Improving HB mental health care … “a candle in the dark”

In my BayBuzz article last November, ‘Must move on mental health’, I explored the systemic issues in our mental health system and the 2018 He Ara Oranga Inquiry’s recommendations for a radical overhaul, shifting attention from the apex of acute need to the flaxroots of prevention and wellbeing. 

Or in other metaphors, moving the ambulance from the bottom of the cliff to the top. 

While systemic transformation, clearly, will take more than 10 months, has there been any movement?

The government has still to draw up a plan.

Meanwhile, levels of distress and demand for services continue rising, seemingly unabated. 

The Mental Health Foundation’s study published this February, found a quarter of New Zealanders have poor levels of mental health and emotional wellbeing, including nearly a third of women. And an RNZ investigation corroborates what everyone knows, that national wait-times for non-urgent mental health and addiction services over the last two years have risen across all age groups. 

There’s just not enough available for the mild-moderately unwell, who end up funnelling into more acute services. The increase in access to mental health and addiction services (MHA) over the last decade has risen by 73%; funding by only 40% (Stuff, Jan 2021).

A major challenge is the fact that we simply don’t have enough qualified clinicians – New Zealand is short some 940 psychologists in the public health sector alone, and psychiatrists are rare as hens’ teeth, I’m told. Professions that take years of training, with not enough being trained annually to fill the void. It’s been called by Stuff’s Helen Harvey, “a psychological crisis”, as wait times for psychologists in the public system edge up to four months. 

Working in social services, supporting the socially distressed is stressful; there’s a massive turnover of staff. You only have to follow Seek’s stream of job vacancies in the mental health and addictions sector to see this first hand. 

“Burn out happens when you don’t feel like you have what it takes to meet expectations,” a community-based, family social worker, tells me. And the expectations and pressures are huge. Compounding, “intense” social issues, dwindling resources, not enough support. “We’re over-worked and under-funded, and the government has not stepped up.” At the beginning of the year, the agency they work for had a double-digit exodus of staff.

Troy Wathey, clinical social worker and MHA therapist, works both in private practice and in emergency mental health services. Over the years he’s seen the increasing “volume of people” coming through the doors, against a backdrop of increasing societal work and life pressures, which manifest in stress, anxiety, depression, addictions and relationship issues. It’s the same with the healthcare workers he supervises as it is for his clients.

“I always ask, ‘How’s your base?’ Your base is always your number one thing: good home, good sleep, good eating, good connection.” Invariably, for those who’re struggling, the base is insecure or rocky.

“Most people have 10, 15 years’ of stuff and then they come to us. The idea that the DHB’s going to work that all through … sometimes it can be done in a short time but mostly it takes a good year or two to change someone’s situation. We have to start addressing the earlier stuff, and that often goes right back to mum and dad, to the whānau, and the pressures they’re under.”

So where has that $450 million budgeted in 2019 for expanding access to services gone? And is it making any difference?

In Hawke’s Bay, some of that funding’s been channelled through the region’s primary health organisation, Health Hawke’s Bay, into a new integrated primary mental health programme. 

Free, timely, accessible

The PHO is six months into rolling out their ‘HIPs and health coaches’ model as part of their integrated primary mental health and addiction service (IPMHAS). Health improvement practitioners (HIPs) are registered health practitioners (such as social workers, nurses) or DAPAANZ (drug & alcohol)-registered counsellors, who undergo “rigorous” six-month training before being placed within general practices to provide free, brief interventions. 

It’s a ‘shoulder tap, book-them-straight-in, no forms’ approach, and it’s discrete – no one in the waiting room knows if you’re there for anxiety or endometriosis, for a HIP or a jab. Half of the appointment slots are kept available for immediate on-day referral, often made through a ‘warm handover’ by the GP or triage nurse in person. 

The HIPs work alongside health coaches (who work closely, encouragingly with patients and whānau on behavioural changes to do with health, such as managing their diabetes) and community support workers (CSWs, who help patients get through doors and navigate services). The CSWs sit within the NGO space, under a contract with the PHO, and provide the third tier of collaboration. 

“This whole programme is about integrating care across the sectors, breaking down those barriers,” says HIP team leader, Samara Kelly. The service has “flex” – if the HIP is not available the health coach can step in, and vice versa. For those with higher-end needs, HIPs and health coaches can help “straddle wait-times or access to secondary services,” engaging them, meantime, in doing something towards their wellness. 

‘It’s super positive and we’re getting really good feedback. This is about establishing strength and connection before anything else; having someone in your local community that you can come in and talk to.” 

The Ministry of Health’s funding model allocates 1 FTE HIP and 1 FTE health coach per 10,000 enrolled patients in a general practice. So, Hastings Health Centre, with a patient roll of 35,000, for example, will eventually be entitled to 3.5 full-time HIPs and 3.5 full-time health coaches. 

