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A day in the life of a mental health nurse in New Zealand

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This blog was sent to us by a NZNO member who works in mental health. We are choosing to keep their details anonymous because of the intense scrutiny that mental health services are currently under. This blog is a personal reflection on their own experience, rather than NZNO’s view, but we are sure it resonates with many of you who work in the sector. We really appreciate them sharing their story, and hope it gives some context to the recent media coverage of our mental health services. 

It is 7am and I am off to see a patient in the emergency department. It is a young man who has self-harmed overnight. This scenario is becoming all too common in today’s mental health setting. You see, mental illness is the invisible disease. Presenting to the emergency department in emotional distress, the only visible signs are an unkempt man with a frightened look on his face.

Coming into the cubicle I see a young man in obvious distress. A feeling of hopelessness comes from him. I walk in and introduce myself. We begin to talk. Eyes downcast, feeling somewhat embarrassed as he shares his story with me. He talks to me in a quiet voice. He knows he needs help but does not know where to obtain the help he needs. His relationship with his family has become strained. They have tried to help, but are unable to provide the support he requires.

This man begins to articulate his struggle with schizophrenia. His self harm is due to despair: a belief that life holds nothing for him.  By the end of the interview I know I have several options open to me as a clinician:

  • We could send him home to his parents. But evidently his parents are unable to cope anymore with his distress.
  • We could suggest his GP follow up and maybe a visit from the already over-stretched crisis team.
  • Another option is to find a community respite bed for a few days. But we know that these are few and far between. I will have to telephone and “sell” his case to the respite coordinator if I am to make this happen.
  • Another option is to try and organise for him to be admitted into the inpatient ward. But I know they are nearly always full or over capacity. This is yet another hard sell to find this young man a place to be safe and be supported.

I go to discuss treatment options within the consult liaison team and the decision is made to admit the young man to the inpatient unit. I call the ward coordinator.  “What are his risks they ask?” Not, ‘who he is’, but, what logistical problems might he bring to the unit.

This is mental health nursing today. There is now a ‘risk adverse’ culture that always errs on the side of organisational safety: a system characterised by a lack of choices due to limited resourcing.

This is the young man’s first time in an inpatient unit. I try and reassure him, but as soon we get to the unit the door closes.  People are busy. I try and find a nurse. They are few and far between. I eventually find the nurse assigned to my client. A brief introduction is shared, but I know the nurse is trying to get the paperwork done. Admission note, risk assessment, interview with the psychiatrist, place them on the observation board and a host of other tasks. This leaves little time to begin getting to know, understand and work alongside my client to better support them.

I leave my client and return to the ED, there is another case on the board.

This time another young person in a self-harm situation – they were bullied at school and decided to end their life.

Nurses do care, but we are not being given the time or resources to provide the level of service and care that I would want or expect if it was my family member presenting to mental health services.

We do not want to restrict or deny the people we care for their freedoms. Too often the concept of least restrictive practice is sidelined by lack of resources.

The organisations we work for are worried. Worried about risk and what could be in the papers tomorrow. So much so they seem to have forgotten about the core reason we are here – we are here to help.

I as a clinician welcome the reviews and public scrutiny. The current structure needs looking at so we mental health professionals are able to provide the service, care and support that our clients deserve.

 

 


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Arohanui Christchurch

I’m a mental health nurse and I know how challenging the role can be at the best of times. So when Canterbury DHB announced that, because of funding cuts being forced on them by the current Government, they may have to cut funding to mental health services I was very worried.

Today is the anniversary of that awful 2011 quake. My thoughts are with the people of Christchurch and with the families of those who were killed. My thoughts are with every person who still bears the scars of the earthquakes, be they physical or mental.

Things are pretty tough in Christchurch and I fear they’re going to get tougher.

I have been talking with some of my Christchurch-based mental health colleagues over the last couple of days and I share their concerns.

Mental health needs

  • The anniversary of the February 2011 quake is today. This, along with the recent earthquakes is re-traumatising people.
  • The long-term prognosis for mental health in the city is deteriorating, because young people aren’t getting early intervention from specialist mental health services. There is a rise in young people who have little resilience left and just aren’t coping being referred onto adult mental health services.
  • The referral rate to child and adolescent mental health services has doubled, and there’s been a huge increase in presentations to the Crisis Resolution Team. It’s really hit home in the last 12-18 months.
  • People are moving from place to place, relationships are breaking down, and children’s mental health is suffering.
  • Some Special Education Services staff have been told not to give a diagnosis of PTSD to children they are working with, partly because there is not enough funding to treat them.
  • People with long-term, chronic mental illness have been destabilised after being ousted from their council house, losing the support of nearby friends and familiar shops.
  • There has been an increase in Alcohol and Other Drug (AOD) use.
  • 100,000 people have come to Christchurch for the rebuild. The guys are working up to 16-hour days, burning out and turning to alcohol and drugs. A lot of them are turning up in mental health services. The DHB is expected to absorb that increase out of existing budgets.
  • There is noticeable rise in mental health problems among Canterbury farmers.

