
(Timelines are indicative only, as Auckland metro District Health Boards will have to
consider these actions alongside their existing regional mental health plan).
Objective
Year 1 Milestone
Develop guidelines and policy for
communicating with iwi, and other Maori
stakeholders in Auckland metro.
October 2002
Establish Maori Mental Health Advisory
Group to the Northern District Support
Agency.
October 2002
Cost
Year 2 Milestone
Cost
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Objective
Year 1 Milestone
Investigate and action regional funding
inequities:
April 2003

Level 4 residential prices

Maori provider contracts with respect
to lack of increases to keep pace with
inflation.

Disparity in price between
mainstream and Maori provider FTEs.
Develop intersectoral regional
relationships that will positively affect
Maori health outcome.
Cost
Year 2 Milestone
May 2002
With Maori co-purchaser develop a tenyear Maori Mental Health Strategy.
August 2004
Develop a regional Risk Mitigation
Strategy for whaiora currently residing in
“unregistered Boarding Houses” in
Auckland metro.
September 2004
7.3
Cost
Provider Services
Non-government and mainstream providers, including Maori should organise their services
around the structures and needs of whanau, hapu and iwi.
7.3.1 Building Capability and Capacity
(Timelines are indicative only, as Auckland metro District Health Boards will have to
consider these actions alongside their existing regional mental health plan).
Objective
Year 1 Milestone
Establish plan to build appropriate
relationships key Maori groups and other
providers of mental health services.
October 2002
Develop and implement systems for
improving collection of accurate Maori
data.
February 2003
Develop and implement Treaty of
Waitangi Responsiveness Framework
March 2003
Develop appropriate tool for assessing
Maori whaiora satisfaction with the
service.
June 2003
Cost
Year 2 Milestone
Establish a policy and process for working
with relevant intersectoral agencies.
July 2004
Establish plan to develop and introduce
clinical and cultural outcome measures of
service.
August 2004
Identify Maori health workforce
development needs and provide plan to
resource Maori staff recruitment, retention
and development.
September 2004
Cost
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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8.
Risk Management
There are inherent risks for Maori in the health sector. The table below contains an analysis
of perceived risks from the Maori perspective that are covered in the Action Plan.
Description of Risk
Mitigation Factor
1.
Failure to achieve appropriate relationships with key
Maori stakeholders.
Boards have appropriate partnerships with iwi.
2.
No “buy in” from regional Maori community to
health planning.
Northern District Support Agency has appropriate Maori
representation on its Maori advisory group.
3.
Inadequacy of information technology systems
collection of appropriate Maori data.
Implement Maori Information System Project within the
Information Strategy of District Health Boards.
4.
Shortage of skilled Maori Workforce.
Develop local Maori workforce planning initiatives.
5.
Quality failures.
Funders build robust relationships with kaupapa Maori
services.
Funder and provider services have appropriate
relationships: with Maori co-purchasers, and Maori
providers, and adopt Treaty principles in working with
Maori.
Funders and providers, develop Quality Plan including
long-term plan for measurable clinical and cultural
outcomes.
6.
No capacity building occurring in the Maori
community.
Develop Intersectoral Strategy.
7.
Untoward community incidents.
Assess needs of whaiora including those in “unregistered
accommodation”.
8.
No “Closing Gaps” between Maori in mental health
services and other New Zealanders.
Include specific performance expectation in services
agreements and contract for whole systems that will
produce the desired results.
Identify Maori Provider Development plan.
Monitor all providers against those expectations.
Develop fiscally prudent objectives and long term plans
for investing in kaupapa Maori services
Bibliography
1. Te Puni Kokiri, Ministry of Maori Development, 1996. Nga Ia o Te Oranga Maori- Trends in Maori Mental
Health, 1984-1993. Wellington: Te Puni Kokiri.
2. Durie M. 1997. Puahou: A Five Point Plan for Improving Maori Mental Health. Maori Mental Health
Summit.
3. MHC. 1998. Blueprint for Mental Health Services in New Zealand: How things need to be. Wellington:
Mental Health Commission.
4. Mental Health Information Service, Waitemata District Health Board, July 2001-June 2002.
5. Mental Health Information Service, Auckland District Health Board, July 2001-June 2002.
6. Mental Health Information Service, Counties Manukau District Health Board, July-August 2002.5.
7. Ministry of Health 2000. Social Inequalities in Health: New Zealand 1999. Wellington. P 1
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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Appendix 7: History of the delivery of mental health services
Deinstitutionalisation
Twenty-five years ago the majority of mental health services in the Auckland region were
delivered from hospitals that provided inpatient facilities and attached outpatient clinics.
Acute short term hospitalisation was provided at the three major psychiatric hospitals:
Carrington, Oakley, Kingseat, and Ward 10 at Auckland Hospital. Longer term treatment and
residential support for service users were provided within the longer term inpatient units at
the psychiatric hospitals.
Key factors that resulted in the move away from residential care in large psychiatric hospitals
were:

The international development of community based mental health care, both to support
services users in their own home environments, and to intervene before people become
significantly unwell.

Changed views on the rights of people with disabilities, including psychiatric disabilities,
and a growing recognition that they have a valid place in society

Changes in the way mental illness is managed. Newer medications mean that symptom
reduction and elimination have become practicable for an increasing number of service
users.

Increasing attention to the roles of demoralisation, the secondary consequences of having
a mental illness including "institutionalisation", stigma and discrimination, in
perpetuating chronicity of mental illness.
Despite the necessity for deinstitutionalisation in Auckland, there is evidence that it
precipitated wide ranging and on-going funding problems. For example, the
deinstitutionalisation programme at Carrington coincided with a breakdown in management
structures within the Auckland Area Health Board, resulting in the process being poorly and
hurriedly executed16. People were discharged to alternative residential accommodation before
appropriate support services were set up in the community. Approximately $18 million
earmarked to provide some of the community support facilities was not ringfenced and
consequently some community services never eventuated. Furthermore, plans to provide
services for people with serious mental illnesses already in the community, including
supported accommodation, were never fully implemented or funded. Thus one of the key
foundations on which current mental health service provision is built in Auckland was
underfunded and seriously flawed in terms of planning for service provision.
Longer-term service users who had previously lived in a psychiatric hospital have
experienced particular difficulties with the move to community-based services. In hospitals,
longer-term service users had free and direct access to a range of services such as dentists,
general practitioners, physiotherapy, recreational and social activities. Cost for provision of
these services does not appear to have been transferred to funds for care in the community.
Recent service descriptions have not included the requirement for providers to fund all such
services. Service users have had to rely on additional support through the benefit system for
services that were formerly free. Accessing and negotiating such support places particular
stresses on those with multiple problems.
Auditor General's Report on the closure of Carrington Hospital – full reference needed. The Audit Office
1993 Report of the Controller and Auditor-General on Community Care for People with Mental Illness
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
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71
The types of accommodation provided for service users have also seen considerable change.
Funding for residential services was transferred from Social Welfare to Health in 1995.
Initially, many of the residential homes were established as “homes for life,” but now
residential services are provided for people who need them for as long as they need them,
with the expectation that most people will move to more independent living situations. Since
1995 funders have funded more supported housing at levels 3 and 4 while exiting levels 1 and
2. In addition, more community support services have been funded to support people in their
own homes. The newer, antipsychotic medications available have made independent living a
reality for more people.
With the shift in funding of residential services from Social Welfare to Health, only the
funding for people living in registered homes and who were receiving maximised benefit
payments through the Community Funding Agency was transferred to Health. A number of
accommodation providers who were registered under the DPCW Act but were not funded by
the Community Funding Agency, were not contracted under the new regime. However, the
so-called ‘non-contracted’ providers (such as boarding houses) provide the accommodation
for a significant number of mental health service users and many believe that because they
meet the current registration standards they should be funded by Health. To comment on the
validity of their individual claims is clearly outside to scope of this review, however their
contribution to care provision does need to be acknowledged.
The move to people with psychiatric illness living in the community has meant that most are
now directly reliant on government income support through the benefit system. They face a
range of issues including a lack of additional benefits for people with a psychiatric disability
living in community accommodation, and the impacts of benefit abatement rates on part-time
work.
The contracting model
The present purchasing arrangements are a carry-over from the era of the ‘funder/provider’
