Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 8 - Evidence - May 5, 2004 - Evening meeting
OTTAWA, Wednesday, May 5, 2004
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 7:00 p.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the Chair.
[English]
The Chairman: Hello, I am Mike Kirby, the chair of Standing Senate Committee on Social Affairs, Science and Technology.
Thank you very much for coming for this teleconference. I know you have been told about the study that we are undertaking. We are in the relatively early stages of it.
In addition to talking to a wide number of Canadian groups, we have selected four countries to understand what they have done. We have selected New Zealand because we have heard such very positive comments on many of the changes that you have made in the last decade or so. We are interested in trying to learn as much as we can to see if we can implement some of your ideas here. There is no sense in reinventing the wheel.
I will tell you in advance that we are beginning way behind you. We do not have, nor have we ever had, a national mental health policy in Canada. There is no national mental health legislation. Although some of the provinces have mental health acts, they are substantially outdated. The notion that we are to begin to look at mental health and addiction as part of the overall health care system is a concept that many people in the health care sector would agree is needed. Frankly, governments have been way behind in taking action in this field, which is not to say that we do not have some form of mental health system. Obviously, we do.
However, there is no national coordination or national policy. The policy at each of the individual provincial levels varies extraordinarily across the country. It varies enough that interprovincial data comparisons of systems performance are just not possible.
We are very much at the embryonic stages. We are only starting a process of determining how to attack the mental health and addiction problems from the perspective of the national government. I give that as background so that you understand either the complexity or the simplicity of the problem we are dealing with. The problem is complex but where we are is extremely simple because we are nowhere.
We are delighted that you have taken the time to be with us. It has been suggested that Ms. Wilson, the deputy director general, make an opening statement or series of opening comments. Ms. Wilson, please introduce for our record introduce your colleagues. If they want to make some additional opening comments also, that is fine.
We will then turn to a series of questions.
Ms. Janice Wilson, Deputy Director General, Mental Health Directorate, Ministry of Health, Government of New Zealand: Honourable senators, thank you for asking to meet with us. We are honoured that you have asked us to engage in this dialogue. As you know, we are a much smaller country than you are and our systems are somewhat different. It will be a very interesting interchange with about what we are doing and determine what you are doing and what your challenges are.
I will ask my colleagues to introduce themselves and speak about their role.
Mr. David Chaplow, Director and Chief Adviser of Mental Health, Government of New Zealand: Honourable senators, the core part of my work is to administer the Mental Health Act and some three or four other acts on behalf of the government and to be a conduit between the sector and the government.
Ms. Phillipa Gaines, Manager of Systems Development of Mental Health, Government of New Zealand: I am principally concerned with the use of information in terms of informing monitoring progress, service development. I also look at integration of services using information sets.
Ms. Arawhetu Peretini, Manager of Maori Mental Health, Government of New Zealand: Some of the portfolio areas that fall under my section cover more than indigenous issues; they cover issues such as alcohol and other drugs. On July 1, we also incorporated problem gambling services to the addictions string that we are looking at and data on forensic services.
All of us at this table are involved in workforce development as well. Those are some of the key areas on which the team that I manage focus.
The Chairman: Please proceed, Ms. Wilson.
Ms. Wilson: I did wonder whether you might find it useful to look at our presentation. We have done a number of presentations internationally on the New Zealand mental health system.
The Chairman: Yes, we would.
Ms. Wilson: I am quite happy to start. I understand that the technical people have managed to get it sent to you so you will be able to see it as we go along. We will stop from time to time just so that you can ask questions.
I will start with the configuration of New Zealand and provide some of our demographics and explain the health structure because you need to understand the context to make any sense of the mental health policy environment.
You probably know that there are four million New Zealanders. We have 10 times more sheep in our country than people. About 75 per cent of the country is urban and the rest is rural. About 80 per cent of the population is European, mostly as a result of immigration from the U.K. That is much the same as Canada, I expect. About 15 per cent of our population are indigenous Maori, about 6 to 7 per cent are from the Pacific islands and about 5 per cent are Asian immigrants. That is our demography.
Our Parliament is fairly similar to that of the United Kingdom. We are based on the British system, except that we have proportional representation form of government. We have a mixed member party with a three-year cycle of government. Our economy is predominantly agricultural based. Our GDP growth was about 3.2 per cent compared with the OECD average of 1.3 per cent. Our unemployment rate is currently running at about 4.7 per cent.
We have had a universal health system since about 1938. It is a bit like the National Health Service in the U.K. Canada has a universal kind of national insurance system so it is different from your system in respect of funding.
However, our system is not totally funded. There are some co-payments for pharmaceuticals, laboratory pharmacology, radiology, et cetera. The only difference to the United Kingdom is that the primary health care system has not been universally covered but has had targeted funding on the basis of income and on chronic illness. Last year, or the year before, a primary health care strategy was launched that progressively over the next five to 10 years build up that universal payment until it covers about 80 per cent of the population.
These new primary health care organizations will eventually cover 80 per cent of the population. This is important because we have not had good mental health coverage in the primary health care sector. In that respect, we are different from some other countries. We have had a significant amount of development in the secondary or specialist area of mental health care delivery but not necessarily in the primary health care sector. We also have a special kind of no-fault accident compensation scheme that is public funded and covers accident and trauma. It covers mental illness where it is associated with a physical accident or trauma.
Our total Vote Health is about 8 per cent of GDP. That is a kind of comparison but I do not have the Canadian data here because this was done for another purpose. I will quickly go through that. That figure is used when we compare ours with yours on this graph.
We have had a decade of health reform. Currently, our system has a central ministry of health. Our health care is funded through 21 district health boards that also provide a significant quantity of hospital and community services. This is based on a health and disability strategy and, as I said, on a primary care strategy. The majority of the district health board members are elected by their local communities every three years. Most of our mental health services are either organized or funded through these district health boards.
