developing the mental health workforce - a report of the mental health workforce development...

Developing theMental HealthWorkforce

A report of the National Mental Health

Workforce Development Co-ordinating

Committee

JULY 1999

National Mental Health Workforce Development Co-ordinating Committee

Disclaimer

The authors of the reports have taken extreme care in the preparation of theinformation contained in this document. The National Mental HealthWorkforce Development Co-ordinating Committee does not accept any legalliability for any errors or omissions.

The document may be reproduced in whole or in part subject to theinclusion of an acknowledgement of the source.

Published by the National Mental Health Workforce DevelopmentCo-ordinating Committee, Wellington, July 1999

ISBN 0-477-01884-X


Foreword

The Mental Health Commission’s Blueprint identified in broad terms the size and type ofworkforce that would be required if the national mental health strategy were to be fullyimplemented, while the Funding Needed for Mental Health Services in New Zealand clearly speltout the funding and resource gap between what we have and what we will need to deliver on thestrategy.

It is patently clear that the primary impediment to achieving the national targets is the size and skillmix of the workforce. It is also clear that in some skill areas, the length of time required beforepeople can qualify and become effective in delivering services can be extremely long and evenexceed the planning period.

These observations underline the urgent need to prepare a practical, detailed workforcedevelopment plan so that dollars available can match the ability to provide and staff services.They also emphasise the need to put in place by the end of the current planning period, trainingprogrammes and incentives that will ensure a sustainable, adequate and balanced workforce.

This Committee has endeavoured to build on work done by others, particularly the Ministry ofHealth, and advance strategies in priority areas which will, in a practical way, begin to meet themental health service needs.

The Committee expected when it was first established to have two years to complete the work. Infact the Committee’s life was reduced to one year and every effort has been made to complete asmuch work of the two-year programme as it could in half the time.

I believe it has done well and this report should form a sound basis for any organisation, which isclearly needed, that will follow the Committee.

My profound thanks to the Committee members, in particular Margot Mains, CEO, MidCentralHealth who was chairperson for much of the Committee’s work. I would also like to recognise thehigh quality work of Marion Clark and the small team of contractors who supported theCommittee.

Bob HenareChairpersonNational Mental Health Workforce Development Co-ordinating CommitteeJuly 1999


Acknowledgements

The National Mental Health Workforce Development Co-ordinating Committee comprises thefollowing members.

Bob Henare Mental Health Commissioner (Chairperson)Margot Mains Chief Executive, MidCentral Health Ltd (Chairperson until August 1998)Barbara Anderson Chair, HOMES NZJane Cartwright Mental Health Director, Healthlink South Ltd (from July 1998)Mason Durie Professor of Maori Studies, Massey University (until May 1998)Karleen Edwards Senior Project Manager, Mental Health, HFA (from June 1998)Kath Fox National Director of Mental Health Services, HFA (until June 1998)Cheryll Graham Administrator, Wellington Mental Health Consumers Union (from February

1999)Jacqui Graham Joint Director, Pathways IncMadeleine Heron Mental health consumer (until January 1999)Murray Johnston Mental Health Manager, Capital Coast Health (until July 1998)John Matthews Consumer representative, Tai Tokerau, Mental Health Services, Northland

Health (from February 1999)Winston McKean General Manager, Clinical Training AgencyKarl Pulotu-Endemann Mental health consultantMike Sukolski Consumer Advisor, HFA (until December 1999)Rees Tapsell Psychiatrist, Mason Clinic, Waitemata Health Ltd (from May 1998)Cindi Wallace National President, Schizophrenia Fellowship (from May 1998)

Dr Janice Wilson Director of Mental Health, Ministry of Health, advisor to the Committee

The Committee wish to acknowledge the assistance of the following individuals, groups andorganisations who contributed to the development of the report, especially:

Manager

Marion Clark Managing Director, Clark Consulting Ltd

Contractors

Eve McMahon (Clark Consulting Ltd), Lesley Askew, Joanne Chiplin, Tutahanga Douglas,Bernadine Doyle, Dr Siale Alo Foliaki, Chas McCarthy, and Helen Potaka.

Bodies consulted

Health Funding Authority, Mental Health Commission, Ministry of Health, mental health serviceproviders, Clinical Training Agency, Alcoholic Liquor Advisory Council, professional regulatorybodies, health professional education providers, professional associations, and Pacific IslandsAdvisory Committee.


Table of Contents

1 Executive Summary 11.1 Background 11.2 Achievements of the Committee 21.3 The report 31.4 Environmental scan 31.5 Overarching strategy 41.6 Organisational effectiveness 61.7 Child and youth workforce 71.8 Maori workforce 81.9 Pacific Islands people’s workforce 101.10 The future 10

2 Introduction 112.1 Key problems 112.2 Recent progress 122.3 The National Mental Health Workforce Development Co-ordinating Committee 132.4 The report 16

3 Mental Health Workforce Development Environmental Scan 193.1 Executive summary 193.2 Introduction 203.3 General reports 213.4 Mental health reports 253.5 General mental health workforce 283.6 Other specific relevant reports 383.7 Specific skills required 44

4 Strategic Framework for Workforce Development: Competencies for the MentalHealth Workforce 55

4.1 Executive summary 554.2 Introduction 554.3 Preamble 564.4 Competence 574.5 Clinical experience/practice 584.6 Core competencies 584.7 Detailed competencies 624.8 Role of regulatory bodies 724.9 Strategic direction 72


5 Guidelines to Improve Workforce Effectiveness in Mental Health ServiceOrganisations 77

5.1 Executive summary 775.2 Introduction 775.3 Background 785.4 Characteristics of an ideal organisation providing mental health services 795.5 Strategic plan 825.6 Views of current mental health providers 855.7 Recommendations 86

6 Workforce Development for Child and Youth Mental Health Services 876.1 Executive summary 876.2 Introduction 876.3 Background 886.4 Workforce development for specialist child and youth mental health services 916.5 Framework for action 93

7 A Development Framework for the Maori Mental Health Workforce 1037.1 Executive summary 1037.2 Introduction 1037.3 Maori mental health workforce principles and goals 1057.4 Background 1067.5 Strategic framework for workforce development of the Maori 1077.6 Strategic issues and goals 107

8 A Development Framework for the Pacific Islands People’s Mental HealthWorkforce 117

8.1 Executive summary 1178.2 Introduction 1178.3 Background 1178.4 Guiding principles 1188.5 Pacific Islands mental health workforce requirements 1198.6 Issues 1248.7 Essential service components 1268.8 Strategic framework 1278.9 Conclusion 132

AppendicesAppendix 1: Terms of Reference of the National Mental Health Workforce Development

Co-ordinating Committee 135Appendix 2: Medical Practitioners in the Mental Health Workforce 1998 143Appendix 3: Nurses Working in the Mental Health Services 1998 151Appendix 4: Occupational Therapists Working in the Mental Health Services 1998 159Appendix 5: Registered Clinical Psychologists Working in Mental Health Services 1998 167Appendix 6: Maori Working in Mental Health Services 1999 175Appendix 7: Workforce Development and Training to Promote Recovery – Draft (Mental

Health Commission) 183

References 191


List of Tables

Table 1: Mental health workforce 1994 30

Table 2: Mental health workforce 1996 31

Table 3: Mental health post-entry clinical training volumes for 1999 36

Table 4: Skill clusters identified 47

Table 5: Basic core competencies 62

Table 6: Advanced competencies 65

Table 7: Specialist competencies 69

Table 8: Strategic directions 73

Table 9: Characteristics of an ideal organisation 79

Table 10: Plan to improve recruitment 83

Table 11: Plan to improve retention 83

Table 12: Plan to improve training 84

Table 13: Plan to improve research 84

Table 14: Staff development plan 85

Table 15: Recommendations for agencies 86

Table 16: Population of New Zealand children by age group, ethnicity and HFA region 89

