[As published in March/April BayBuzz magazine.]
Is our mental health system truly broken or is that an on-going trope we default to?
This question kept coming into my mind as I set out recently to do a health-check on Hawke’s Bay mental health services.
Late last year Opposition politicians lambasted the government’s Wellbeing Budget of 2019, which had set aside $1.9 billion to tend to New Zealanders’ mental wellbeing, as a huge waste of money, with 2021 Stats NZ data showing a significant increase in the proportion of people with poor mental wellbeing – up from 22% in 2018 to 28% in 2021. Alongside that, alarm was raised at mental health staff leaving their jobs in droves, creating an ever increasingly depleted and burnt out workforce.
“There is a lot of mental illness in our community and this is likely to increase,” says retired Napier GP and Senior Medical Officer, Tim Bevin. He was recently awarded an Order of Merit for his work as a general practitioner for 30-odd years in Hawke’s Bay, and for his long-time involvement with our addictions treatment community.
“The load of uncertainty with mental health is greater than with most other medical conditions,” says Tim. “You can’t just do a blood test and say this is what we’ll do. It takes time and we need to give it that time.”
I began my story by getting some statistics from David Warrington, General Manager Mental Health and Addictions Group Hawke’s Bay. He confirmed that, “Recruitment remains a well-documented challenge across the health sector and Te Whatu Ora Hawke’s Bay is actively working to recruit health workers into the region, including mental health professionals.”
His stats show that in all areas the numbers of mental health staff for HB falls short of the roles budgeted. For example, Te Whatu Ora has budgeted for 12.4 consultant psychiatrists and currently employs 8.4. So four vacancies for psychiatrists in our secondary services. And incidentally there appears to be no psychiatrists in private practice in HB. Te Whatu Ora is down 3.9 on budget for full-time psychologists and down a big 17.7 registered nurse vacancies to work in Mental Health and Addictions.
Current FTE for Hawke’s Bay Mental Health and Addictions in Hawke’s Bay is as below:
The serious patients
One person who sees the impact of depleted services on Hawke’s Bay’s mental health patients is Andrew McGarrol. He runs his own private counselling practice in Hastings (Nautical Counselling Ltd) and has had extensive experience as a clinical manager of several mental health and addiction services for DHBs and major addiction facilities in Hawke’s Bay. He is currently clinical director of Hastings-based Ocean Hills private detox and rehabilitation addiction centre.
Andrew is often working with a very difficult portion of our mental health population – people with co-existing problems: serious mental health and addiction issues. His view is that our Secondary Mental Health Services for seriously ill patients is “run like a factory. Someone is seen but discharged very quickly.
“This is due to high demand with limited resources,” he says. “When you work in the system, you are band-aiding problems that create a perpetual cycle where patients remain untreated and the workforce becomes fatigued.
“Most people I deal with have trauma from adverse childhood experiences that include physical, sexual, emotional neglect, and substance abuse.
“Trauma is a big one. Secondary services have been guilty of taking a medical model approach in treating someone’s symptoms, but at times they never get to the root cause as to why someone is unwell in the first place. When you treat someone with addiction – it’s not their substance consumption that is the issue, but it is the underlying causes that drives that behaviour.”
Andrew, who is a trained social worker and counsellor, is concerned that there is still stigma and discrimination around people with addictions in our HB community.
“We form biases against people with a substance use disorder (SUD) and label them as hopeless, worthless and weak,” he says. “I always have a saying that the person is not the problem, the problem is the problem. We need to see people with a SUD as someone who has major trauma and the addiction aspect is a maladaptive coping strategy for survival. These judgements stop people accessing treatment or in some cases it creates professional biases where the individual does not receive the correct treatment.”
Andrew says we need a step care approach that provides a plethora of services with a biological, psychological and social focus. “However that is the tip of the iceberg, we also need leadership, governance, community awareness, workforce development, risk management, and infrastructure. All those things that the mental health inquiry promised but unfortunately hasn’t delivered. It’s a bottomless pit that creates a sick society.”
One aspect of Andrew’s work which has a preventative focus is as a clinical advisor to Hawke’s Bay’s very successful suicide awareness and prevention training programme Mates4Life Te Matau-A-Maui. “They are doing a lot of mental health prevention work, building connections and establishing a mental health tool kit in the workplace.”