We have little private practice in New Zealand. Our first national mental health strategy was launched in 1994 and we are currently in the process of doing the second 10-year plan for that. As a result of deinstitutionalization in the last decade, we have no stand-alone psychiatric hospitals. Rather, we have a total community-based health care delivery.
We have an organization called the Mental Health Commission, which was formed after a major inquiry in 1996. It is an independent body appointed by government to actually monitor mental health and, particularly, to monitor the implementation of the strategy — the progression and the development of mental health service delivery. To date, our strategy has been focused on about 3 per cent of the population who, as you may know from epidemiology studies, have the most severe illness.
By the early 1990s we had 10 stand-alone psychiatric hospitals. We have had quite rapid growth — particularly of community mental health services. We have now moved to a much more comprehensive range of services based in general hospitals and in the community with a large non-government sector — predominantly non-profit — that provides much of the community support and residential services in the community.
I am showing the committee a diagram of our position. The ministry has the oversight for policy regulation and monitoring. District health boards are responsible for funding and delivery and also for funding primary health care and the NGO community. The Mental Health Commission monitors all of us.
Of interest to the committee is that since 1993 we have had an increase in funding for mental health services of close to 150 per cent. That figure is discounted for inflation, et cetera. We have had a commitment from the current government to continue the funding stream at this rate until at least 2007 because we have not yet completed all of the reform agenda.
Mental health funding is split such that about 70 per cent is spent on community services, which also include the NGO component, and about 30 per cent on in-patient services. That tells you something about the strategies and plans that we developed through the 1990s, including for Maori health, for child and youth, alcohol and other drugs, and workforce development.
The strategy in 1994 was predominantly focused on deinstitutionalization so that people were moved out of the large institutions to change the way of mental health care delivery. There was very active participation of consumers and families in this drive. The next graph shows senators how the number of beds in New Zealand has declined from the 1970s, with a faster rate of decline through the 1990s. It has steadied off now because we have a reasonable balance of in-patient hospital beds, residential beds in the community, and other community services.
I wonder whether it might be best to just stop there for the moment as this might be a good point for a bit of an interchange.
The Chairman: Ms. Wilson, you started your first national strategy in 1994. What were the motivating political or public factors? There must have been a trigger, or set of triggers, that prompted the development of a national policy. This may sound simplistic, but what put it on the national agenda? It has not made it to the national agenda in Canada, yet.
Ms. Wilson: People had been moving patients out of psychiatric hospitals slowly for some years. There was growing concern in the community and at the government level that there was no policy framework in place to guide this. It was being pushed along by strong providers, psychiatrists, nurses, consumers and a growing consumer movement. Although it was by and large being done relatively well, it was not being supported financially, nor was there any formal structure. Of course, there was some anxiety in the community about people leaving psychiatric hospitals and living in their communities. However, the main thrust of the policy at that time was to get a framework around what is called deinstitutionalization.
The opportunity was taken, though, not to focus on deinstitutionalization, but to talk about adequacy and what one needs to have a range of services. What makes an adequate mental health service or system? What is required for the community to feel confident that their mental health needs are being met? That was the perspective that the policy framework took.
The Chairman: Is it fair to say that, with deinstitutionalization underway, the public policy emerged as a result of concerns about the consequences of that for the rest of the community. That, in turn, led to a decision to develop a policy that, among other things — and we will talk about communications and removing stigma in a few minutes — would make the community more comfortable with the policy of deinstitutionalization?
Ms. Wilson: That was part of it. It was also partly driven by questions relating to the evidence about best practice in respect of a health service. How do you actually deliver the best mental health service that meets people's needs? Best practice internationally was certainly telling us that this needs to be much more community-based and integrated into other health services. It needs to take a more whole-of-government approach, linking with other sectors such as housing, employment, labour and so on. That became the focus.
Senator Kinsella: As you went through the process of creating community-based mental health delivery systems, what kind of quantifiers were you able to identify in terms of the cost and the amount of public resources to put into the community-based delivery?
That whole process of normalization has sometimes had consequences that were not terribly salutary. Did you come up with measures of how much has to be spent on a per capita basis? How do you measure the amount of financial public resources required to sustain a community-based system that will make sure that some of the adverse consequences of deinstitutionalization do not occur? For example, some would argue that the increase of street people is directly related to deinstitutionalization.
Ms. Wilson: That is a very good question. The way it happened in New Zealand was the process of a big national inquiry, which was called the Mason Inquiry. A retired High Court judge by the name of Ken Mason headed the inquiry. That inquiry resulted in the establishment of the Mental Health Commission in 1996. They prepared the ``Blueprint for Mental Health Services in New Zealand,'' a very detailed document which details the kind of beds and full-time equivalent, FTE, staff that are required if you have a comprehensive service that interdigits and works as a system. There are components such as how many acute inpatient beds are required for 100,000 population, what is the full-time equivalent staff required for the number of community teams, how many residential beds are required in the community and at what level? Thus, if you have high-intensive community beds that need higher staffing from lower levels, what other kind of community support is required?
They looked at mental health services adults, for children and youth, for seniors, as well as forensic services. It is a detailed document. They then figured out the costs —the price of the bed and the price of the FTE, and so on — for 100,000 population. They priced it on 1996 dollars and it has been adjusted once since then in 2000. They came up with a total figure that needs so many million dollars over a period of 10 or 20 years to implement the strategy.
That is what has driven our funding stream. We have had additional grants of about $20 to $25 million a year in a steady progression and added on to implement these services. They set targets and we have implemented about 75 per cent. Some parts of the country are closer to 60 per cent and some are almost fully implemented at close to 100. We have regional variation, depending on population growth and other factors.