Table 17: National co-ordination of child and youth workforce development 97

Table 18: Plan to co-ordinate overseas recruitment 98

Table 19: Plan to enhance capacity of the sector 98

Table 20: Plan to increase training and support opportunities for child and youth supportworkers 99

Table 21: Plan to increase the health professional workforce 100

Table 22: Plan to increase the number of child psychiatrists 101

Table 23: Plan to increase Maori staff 101

Table 24: Plan to increase Pacific Islands workers 102

Table 25: Plan to increase Maori working in mental health services 111

Table 26: Plan to increase the competence of the Maori mental health workforce 112

Table 27: Plan to increase access to Maori workers 112

Table 28: Plan to increase access to a range of services 113

Table 29: Plan to increase retention of Maori workers 113

Table 30: Plan to strengthen primary health service 114

Table 31: Plan to ensure continued access to workforce information 115

Table 32: Age structure of the Pacific Islands peoples and national populations (rounded) 118

Table 33: Increase Pacific Islands mental health workers 129


Table 34: Increase the competence of the Pacific Islands mental health workforce 130

Table 35: Upskilling current mainstream workers in Pacific Islands mental health issues 131

Table 36: National representation 131

Table 37: Development of a sustainable Pacific Islands workforce 131

Table 38: Define future Pacific Islands mental health services 132

Table 39: Active medical practitioners working in psychiatry 143

Table 40: Type of medical practitioner 144

Table 41: Ethnicity of medical practitioners working in mental health 144

Table 42: Gender of medical practitioners working in mental health 145

Table 43: Gender by type of medical practitioner working in mental health 145

Table 44: Graduation country of medical practitioners with a worktype of psychiatry bygender 146

Table 45: Specialists, MOSSs and registrars with a worktype of psychiatry by age groups1996 and 1998 146

Table 46: Employment setting of medical practitioners with a worktype of psychiatry1996 and 1998 147

Table 47: Medical practitioners with a worktype of psychiatry by employment setting1996 and 1998 147

Table 48: Medical practitioners with a worktype of psychiatry by detailed worktype 1996and 1998 148

Table 49: Medical practitioners with a worktype of psychiatry by geographical region 149

Table 50: Ratio of specialists, MOSS and registrars with a worktype of psychiatry byestimated resident population at 30 June 1998 149

Table 51: Total active registered nurse and enrolled nurse workforce 151

Table 52: Active registered nurses and enrolled nurses working in mental health 1994 to1998 152

Table 53: Ethnicity of active registered nurses working in mental health in 1996 and 1998 153

Table 54: Ethnicity of active enrolled nurses working in mental health in 1996 and 1998 153

Table 55: Gender of active registered nurses (RN) and enrolled nurses (EN) working inmental health in 1996 and 1998 154

Table 56: Age of active registered nurses and enrolled nurses working in mental health in1996 and 1998 154

Table 57: Employment setting for active registered nurses and enrolled nurses working inmental health in 1996 and 1998 155

Table 58: Active registered nurses and enrolled nurses working in mental health bygeographical region in 1996 and 1998 156

Table 59: Active registered nurses working in mental health per estimated residentpopulation at 30 June 1998 157

Table 60: Age and gender of active occupational therapists for the years 1994, 1996 and1998 160

Table 61: Ethnicity by number and as a percentage of the total active workforce 161


Table 62: Worktype by prioritised ethnicity for active occupational therapists in mentalhealth services 1998 162

Table 63: Worktype by main employment setting for active occupational therapists inmental health services in 1998 162

Table 64: Numbers of occupational therapists reporting that they work in acute psychiatryby employment setting 1994-1998 163

Table 65: Numbers of occupational therapists reporting that they work in continuing care(psychiatric) by employment setting 163

Table 66: Numbers of occupational therapists reporting that they work in rehabilitation byemployment setting 163

Table 67: Numbers of occupational therapists reporting that they work in community/domiciliary by employment setting 164

Table 68: Main worktype by geographic region for active occupational therapists 1998 165

Table 69: FTEs worked in main employment setting in each region for occupationaltherapists 166

Table 70: Number of annual practising certificate APCs purchased 167

Table 71: Sex by main worktype in clinical psychology, psychotherapy and counselling in1994, 1996 and 1998 169

Table 72: Worktype by age group of active registered psychologists 1998 169

Table 73: Worktype by prioritised ethnicity for active registered psychologists 1998 170

Table 74: Worktype by main employment setting for active registered psychologists 170

Table 75: Employment type by region of active registered psychologists working inclinical psychology in a CHE/HHS in 1998 171

Table 76: Main worktypes by region for active registered psychologists 1998 172

Table 77: Active registered psychologists in CHE/HHS main employment setting byworktype in each geographical region in 1998 and per estimated residentpopulation at 30 June 1998 173

Table 78: Maori workforce identified in the survey by Health Funding Authority regionand work type 179

Table 79: Maori mental health workforce by provider category and work type 180

Table 80: Maori mental health workforce by service type 180

List of Figures

Figure 1: The Maori mental health workforce by worktype and employment 176

Figure 2: Graph of identified Maori mental health workforce by HFA region 178

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1 Executive Summary

The Government has invested considerable resources over the past ten years in an effort toovercome the well-documented problems of New Zealand’s mental health services. It has becomeincreasingly clear that the skills, values, morale and attitudes of the mental health workforce havean enormous impact on the cost, quality and efficacy of the services. The importance of having theappropriate workforce to meet service plans has been highlighted by the difficulty in recruiting andretaining sufficient numbers of skilled, experienced staff to match the changes in the sector. Inparticular, the significant restructuring of the mental health services over the past 10 years, whilehaving many positive effects for the consumer, has led to fragmentation of services which, in turnhas weakened the accountability of the various agencies in addressing workforce development.

Key problems which have been identified in the mental health workforce include:

• lack of co-ordination in workforce development

• insufficient numbers of staff with certain skills

• unsatisfactory skill mixes

• inappropriate attitudes and values

• inappropriate training to deal with a changed delivery environment

• recruitment and retention difficulties.

1.1 Background

In 1995 Janice Wilson, Director of Mental Health, Ministry of Health set up a Working Party tolook at mental health workforce issues.

Since the Ministry of Health’s National Working Party reported, a number of initiatives have beenimplemented to progress the issues identified. In particular there has been increased Governmentspending on mental health. ‘Mason’ money, allocated by Government for mental health servicesand workforce development, has enabled the Health Funding Authority and the Clinical TrainingAgency to increase spending on the training of mental health workers, including support workers,nurses and psychiatrists. Massey University’s Te Rau Puawai Workforce 100 project, training inspecialist areas of mental health treatment such as dual diagnosis (combined mental health andalcohol and drug problems) and cognitive behavioural therapy are more recent examples.

The report of the Working Party recommended the establishment of a mechanism for nationalco-ordination of workforce development. This was followed in 1996 by the setting up of aninterdepartmental working group which brought together officials from the Ministries of Healthand Education to examine training programmes and set standards for them. In 1997 a SteeringCommittee was established as a joint venture between the Mental Health Commission, theMinistry of Health and the four former regional health authorities to develop an overall mentalhealth workforce strategy and to develop training standards for mental health workers.

The National Mental Health Workforce Development Co-ordinating Committee was established inearly 1998. The Committee’s purpose was to take responsibility for national co-ordination andleadership of workforce development, set targets, priorities and directions, and develop andimplement a framework which would satisfy the requirements of the Health Funding Authority’sNational Mental Health Funding Plan 1998-2002, the Ministry of Health’s Moving Forward andthe Mental Health Commission’s Blueprint.