Mates4Life came out of a model TUMU Group developed for its staff, in particular to support people who might be feeling suicidal in the workplace and have no one to talk to and no way of expressing how they are feeling. It is now a four-step free programme funded by local businesses and charities – not government – and has already reached 1,400 people in the Bay.
This year the model is starting to be picked up by other regions and is going out to more HB businesses and even into some staff rooms at schools. It is definitely a positive part of Hawke’s Bay’s mental health services puzzle and an example of the community taking action into their own hands.
Kaiwhakahaere ( operations manager) Tyson Ataera , who leads eight facilitators, says “we know that there are people within local businesses who are struggling with their mental wellbeing. It’s on the rise and it’s important that programmes such as Mate4Life identify those that are struggling and give them some tools to cope, as well as providing support for them within the business.”
Mates4Life has a specific focus on suicide prevention but as part of the first session all staff attend a one hour module called Aroā (Awareness). “Often people become aware, maybe for the first time, of how to bank coping and prevention strategies for their on-going mental health and how to get support if they need it.
“The aim of Mates4Life is to create life-supporting workplaces and ultimately life-supporting communities.
”The ‘mild to moderate’ patient
The 2019 Wellbeing Budget, in particular, earmarked half a billion dollars for the ‘missing middle’ – New Zealanders suffering from mild to moderate anxiety and depressive disorders that did not require hospitalisation, but significantly affected their quality of life.
Funding was funnelled to Primary Care under the Access and Choice programme with new frontline mental health workers to be stationed in doctor’s surgeries and Māori and Pacifika clinics, with the government aiming to help 325,000 people with ‘mild to moderate’ mental health and addiction needs by 2023-24.
Some of this funding was funnelled towards Rangatahi Services addressing the needs of young people aged 12-24 years experiencing mild to moderate levels of distress. Probably the biggest recipient of this in Hawke’s Bay is Āwhina Whānau, based in Hastings and also operating an out-reach service in Napier.
Visit Āwhina Whānau at 110–120 Queen Street East and you’ll find an impressive, highly-resourced Kaupapa Māori organisation. Set up in 1984 to ensure whānau within the community living with trauma and violence had access to support and counselling services, Āwhina Whānau is now a major resource for our whānau and community.
Tumaki/Manager Sam Christie guides me through light-filled counselling rooms resourced with creative tools to help youth ‘to talk’, a kitchen where they can learn to cook and recreation rooms where ‘kids will often get off their phones, play table tennis or pool and make a connection with us, and from there start to open up about their problems’.
Awhina Whānau employs 16 counsellors and about 360 youth (38% non-Māori) are going through the service each year. They present with everything from anxiety, depression and negative thinking to substance abuse, confusion around body image, gang recruitment and lack of male role models. (The centre under a different contract also deals with issues of sexual violation and counsels mainly youth sent to it under the Police Diversion scheme.)
Sam Christie, a former Rugby Union Development Officer, Hawke’s Bay Māori Sport Coordinator and Corrections Facilitator among other things, is very positive about work being done at the centre.
“If we weren’t fortunate in securing this funding, our Rangatahi may not have easy access to our services or the support and help they require, when they actually need it,” he says. “Our Rangatahi are valuable and this opportunity for us to have a positive impact means the world to us here at Āwhina Whānau!”
Another more controversial initiative to cater to people with ‘mild to moderate’ mental health issues is the deployment of Health Improvement Practitioners (HIPs) and Health Coaches (HCs) in General Practices across the country.
In HB, there are currently 15 people employed as HIPs and 14 as HCs, with Health Hawke’s Bay (HHB), who is running the local programme, aiming to have these roles in all its clinics by the end of 2023.
Called Te Uru Matai – Integrated Primary Mental Health and Addictions Service in HB – these new roles are modelled on behavioural health consultant roles in the United States. The focus of their work is to facilitate and support behavioural change in their patients. To date 20,235 people have accessed services through Te Uru Matai.
A HIP is a qualified clinician, usually either a counsellor, social worker, occupational therapist or registered nurse with mental health credentials.
They hold a current annual practicing certificate and have preferably worked in mental health and addiction.
Health Coaches are from a variety of backgrounds with training and experience in community health and/or people with lived experience of mental/health issues. They provide self-management support that will help individuals and whānau to achieve their goals.
Anyone who turns up at their GP practice with a ‘mild/moderate’ mental health condition – “has thoughts, feelings, or actions that are impacting on their daily health and wellbeing” – can be seen for 30 minutes by a HIP almost immediately.