I have to say that we are always a little surprised that our government took the gamble on this — that they actually allowed an independent organization to go out and price what it meant. Successive governments of different colour, as it were, have actually bought into this and have continued to support the on-going funding stream until the so-called full implementation occurs.
That happened in the mid-1990s. Things do change. At the moment, as we develop the second plan, there is likely to be a revision of where we are at. Is the configuration of services the right one? Do we need to put more emphasis on building the system, on the linkages between components, to ensure that there is less fragmentation because fragmentation still occurs? Will this have a physical impact? We do not know the answer to that yet.
Mr. Chaplow: If I may just address certain aspects of your question, senator. The first thing is that it is a process that occurs over a long time. I would have to say that 10 years after embarking on the strategy, we are still part way through it. The first few years are quite fraught with the tension that anything adverse is blamed on this new model.
Certainly, as we have incrementally increased the money to enable the blueprint to be realized, the district health boards that provide the services have had to be very strategic as to how they apply that to minimize the adverse consequences.
Last year, we commissioned some research to determine whether or not the community was in more danger currently than it was prior to this program. The conclusion was quite a clear no vote that they were not. It does require a significant amount of support and communication with the community in order to keep facilitating what is happening.
Senator Kinsella: It strikes me that your model is clearly psychosocial. Have you had any push resistance from those who favour a medical model in mental health delivery?
Mr. Chaplow: There is no doubt that this polarity will be with us until certainly I die. This is the tension all the time that we are managing. There is now an acceptance, from all political parties, that we cannot go back. It is not a matter of rejecting any one model; it is a matter of taking the best elements of all of the models.
Can I just say, senator and chair, that at no time have we diminished the total number of beds in what were the old asylums. We have spread those places in a variety of configurations, so that some are still configured in hospital units and some are in community placements. It is a matter of explaining the model.
Ms. Peretini: I think two of the essential elements that we have had in the last 10 years, if not 15, is that we have had champions and leaders prepared to give the continuity that this model needed, around championing and leadership.
The Chairman: I have just a quick question on your champions and leaders.
Have your champions and leaders been either politicians, at some level or other, or have they have been what I would call ``community leaders'' in the broader sense, or indeed leaders just in the mental health community?
Ms. Wilson: I think they have been across the board, fortunately. We have been fortunate to have had quite strong leadership from a successive number of ministers of health. We have had strong political leadership and commitment at the national level. We have had some community leaders who have been supportive and have given that leadership. Within psychiatry and mental health services themselves, and within the consumer group, we have had quite sensible and fair-minded leadership, as Mr. Chaplow has said, that has managed to communicate well the vision and the strategy, and to bring people along together.
The Chairman: I gather the political leaders, if I am correct, have crossed the political spectrum. It has not been just a pet issue of one party or another; is that right?
Ms. Wilson: That is correct.
The Chairman: That is a very important point in terms of where we go.
Senator Morin: I think that your move away from dedicated psychiatric institutions occurred later than it did for us, and was probably more controlled and less drastic. I think this may have been a factor in the success you have had.
I would like to address what is a major issue here in Canada. I think you have a similar one, and you may have had some success with it. It is what we call Aboriginals and what you call indigenous populations. I think that in both countries there is a higher prevalence of mental illness, suicide and so forth among these populations. I notice, in your blueprint of 1998, the delivery of mental health services for the Maori population was the second priority, right after community-based mental health services.
Did you have any programs that were successful? How do you address this issue, and have you had successes or failures? As you know, this is a very serious issue in Canada. We are still groping our way with it; we do not know which way to go. Resources have been allocated to this without much success. We are eager to hear what you have to say on that issue.
Ms. Peretini: One of the approaches that we have taken, which is articulated in the national mental health plan and the blueprint, is that we have looked at the responsiveness that is necessary in the mainstream services and the district health board services, as well as what we need to do in the community seatings, such as the non-government organizations. In the last 10 years, as a result of the switch from deinstitutionalization to community-based services, we have seen the growth of the indigenous services, in particular in the NGO area. That has just dramatically increased — 10 years ago, I think it was almost 11, and now it is 80.
Some of the problems have resulted from the fact that a lot of indigenous Maori within this country tend to appear at services at acute stages of mental illness. The NGO sector has worked very much around how to work with communities to get a better understanding of mental illness. We have not resolved a lot of the problems, but at least there is a lot of goodwill and willingness between the mainstream services and the indigenous services to see where on the continuum that we can actually share some of the knowledge and build some of those partnerships that are needed.
Probably some of the successes have been where you have had mainstream services focus on how to provide culturally appropriate and relevant services to the indigenous peoples coming in. Mr. Chaplow managed one of the key forensic services in this country, where the proportion of Maori, at that stage in the forensic clinic, was over 50 per cent. Mr. Chaplow can talk about some of the programs that he introduced that cater to the cultural needs.
One of the emerging issues for us that we are finding is that we had developed in the 1970s and 1980s, which was to revitalize the indigenous language. One of the struggles that some of the mainstream services are facing more than the NGO sector is that we now have some of those children — or the children of the original children — who are now native speakers of the indigenous language. When they become unwell, they revert to their mother tongue. In mainstream services, where they tend to actually be admitted, there is very little capacity to communicate. That is an evolving issue that we had not anticipated.
It has been very much the risk between the responsiveness of mainstream services and the growth of the NGO sector — how do we do that? One of the things that we have invested a lot in — particularly over the last seven or eight years — from the Ministry of Health with other key sectors, is in the research and development end. We have looked at the development of an outcome measurement tool that is indigenous-based and how do we actually define better outcome measures for indigenous peoples?