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The composition of the Committee was determined after consultation with the variousstakeholders. It had a strong provider focus with representation from Hospital and Health Services(HHSs) at the chief executive and mental health manager levels, non-governmental organisations(NGO), consumers, families, Maori, Pacific Islands people, the Health Funding Authority (HFA),Mental Health Commission and the Clinical Training Agency (CTA). The Ministry of Health hadan advisory role to the Committee. The unique strength of the Committee was that it representedpolicy developers, providers and consumers committed to working together and sharinginformation to ensure that the mental health workforce is co-ordinated and more effective.Membership of the Committee focused on those delivering services rather than specific healthprofessional or specialist practice groups. The Committee was initially chaired by Margot Mains,Chief Executive Officer, MidCentral Health and subsequently by Bob Henare, Mental HealthCommissioner.

The Committee was funded by the HFA for an initial period of one year and this was managedthrough a contract with the Mental Health Commission.

1.2 Achievements of the Committee

The National Mental Health Workforce Development Co-ordinating Committee has built on whathas been done while focusing on dealing with the ‘gaps’ and developing a framework to addressissues in an ongoing way.

The presence of the Committee has significantly raised the profile of workforce developmentthroughout the sector. It has served as a catalyst for key agencies and service providers to focus onthe needs of the workforce as well as encouraging new workforce initiatives. The Committee’swork has been achieved through the work of project teams reaching out into the sector. Theworkplan comprised five projects. Two of these had an overarching strategic focus. The first wasto develop a strategic framework for the mental health workforce and the second to addresseffective organisational practices to recruit and retain staff. The remaining three projectsaddressed the workforce issues in the key priority areas of child and youth, Maori and PacificIslands people.

In addition the Committee has successfully brokered workforce solutions and influenced decisionmaking. For example, support provided for the Te Rau Puawai 100 project proposal which wassubsequently funded by the HFA; the instigation of the development of a national Pacific Islandsmental health workforce database; the establishment of a Working Party funded by the HFA todevelop training sessions and workshops on increasing the skills of Pacific Islands workers inmainstream services; and co-ordinating discussions on the organisation of a national meeting ofkey Pacific Islands stakeholders to define and specify mental health services for the sector.

For its first six months, the Committee took responsibility for running the StandardsImplementation Body, set up under the New Zealand Qualifications Framework to ensure qualityin the education programmes for mental health support workers. This activity included accreditingeducation providers to deliver the national certificate, monitoring existing programmes anddeveloping a system of moderation. The Health Funding Authority, through the Clinical TrainingAgency, took over this role in the second half of 1998.

Similarly, the opportunity to add a workforce perspective has led to the incorporation of aninnovative health professional training programme into a new South Auckland Pacific Islandpeople’s mental health service.

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As there was little information about the Maori mental health workforce the Committee conductedan extensive survey of existing Maori providers, the results of which can be used as a baseline toassess progress over the next few years.

The Committee in its submission to the Taskforce on Nursing endorsed comprehensive nursingprogrammes as the preparation for nursing registration and recommended entry to mental healthpractice follow a mandatory new graduate programme. As a result of the Committee’srecommendations, the Nursing Council was directed by the Minister to formally report on theoutcome of audits of the mental health component of nursing education programmes to theCommittee. This information will help the mental health sector to work with the Council onensuring that comprehensive nursing programmes meet the needs of the mental health consumers.

1.3 The report

The Committee was originally established for a two year period and devised its workplan based onthis timeframe. This report is one product of the Committee’s work and describes progress to dateon developing workforce plans and initiatives to address critical workforce issues. It presents acompilation of the work prepared for the Committee after an initial year of operation.

The material presented is in the form of ‘work in progress’ and reflects the planning of theCommittee after a year. The material was originally prepared in the form of working papers to theCommittee and not specifically for publication. As the work of the Committee was terminatedafter one year it was decided to publish the material to provide a useful resource document to thesector and to form a base for any replacement co-ordinating and planning body.

1.4 Environmental scan

An environmental scan was undertaken to bring together recent literature and other informationrelevant to mental health workforce development. Key conclusions identify that, contrary topopular opinion, there has been a great deal of attention paid to mental health workforcedevelopment over the past few years and considerable progress has been made. It is evident thatshortfalls in workforce numbers and skills are still the main contributory factors in the sector’sinability to provide safe and effective mental health services.

The three key mental health services planning reports (Moving Forward, Blueprint and theNational Mental Health Funding Plan 1998-2002) drive the type of workforce required and, asone might expect, specify the skill mix and likely composition of an effective workforce.

Government reviews in the tertiary education sector have major implications for education andtraining of the mental health workforce.

The need for increased kaupapa Maori services and increased access to mainstream services forMaori indicates a clear need for more skilled Maori mental health workers. A similar need,coupled with greater community involvement, is identified for services to Pacific Islands people.Changes in service delivery, with an increased emphasis on the recovery approach and increases inservices, have major implications for the skill mix and the requirement for a large increase inclinical and non-clinical staff numbers. Improvements in service quality (dual diagnosis, alcoholand drug service, child and youth), and a focus on specialist clinical skills and intersectoralworking (such as with the criminal justice system) will need revisions to training programmes.Increased numbers participating in psychiatry training programmes is already occurring, and the

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introduction of nursing post-entry and mental health support workers’ programmes represent majoradvances.

The development of a comprehensive workforce development plan requires accurate qualitativeand quantitative health workforce data. Gaps identified in the quantitative workforce informationavailable include:

• a lack of information on non-registered mental health workers (including voluntaryworkers)

• HFA workforce data which is collected as part of its contract monitoring is not routinelynationally collated and is incomplete

• national data from the education sector on training programmes and student numbers isvery difficult to access.

1.5 Overarching strategy

An initial priority was to develop an overarching strategic framework to guide subsequentworkforce development. To do this the Committee decided to focus on the competencies requiredfor a skilled workforce rather than on the individual numbers and specific requirements of healthprofessional groups. This approach, which is consistent with that of workforce developmentinternationally, was considered to be more useful to the sector as a whole and would encourage thedevelopment of a more flexible workforce.

To address the skill issue, a three-level model of core competencies (basic and advanced) andspecialist skills was developed.1 Based on current and future roles for people working in themental health service, they should be used by:

• educators in the development of education and training programmes

• regulators in the development of competencies required by applicants for registration andvalidation/accreditation of education programmes

• employers for provision of services, performance appraisals, personal development plansand design of career pathways.

Raising the standard of competence in the mental health workforce will require not only theapplication of the core competencies but also a sufficient number of appropriately trained teams ofmultidisciplinary workers. The key goals identified are the need to:

• upskill the current and future mental health workforce to address changes in mental healthdelivery eg. recovery model

• ensure the availability of adequate numbers of appropriately trained staff.

The core competencies were collated and developed from already published competency andstandards materials from a range of professional regulatory and non-regulatory bodies, theNational Qualifications Framework unit standards in Mental Health Support Work, and publishedand unpublished reports on New Zealand mental health services. They have not been developed toidentify a generic, multi-skilled mental health worker but rather to demonstrate that there are setsof core competencies which need to be demonstrated by all mental health workers, whatever theiroccupation or discipline, at different stages of their careers.

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The basic, advanced and specialist core competencies are set out in Tables 5, 6, and 7 in the chapter “Strategicframework for mental health workforce development: Core competencies and skills for the mental health workforce”.