The PHO currently employs 7 HIPs across 6 general practice groups, 12 locations, and is recruiting for 4 FTE positions starting in September. As part of Tranch 1, it’s been prioritising practices with high enrolments of Māori, Pasifika and youth. Tranch 2 (starting August) is about reaching full implementation in those practices, before slowly expanding it out to others through expressions of interest. 

Space is the challenge, practice readiness, and an already over-stretched workforce. Contract-wise, Health Hawke’s Bay has had the go-ahead and funding for a year, but it proved challenging to recruit practitioners. 

[See list of participating practices at end.] 

The government’s ambition is to have HIPs and health coaches in all general practices by 2023. 

An obvious catch is the fact that Hawke’s Bay has a shortage of general practitioners (GPs) and most practices have had to close their books to new patients, meaning not all can find a GP to enrol with. 

Health Hawke’s Bay CEO, Phillipa Blakely, says the PHO is developing plans with the College of GPs to plug some of the gaps – “it is a major issue” – and looking to enable more direct access to primary mental health support through another programme. 

“We’re very aware that we need to open this up and make sure it’s accessible to our communities and where they need it. We’ve talked about marae-based clinics, community-based clinics in places that may not have a practice or that kind of connection to primary care. But at the moment the ministry guidelines is for enrolled patients, and that’s what we’re working to.” 

Any age, any stage, any problem 

After eight years as an inpatient mental health nurse, Veronica Luckman was feeling a little jaded with “the conveyor belt, revolving door” nature of the mental health system and didn’t feel she was making much difference in the lives of those she cared for. 

Since January, she’s been working as a HIP across several Napier medical centres and is excited about the holistic approach of her new role, and what working at the top of the cliff, rather than at the bottom, can mean for her patients. 

“In the unit you’d see somebody, who, if they’d just learnt a few little skills back then to deal with the stress or to manage their anxiety, it wouldn’t have escalated into something more acute.” This is particularly the case with teens who “we’re seeing a lot of” as HIPs, and to this end, some good gains: “I can count at least half a dozen teens we’ve been able to keep out of secondary services so far.” 

“In our HIP sessions we try to be really proactive – yip, life’s really hard but what can we do right now that’s going to help improve it, what are the action-focused steps we can take? It’s quite a different way of working.” 

The half-hour, targeted sessions draw on Te Whare Tapa Wha (physical, mental, spiritual and whānau cornerstones) and ACT (Acceptance and Commitment Therapy, a behavioural-cognitive approach with a focus on mindfulness), looking not only at what’s happening in the person’s life but what’s important to them (values), what ‘fills their cup’, and ‘what’s sitting on top’ today (the problem that’s most pressing). The HIP will work with that person on creating a manageable plan focused on achievable actions, connecting them in to other services and resources as required, with the option of follow-up sessions and contact. 

Working as a HIP has shifted Veronica’s own perspective on mental wellbeing and what it means: “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.” 

Checking in with someone about your mental wellbeing, she says, should be seen as routine as getting your blood pressure checked. And to this end we need more awareness and education in Aotearoa, “just normalising things, reducing that stigma. It’s ok to not be ok. It’s normal to have ups and downs.” 

“In New Zealand our mental health message has been ‘get help, get professional help’. But if we’re not professionally equipped with the resources to deliver that, we should be using the air time to say: ‘Here are some steps you could take today, some techniques you could try; this is what mental wellbeing looks like; here’s what you should be looking out for; these are some conversations you could be having with your kids, and tips on how to start them, etc.” 

HIP consults, clearly, are not going to help everyone. Those with trauma issues or even more moderate needs require psychological therapy rather than strategies, and it’s not going to heal suicidality or severe illness. As Veronica is quick to point out, the HIP is not a substitute for appropriate mental health care. But it can lead to some immediate relief and provide a pathway forward for those who’ve become stuck, overwhelmed, don’t know what to do. 

Step in the right direction 

“Accessibility and trust is everything for our clients. If it’s not within walking distance it’s not going to happen.” 

Dr Almarie Van der Walt has been working at Maraenui Medical Centre for 27 years, along with her husband (also a GP), and has a special interest in mental health. Because of the centre’s high-needs, priority-population demographic (65% Māori, 10% Pasifika, 80-90% in the ‘deprived’ socio-economic bracket), they were among the earliest candidates for the IPMHAS, making space in a very busy practice for the new extended care team. 

Previously, Almarie says, mental health services were rolled out as equal access for everyone, for example, with the packages of care (4x counselling sessions), a limited number of which could be allocated each month. “Counselling is expensive for anyone but for our patients it is totally unaffordable. Giving the same number of packages of care to those who could possibly afford it as to those who are struggling to put food on the table did not seem fair – now with the HIP system this is taken into account.” 

