Mental health funding mystery and mischief

One of the difficulties that can occur in parliamentary politics is that the response of the government of the day responds to an opposition party spinning a yarn that makes it look bad is to either behave like a possum in the headlights or defensively spin back. The more sensible and effective response would be empirical; sticking to and better explaining the facts.

This was illustrated by the controversy involving the $1.9 billion funding boost for mental health announced by the New Zealand government in its Budget for the 2019-20 financial year and the claim by the National Party mid this year that so little of it has been used highlighting the low increase in hospital beds (reportedly five).

This keeps being repeated but what is omitted by critics is that the $1.9 billion boost covers five financial years. The controversy has caused much frustration among those working in mental health in both district health boards responsible for delivery and within the Ministry of Health.

What does the $1.9 billion mean

The significant of the $1.9 billion for mental health is that it was one of the cornerstones of Minister of Finance Grant Robertson’s Budget branded as the wellbeing budget. What is less well understood is how this funding has been allocated. Only a little has to date actually found it ways into mental health services. A smoke and mirrors illusion of a big increase in funding comes to mind but, for those on the mental health ground, nothing substantive has really changed.

Of the $1.9 billion, around 47%% ($900 million) went to the Ministry of Social Development, Oranga Tamariki, Ministry of Education and Department of Corrections. This is laudable but the point is it wasn’t funding for district health boards (DHBs) who are responsible for ensuring the provision mental health services to their defined populations.

Of the remaining 53%, only $300 million went to increasing the ‘mental health ringfence’ (what DHBs are expected to spend on mental health from their total government funding envelope). $400 million was for various programmes and $80 million to specialist mental health services (around $800,000 to a DHB serving 10% of the country’s population). Again remember that this is all over five years. Divide the amounts by five if you want a notional per annum average.

Hospital beds

This then leaves mental health hospital beds for which the funding is $200 million over five years. Notionally this would suggest spending on average around $40 million annually. In reality the planning and approval process means that bed expansion would be slow starting (unlikely to be many in the first year or two) and then, if all goes well, increase exponentially.

National Party leader Judith Collins was mischievous when she said after the controversy first broke that she was tempted to go to Bunnings and personally buy a couple of beds. Physical beds are not the big cost issue. To begin with suitable facilities have to be considered. Can new beds be added to existing wards, do existing facilities have to be reconstructed, or should new facilities be built?

In the first instance a business case has to be put to the DHB’s governance board. If the cost is $10 million or more (a ridiculously low threshold) a board supported business case then goes to the national Capital Investment Committee (via the Health Ministry) which then makes a recommendation to cabinet. This is a slow and arbitrary process with much going back and forth; especially as $10 million these days doesn’t buy much.

Bay of Plenty experience

The experience of the Bay of Plenty District Health Board is revealing. It has come into conflict with the Health Ministry over the number of beds needed in a planned new mental health unit at Whakatāne Hospital. Whereas the Ministry was insisting on a 10-bed build (the same number as the existing unit), the DHB considered the minimum should be 14 based on a needs assessment.

There is no doubt in my mind that in recommending a minimum of four extra beds, the DHB’s recommendation was based on expert clinical advice including from its psychiatrists, psychologists and nurses. This was required if the substandard existing facility was to be fixed. By contrast, the Ministry’s relevant experience was less.

For perspective on how far the Government’s $200 million over five years can go, just to rebuild the existing 10-bed facility with the same number of beds was estimated to cost $18 million.

What characterises this experience is how highly centralised the decision-making process already is and how much this centralisation slows things down. The decision over the unit rebuild, including bed numbers, should have been left to the DHB who, through its frontline health professional workforce, had the greater expertise.

The Government’s unilateral decision to abolish DHBs will increase this already high level of centralised decision-making thereby making the situation worse than it is now and increasing the likelihood of the wrong decisions being made.

Workforce crisis

But capital works isn’t the end of the matter. Beds are plant as are the facilities they are located in. Compounding the situation is the fact that health is highly labour intensive, particularly with health professionals including medical and nursing. Mental health is invariably the largest service that DHBs directly provide.

Beds are useless without health professionals. They don’t even have a bedside manner. Increasing beds requires increasing the number of psychiatrists, psychologists and nurses (among others). But DHBs already face severe shortages and are dependent on international recruitment at least for psychiatrists. The lead-in time is immense and the competitiveness of our remuneration and working conditions poor. This is a crisis.

This will only be addressed if the Government develops a plan to overcome the crisis, which isn’t confined to mental health (its widespread across all DHB services). Unfortunately, to date, its approach to planning has been not to have a plan.

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