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All mental health workers are expected to demonstrate the basic core competencies. The advancedcompetencies are included among the competencies and performance criteria expected at entry topractice of most health professionals who work in New Zealand’s mental health services. Therecovery approach is a dominant theme throughout.2

There is an expectation that all health professional practitioners (except medical practitioners) willbe able to demonstrate the advanced core competencies within 12 months of entry to practice inthe mental health services. House surgeons would be expected to be able to meet the advancedcompetencies at the end of their three-month clinical placement.

The additional mental health clinical professional skills required by individual professional groupssuch as occupational therapists, clinical psychologists, psychiatrists and nurses are expected to bedeveloped and monitored by the relevant professional groups. Some health professional groups,for example nurses and occupational therapists, have already developed and use competencies toguide professional practice.

Progression through the three core competency levels is dependent upon clearly proscribed andsupported post-entry and continuing education courses for all workers. Assessment of thecompetencies is the responsibility of employers, educators, regulatory bodies and consumers usingcriterion-referenced processes. If these bodies implement the action points set out in the strategicframework within the recommended timeframes, the Committee believes that the workforce willbe well underway to meet the needs of the mental health service.

The application of the core competencies in clinical practice will need to be regularly reviewed tomaintain relevance and content specificity. Their inclusion in education programmes, performanceappraisals and performance development plans, and standards for entry to professional practicewill require ongoing monitoring.

Upskilling alone will not meet the needs of the mental health service. An analysis of 1998 healthworkforce data reveals a number of significant workforce gaps in key clinical areas (Appendices 2-5).Overall there are low numbers of Maori and Pacific Islands people in all occupational groups, andan uneven distribution of psychiatrists, registered clinical psychologists and registeredoccupational therapists particularly in areas away from the main centres. The analysis alsoindicates an ageing workforce across all groups. For example, 15% of specialist psychiatrists areover 60 years of age. There have also been some areas of improvement, for example the registeredmental health nurse workforce has increased 13% since 1996, with an increased percentage ofmales.

To meet the Government’s aim in Moving Forward for more and better services, more people mustbe attracted to and retained in the wide range of services that work for mental health consumers.The recruitment and retention of a competent and skilled workforce is critical to the delivery of aquality service to consumers. In addition, patient care is enhanced where good workforce practicesare found at all levels throughout an organisation. The next phase of workforce development mustaddress recruitment and retention.

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Note that a paper from the Mental Health Commission is attached as Appendix 7.

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1.6 Organisational effectiveness

Workforce utilisation practices and issues were examined and analysed across a range of HHSsand NGOs in the preparation of the report on strategies to improve the effectiveness of the mentalhealth workforce.

Mental health service provision can be enhanced by effective workplace practices which ensurestaff perform at their optimum. Activities to destigmatise mental health need to be implemented.Services need to be structured to enhance the ability of staff to work in a way that encouragesrecovery in consumers. This needs collaboration and good links between services as well as staffallocation systems which are flexible to meet consumers needs. In particular, services should beorganised to:

• ensure that there is leadership and a vision upon which consumer care is focused, and thatthe organisation is structured to deliver this vision

• show clear lines of accountability

• improve the organisation’s culture of training, research and development

• improve recruitment and retention of staff to ensure excellence in practice

• support innovation

• proactively manage risk

• align individuals’ training and performance to agreed core work practice competencies.

Mental health service providers should also:

• foster liaison particularly where supervision is shared

• share common forms of in-service and other training, eg. workshops on service-relatedtopics by visiting speakers

• provide mutual mentoring at both an individual and organisational level

• support each other, especially larger or more established services assisting smaller ornewer groups to become established, eg. new specialist child and youth services, Maori orPacific Islands people’s providers

• negotiate and document transparent inter-agency case management processes.

While HHSs and NGOs are working and need to continue to work on local solutions based on theirpriorities, a number of effective activities have been identified to assist their processes. Theseinclude:

• collaboration for overseas recruitment through the establishment of a central agency

• multi-directional open communication channels between senior management and staff

• focused staff development programmes

• flexible staff management and working conditions

• effective utilisation of clinical expertise in multi-disciplinary teams

• collaboration with other providers over staff development training programmes andrelevance of course content

• promotion of a learning and research culture

• promotion of evidence-based practice

• an understanding of the implications of HFA contract and service specifications.

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1.7 Child and youth workforce

In recent years there has been greater recognition of the specific mental health needs of childrenand young people. This has led to an increased focus on expanding and strengthening servicesprovided for these groups across primary, secondary and tertiary services.

There are currently, in New Zealand, insufficient dedicated mental health services provided forchildren and young people. The level of services available falls significantly below the MentalHealth Commission benchmarks. While considerable effort is being invested in expanding andstrengthening the available services as a national priority, the greatest single barrier is the shortageof appropriately skilled clinicians to work in these services. The most critical shortages are childand adolescent psychiatrists and Maori clinicians.

Access levels to services, currently estimated to be at 1% for the age range adopted for theprovision of child and youth mental health services (0-19 years inclusive), are expected to increaseto 1.6% nationally by 2002. This level is still well below the national target of 3%. Maori have avery young demographic profile. They make up 23.3% of the child and youth population, with55.72% in the 0-9 age group. The population of Pacific Islands people is fast growing and has arelatively large proportion of children and young people. Pacific Islands children make up 7.5% ofthe child population, with 57% of these children 9 years and under.

Young people are more affected by mental health problems than those in any other age group.Although comprising only 7% of the population, they account for almost 12% of those who have amental illness requiring treatment.

There is a range of national programmes addressing aspects of child and youth mental health.These include the New Zealand Youth Suicide Prevention Strategy, the Strengthening Familiesproject and Special Education 2000 (SE2000). Each of these programmes includes workforcedevelopment components designed to enhance the understanding and capability of the communityto recognise and respond effectively to the needs of young people.

In order to maximise the benefits of the proposed service expansion workforce developmentinitiatives need to be prioritised so that they are aligned with funding plans and service provisionpolicy. Most services experience serious problems recruiting appropriately skilled and trainedstaff. Without co-ordination, leadership and commitment across the sector, this problem is likelyto increase significantly as further expansion in services occurs over the next three years. It is vitalthat any plan to expand the workforce recognises the different effects of short and long-termrequirements. In the short term, the focus is to obtain a critical mass of skilled clinicians to enablethe establishment and safe provision of services. The long-term focus is on the development of asustainable workforce that is broadly based and capable of providing excellent specialist mentalhealth services for children and young people.

To support the level of child and youth mental health services expected in the future, a number ofkey goals have been developed based on the following key issues:

• lack of national co-ordination and leadership

• limited capacity for the child and youth sector to provide clinical training opportunities

• shortage of experienced child and youth mental health clinicians across all professionalgroups

• critical shortage of child and adolescent psychiatrists

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• critical shortage of Maori workforce

• shortage of Pacific Islands peoples workforce

• limited opportunities for training and development of support worker roles

• lack of national co-ordination for overseas recruitment of clinicians.

The key goals, actions and their recommended dates for implementation are expected to ensure,that a skilled workforce is available to match service development in both the short and long term.

These include:

• the need for a nationally co-ordinated approach to child and youth mental health workforcedevelopment which is actively supported by all key agencies within the mental health andeducation sectors

• a robust child and youth mental health sector that is able to support and provide sufficientnumbers of high-quality clinical training placements for pre-entry and post-entry students

• pre-entry health professional training programmes that will prepare graduates to work asbeginning practitioners in child and youth mental health

• nationally available multidisciplinary post entry training programmes in child and youthmental health

• post-entry mental health speciality training programmes for mental health professionalsthat contain a child and youth component

• mechanisms in place to recruit and retain experienced clinicians in child and youth mentalhealth services

• the establishment of sustainable training programmes for child and adolescent psychiatristsin Auckland and Christchurch

• the development of sustainable Maori people’s workforce in child and youth mental healthservices to support mainstream child and youth mental health services that are safe andeffective for their Maori people consumers

• the development of sustainable Pacific Islands people’s workforce in child and youthmental health services to support mainstream child and youth mental health services thatare safe and effective for their Pacific Islands people consumers

• appropriately trained and supported cultural support workers in child and youth mentalhealth services

• access to consumer support networks for families and young people using child and youthmental health services

• national co-ordination and management of the recruitment of experienced child and youthmental health service health professionals from overseas.