There are no barriers as to who can see a HIP if the person is enrolled in the Practice. Appointments are available every day for 20-30 minutes and doctors and other General Practice staff can do ‘warm handovers’. Often the Health Coach will follow up and help keep a patient focused on a behavioural change.
“It’s not classical counselling,” says Samara Kelly, Mental Health Service Lead for HHB. “It’s patient led, it’s structured, and usually the most important behaviour change for the person is identified and what steps they can take.
“One example of a behavioural change could be someone who is really stressed at work making a plan not to answer an email from their manager straight away, but instead take a breath.”
A newly diagnosed diabetic who has to change the way they think around diet and exercise might be another example of someone who could benefit from a HIP and Health Coach, to put some plans and behaviour changes in place.
In September 2021 BayBuzz looked at these new roles as they first rolled out in HB and spoke to Veronica Luckman, a former inpatient mental health nurse, now a long-term HIP working across several Napier Centres. She said then that the role had taught her, “It’s not big, grand gestures but what we do every day that makes or breaks mental wellbeing. It’s about those small steps that we do, and habits.”
David Warrington Te Whatu Ora says nationally, the Government’s Access and Choice programme has introduced more than 1,000 contracted FTE roles to support people with mild and moderate mental wellbeing challenges. He adds that the programme is delivering frontline primary mental health and addiction support that simply didn’t exist a couple of years ago.
Karen, a qualified counsellor who trained as a HIP and worked in Napier, holds another view. She sees the validity in trying to deal with the ‘mild to moderate’ and take the burden off the Secondary Care health system. However, she became disillusioned with the HIP role as “too prescriptive” and was concerned that some patients being directed her way were much more serious than ‘mild to moderate’ and actually needed to be at an addiction centre. She has since returned to a counselling role.
“Primary health is not always dealing with the ‘mild to moderate’ clients as per the contract,” says Andrew McGarrol. “This shows the real need and Secondary Services inability to manage referrals or demand when they are pushing this back to Primary.”
Dr KJ Patel, director of Havelock North’s Te Mata Peak Practice, expressed frustration at funding being withdrawn from two mental health nurses in their clinic to fund a HIP and a HC.
“We are promised funding and initiatives and then serially have them re-fashioned or withdrawn by either the PHO or the government. The most egregious example of this is giving us funding to train two immensely capable mental health nurses, then withdrawing it.
“What happens if in two years they do the same thing to our new and very valuable Health Improvement Practitioner and Health Coach?”
Howard Dickson, managing director of Tōtara Health with practices in Hastings and Flaxmere, says he gets grumpy and cynical about constant bureaucratic changes in General Practice. But he says the Health Improvement Practitioner and Health Coach roles are working well alongside counsellors in their Practices.
“I think it is a good initiative,” he says. “It took a while to get going but it is working really well for us and is meeting the level of need it is designed for and helping quite a lot of our patients. “But it is not enough,” he cautions. “More is required, particularly for people with a greater complexity of mental health needs.”
Tim Bevin retired from his practice at Central Medical in 2019 so can’t comment directly on the new Primary Care HIP and HC roles but he suggests increased funding of GP practices for the provision of practice-based mental health workers is vital as is the provision of adequate leadership and peer support for this group.
He also thinks there needs to be more emphasis in the community and in schools on preventative strategies for mental health; encouraging things like exercise, good diet, teaching people how to deal with issues in their life, mindfully.
Our alcohol consumption is also of great concern. “We have a drinking culture and alcohol underlies a lot of our mental health conditions.”
Another place I was directed to for this article was the Heretaunga Women’s Centre. Like Mates4Life it is not reliant on government funding and is run as a charity.
Since October 2020 the Centre has employed a trained counsellor on staff, Jenny Whitehead, for 30 hours per week, and she is supported by additional volunteers, either counsellors, or in-training. Between June 2022 and December 2lst 2022, the centre ran 96 counselling sessions. These one-hour sessions can be ongoing and are paid on a koha basis.
“We get referrals from police, Age Concern, doctors and we have walk ins,” says Jenny. “We can’t take borderline cases, but we have noticed an increase in complexity and intensity of things women are dealing with – grief, loss, depression and anxiety, family violence and wanting emotional support.
“I see women come in here and leave looking lighter,” says Jenny.
And that feels like the right note to end on. There is some good work going on in mental health in Hawke’s Bay – probably more than I have covered here.
And perhaps it’s time to hold onto that.
Public Interest Journalism funded through NZ On Air