We have also invested a lot more research in how to get the data correct. That is part of what Ms. Gaines is doing. There are still gaps in a knowledge base about things such as admission and re-admission rates. We do know that some of the 21 services — because we did a survey three years ago now — are actually responsive to the needs of the Maori, by just incorporating a cultural assessment component as part of the clinical assessment. There were very few at that stage. Of nine district health boards, only seven had even considered policies around meeting the needs of indigenous people being admitted to the mainstream services. Of those seven, only three had cultural assessment tools that were well developed enough to be useful.
Myriad things have happened.
Senator Morin: Do I understand that you do not have hard outcomes to measure at present, for example, on the prevalence of mental illness, or on the incidents of suicide or this sort of thing? I realize what your programs are, but you still do not have hard outcomes? Am I right in saying that?
Ms. Wilson: We know about suicide rates, because you will be aware that we have one of the highest suicide rates in the world. Our suicide statistics are good and we know the rates well.
However, in terms of our overall prevalence, we are actually right in the middle of doing a major mental health survey that is nationwide. We will know the results of that by about 2006.
For that survey, we are not only interviewing about 10,000 people but also oversampling for Maori by doing 2,500 extra and oversampling for Pacific Island people.
Ms. Peretini: We do know that admission rates are disproportionately high for Maori entering mainstream services; we just have not qualified those statistics yet. However, we do know some of the data.
Senator Morin: Do you have many health professionals among your indigenous population? I am thinking of nurses and physicians among the Maori population.
Ms. Peretini: That is an excellent question. Two years ago, the Ministry of Health, as part of our workforce development strategy, commissioned the development and establishment of a Maori-focused workforce development organization. Almost a year ago, that organization undertook a series of surveys on our workforce. Rather than going into the detail, I will say is that we do not have a large workforce. We currently have probably about five psychiatrists in training.
Mr. Chaplow: There are five psychiatrists practicing and probably about 30 in training.
Ms. Peretini: We are not major players at all as a workforce in either in the addictions field or the mental health field.
The Chairman: The five Aboriginals practicing and the 30 in training are all Maoris. Is that right?
Ms. Peretini: Yes.
The Chairman: In general, do members of that community provide the services that you provide to the Maori community? I do not think that there would be nearly enough Aboriginal Canadians who are adequately trained to be able to deliver mental health services to any but a small minority of our population. Senator Morin, who was dean of a medical school, says that does not think that there is a single Aboriginal psychiatrist.
Have you reached this point because you made a conscious educational effort to get there? How have you had this very positive result in terms of human resources?
Ms. Wilson: The approach helped. There have been targeted policies to increase the health professional workforce among Maori — that is just for doctors and nurses, and they are a subset of that. Yes, we have had specific targeted policies, which include scholarships.
Ms. Peretini: As Dr. Wilson was saying, there have been educational quotas for certain themes in this country. They have existed for at least the past 20 years. We also have had some key leaders in Maori health who have become psychiatrists.
Over two and half years we have offered scholarships specifically for psychiatric registrars as well as looking at how to make it a more attractive career option. We are working on the entire strata across education.
The Chairman: We use different terminology, but you have run a strong affirmative action program.
Ms. Peretini: Very much so.
The Chairman: It is hard for me to get my mind around how different our situations are. The percentage of Aboriginal Canadians who even finish high school is many percentage points below what it is for the rest of the population. Is it reasonable to conclude that not only have you had an affirmative action program to get indigenous people into the health professions but also there is a pretty heavy emphasis on the education system as a whole for Maoris? Is that correct?
Ms. Peretini: The tribal leaders have been involved and there has been a major impetus on education. Our success rate in the education system is still quite poor. Almost 50 per cent of indigenous peoples do not make it to a form school certificate. I do not know your equivalent. The education achievement is still low but high enough for us to gauge that influx of workforce that we need.
The Chairman: To what extent is your success in delivering programs to the Maori population dependent upon the programs being delivered by Maoris? If you were in our position, without the supply of Aboriginal health care professionals and wanted to deliver the same services, you would do so using non-Maoris.
I understand this is speculative. What is your guess on the impact of the success of the program?
Ms. Peretini: It is an excellent question and a hard one to answer.
Ms. Wilson: One of the key things about mental illness is that it affects the way that you think about yourself — your spiritual and cultural beliefs. People relate much better to people of their own culture. If you are the person with the illness, the relationship you have with your care provider — your doctor or nurse — is probably the most crucial thing to getting well and gaining recovery. If that person is able to understand your cultural belief system, then the chances of a successful outcome are better.
That is what we think happens. The truth is we have not done any comparative research yet to see if that is really true.
Mr. Chaplow: Having built services 15 years ago that struggled with all these issues of workforce, it would be true to say that a decade or so ago there was a renaissance in New Zealand in respect of language and government recognition that if the indigenous people, were to flourish, they needed to do it themselves. They needed to have ownership.
There was an incremental development of services. Whether they purchase skill from another culture is a slightly different issue. I am trying to say is that one of the significant advances is that now Maori people own their services and own the challenge. We are in an interim stage. The indigenous psychiatrists will have to be augmented or supplemented by others. That is one of the realities that we face.
The Chairman: The point you stated is that even if you do that, the Maoris have in fact taken ownership of the program, regardless of who is doing the service. They understand that it is their program. It is not as though they have been given a program by a bunch of outsiders, which is where we would have to begin. Nevertheless, that is a useful long-term observation.
Mr. Chaplow: We talked about the medical model or the psychosocial interventionist model. The indigenous model puts alongside the doctor or the psychiatrist a partnership with elders. I would think that this would work similarly in your indigenous culture. If the elders and the specialists can work together, you will have a good outcome.
Senator Cook: I am trying to get a sense of the parallel between your system and ours. I will ask my questions by trying to understand your system — that may make it easier for all of us.
New Zealand has a population of 4 million. What is the indigenous population? Do they live separately or are they integrated with the rest of the population? In this country, there are reserves and self-governance and so forth. They are also found in our cities. Are the Maori also found in urban areas? I am trying to understand where the Maori population live before I can go further with my questions.