And there were large failures with the external referral process, in contrast to the personal recommendation and warm handover with the in-house model. “It is much easier to encourage a patient to see a counsellor/ HIP,” she explains, “if they meet them, they work in the practice building, or you, as their trusted GP, can vouch for them.” 

“Now, by October we will have a HIP on site 2.5 days per week and a counsellor for 1.5 days (for those who need therapy), plus the health coach. It’s still capped (by time) but it’s a whole lot more, it’s transparent, it’s more equitable, and having these services under one roof is a gamechanger. There’s real collegiality and team-work, and that’s hugely different. 

“Previously I would write a half-page referral letter to a counsellor. Now, the HIP can access the patient’s notes as needed and we can speak in person.” 

“The hope is that if you catch the issues earlier, they won’t escalate – we believe in it, but it’s hard to see when you’re working in the trenches. Will we ever know if it takes the load off the severe end? We have to try; we can’t not do anything.” 

Currently, “Approaching secondary services, you feel like Oliver Twist with your bowl out asking for more. I don’t cry ‘Wolf!’, I ring only when I think someone is going to kill themselves, but they tell me they have no capacity. The police used to take psychotic or suicidal patients in the past, but don’t anymore. We’ve had our receptionist drive patients to the emergency department.” 

In March, the government announced funding for a stand-alone mental health crisis hub in Hawke’s Bay, which will provide integrated services at secondary level for people in acute need, in conjunction with government agencies, community groups, iwi, the PHO. It was hoped Te Tāwharau would be operational mid-year, but the logistics of relocating services to free the earmarked facility for refurbishment has meant delay. The DHB assures me, they are busy working on this, with a plan of how the hub will operate, and aim to be up and running by the end of this year. 

There is much still unanswered in that middle space between health improvement and mental crisis, where necessary professional support remains difficult to access. That’s where we need a roadmap from the government as to how they plan to implement the full suite of He Ara Oranga recommendations they agreed to. As commentators fear, without one it will be a piecemeal job rather than the transformative, systemic change needed. 

But from Dr Almarie Van der Walt’s point of view from the ground level of primary health, four months in, the new integrated model that’s unfolding is “definitely helping.” 

“Mental health has felt hopeless for a long time, and this is a bit like a candle in the dark.” 

Extended care team in action 

Three examples: 

• The GP sees a young woman who’s struggling with sleep issues and getting to work as a result of anxiety, which is negatively affecting her mood. Rather than simply prescribing anxiolytic/ antidepressant medication and sleeping pills, the GP introduces her to the health improvement practitioner (HIP). During the 30-minute consult, the HIP provides some psychoeducation about what anxiety is, talks through some basic anxiety management techniques, such as diaphragmatic breathing, and strategies to manage anxious thinking patterns, along with sleep hygiene skills. The tools prove effective, thus avoiding the need for medication. 

• The GP sees a patient, prescribes some medication for his presenting issue and observing there’s something else going on, makes a ‘warm handover’ directly to the HIP. The HIP has a mental health specialty and picks up during the follow-on consult that the patient appears to be suffering a bipolar illness that is creeping up into mania, which the new meds could be counter-aligned with. She feeds this back to the GP, who promptly reviews the prescription and what other referrals may be required. 

• A woman with a trauma background and pre-diabetes sees the HIP in conjunction with the health coach; she’s been given a Greenscript (subsidised group sport and exercise) by her GP. But although she’s keen, she is extremely anxious about going. They bring in the CSW who is able to literally walk that journey with her, connecting her in with the community service in a way that overcomes the psychological hurdle, leading to “good wins” for the patient on several fronts. 

Where to turn for help

Need to talk? Free 24/7 helplines 

• Call or text 1737 anytime to talk with a counsellor or to connect with other mental health and addiction helplines. 

• Lifeline: 0800 LIFELINE (0800 543354) or free text HELP (4357)

• Youthline: 0800 376 633

Local services

• Emergency Mental Health Service, Hawke’s Bay: 0800 112 334

• Your GP – if you’re enrolled at any of the following general practices, you can also book in with a health improvement practitioner free of charge: 

Hastings Health Centre 

Te Taiwhenua o Heretaunga 

Hauroa Heretaunga 

Totara Health (Hastings & Flaxmere) – from October 

The Doctors (Hastings, Napier, Greenmeadows) 

Tamatea Consortium (Carlyle, Shakespeare, Maraenui & Tamatea medical centres) 

Wairoa Queen St Practice

• Awhina Whānau Services (free kaupapa Māori counselling services and education programmes for individuals and their families, open to all): awhinawhanauservice.org.nz, 06 878-4827

• Directions Youth Health Centre (one-stop shop in Hastings for youth health and social support): 0800 967742 

Free e-therapy tools

• There’s a raft of interactive online tools, programmes and apps to help with depression, anxiety, stress and support wellbeing. See the ‘E-therapy handout’ under ‘Mental health resources’ at healthhb.co.nz