Funding must follow devolution

A genuine conversation is needed when changes to mental health services are proposed, writes Max Reid.

I have followed with interest recent articles on the proposed closure of some sub-acute mental health beds by the Southern DHB.

Each commentator carries something of the truth, despite the fact their views may appear, at first glance, contradictory.

For example, Labour Party MP Dr David Clark's observation the move reflects the current Government's de-prioritisation of mental health is an accurate one and in line with the earlier removal of the previous ''ring fence'' whereby mental health funding could be redirected but had to remain within mental health services.

It could not be siphoned off to support elective surgery, nor to help reduce a DHB financial deficit.

Work needs to be done to ensure that if patients are indeed moved from Wakari Hospital into the community, an appropriate level of funding follows. Historically, this has not always been the case.

While there is widespread support for the principle ''hospitals should only provide the services that only hospitals can'', the New Zealand health system already has a dubious reputation around such devolution - shifting the responsibility for service provision into the community, but without the necessary funding following suit.

That is not to suggest the current proposal for closing some of the inpatient beds at Wakari Hospital is not without merit, financially and for patient care. In reality, the cost of providing care in a hospital setting is invariably higher than providing the equivalent level of care in the community.

One reason is that DHBs are funded to a level where they are able to pay their own health-care staff at higher rates than they fund contracted community providers to pay.

Nurses and care workers (or their equivalent) employed by DHBs tend to be paid more than their respective colleagues in the community.

From a pay equity perspective, this is a longstanding issue. Yet, paradoxically, this disparity is one reason why a mental health dollar spent in the community setting goes further than in an inpatient setting.

Such financial realities support the Southern DHB's proposal to transfer a proportion of mental health patients from Wakari Hospital into appropriately supported community accommodation.

But as Dr Clark, Miramare's Kerry Hand and mental health advocate Graham Roper each rightly point out, some level of DHB funding must follow such devolution - perhaps not all of the DHB's projected $250,000 saving, but certainly enough to ensure sufficient provider capacity, safe staffing and an equivalent level of patient care in the community setting.

As an NGO (non-government organisation) representative, I was involved with the Ministry of Health's recent mental health and addictions KPI (key performance indicator) project - a three-year consultation enabling DHBs across the country to agree on a key suite of indicators from all the mental health data they at present collect and, by comparing performance across DHBs, using such indicators to better inform mental health service design and provision. One of the major learnings from the project was that few of the KPIs were meaningful in isolation.

For example, average length of stay in mental health inpatient units was as much shaped by the availability of beds as by demand for admissions.

Similarly, the project found many mental health patients remained as inpatients not because their continuing placement there improved their health status, but simply because there were no suitable beds available in the community, a point well made by Pact chief executive Louise Carr in her recent comments.

The Southern DHB, along with many others, faces significant financial challenges as it struggles to work within the current Government's ''more for the same or less'' health funding philosophy.

And while cost-cutting - seeking to work in more efficient, effective ways - is not in itself a bad thing, excellence in patient care must remain the primary driver of change.

To paraphrase British gerontologist Julia Twigg, when it is suggested that certain changes in health provision will make things better, it always pays to ask: ''Better for whom?''

What is needed in the face of such proposed changes to our mental health services, even more than our comments in the press, and our responses to a formal consultation document, is a genuine conversation.

Each of those with an interest in mental health services - funders, providers, advocates, politicians and family members alike - need to put aside whatever may be our respective agenda, and engage as actively as we can in such critical health service planning.

We may not agree, but we will have the assurance the experience, expertise and passion we bring has been heard, not simply as a response to a consultation document, but as part of a real and necessary conversation.

Max Reid, recently returned to Dunedin, is a former general manager of service strategy for mental health and disability support provider Richmond NZ Trust and most recently chief executive of Hospice Southland.

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