It is now well established the local branch of Health New Zealand (the former Southern DHB) would retain large staff numbers in Dunedin if an equitable reallocation meant the current staff of about 26 in Central Otago Queenstown Lakes increased to about 100 by transferring 75 positions.
It is equally clear that they do not intend to do that.
But the solution could be that somebody else takes the funding and then operates in a more modern way than the current corporate model.
One option of many comes from Trieste in Italy, a World Health Organisation site, which is often described as the "best place in the world to be ill".
So how bad is the current post code mismatch? Figures for last year supplied by the former SDHB show it directly employs 335 specialist community health staff in Otago.
It’s a powerhouse of resources — nurses, doctors and others, bigger than many nationally known companies.
But, strangely, it allocates only about 26 community mental health staff to Central Lakes.
This means as the inland population increases, over 3000 people in Central Lakes have to share a single specialist worker.
And for Dunedin people, it’s only 450 or so sharing each specialist worker.
You do not have to be precise to see the mismatch is outrageous.
The solution is to shift 75 staff positions out of Dunedin into Central Lakes, taking the staff roster from about 26 now, to more than 100. It doesn’t cost, it’s a rearrangement. You could do similar in Clutha and Waitaki.
You can run a very useful service across Central Lakes with 100 staff, and it is entirely possible for the residents of Wānaka district to have an advanced modern mental health service.
Their population justifies a staff role of about 20, maybe 25.
Those staff positions exist now, just in the wrong locations.
You can use those staff within a modern practice that responds to the client’s need as it presents, and not limiting itself to set professions and techniques.
That’s quite different.
If we followed the Trieste model, Wānaka people would see a physical centre they easily recognise and self-refer to. They will see little difference between using the service and using their primary health (GP) service. The two would be closely associated with an easy flow between them.
Using mental health support will become an ordinary thing. In Trieste they just walk in the door.
Users of the service could expect to see workers they know and who know them well. They won’t have to explain their story multiple times. The story and plan that is formulated between the user and worker would recognise the families and local situation of the client as much as diagnosis. It’s important to reduce referrals as much as possible, which then means the staff in front of you start work with you immediately.
The user can expect a generalist flexible response, driven by their particular need.
In Trieste, rather than being confined to narrow professional roles, workers and the team can adapt what they do to the client situation. Within a small team approach, staff seek to provide solutions directly, limiting referrals to the bare minimum.
Multiple referrals, and seeking just the right specialism, have high costs in communication time and patients’ personal story can be lost in the translation.
In the new service, users will experience contact with a small number of people they get to know. No longer the experience of the confusion around referral, wait, seeing new and multiple people, and the confusion that process creates.
Solving a housing issue may help the mental health issue greatly for example. For children there are often multiple agencies involved such as the school. Close work with agencies in education housing and welfare will be a common technique. Services in smaller areas already do that much better than city services.
Our current system is very structured, with firm defended boundaries between professions.
While the multidisciplinary process is well praised, what actually happens is vast dollars are spent communicating between staff and organisations.
When I worked in Dunedin, more time was spent communicating with other organisations than the time spent with clients. Further, there was always confusion and information was lost. Mental health stories are personal and nuanced, and there are losses as the story passed along. "Chinese whispers" are a way of describing that sad process. Clients tell and retell their story. Many clients find it hard to keep their story understood.
Trieste workers by comparison knew their clients well. It was warm personal knowledge, not dependent on files and reports.
I saw this with my first visit in 1988 and most recently in 2018.
The Barcola Centre, where I spent most of my time, served 44,000 people and had a staff of about 30. Most staff worked in the day although it was open continuously.
A guiding principle was that what needed to be done should be done immediately and not deferred to another time, referred to another person or clogged up in a series of diaried appointments, pieces of paper or organisational telephone calls.
In the first decade the centre had been open, the way clients came to the centre changed dramatically. According to the staff, at first clients presented much as they still do in New Zealand; they knew to present a major crisis or difficulty bad enough to be seen by the psychiatric services. Nowadays in Trieste, the public have become used to the idea that they could gain a psychiatric consultation for their difficulty without having to present a dramatic situation and thus taking a problem to the Mental Health Centre created no great trauma of itself.
Anybody who came to the centre was seen by a member of staff, at that time, and frequently standing immediately in the front doorway. Work with a client always started "now" and for many people this meant they frequently had only one consultation with the mental health services.
Twenty five staff seems an amazing number to those used to the current minimal situation. But twenty five is justified as Wānaka’s valid share of the workers Health New Zealand Southern already employs directly. Remember also it’s a complete service aiming to keep people in the district. Alcohol and drug work is included. Some mobile service is necessary and Wānaka district is large. Children and young people will access the service in significant numbers. The talking therapies take time. There are also very disabled people requiring daily care and attention.
I felt quite secure in our New Zealand quiet bureaucratic ways, but sometimes when things really clogged up, some Trieste style would have been welcome.
- Kerry Hand operated the successful mental health agency Miramare.