1.8 Maori workforce

There are major disparities between the health status of Maori and non-Maori in the field of mentalhealth. To improve the status of Maori mental health requires a major focus on the Maoripopulation which experiences mental illness across the spectrum from mild to moderate to severe.For health gains to be achieved across the primary, secondary and tertiary mental health sectors,and in drug and alcohol services in particular, the availability of a sufficient highly competentMaori mental health workforce needs to be addressed.

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A telephone survey of Maori mental health service providers in early 1999, was designed todetermine the approximate numbers and skill mix of Maori working in mental health services inNew Zealand. Although it is an incomplete snapshot of the Maori mental health workforce, itprovides a picture of the current Maori mental health workforce and a benchmark against whichthe future Maori mental health workforce can be measured (Appendix 6).

The survey was undertaken over a three-month period and provides a ‘snap shot’ of Maori workingin mental health services at this time. The survey represents an 88.6% response rate. Of thesample obtained, 74.7% were employed on a full time basis and 25.3% part time. The Maorimental health workforce is made up of support workers, including Maori mental health workers,(45.9%); registered nurses (17.3%). The proportion of health professionals comprising socialworkers, psychiatrists, therapists, counsellors, psychologists, occupational therapists, and nurses inthe sample is 31.4%. The survey demonstrated a balance between mainstream services and Maoriservices. The major services where the Maori workforce are employed are residential services,adult community services, acute/sub-acute in-patient services and alcohol and drug services.

A strategic framework for the development of the Maori mental health workforce has beendeveloped with key issues and goals that can be addressed in a planned way. The goals areunderpinned by a number of guiding principles which include:

• Maori aspirations and goals for development

• education and training that is relevant to tangata whaiora needs

• educators and trainers who are experienced, skilled and knowledgeable in mental healthand working with Maori

• competencies which complement Maori health approaches

• incentives for training

• sustainable resourcing for training initiatives.

Key goals identified include:

• increasing the proportion of Maori working in mental health services to represent thenumbers of tangata whaiora using mental health services

• increasing the number of Maori mental health workers with essential mental health skillsand competencies

• increasing the numbers of trained Maori mental health support workers

• developing more and better mental health services for Maori in a range of settings

• providing tangata whaiora with a choice of mainstream or Maori clinical staff in clinicalsettings

• developing a competent Maori primary mental health workforce

• supervising and mentoring to support and retain the Maori workforce

• gathering relevant, timely and accurate data on the Maori mental health workforce tosupport workforce initiatives.

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1.9 Pacific Islands people’s workforce

Pacific Islands people’s migration to New Zealand began in the 1950s and accelerated dramaticallywith the economic boom of the 1960s and early 1970s. There is now a large population of PacificIslands people in New Zealand, with the largest concentration in the South Auckland region.Unemployment, low income, poor housing, breakdown in family networks, cultural fragmentationand rising alcohol and drug problems are having an increasing impact on the mental health ofPacific Islands people.

Increasing numbers of Pacific Islands people are accessing mental health services. They are facedwith the prospect of institutionalised work practices, staff who misread normal cultural behaviouras signs of illness, and mainstream health services that are well short of providing culturally safeand sensitive care for Pacific Islands people. In comparison with the national population thePacific Islands population has a relatively young age structure and lacks the higher proportion ofpeople over 60 years typical of the national population.

The most critical priority identified is the relative absence of an appropriately skilled PacificIslands mental health workforce.

Strategies to address the current deficiencies and establish long term mechanisms to improvenumbers and skills include:

• recruiting Pacific Islands people into health professional training programmes throughcareer awareness, financial incentives and mentoring programmes

• increasing the numbers of Pacific Islands mental health researchers and managers ofPacific Islands mental health services

• increasing the numbers of mental health support workers

• making available appropriate Pacific Islands clinical placements for students

• staff retention policies that support competitively remunerated Pacific Islands mentalhealth workers

• establishing a Pacific Islands people’s mental health forum and coalition of Pacific Islandsworkers.

1.10 The future

The final months of the Committee’s work saw increasing focus on what form of nationalapproach would best continue the work of the Committee and implementation of its strategies.The Committee’s view is that it is essential to establish an ongoing national mechanism tocontinue the momentum built up by the Committee, build on the work undertaken by theCommittee and implement its plans. It considers that such work requires a separate agency toensure national co-ordination and leadership and should be led by mental health providers.

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2 Introduction

The significant restructuring of the mental health services over the past ten years, while havingmany positive effects for the consumer, has led to fragmentation of services which, in turn hasweakened the accountability of the various agencies in addressing workforce development. Therehas been difficulty in recruiting and retaining sufficient numbers of skilled, experienced staff andinsufficient investment in the required training and upskilling of the workforce, which has laggedbehind the changes to service delivery. In particular, the education sector has been slow torespond to the training needs of the mental health workforce.

During the last few years the Government has invested considerable resources to overcome thewell-documented problems of the mental health services. The skills, values, morale and attitudesof the mental health workforce have an enormous impact on the cost, quality and efficacy ofmental health services.

2.1 Key problems

The following key problems have been identified in the mental health workforce.

2.1.1 Lack of co-ordination in workforce development

The major issue is that a number of organisations share interests in workforce development,including the Ministries of Health and Education, organisations concerned with the purchase andprovision of services, and professional organisations. However, fragmentation and lack of clarityabout roles and responsibilities reduce the incentives for each player to invest in the developmentof the workforce.

2.1.2 Significant shortages in numbers

The ability of providers to expand services in accordance with their business planning and serviceprovision contracts has been curtailed by the unavailability of a skilled workforce. It is apparentthat there is an ongoing need for continued development of the mental health workforce in orderfor the expansion of services to occur.

There are many factors contributing to the shortages. They include:

• difficulty in attracting people to work in mental health, particularly among healthprofessionals who are trained in the general health sector rather than specific mental healtharea (such as nurses, doctors and social workers)

• difficulty in retaining experienced clinical staff because of the stress of working in thesector and employment practices, among other factors

• shortage of appropriate training programmes to prepare people to work in mental health.

2.1.3 Skill shortages

The significant restructuring of mental health services and changes in the delivery of services havenot been matched by relevant changes in competencies. Individual health providers have beenunable to influence the education sector to be more responsive to mental health sectorrequirements. This has resulted in both a shortage of relevant programmes able to provide thecompetencies required for mental health work and discrepancies between the actual skills required

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and content of curricula. There is also limited scope for re-allocating education resources to bettermeet the demands of the sector. Although the new tertiary education funding policy in 1999 withuncapped equivalent full time student (EFTS) funding will help the sector to address this, fundingfrom the health sector and the number of expert teachers available to support the training ofcurrent staff is limited.

Consequently, there are significant skill shortages at all levels of the mental health workforce. Forexample, there is a particular reliance on a largely untrained body of support workers to assistmental health consumers in a range of accommodation/residential and community settings on aday-to-day basis.

2.1.4 Inappropriate attitudes and values

The negative ‘stigma’ associated with mental illness has contributed significantly to low morale,high turnover, and difficulty attracting and retaining people to work in the sector. It also can leadto the possession of discriminatory attitudes towards their client group.