Ms. Peretini: Our indigenous population is currently at 15 per cent of the total population. The majority of that 15 per cent live in urban settings. They have no reservations. They tend to be fairly integrated into mainstream society. The majority exist probably in one city in particular in the northern part of the island, which is mostly urban. There has been, over the last 10 years, a call for many Maori to return to their tribal lands, or which about 90 per cent are rural based. However, the call has not occurred for many because most work in the urban settings.
Senator Cook: Is the Maori population serviced completely by the 35-40 Maori psychiatrists and other professionals or is there an integrated delivery system? Do the Maori psychiatrists look after your other population, or are they separate and apart?
Ms. Peretini: They are based mostly in the mainstream services. They work across the board.
Senator Cook: Is substance abuse and addiction higher in the indigenous population of New Zealand? Does the state fund the Maori so they can pursue a medical career or do they pay for their own education?
Ms. Peretini: There are a few intervention programs that support the quota system for the Maori to get into education services. We also have scholarships. There is a form of support but the majority of funding for all peoples in this country tends to be through the individual.
Senator Cook: Does that apply to other indigenous health professionals as well?
Ms. Peretini: The Pacific Nations people have a quota system and we have funding available for nurses and other health officials.
Senator Cook: You said that you have a community-based service in the form of district health boards. Are other services included or are they primarily for mental health services? Is it a public health care service system? Are the district health boards dedicated to mental health services?
Ms. Wilson: At the moment, they are for mental health only. We have community-based centres or teams of mental health professionals that work together. It is predominantly a mental health system.
However, Mr. Chaplow made the point that this being an evolutionary, developmental process, it looks as though, over the next 10 years, one of our challenges will be to look at how we integrate the community mental health system with the primary health system. In some parts of the country there may be a centre that would provide a combination of health services. We are moving toward that in some areas.
Senator Cordy: Ms. Wilson, you said that when you implemented your national health strategy you had two key goals. One was related to family — reducing the impact on consumers, families, and caregivers. A witness earlier today from Canada spoke to the hidden burden on the families of those who are mentally ill. That burden related to the stigma, to the frustration of dealing with the system, and to dealing with the family member who is mentally ill and who sometimes may not be as rational as one would hope.
What do you do to help the families of people who are mentally ill, given that was one of your key goals? How do you give them the support systems that they need?
Ms. Wilson: That is a good question, which I will try to answer. Others may add their comments on this. Nationally we have help to support the funding of a national family organization that has grown out of an organization called Schizophrenia Fellowship, which, as you know, is an international organization. Through that, they have built a strong support of advocacy, training material and support for families throughout the country. That was the first step.
As well, we have produced guidelines for services to use on how to allow families to and be involved in services and how they need to be involved when dealing with their family members. It is one thing to produce national guidelines, which is easy to do, but it is another thing to get people to use them; that is the challenge.
It has been a significant challenge for us over the last five or six years, partly because we have quite strong privacy legislation. The way in which mental health professionals have tended to interpret privacy legislation has often meant that families have been excluded. We have been working hard on that and I would ask Mr. Chaplow to speak to some of the ways that we have been trying to tackle that issue.
In the blueprint we have specific positions in services for family advisers. Although that has not been implemented as rapidly as we would like, services are beginning to appoint people to act as a kind of family adviser to the services about how to involve families much more and how to deal with some of the often complex privacy issues, particularly if an individual does not want family to know. That is a rather loose answer.
Mr. Chaplow: It is a very relevant issue, senator, and one that we have not cracked yet. The first complaint we hear is that families are not consulted. The second complaint we hear is that the burden of care sometimes becomes too great, particularly with deinstitutionalization. In about 2001, we amended the Mental Health Act to strengthen obligatory consultation with families. The move toward that position has been slow and difficult. As you know, some families are difficult to deal with and are part of the problem rather than part of the answer. Thus, we have had to move carefully on that.
The second issue surrounding the burden of care is that sometimes there is an immediate lack of a place for a person to be placed in an institution. That becomes a criticism of the system. The provider services are working through that, again using some of the blueprint money for respite care and for other support for the family. Thus, it is not a done deal and we are working through all of those very pertinent issues.
Ms. Gaines: I wanted to let you know about our research and development stream. We are in the early stages of developing and implementing consumer outcome measures into services on a routine basis. Ms. Peretini mentioned the Hua Oranga, the Maori outcome measure, which specifically includes a ``whanau,'' or family, care perspective. Our agenda is to develop a specific care and perspective in terms of measures that will be collected as a suite of measures in the future.
Senator Cordy: You spoke about an adviser to help somebody work through the system. I will just ask you to be a little more specific in relation to children who are suffering from mental health problems. In my other life, I was an elementary school teacher. I found that sometimes parents were being pulled from all directions. They had school officials speaking with them, psychologists, hospital officials, and family friends who were trying to be helpful, but everybody was giving them conflicting advice.
Would your adviser help parents of children who are suffering from a mental illness work through the system?
Mr. Chaplow: These adviser positions are relatively new. In a sense they came about as a balance from the consumer perspective. Often, the family and the consumer form a tension there. Most of the advisers operate as advocates to support the family. They also operate as intermediaries or facilitators so that they can actually help work with the family and the team. That is exactly what happens.
Senator Cordy: I suppose we are making an assumption here that the families wish to work through the system, are we not?
Mr. Chaplow: Absolutely.
Senator Cordy: Sometimes they are part of the problem.
Mr. Chaplow: Yes.
Senator Cordy: In regard to human resources, do you have enough psychologists and psychiatrists to work through, or do you have long waiting lists as we do in Canada?