split. Since 1993 health services have been typified by the separation of ‘funders’ and
‘providers’ whereby services have been specified (and in many cases priced) by the ‘funder’
and then provided by a ‘provider’. A contract has been the means by which the interests of
both are managed.
A characteristic of the separation of funder from provider was competition between providers
(particularly NGOs) for the provision of specific components of the service according to
contract specifications.
Increasing demands for a wider range of services
Over the last thirty years there have been growing expectations that mental health services
will manage a wider range of conditions than before. The move into the community has
meant that the potential coverage of mental health services has been seen to be much wider.
Thus while there has been more money going into mental health services, at the same time
there have been increasing demands on mental health services to do more with it.
Rapidly changing and diverse social conditions have placed increasing demands in mental
health services. A massive upsurge in the use of illicit drugs, particularly marijuana, along
with complex combinations of major mental illness, substance abuse, and personality issues
have also exacerbated demands in both the range and extent of services.
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Consumer advocacy
Advocacy by an increasingly political service user movement in Auckland since 1987 has led
to calls for more responsive and less paternalistic services. There are a number of service user
run services in Auckland, as well as the desire to provide service user run alternatives to
services such as acute services.
Alongside these changes has been the advocacy of a recovery approach particularly through
the Mental Health Commission Blueprint and subsequent publications such as the “Recovery
Competencies for NZ Mental Health Workers”. These have been reinforced by recovery
workshops for both service users and staff especially in one of the DHBs. The Consumer
Advisors in that DHB report that the impact of these workshops has been to significantly
change the culture within services and attitudes of clinicians with direct benefits to service
users.
The Mental Health Act
The passage of the Mental Health (Compulsory Assessment and Treatment) Act in 1992
brought with it a number of fundamental changes to the way compulsory assessment and
treatment for service users with mental health disorders were managed. Major changes were
the requirement that people be cared for in the least restrictive environment possible, and a
focus on the protection of individual rights. Clinicians are required to formally review a
service user’s/tangata whaiora need for compulsory treatment at prescribed intervals. District
inspectors appointed by the Ministry of Health have wide powers and have a role to ensure
service users’/tangata whaiora rights are upheld. There are key linkages with the Justice
system, including Family Court Judges and with the Police.
Some sections of the public and media see the Act’s focus on the individual rights of service
users as directly conflicting with society’s need to be kept safe. There is a perception that
people with mental illness have a higher risk of violence than any other members of the
community. The infrequent but often sensationalised violent incidents concerning mental
health service users have often created a climate of fear in the community, and calls for
secure psychiatric institutions. Community care, appropriately resourced and managed,
provides adequate safety for the community. It is also clear that for the vast majority of
service users it provides a much better quality of life.
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Appendix 8: Expenditure Current and Guideline by DHB, as at 30/6/2002
New Zealand
$M 2001/2
$675
NORTH
Northland
Auckland Total
Waitemata
Auckland DHB
Counties Manukau
MIDLAND
Waikato
Bay of Plenty
Lakes
Taranaki
Tairawhiti
CENTRAL
Hawkes Bay
Whanganui
Manawatu
Hutt
Capital and Coast
Wairarapa
SOUTH
Nelson Marlborough
Canterbury
West Coast
South Canterbury
Otago
Southland
$241
$25
$217
$88
$78
$51
$127
$63
$25
$14
$16
$7
$138
$19
$14
$22
$20
$57
$6
$168
$18
$84
$8
$6
$39
$13
Total Funding 2001/02**
%Blueprint
Population*
65%
3,862,506
58%
57%
58%
64%
67%
42%
58%
67%
46%
49%
59%
58%
73%
57%
92%
56%
66%
94%
67%
76%
59%
78%
110%
51%
95%
56%
1,371,132
146,446
1,224,686
442,256
391,684
390,746
761,764
329,175
180,842
100,268
104,844
46,635
801,442
146,911
67,000
161,585
136,271
251,376
38,299
928,168
122,089
437,851
32,407
53,713
176,733
105,376
$M/100000
17.49
$M
$1,047
17.61
16.77
17.71
19.83
20.01
12.99
16.71
19.09
14.08
13.99
15.62
15.56
17.25
13.20
20.76
13.43
14.91
22.73
15.01
18.15
14.66
19.21
25.24
11.25
22.07
12.52
$417
$43
$373
$137
$116
$120
$219
$94
$56
$29
$28
$13
$189