Service delivery has over the last few years moved towards providing consumer-focused care andsupport in a way which aids recovery through empowerment of the consumer. The correspondingshift in attitudes and values needed to implement these changes successfully has not occurred tothe extent required. There has been on-going concern that limitations in the skills, numbers andutilisation of the mental health workforce are restricting the ability of the service to improve andexpand. In order for planned service growth in the mental health sector to be achieved it must bematched by a growth in numbers and in the development of fundamental competencies in theworkforce, including the components of recovery education. This requires significant investmentin training by all relevant agencies.

2.2 Recent progress

In 1995 Janice Wilson, Director of Mental Health, Ministry of Health, established a Working Partyto look at mental health workforce issues. The report of the Working Party3 identified the need fora national co-ordination mechanism. This idea was further developed in 1997 by a strategy projectteam led by the Mental Health Commission.

Since the Ministry of Health’s National Working Party reported, a number of initiatives have beenimplemented to progress the issues identified. In particular there has been increased Governmentspending on mental health. This includes:

• an additional $65 million ‘Mason’ money allocated to investing in mental health servicesand workforce development

• investment by the HFA in the development of a national certificate for mental healthsupport workers:

– in supported training programmes and individual providers to release staff for training

– recently, in support for Massey University’s Te Rau Puawai Workforce 100 project toaccelerate Maori professional participation in the health workforce over a five-yearperiod

3 Ministry of Health, 1996. Towards Better Mental Health Services: The report of the National Working Party on

Mental Health Workforce Development. Wellington: Ministry of Health.

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• increased spending by the Clinical Training Agency on the training of psychiatrists, nursesand other mental health professionals. This includes training in specialist areas of mentalhealth treatment, eg. dual diagnosis (combined mental health and alcohol and drugproblems) and cognitive behavioural therapy.

In May 1997 the Mental Health Workforce Development Steering Group was established as a jointventure between the Mental Health Commission, the Ministry of Health and the four formerregional health authorities to:

• develop an overall mental health workforce strategy to ensure the availability of a mentalhealth workforce which is appropriately educated and trained, and of sufficient numericalstrength to achieve the long-term planning objectives of the central agencies

• develop training standards for mental health support workers.

By December 1997, unit standards had been developed for a one-year National Certificate inMental Health (Mental Health Support Work). These were registered on the NationalQualifications Framework by the New Zealand Qualifications Authority (NZQA) in February 1998and launched by the Minister of Health. This has been a major achievement which has led to thedevelopment of approximately 16 training programmes for the previously untrained mental healthsupport workers.

Work undertaken on behalf of the steering committee indicated strong support for urgent, practicalsteps to be taken at the national level to address the issues, facilitate change and instigatemovement forward. This was seen to be particularly important given the major reforms to thetertiary education sector planned over the next few years and the planned shifts in mental healthservice delivery to fully implement a recovery model focus. The development of the nationalcertificate clearly demonstrated the benefits which can be achieved from effective workingbetween the industry and other critical players.

2.3 The National Mental Health Workforce Development Co-ordinatingCommittee

The National Mental Health Workforce Development Co-ordinating Committee was designed inDecember 1997 and established by February 1998. Its main purpose was to take responsibility fornational co-ordination and leadership of workforce development; to set targets, priorities anddirections; and to develop and implement a framework which would satisfy the requirements of theHFA’s National Mental Health Funding Plan 1998-2002, the Ministry of Health’s MovingForward and the Mental Health Commission’s Blueprint.

The Committee had the support of the Hon. Bill English, Minister of Health and all the leadingagencies involved in mental health services. A co-ordinating mechanism was seen to be requiredfor a period of two years, and the work of the Committee was planned with a focus on short-,medium-, and long-term priorities. The HFA agreed to fund its work for an initial period of oneyear. The Mental Health Commission accepted accountability for the work of the Committee bycontracting to the HFA on behalf of the Committee.

The national co-ordinating mechanism was seen as an interim measure. It was envisioned that thenew body would act as a ‘broker’ and that mental health providers would subsequently take overthis role. The Committee’s focus was to ‘kick start’ effective workforce development strategiesand co-ordination until contracts between funders and providers are longer term and morecollaborative, information channels are clearer, responsibilities for wider health workforce

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development have been clarified, and tertiary education reforms have addressed allocationproblems.

The composition of the Committee was determined after consultation with the variousstakeholders. It has a strong provider focus with representation4 from the HHSs at chief executiveand mental health manager levels, the NGO sector, consumers, families, Maori, Pacific Islandspeople, the Health Funding Authority, Mental Health Commission and Clinical Training Agency.The Ministry of Health undertook an advisory role. The unique strength of the Committee is that itrepresents policy developers, providers and consumers committed to working together and sharinginformation to ensure that the mental health workforce development is co-ordinated and moreeffective. It has also provided a single reference point for mental health workforce development.The Committee was initially chaired by Margot Mains, Chief Executive Officer, MidCentralHealth and subsequently by Bob Henare, Mental Health Commissioner.

With its broad skill base, the Committee has been able to draw on the considerable expertise of itsmembers. The involvement of key stakeholders has ensured that it has been fully informed, andthat goals and strategies have been shared. Its strong provider focus has been considered crucial toits success, as providers best understand the factors which influence recruitment and retention ofstaff with the skills, attitudes and knowledge required in the mental health sector.

Membership of the Committee focused on those delivering services rather than specific healthprofessional groups or representatives of specialist practice areas. To ensure the Committeeaccessed appropriate specific professional and specialist input it established working relationshipswith health professional groups through professional colleges and associations. The Committeeworked with the alcohol and drug sector through representation on the ALAC sponsored Alcoholand Drug Treatment Workforce Development Group.

A strength of the Committee was it offered a workable model for consumers and families,incorporating consumers’ views into its work.

2.3.1 Achievements of the Committee

The Committee developed an operating plan and has focused on five major projects consistentwith HFA priorities, with completion planned for May 1999 when the current funding was tocease. In order to achieve some quick solutions as well as develop a basis for the ongoing settingof priorities, the Committee agreed to a mix of strategic analysis and short-term initiatives. Itdecided on a mixture of overarching strategic issues and specific workforce priorities. Itsobjectives for the year were to develop:

• a strategic framework for the mental health workforce

• guidelines to improve effectiveness of the workforce in mental health organisations

• a plan to increase the workforce in child and youth services

• a strategic framework for increasing the Maori mental health workforce

• a plan to increase the Pacific Islands people mental health workforce.

As well as these key objectives, the Committee has provided leadership to the sector by workingwith it to address emerging or topical issues. As all the key stakeholders were represented on theCommittee, it helped to ensure that workforce development efforts were aligned and given priority.The Committee has used a range of approaches to working with the mental health sector. Thesefocused primarily on reaching-out into the mental health sector through the work of the projectsand formal strategies, including preparing submissions to Government. The Committee provided

4 See Appendix 1 for list of members.

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leadership to the Standards Implementation Body for Mental Health Support Work in its earlystages.5

The Committee, through its various members and project teams, has successfully stimulated a widerange of initiatives in workforce development with others still in progress. It is difficult to assessaccurately the full extent of the influence achieved by the Committee. However, since theCommittee’s inception each of the key central agencies has actively focused on mental healthworkforce development. The various projects of the Committee have been fed in to otheragencies’ projects so that workforce development was aligned. Examples of this are the workingtogether of the HFA and Committee on the Maori workforce project, the alignment of the MentalHealth Commission’s child and youth workforce development work and Pacific Islands projectswith the use of the same teams. An example of the Committee’s work is in the support providedfor the Te Rau Puawai 100 project proposal which was subsequently funded by the HFA.