Impact on mental health services

  • There are long delays to be seen in specialist mental health services, especially for new referrals and especially for children and young people. There is a waiting list at Whakatata House, a community mental health service for children and families.
  • The delays are due to wider system pressures, as well as rising need among Christchurch residents. So, for example:
    • The biggest and widest impact of funding cuts has been felt by NGOs who support people in the community, so they don’t become so unwell that they need specialist services (this trend is expected to continue).
    • All sexual assault support services were closed last year, along with Relationships Aotearoa.
    • Recently, The Pacific Island Trust has gone, and the drop-in centre at Latnam House has been forced to shut its doors.
    • Even some DHB mental health services have shut down. The Day Programme at the Youth Inpatient Unit at Princess Margaret Hospital closed about a month ago.
    • Caseloads for community mental health nurses are 30-40. This means nurses do not have enough time to do their job. Case managers are staying at work until 6pm routinely – doctors even later, until 7 or 8 in the evening. This is overtime is unpaid. Running a service on the goodwill of staff in this way is not sustainable.
    • Staff in community mental health were recently told that they’re not allowed to organise taxis any more, to help clients get to appointments. Now the next cut which they have been told is coming, is that they are going to lose some of their DHB cars, so staff will be less able to visit clients in their homes.
    • The increasing use of “Level 2 specials” (ie. one-to-one care in the inpatient unit, for high needs service users) has meant that nurses have to push to get the extra staff they need.
    • Staff are being cut by not filling vacancies.

The mental health of the nursing team

  • Staff are having to deal with the same issues as the rest of Canterbury: dealing with EQC, fighting Fletchers, moving house. People are tired.
  • All the staff are on edge. Some say it’s almost like they are suffering from post-traumatic stress themselves.
  • There is huge staff turnover. Since last weekend’s earthquake, three staff in one ward have resigned. They say they are looking for work in other regions and who can blame them?

All the people I spoke to said they and their colleagues are dismayed and disgusted at this Government’s decision to not adequately fund Christchurch’s mental health services.

It doesn’t have to be like this. We all chose to prioritise some things in our lives over others. And the Government is no different. They have not prioritised the health and well-being of Christchurch people.

I guess the good thing about priorities is that they can changed. I’d like this Government to prioritise mental health services in Canterbury. I urge them to do it!

by Grant Brookes, NZNO president


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What’s wrong with social bonds for mental health services?

hospitals2_(1)Sometimes a long read is what we need. NZNO delegate and member of the Mental Health Nurses Section (as well as NZNO president-elect), Grant Brookes talks about what’s wrong with social bonds for mental health services.

Health services funded by Social Bonds are due to open in New Zealand by the end of the year. Under the controversial new scheme, the private sector will be invited to invest in health and social services in return for “success payments” if targets are met.

ANZ Bank is behind the first of these profit-driven services, designed to get people with experience of mental illness in Wellington into the workforce. Also in the pipeline are schemes to reduce reoffending in Auckland and to “manage chronic illness” in Bay of Plenty/Lakes.

Despite inquiries from NZNO and the imminent launch, little is known about these pilot projects. “There has been a dearth of information”, says NZNO Senior Policy Analyst Marilyn Head.

Dr Charlotte Chambers, Principal Analyst for the ASMS senior doctors union, agrees. “While the minister of health remains adamant that information is readily available on the Ministry of Health’s website, there is a worrying lack of detail.”

Evaluations are therefore forced to rely heavily on recently published cabinet papers dating from 2013; here and here.

Paternalistic, not person-centred

From a nursing perspective, supporting recovery for mental health service users means working in partnership to help identify and achieve goals which are meaningful to them.

In services funded under the Social Bonds pilot, by contrast, goals will not be set in partnership. Instead they will be “selected from ideas generated by the market”.

Clients will be expected to meet the organisation’s goals, rather than the other way around.

In this way, Social Bonds create services which are paternalistic and provider-centred, rather than person-centred.

They will also be prone to the generic problems afflicting all services driven by health targets – the loss of a holistic focus as people are viewed narrowly as “prospective employees”, “offenders”, “sufferers” and so on.

Then there’s the question of whether it’s ethical for investors to speculate on the lives of vulnerable members of our community.

“The introduction of social bonds signals a dramatic change in our values around assisting people with mental health problems”, comments NZ Psychological Society Dr Kerry Gibson. “Many New Zealanders might struggle with the idea of some citizens profiting from the misery of others.”

Failing overseas

Three international examples are cited for comparison in the cabinet papers released by the Ministry of Health. Two of these have since failed.

Launched in 2010, the Peterborough Social Impact Bond was intended to reduce reoffending among a group of male prisoners in England. It was hailed as “a world leader” by the Ministry of Health.