Mr. Chaplow: In terms of world health statistics, such as the suggestion that there should be one psychiatrist for 10,000 people per population, we only have one psychiatrist per 15,000 people here. We are short a hundred or so. That is often not the issue. The issue is how you utilize psychiatrists as part of the team. Also, psychiatrists tend to cluster near universities or schools. That is what happens. You often have an imbalance between urban and rural access to good psychiatry.
At the moment that is not a significant impediment to the successful operation of our services. We do find that our psychiatrists are competitive on a world scale — no doubt as yours are. We import psychiatrists from Canada, the U.K. and the United States. We export psychiatrists to Australia, to the U.K., and so on. About 50 per cent of our psychiatrists come back and one of our challenges is how to get them all back and to build capacity. Part of our workforce strategy is to do that.
Ms. Wilson: In respect of the workforce overall, of course we are short throughout the system. It is not just psychiatrists. We have shortages of nurses, psychologists and all the other professionals. That is why we have a major workforce initiative that includes looking at how we recruit as well as retain.
The Chairman: You talked about changing the laws so that there was obligatory consultation with families. I presume that meant obligatory consultation as long as the patient agreed. Is that right?
Mr. Chaplow: There are caveats to that amendment. It must be seen as advantageous to the patient. Quite often, if, for example, a patient is informal or not coerced into treatment, of course there cannot be any obligatory consultation without their permission.
If the patient is coerced, then strong consideration must be given as to whether to bring the family into that setting.
The Chairman: In responding to Senator Cook, Ms. Peretini made the observation that you are moving in rural areas toward a more holistic, comprehensive approach. Can you expand on what is included in that and tell us what is covered by that approach and how it is actually delivered?
Ms. Peretini: The holistic approach incorporates spirituality, involvement of family, culture, and tribal and sub- tribal identity. Those are some of the key elements. Across the board it is not just about mental health but also about the issues of unemployment, housing, education, and physical health.
The Chairman: What is the background, the training, et cetera? This is obviously a multi-person team; it is not a single individual. Could you tell me something about the make up of the team?
Ms. Peretini: Some providers of services are very well developed and have structures around them that incorporate both clinical and cultural staff. Some of the smaller non-government organizations have less clinical specialization and more cultural. Much of the support provided to consumers and their families is by community support workers. Part of the primary job is to ensure that their cultural-clinical coordination occurs. If it cannot occur within that service, then they coordinate to see what other services can support that family and that individual.
The Chairman: Has it been your experience — at least in the early stages — that adding this sort of holistic-cultural dimension has had a noticeable impact in terms of the delivery of service and the impact on the patient?
Ms. Peretini: We have no definitive evidence. However, anecdotal evidence in the services that many of us have seen across the board — not only in mental health — we have seen that the individual community and family involvement has increased health status significantly.
In the tribal area from which I come, with the involvement of family, the individual and the sub-tribe and the emphasis on mental health and asthma and diabetes, in particular, has been far better coordinated and more affirming when it is done sub-tribally. In my own tribal area, I have seen significant change.
The Chairman: I am sure the answer to my question will be that you have not tried it. However, if this focus on the holistic approach and the cultural background of the patient works for Aboriginals, why is it that the rest of us in society assume it would not work for us and, therefore, we never try those kinds of service delivery approaches with the ordinary white Caucasian population? Has anybody looked at that?
Ms. Peretini: Well, there are two things that I said constantly. One is, ``By indigenous peoples, what is good for us will be good for all of you.'' When non-indigenous people say, ``We are a whole person, we have a spiritual element.'' Being indigenous does not exclude you from any of that.
Mr. Chaplow: I actually think that this pertains very much to cultural ideation as to how the Caucasian world might separate out their lives. In looking at indigenous statistics, the issues of access, acceptability and compliance are very important in terms of outcomes. Engaging so that you increase the access, acceptability and the compliance, are largely cultural factors. Those are issues that we are trying to use to better the outcomes.
The Chairman: I share Ms. Peretini's position; it probably ought to work for everybody else but the rest of us are either too scared to try it or too scared to admit that we might actually have a spiritual side. I think that is the problem.
Senator Morin: I would like to return to your mental health strategy that was released in 1998. As Senator Kirby said earlier, we do not have a national plan for mental health in Canada.
From your experience, was this blueprint worth trying? I notice that it coincided with extremely generous extra resources: You went from a budget of $270 million to $725 million in a short time. That is generous funding.
Do you think that a national plan like the one you have can be done without additional resources? If you think it was successful, was it a result of the resources or the plan or both?
I notice that you had seven strategic directions. Were they all implemented? Did you have a chance to evaluate this?
There is no doubt that you have had successes that we have not reached here by any means. Would you recommend this? Do people in the field refer to it? Where there yearly reports? Has this been a major element in the mental health field since 1998?
Ms. Wilson: The short answer to that is yes, it was a major element. It is referred to almost like the Bible. It is the benchmark that they apply or work toward. It does have problems because it is generally input driven, however, we are trying to move away from that in our second plan. We can talk about that later, if you like.
Was the funding important? The history of mental health care in this country was that it was a ``Cinderella'' of health services funding. It probably did not have adequate resources in the first place. It needed resources. Second, if you have a major reform agenda that is moving from an institutional way of treating people to a much more complex way of treating people, you actually need resources for the reform agenda itself.
There are those two elements. First, mental health care was behind the eight ball by a long way, so it needed to catch up. Second, you are totally reconfiguring the way people think about mental health and the way they deal with people with mental illness. You are changing attitudes and trying to change the way a community thinks about those people in terms of stigma and discrimination. You need resources when you have a major reform agenda like that.
Has it been successful? We have had yearly progress reports. The Mental Health Commission must report to Parliament annually on how we are progressing. Overall, we are about 75 per cent of the way there. Some of the strategic directions are further along than others.
Most of the targets that we set in that mental health plan have been implemented. We are now at the start of formulating the second plan with some new targets.