$34
$15
$39
$31
$61
$9
$223
$30
$108
$7
$12
$41
$24
Total Funding Blueprint Guidelines
Population*
$M/100000
4,134,965
25.32
1,556,893
156,574
1,400,319
512,122
441,309
446,888
804,466
346,454
206,120
105,060
101,532
45,301
813,868
147,354
64,354
168,046
134,104
262,638
37,371
959,738
130,712
468,200
31,567
51,573
176,499
101,187
26.75
27.50
26.67
26.73
26.39
26.88
27.23
27.20
26.97
27.45
27.37
27.76
23.19
23.08
23.48
23.18
23.05
23.24
22.83
23.19
23.22
23.13
23.54
23.07
23.26
23.23
* Populations are from 1996 Based DHB medium population projections projected to 2001 and 2010.
**Note many regional services have been allocated to a lead DHB within the region rather than geographically spread
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Appendix 9: Revised metropolitan Auckland Mental Health Structures and Relationships
Revised Metropolitan Auckland
Mental Health Structures & Relationships
WDHB
ADHB
CMDHB
NDHB
Client of NDSA
NDSA Board
WDHB-CEO, ADHB-CEO, CMDHB CEO,
3 DHB GMs F&P, ARGM - MeH
Auckland Regional GM Mental Health*
Regional MH Funding
& Planning Team**
Regional MH
Service Coalition***
Local network
Proposed membership
Leader
3 DHB MH Service Managers
3 NGOs
3 clinical directors
2 Union reps
3 consumers
1 AoD
1 primary care rep
Local network
Northern Region MH & Addiction Network
Local network
NDSA, Planners, Funder, Local networks consumer, Maori, Pacific, older people,
alcohol and drugs, primary care, unions, DHB managers, clincinal directors
Local network
*responsible for Auckland Regional MeH budget, contracting and clinical direction
**3 MeH Funding and Planning Portfolio Managers & NDSA MeH team
*** coordinating body on service coordination, service/contract distribution
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Appendix 10: Mental Health Structures and Relationships
1. General Manger, Regional Mental Health Services (GMRMH)
Primary responsibility:
To ensure the provision of a co-ordinated mental health service and
a seamless continuum of care for service users in metropolitan
Auckland.
The GMRMH will be required to oversee the development of the regional strategic and
annual plans and be responsible for the distribution of funds through suitable service
contracts. In carrying out this work the GMRMH will seek advice from the Auckland
Regional Mental Health Service Coalition to ensure co-ordination of a regional system of
services. The GMRMH will have a role of ‘clinical’ oversight to assist with the co-ordination
of inter-district admission, discharge and transfer. The GMRMH will be gazetted as a
DAMHS for the three districts.
The GMRMH will be accountable to the CEOs of Auckland, Waitemata and Counties
Manukau DHBs and will be a full member of the NDSA Board.
2. Planning
The planning team will be required to prepare the regional mental health plan. This plan will
inform the district strategic and annual plans of each DHB. The regional plan must be
informed by the Auckland Regional Mental Health Service Coalition. The planning team
will be responsible for advising on the allocation of funds across the service continuum.
The planning team will also work with each DHB to ensure co-ordination with the DAP
process and alignment with other services (eg primary care).
3. Auckland Regional Mental Health Service Coalition
The Service Coalition will comprise representatives of providers, both private and public,
together with union, consumer and clinical representation. Its responsibility will be to
coordinate all services within metropolitan Auckland taking into account service user need
and include balancing resources, both clinical and support resources, ensuring quality
provision, determining service requirements and advising adjustments to service contracts to
achieve improved outcomes. The Service Coalition will also be required to assist with
capacity building and to encourage alliances to obtain more effective and efficient service
provision.
4. Contracting
The existing NDSA has considerable contracting experience and it is envisaged that that
expertise will be used in terms of document formulation, general administration and
monitoring against specifications. Contracts will be constructed to enable adjustments to be
made during the tenure of the contracts. This will be important during the early stages of
development.
5. The Regional Mental Health System
To place the change in perspective, the mental health services in Auckland will be viewed by
the GMRMH as a system of providers and service users. This means that providers will need
to work collaboratively in pursuing system-wide objectives that promote pathways to
recovery for individuals with mental health problems. The GMRMH will be responsible for
the leadership of this vision.
Review of the Continuum of Mental Health Services Funded by the District Health Boards in the Auckland
Region
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