The Committee prepared a submission to the 1998 Ministerial Taskforce on Nursing, in which itendorsed the appropriateness of comprehensive nursing programmes as the preparation for nursingregistration and recommended further mandatory preparation for entry into mental health nursing.The Committee’s recommendations were accepted by the Taskforce and, as a consequence, theNursing Council is formally reporting on the audit of the mental health component of nursingeducation programmes to the Committee.

A priority for the Committee has been the development of a competency framework for the mentalhealth workforce. Integral to the framework is the incorporation of competencies to promoterecovery approaches. Work developing core competencies for the alcohol and drug workforce hasbeen undertaken in conjunction with the Alcohol and Drug Treatment Workforce DevelopmentAdvisory Group.

The Committee has analysed available data on the psychiatry, nursing, clinical psychology andoccupational therapy mental health workforces. These reports are included in the appendices tothis report.

In the key priority area of child and youth mental health workforce a number of initiatives havebeen instigated through the Committee. These include promotion of the development of guidelinesfor practitioners working with youth where there is also drug and alcohol use or abuse. Exploringthe feasibility of developing a distance learning model for training clinical psychologists andothers in working with children and young people with mental health problems.

The Clinical Training Agency has recently agreed to fund the positions of Director of Training inpsychiatry at both Auckland and Christchurch child and adolescent training programmes. Theformal establishment of these positions with a focus on national recruitment and training ofpsychiatrists should improve the number of trainees and quality of the child and adolescentpsychiatry training programmes.

The Committee found that there was little information about the Maori mental health workforce,so has conducted an extensive survey of it to enable some assessment of progress over the next fewyears. An environmental scan was completed on the present status of Maori mental healthworkforce development.

The Pacific Islands people project team, through successfully working with providers andeducators, has facilitated the development of a shared training initiative to place students in healthprofessional training programmes with a Pacific Islands mental health service. The service is

5 Responsibility passed from the Committee to the Clinical Training Agency in July 1998.

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especially interested and focused on providing a good learning environment to attract thesegraduates into mental health. This model seems likely to be effective in other parts of the country,and initial discussions provide positive indications of take-up elsewhere.

The Committee also instigated the development of a national Pacific Islands mental healthworkforce database; established a working party, funded by the HFA, to develop training sessionsand workshops on increasing the skills of Pacific Islands workers in mainstream services andco-ordinated discussions on the organisation of a national meeting of key Pacific Islandsstakeholders to define and specify mental health services for the sector.

The final months of the Committee’s work saw increasing focus on what form of nationalapproach would best continue the work of the Committee and implementation of its strategies.The Committee’s view is that it is essential to establish an ongoing national mechanism tocontinue the momentum on workforce development, build on the work undertaken by theCommittee and implement its plans. It considers that such work requires a separate agency toensure national co-ordination and leadership and should be led by mental health providers.

2.4 The report

This report presents a compilation of the work prepared for the Committee after an initial year ofoperation. The purpose of the Committee has been to progress mental health workforcedevelopment issues. The Committee was originally established for a two-year period and devisedits workplan based on this timeframe. The material presented is in the form of work in progressand reflects where the Committee had progressed to after a year. The material was originallyprepared in the form of working papers to the Committee and not specifically for publication. Asthe work of the Committee was terminated after one year, it decided to publish the material toprovide a useful resource document to the sector.

The report begins with a summary of the recent literature and other information relevant to mentalhealth workforce development and subsequent chapters present the work from each of the projects.Each chapter provides an analysis of the issues relevant to that sector, identifies strategic issues,sets goals to address them, and identifies action points with suggested timeframes within whichthey should be achieved.

Chapter Three presents a strategic framework for mental health workforce development. Thisframework is developed around the identification of competencies for all people working in mentalhealth. The Committee identified the basic competencies needed by all workers, the advancedcompetencies needed by experienced mental health workers, particularly health professionals, andthe specific competencies needed by workers in specialty areas of mental health. The competencyframework is intended for use by regulators in setting standards for education, by educators indesigning curricula, and by managers for performance measurement and staff development.

Chapter Four presents recruitment and retention strategies for improving the employment of themental health workforce in organisations, including the importance of developing and maintaininga culture focused on training and research.

One area, which has been identified as an urgent priority, is child and youth mental health.Chapter Five presents an analysis of the workforce issues in that area, the most critical of which isthe sheer size of the shortfall between the current workforce and that needed to meet servicetargets over the next five years. Meeting that shortfall will be a major challenge and a range ofappropriate training will be required to develop clinical expertise for working effectively withyoung people so that early intervention can reduce the mental health problems later on. The

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Committee suggests a range of key strategies and has also worked with the sector to facilitate thedevelopment of some innovative approaches to the workforce training required.

Maori mental health is a further priority. A strategic framework has been developed and prioritystrategies identified. The Committee, along with other key stakeholders, has strongly advocatedfor increased training places, and has been delighted to see funders support some major initiativesthis year, which will produce strong ‘pay-offs’ in the future. The University of Auckland schemeto attract and support Maori and Pacific Islands students into their health science courses and theMassey University programme for Maori-focused health professionals are very importantinitiatives.

Pacific Islands people’s mental health is another priority addressed by the Committee. It is criticalthat the number of Pacific Islands people working in mental health increases so that Pacific Islandsconsumers have better access to appropriate services.

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3 Mental Health Workforce DevelopmentEnvironmental Scan

3.1 Executive summary

This report summarises the key recent literature and other information relevant to mental healthworkforce development.

Key conclusions from the literature are:

• a lot of attention has been paid to mental health workforce development over the past fewyears as it has become increasingly obvious that the desired service development cannot beimplemented because of workforce deficiencies and lack of skilled staff, for example,workforce deficiencies have been cited as the major contributory factor in the HFA’sinability to meet expenditure targets for ‘Mason’ funding

• there have been some important initiatives over the past few years (such as development ofnational qualification and unit standards for support workers and increasing postgraduatenursing programmes). Remaining barriers to achieving objectives include difficultyattracting and retaining staff, and difficulty influencing the education sector to provideenough programmes with appropriate content.

• the Government is currently carrying out major reviews of the way the tertiary educationsector is organised and funded. This will have significant implications for mental healtheducation and training.

• mental health services are under intense scrutiny, as the need for improvement is urgent.The three current planning reports (Moving Forward, Blueprint and the HFA NationalMental Health Funding Plan 1998-2002) have major implications for the type ofworkforce required. Some key issues to address are:

– the need for increased kaupapa Maori services and increased access to mainstreamservices for Maori indicates a high priority for Maori workers both in terms ofnumbers and skills. Training for Maori needs to include kaupapa Maori as well asmental health understanding and skills.

– changing service emphasis to early recognition and intervention and rehabilitativemodels of care will require different skills in the workforce

– increasing services, particularly community-based services (for adults and children,young people and families) will have major staffing implications. Both a differentskill mix and a large increase in clinical and non-clinical staff will be required.

– improved service quality (dual diagnosis, a focus on specialist clinical skills such aspsycho-social therapies, and intersectoral working such as with the criminal justicesystem) will need different training programmes and competencies. Specific skillsneeded include clinical skills (such as psycho-social therapies, risk assessment andmanagement, and specific sub-specialty clinical skills in areas such as drug andalcohol, child, adolescent and family, and dual diagnosis) as well as skills in areassuch as early recognition of symptoms, early intervention, working with families,cultural awareness and assessment.

– expansion of Pacific Islands people’s services will need increased numbers andtraining of Pacific Islands people to provide culturally specific services.

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• ensuring the principles of recovery education are incorporated into all generic, post-graduate and specialty health professional training. The skills required will differdepending on each professional role.