Mr. Chaplow: I would like to add that one other issue is advocacy. The question politicians asked of the mental health sector was, ``Why it is so bad, and what can we do about it?'' Having a costed plan with analysis of the gap between what existed and what we needed was a very powerful advocacy tool. Our treasury saw that and said, ``Well, you have a plan. You have a shape. We know the dimension of the problem. We will try to close the gap.'' That was very important.
The Chairman: Ms. Wilson, in your comment a moment ago you spoke about the programs that you would run to reduce discrimination. I thought the title, ``Like Minds, Like Mine,'' was very clever.
As I understand it, for a number of years you ran what I would call an awareness-raising program. You subsequently moved beyond awareness raising into actually attempting to reduce stigma and discrimination. If you have samples of your old communications material — the material you used in the awareness-raising campaign — I would love if you would send that to us. That would give us a real feel for what it is like. Indeed, we would also appreciate some examples of the current program.
Can you give me some sense of what resources went into it? As well, how did the population as a whole react? In Canada, people are fond of saying that the mental health system is the ``orphan'' of the health care system, in that people pretend it is not there and certainly do not talk about it in public conversation. How effective was the program? Did you measure its effectiveness? What did it involve?
Ms. Wilson: First, it is quite important to understand at the very beginning of this initiative or program, a significant amount of base research was undertaken. There was research done on attitudes in the community and on how people might respond to such an awareness raising. That went alongside our community development approach.
This campaign is not run by mental health experts; it is run by public health experts who are experts at public health campaigns such as HIV, anti-smoking, alcohol and drug and so on. There is a significant amount of expertise from that perspective. They used a community development approach where a range of public health professionals alongside other people such mental health consumers built relationships with local government and small community groups raising awareness in a different kind of way.
Then first national campaign was run and the research that followed indicated a surprising change in attitudes. There seemed to be increased understanding the common mental disorders such depression, anxiety disorders, alcohol addiction and so on.
The campaign was based on famous New Zealanders who were willing to talk publicly about their problems with depression and anxiety disorders. I have some of the clips here. I will show you one of them. You probably have heard of the All Blacks, New Zealand's national rugby football team. One of their players was on the national campaign. Every successive bit of the program has been thoroughly evaluated with independent research that shows the ongoing change in awareness and attitudes in the community. It has been quite carefully done.
The current campaign has moved away from the famous people to ordinary people who have also suffered significant illnesses such as manic-depressive or bipolar disorder, schizophrenia and so on. It focuses on them, their families and lives.
On the amount of resources, I do not have the figures, but I can certainly get them for you. They may have a base budget of something quite small — $2 million a year. Each campaign is funded on top of that. Everybody gave their time for free, so even the famous people who were in the advertisements did not get paid for it. They did it voluntarily. There is a significant amount of goodwill amongst New Zealanders in donating their time. Of course, it has gone alongside a media campaign — a relationship-building with organizations such as the police and other agencies and community organizations and how they deal with people with mental illness. I could send the committee a large package; that is not a problem.
The Chairman: That would be wonderful. My guess is that attitudes among young people changed far faster than attitudes among people our age. Is that right?
Ms. Wilson: I do not know off the top if that is true, although it might be true. I would have to look at the statistics.
The Chairman: For example, there have been a number of polls on same-sex marriage, which is a big issue in this country. The polls show that of those who are under 35, two-thirds to 70 per cent say there is nothing wrong with it; and among those who are over 65, two-thirds to 70 per cent say it is a terrible idea. It just seems that changing basic attitudes is easier when you are young and fresh rather then when you are old and crotchety like we are. I was curious if that applied there, too.
Senator Cordy: I am still amazed at how you managed to convince everyone to buy into spending the amount of money for the plan, which is a wonderful idea. Did it just snowball? You had leaders that came from the medical sector, from the community and from the patient base. How did it begin? Did it start slowly and gradually build up? What was the momentum? Was there a turning point when you said, ``We've got it!''?
Ms. Wilson: People may have different perspectives — and this may seem cynical — but the truth is we had a series of critical events in which an identified person, or people, with mental illness committed homicide. New Zealand is small and everybody knows everybody else, more or less. These things are painful, difficult and tragic, and there is often a significant amount of adverse publicity around them.
I do not think that we have more such incidents than any other country, to be honest, but it is just the nature of New Zealand and that we have a totally public-funded national health service. It becomes a political issue. Although we had the strategy and some funding to implement it, the general sector and the community were not happy. This resulted in a lengthy inquiry that lasted over one year. The inquiry talked to people across the country and internationally — just as you are doing. It resulted in a number of recommendations, including the one for a significant increase in resources and the development of this blueprint to analyze more accurately the kind of resources required. I must say that the politicians of the day basically bit the bullet and decided to go ahead with it.
Is my perspective right?
Mr. Chaplow: That is pretty much right, yes.
Ms. Wilson: Does that answer your question?
Senator Cordy: It does, thank you.
When you spoke to the issue of deinstitutionalization, I found it interesting to learn that you retained the same number of hospital beds, despite the fact that people were going into the community for services, but their disbursement was reconfigured. I was not sure what you meant. Were you referring to group homes where people would live in a home situation together? Could you clarify that?
In Canada, we have lost hospital beds because of deinstitutionalization but that money is not necessarily going to the community, which was the plan when this happened. How does that work?
Mr. Chaplow: It often depends on how you count things. One of the characteristics of the asylum — or the big bin — was that all of the beds were together. The advantage to that was capacity and flexibility. We took out the various streams. For example, we felt that it would be far better for the acute beds to go on hospital campuses where diagnoses can be made. By and large, the forensic services should be in their own stream — likewise for the elderly and children and so forth.