Yet in 2014, just over half way through its seven year term, the contract was cancelled after it failed to meet its targets.

The second international example cited in cabinet papers, a scheme to reduce recidivism at Rikers Island Correctional Facility in New York, also failed to meet its target. It was announced in July this year that it too has been cancelled.

Inherent inefficiencies

The strongest local backing for Social Bonds comes from the New Zealand Initiative (a think-tank formed in 2012 when the NZ Institute merged with the Business Roundtable).

But even these right-wing lobbyists acknowledge that Social Bonds “involve multiple players, agreements and contracts, creating great complexity. As an example, the Peterborough SIB took 18 months to set up, and required the equivalent of 2.5 years of staff time and 300 hours of legal and specialist tax advice” – all in order to deliver a programme for just 936 people, which ultimately did not succeed.

This is not to mention the other private sector inefficiency – the need to divert a portion of funding away from service delivery in order to provide a profit for investors.

Finance minister Bill English has admitted that Social Bond schemes may end up costing taxpayers more.

Flawed pilot?

Although details are sketchy, there are signs that the government may be repeating some of the mistakes of its Charter Schools experiment.

Cabinet papers assure investors that “favourable terms [will be] offered by government as part of the pilot”. “Payments or contracts will be structured to ensure investors have sufficient incentive or obligation to ensure their funds remain in the services”.

In other words, it appears that the government may spend much more on the privatised model than on comparable public services, just as in Charter Schools. This would skew any evaluations of the pilot schemes against existing services.

To this end, $28.8 million has been allocated to Social Bonds pilot schemes in the 2015-16 Budget – at a time when other health services are facing cuts.

In addition, the pilots will only include “proven” services which already have “a track record of success”.

This will make it difficult to generalise the outcome of the pilots across the sector.

No independent health professionals have been consulted in the design of the pilots.

Unhealthy incentives

The cabinet papers acknowledge possible risks that “providers ‘cherry pick’ to avoid hard to reach users” and that “parties delivering outcomes manipulate results”.

This is a feature of many privatised services. Private surgical hospitals, for instance, tend to cherry pick the routine electives and leave the complex cases to the DHBs.

Private operators like Serco have been caught out repeatedly manipulating their performance data and covering up service failures, the world over.

These behaviours are incentivised when the profit motive is made central to service provision.

As the Dominion Post editorial on Social Bonds said: “There are obvious reasons for companies to massage the numbers, to push for lenient contracts, and to make worrying decisions in pursuit of targets. Social bonds smell like a gimmick. The pitfalls outweigh the prospects of a happy ending.”

Ignoring the evidence

Social bonds are touted as an innovative model for tackling “intractable” health problems.

But these problems have social roots. For example, Mental Health Foundation chief executive Judi Clements says, “The biggest issue people face trying to get into work is discrimination, and whether social bonds of themselves will enable that discrimination to be eliminated or reduced I think is a stretch.”

International evidence shows that the prevalence of problems like substance use and teenage pregnancy rates – also mentioned as possible targets for Social Bonds here – correlates with income inequality.

Rather than address this social determinant, Social Bonds reward institutions which are widely blamed for making it worse.

Overseas, the main private investors in Social Bonds are Goldman Sachs and Bank of America Merrill Lynch (John Key’s former employer), which both contributed to the Global Financial Crisis and the rising inequality which followed.

Here in New Zealand, the two firms looking to profit from Social Bonds are the ANZ Bank and Cranleigh, a merchant bank co-founded by National MP Andrew Bayly and his brother.

Neither of these companies are known for their efforts to reduce inequality, either.

Ideological tunnel vision

Social bonds are not the first reform of public services undertaken by the current government.

Privately owned and managed Charter Schools were established back in 2011, and in some cases are now nearing collapse. Prison management has been privatised, under the now-notorious Serco.

State houses are currently being privatised, and the prime minister has acknowledged a possible role for Serco.

He has also signalled the privatisation of parts of CYFS, and social development minister Anne Tolley said she had no problems with companies like Serco picking up contracts.

The fact that such a similar model is being used across widely varying sectors, and that reforms are being rushed through in quick succession, strongly suggests that the changes are not based on careful analysis of the specific needs of service users.

It looks a lot like a template of predetermined “solutions” is being placed over public services, regardless of their diverse characteristics and regardless of past failures.

The cabinet papers stress that “exit points” will be built into the Social Bonds schemes, allowing government to cancel contracts if goals of service improvement are not being met.

But as the crisis at Mt Eden Prison has demonstrated, admitting failure has a high political cost for the government. A month after catastrophic failures forced the Corrections Department to resume responsibility for running the prison, they still haven’t cancelled Serco’s contract.

This all adds to an appearance of tunnel vision, and an inability to contemplate alternatives to privatisation.

These are some of the reasons why the NZNO Mental Health Nurses Section supports the petition to Stop the privatisation of the mental health sector.