In pointing out the challenges facing the Minister for Mental Health, Southern Say has high hopes for Matt Doocey (ODT 20.1.24). Your report on his Otago visit (23.1.24) is heartening.
But to describe Mr Doocey as New Zealand’s first ever Minister for Mental Health overlooks history. Thirteen ministers held charge of an equivalent but identifiable portfolio from 1907 to 1947. The portfolio ranking in Cabinet was invariably middle-placed or well down — a reflection of the low sociopolitical and fiscal priority of a Cinderella service. Ten were neophyte ministers.
Ministerial effectiveness depended on personal energy and aspirations, the life cycle of governments, electoral calculations, fiscal pressures, the dominance of the Prime Minister, and the relationship with officials. Ministers in charge of the highly centralised Mental Hospitals Department invariably deferred to their expert advisers.
Mental hospitals were virtually synonymous with mental health services in those days. They were run separately from other health services. Services were beset by an endless nexus of staff shortages and inadequate funding. Service needs and supply were locked in a continuous spiral. Day-to-day problems crowded out long-term vision and resulted in the very variable conditions and institutional culture so perceptively described by Janet Frame.
Policy and services evolved in a boom-bust pattern, with long periods of stagnation interspersed with occasional bursts of overdue reform. A familiar story?
The history of Mr Doocey’s portfolio can encourage him to make a difference now that he holds the levers of ministerial authority and influence. How?
First, find ways to avoid mental health being a partisan political football. Mr Doocey demonstrated admirable leadership and vision in his efforts to build consensus on the long-term development of mental health in 2018. He wants to build on those efforts. Disclosures of mental health issues among parliamentarians could well smooth the path towards a compact.
The minister can be heartened by the agreement reached by his predecessor, Sir Maui Pomare (1923-26), with the Labour Opposition to lay off demands for a public inquiry into the very run-down system in return for time to radically revamp it. Sir Maui used the time well.
With the long-serving departmental head on extended sick leave, long-serving psychiatrist and administrator Truby King was given "special instructions" and mandate to implement significant reform. Outpatient clinics commenced in general hospitals. Procedures were changed to reduce the stigma of compulsory treatment orders. Measures were taken to improve the classification, care and treatment of mental hospital patients generally, especially newly admitted patients.
Second, keep learning first hand about the system for which the minister is directly and indirectly accountable. A whirlwind tour of facilities by an incoming minister is no longer enough given the complexity of today’s mental health system and the close public and media interest in mental health and wellbeing.
As an experienced mental health worker, Mr Doocey is well placed to look very closely and to cut through the disjuncts and overlaps of a plethora of contracting providers, multiple agencies and regulatory overseers. Listening to and personally learning the stories and plight of people involved with ground-level services to find out what is/not working can provide the Midas touch found by some ministerial predecessors.
Sir Maui "spared no pains" to make himself "personally and professionally conversant with the whole situation" he faced. Mabel Howard (1947-49) also worked that way: she personally directed that patients be regularly given fresh fruit to vary the monotonous diet of evening meals, and readily approved expenditure for an inter-hospital sports event. She made sure that the game went ahead by ordering officials to tell her the score.
Third, put health into mental health. Prioritising prevention is the third and last of Mr Doocey’s priorities. Unless he gives primacy to a public health approach, the minister will quickly find himself trapped like his predecessors in the bottomless quagmire of resource problems and burgeoning pleas for more accessible and responsive intervention and treatment services.
Mental health is much more than a euphemism. As long ago as 1905, the head of the Mental Hospitals Department declared that "the intelligent consideration of this complex problem [mental health] does not begin with — nay, it ends with — the establishment of mental hospitals, which are, in truth, the monuments of failure".
Mental health will invariably wait till last if perceived as a clip-on to treatment services. For instance, the Plunket Society (1907) was the Mental Hospitals Department’s only successful gesture towards public health aspects of mental health.
The last Labour Government accepted 38 of 40 recommendations from the Inquiry into Mental Health and Addiction (2018) but rejected the key public health proposal. The inquiry proposed a whole-of-government approach to wellbeing, prevention and social determinants with a clear locus of responsibility.
This intersectoral approach is not new, as the Ministry of Health well recognises in its call to build upon solid foundations for mental wellbeing throughout life. That means social inclusion, freedom from violence and discrimination, physical health and nutrition, cultural identity, spiritual wellbeing and positive environments. Access to meaningful employment, adequate income, affordable and safe housing and education are also fundamental.
Mr Doocey would be a pioneer were his ministerial job description to include as the primary responsibility assessing the likely effect on the mental health and wellbeing of New Zealanders prior to decision-making on government policies.
Southern Say rightly says the new minister needs to start walking the talk on mental health. Mr Doocey has given some promising signs of that. He will have his work cut out. Mental health does not feature in the coalition government’s 100-day plan. He ranks No. 13 of 14 ministers inside Cabinet.
As part of a government whose leader wants to do things differently, may Mr Doocey be inspired by his more memorable ministerial tipuna to be a latter-day pioneer in getting mental health back on track.
— Warwick Brunton worked in the Department/Ministry of Health from 1972 to 1996. His PhD was on the development of national mental health policies.