When we counted up the beds in the various streams, we had not lost the number of beds. We have had to build the capacity in the community. For example, how much support does a person need to be in the community? Do we have respite care available? A person might not need to go to hospital but we need to relieve the family or the caregivers for a number of days, and so on. These are the kinds of things.
Senator Cordy: Did the money for community housing come out of the health budget? Was there bickering between various government departments as to who would be responsible for housing? Are all government departments working together?
Ms. Wilson: That is a good question. In the early 1990s — almost at the same time as the first mental health strategy was being formed — there was a government policy to move funding that had been in Vote Social Welfare for supporting people with disability, in their own homes and in group homes to Vote Health. Part of our increased funding around 1992-93 was a transfer of Vote from Social Welfare to Vote Health. That meant that we picked up most of the funding for the support of people.
We then had different levels — levels 4 and 3, which are more intensive support, received higher levels of per capita funding; level 1 has a lower level of support. We do have group homes of perhaps four or five people. There has been a move toward much smaller, home-like bases that we all experience. There has also been a move, since then, for people to be in their own homes with whomever they wish — alone or with their friends or family. That has been a more recent move.
How do you get a house? Actually, the funding for the house has stayed with Housing New Zealand, the government department responsible for housing. It has been that department's responsibility to find the house. The support required to maintain the house comes out of vote health at this time.
Mr. Chaplow: May I say that it is not all sweetness and light in New Zealand. One or two councils have tried to pass by-laws preventing this from happening. By and large, they have not been successful but it does amount to a rearguard action by people who do not want these people in their communities.
The second thing is that there has been queuing for housing. We have been trying to get preferential treatment for the mental health patients coming back into the community. That has been a struggle sometimes. Sometimes it has been fine, and sometimes it has been a struggle in some areas.
Senator Cordy: Thank you very much. That has been helpful. We also have what we call the NIMBY, or the not-in- my-backyard syndrome. It is not as common as it used to be, thank goodness.
The Chairman: I should like to close by asking you to make some general comments on the way you are developing your new blueprint — you put out the issues paper last month seeking comment. Can you tell us what the timetable is for actually producing the blueprint? I ask partly because Senator Morin just whispered, ``Are we ever behind where they are.'' That is certainly true.
To the extent that we can learn and plagiarize from what you are going to do in your next draft of the blueprint, it would be helpful to us. Can you tell us a little bit about the kind of timetable and where you see that process heading and when?
Ms. Wilson: Before I do, I think it is important that you are clear that we have had a strategy and a plan. The first one was called ``Looking Forward'' and the plan was called ``Moving Forward.'' The blueprint, which came in 1998, was produced by the Mental Health Commission rather than government itself, although government has since adopted it as policy. We are currently preparing the second national plan, and we do not know whether there will be a redraft of the blueprint or not. That will have to follow the second plan.
We are about to go to cabinet on a draft plan, which will then go out for wide consultation in the community. Our timeline for this plan is really the rest of this year. We hope to have our second plan finalized and accepted by government by November-December.
It is not a zero base, so we will try to carry on from where we are. Continuing implementation of the blueprint is still very much a part of the plan. We still have a major focus on the Maori, our indigenous people. We have a major focus on workforce development, infrastructure development, and information development, and developing a performance management system so we can see if we are doing what we are supposed to be doing. Is this working? Is the investment worthwhile? We have a major strategic direction on mental health in the primary health care sector, prevention and promotion and, lastly, social inclusion.
We will be tackling those social exclusion issues relating to why people with mental illness face barriers to reintegrating into communities and society. We will also examine what effects they experience in terms of their income, employment and education opportunities because of their mental illness. Finally, we are bringing addiction into the plan more formally.
The Chairman: We are delighted on that last piece, because we have included addiction in our terms of reference.
When you send the draft plan out for what you call wide consultation, does that make it a public document? If so, could you send us a copy? I assume, like us, wide consultation by definition means it might as well be a public document because someone will leak it anyway.
Ms. Wilson: The media will have it. You might as well have it.
The Chairman: If you could send us one, we would appreciate that. It would be great.
Senator Cook: I walked myself through your blueprint beginning in 1998, and I am at April 2004. Of particular interest to me is the bullet that says: ``A new, non-clinical workforce has emerged, primarily in the NGOs, with nationally agreed minimum standards of training.'' Would you share what you mean by ``nationally agreed minimum standards of training?''
Ms. Wilson: We have an organization here called the National Qualifications Framework. This organization sets all qualifications that are below degree level at universities. This includes certificates and diplomas. We have a certificate in community mental health support work, which has now trained about 2,000 new workers.
We have a new workforce, called community mental health support workers, that has been training over the last five years probably. They work predominantly in the NGO sector but they also work in the public mainstream sector. They are trained to support patients or consumers with mental illness, either in their homes or in formal residential settings in the community, or to help them work through the system. They would be the person who would go with them to the income support agency, to the employment agency, to help them battle the societal barriers.
Does that make sense?
Senator Cook: It does. I am particularly interested in it because in an ad hoc fashion here in Canada — especially where I live — that is happening, but not in an organized manner. There are no standards for training or the delivery of the service. It is out of the caring and goodness of people's hearts that they provide a service when they see a gap. I am particularly interested in how you have managed and achieved those national standards.
Thank you.
The Chairman: Ms. Wilson, may I say on behalf of my colleagues how much we appreciate you and your colleagues taking the time to be with us today. It has been very helpful. It is almost embarrassing to realize how far behind we are. On the other hand, it generates a huge degree of optimism in the sense that it has been possible to make progress over the decade that you have been at it. It would be a huge step forward if we can begin to launch a similar process here next year.
Thank you all for your help. I look forward to receiving your information packages. Inevitably, there may be additional questions, so we unilaterally reserve the right to bug you again and to try to get additional information as it comes to us.
The committee adjourned.