Overview

He aha te mea nui o te ao? He tāngata, he tāngata, he tāngata.

Mental health problems affect New Zealanders from all walks of life, with one in five people affected each year. Many people with serious mental illnesses also suffer chronic physical health conditions and many live shorter lives. Mental illnesses can also impact families, friends and care-givers, and communities. The personal, societal, and economic costs are high.

In November 2016, the Ministry of Health's Director of Mental Health reported that specialist mental health and addiction services are experiencing increasing pressure. Numbers have been increasing every year since at least 2003. In 2015, a record number of people, more than 160,000 or 3.5% of the population, used these services.

Of these, about 15,000 people needed to stay in an inpatient unit during 2015. District health boards spent more than $200 million providing care to mental health patients in hospitals. People who are admitted to a hospital-based inpatient unit for mental health problems are in greatest need of support. Supporting them is difficult and demanding, especially for those directly involved in delivering services, and requires the co-ordination of a wide range of health and broader social services. If the system fails in effectively supporting these people, there are huge implications for them, their families, and the health and other sectors. Getting it right is an investment with significant payback.

International evidence shows that good planning before a person is discharged from hospital to community support services is critical in effectively supporting people with mental health problems. When done well, "discharge planning" brings together a person's health and broader social needs and enables those needs to be met.

This report considers whether discharge planning is completed as intended, whether the needs identified are met after people leave hospital, and whether discharge planning is helping to improve outcomes for people. My staff analysed data for all district health boards, closely inspected practices at three district health boards, and considered the views of a broad range of people directly involved in delivering services.

We focused on people experiencing mental health problems acute enough that they were admitted to hospital. Although they are a relatively small group, their acute and often complex health problems mean that they can need a large amount of care and support from the country's health services.

Overall, the timeliness, quality, and effectiveness of discharge planning (and the associated follow-up work) are impaired by pressures on inpatient and community services and other factors. The extent of these pressures and how well discharge planning is done varies.

Some inpatient units have high occupancy rates – sometimes beyond their capacity – and in some places there is limited availability of community services, such as suitable accommodation, to discharge people to. In these circumstances, discharge planning can be late or incomplete, and may not involve everyone who needs to be included for it to be effective.

This means that people with mental health problems can be discharged from hospital without a plan for their broader needs, such as getting help with housing, their finances, or support from their employer or family.

In my view, improvements are urgently needed for discharge planning to be more effective in enabling better outcomes for people with mental health problems. The pressures on inpatient units and community services need to be addressed.

Most district health boards use a collaborative approach to discharge planning – they seek to involve the inpatient unit and community mental health teams, the person with the mental health problems, and that person's family. However, the extent to which different teams, the individual concerned, and their family are involved is variable and sometimes limited.

Follow-up with people after they had been discharged was also not as timely as expected. Nationally, district health boards follow up with only two-thirds of people within seven days. Their target is to follow up within seven days with at least 90% of people discharged after staying in hospital because of acute mental health problems. There are also barriers to discharge plans being implemented. People, especially those with complex needs, do not always have access to the services they require, including services outside the control of the health sector.

The mental health sector has made progress in recent years in using information to understand service performance and how to make improvements. However, there is more for the Ministry of Health and district health boards to do to make better use of information to understand what influences outcomes for people, including the effectiveness of discharge planning, and make service improvements. For example, more work is needed to systematically gather and use feedback from people using mental health services and those supporting them.

The mental health sector has started to take a more people-centred view in how it uses information to understand how well services are delivered. In my view, it can do more. My staff have been sharing the insights they gained from using the Ministry's data to map when and how people have been in contact with a range of acute mental health and other health care services. We took the concept, developed by people working in the health sector, and refined it to highlight its potential uses, which we have shared with people in the sector.

During the audit, my staff met with many people who are doing the best they can to provide the best mental health support services they can, despite obstacles and hurdles. These people are well aware that the consequences for people with acute mental health problems, their family, communities, and other agencies can be significant if discharge planning is not done well or discharge plans are not acted on.

The increasing demand for acute mental health services and the problems with co-ordinated support in the community are not new. In my view, the Ministry and district health boards need to urgently make demonstrable improvements to deliver better results for people with acute mental health problems.

Since we completed our fieldwork, the Ministry and district health boards have been working on changes to improve mental health service delivery, including to better support people in moving from inpatient units to community mental health services. The effectiveness of these changes is yet to be determined. On this occasion, I have decided to include, as an Appendix to my report, a letter from the Ministry of Health that outlines these changes. This is to provide an update and a reference point to help Parliament and the public hold the Ministry and district health boards accountable for delivering better results for people with acute mental health problems.

I thank the many people in the mental health sector who shared their views, information, and expertise with my staff as they carried out their work.

Nāku noa, nā

Greg Schollum
Deputy Controller and Auditor-General

25 May 2017