• training levels have been increasing over the past few years with a wider range of coursesbeing delivered. However, uneven regional distribution of programmes and access ismarked. There is also maldistribution of training resources where allocations do notnecessarily match mental health priorities. Training programmes need to be increased andmade more accessible. Collaboration between health and education providers needsstrengthening.

• numbers in psychiatry training appear to have increased. The challenge will be to retainthese trainees in the mental health workforce long term.

• the introduction of nursing postgraduate education programmes has been very useful.These need to increase to support planned service initiatives. There is a particular need forsufficient new graduate programmes to provide access for all nurses entering mentalhealth, advanced postgraduate education programmes and a major increase in shortspecialist clinical programmes.

• more education and support for consumers as workers in mental health is indicated. Thenew national certificate for support workers is expected to contribute to this.

• there are gaps in the quantitative workforce information available, for example:

– there is little information on non-registered staff numbers

– the HFA collects workforce data as part of its contract monitoring but it is notroutinely nationally collated and is incomplete

– national data from the education sector on training programmes and student numbersis very difficult to collect. The Ministry of Education does not collect such dataroutinely in enough detail for it to be useful.

3.2 Introduction

The National Working Party on Mental Health Workforce Development, set up by Janice Wilson,Director of Mental Health, in 1995-96, thoroughly reviewed workforce issues pertaining tosecondary mental health services and reported to the Minister in March 1996. This report iswidely used and some of the recommendations have been implemented. It is a key report, and it isimportant that the mental health services build on the work undertaken by the Working Party.

Since then an Interdepartmental Working Group of the Ministries of Health and Education hasworked together to address some of the issues raised in the report.

Some important progress has been made since the Working Party reported. Achievements include,but are not restricted to:

• the injection of extra funding from the Government specifically for post-entry clinicaltraining in mental health (initially $2.4 million) (Government)

• the further identification of workforce development as a priority for extra ‘Mason’ fundingby Government (Government)

• the expansion of training for new graduate nurses; development of programmes foradvanced nursing training; and an increase in the number of psychiatrists trained (ClinicalTraining Agency)

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• the development and funding of other specific training programmes (eg. dual diagnosis,cognitive behavioural therapy) (Clinical Training Agency and HFA)

• the development and application of specifications for psychiatrist training (ClinicalTraining Agency)

• the identification of core basic competencies in mental health for new graduate nurseswhich have been incorporated by the Nursing Council into requirements for initialregistration (Ministry of Health and Nursing Council)

• the development of a national certificate qualification for mental health support workerswith a set of unit standards registered on the National Qualifications Framework with apotential eight or nine programmes to be offered in 1998 (led by HFA and Ministry ofHealth).

3.3 General reports

The education sector has recently reviewed how tertiary education and industry training areorganised and funded. The results of these reviews will have important implications for mentalhealth.

3.3.1 Tertiary Education Review White Paper

The Government in November 1998 released a White Paper on tertiary education and training. Itoutlines the decisions made following the release of the Tertiary Review Green Paper inSeptember 1997 and resourcing policy announced at the time of the 1998 Budget. It includesindicative legislation needed to give effect to government decisions.

The White Paper outlines policies for resourcing, quality assurance, research, informationrequirements, and governance and accountability arrangements for public tertiary educationinstitutions.

From 1999, all students studying for quality assured qualifications taught at viable New Zealandtertiary providers (public or private), will receive taxpayer support for their study – the UniversalTertiary Tuition Allowance. There will be no limit on subsidised student numbers. The subsidywill also apply to courses run in New Zealand by overseas providers, as long as they are physicallysited in New Zealand and meet quality assurance and other requirements of New Zealandproviders. Currently, this policy will not extend to subsidising New Zealand students studyingoverseas.

The Universal Tertiary Tuition Allowance will subsidise all students for the duration of theirtertiary study, regardless of age. There will be no limit on the number of student places theGovernment will subsidise.

Mental health workers at all levels will benefit from these changes, as they will be subsidised inthe same way wherever they enrol. Increased participation and achievement is expected of under-represented groups such as Maori and Pacific Islands students. In addition, new informationstructures and systems will be introduced to achieve, amongst other goals, the provision of qualityinformation so that students can make wise decisions about what and where to study.

A new quality assurance system will ensure that all publicly funded New Zealand qualificationsmeet appropriate quality tests. A new overarching regulatory body – the Quality AssuranceAuthority of New Zealand (QAANZ) – will have overall responsibility for maintaining the qualityof publicly subsidised/funded tertiary education. Interim recognised quality validation processes

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will be those currently operated by the New Zealand Qualifications Authority (NZQA), the NewZealand Vice Chancellors Committee (NZVCC) and the Association of Polytechnics in NewZealand (APNZ). NZQA will be repositioned and renamed Quality Validation Services and willhave as its main focus the validation of the quality of qualifications and providers.

The Government wants to see the regional network of vocational and applied educationalopportunities continue. Base grants for public tertiary institutions may be replaced by a specialfund to assist the long-term viability of high-risk institutions and sustain widespread provision oftertiary education. Courses with higher costs, such as medicine, will continue to be subsidised athigher rates. Consideration is to be given to the ‘uncapping’ of some high-cost courses over time.

The availability of regional training opportunities is important for mental health support workerand nurse training. New monitoring and accountability arrangements will be introduced to enableGovernment to recognise and address problems in public tertiary institutions.

The review recognises that research is inextricably linked to learning in the higher-level tertiaryeducation environment. Research funding will be allocated through subsidy top-ups and acontestable pool. The contestable research pool will support new innovative research as well asestablished researchers. It is important to note that the fund will not replace other existing sourcesof Government research funding, such as the Public Good Science Fund, the Marsden Fund, andHealth Research Council funding. It will be targeted at basic or pure research. The new systemfor allocating research resourcing will be reviewed in 2001. The final arrangements/policy settingsfor tertiary review are under consideration.

The requirement that degree providers carry out research has been examined and will be furthercomprehensively reviewed by 2001, taking into account experience with the new quality assuranceprocesses. Government wants to continue the wide variety of opportunities for degree-leveleducation at many different institutions throughout New Zealand that has developed over recentyears.

An education strategy for Maori is being developed by the Ministry of Education and Te PuniKokiri. It aims to raise Maori education levels to match those of other New Zealanders. Initialemphasis is focused on compulsory education, and will expand to include tertiary education.Under the new resourcing system, tertiary providers are given strong incentives to attract newstudents, including Maori, and to retain them through to the completion of their qualification.

3.3.2 The National Qualifications Framework Green Paper

The National Qualifications Framework (NQF) Green Paper proposes an inclusive framework ofqualifications that meet four criteria:

• minimum quality

• clearly stated outcomes

• specified level (corresponding to 1-8 on the current NQF)

• credit value.

Registration of a qualification on the NQF would be conditional on an approval agency attestingthat the qualification met the four criteria. The requirement that an Industry Training Organisation(ITO) or a national standards-setting body develop qualifications is relaxed.

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The NQF Green Paper proposes that, over time, NZQA would delegate its approval role whereappropriate, and assume a monitoring overview monitoring role of approval agencies (NZVCC andothers that may be recognised).6

As an interim measure, the NQF Green Paper proposes that non-NQF qualifications, which havealready undergone external quality assurance processes, would receive immediate registration onthe inclusive NQF. These qualifications, which could include current university degrees andsenior secondary school national examinations (eg. bursary), would not need to be in unit standardformat. The proposals if adopted would allow non-unit standard-based qualifications developed byproviders (including tertiary education institutions) to be registered on the NQF. These would bein addition to unit standard based qualifications being developed for the senior secondary schools(eg. National Certificate in Educational Achievement), and by ITOs and other national standardssetting bodies.

3.3.3 Towards a Strategy for the Education and Training for the Health andDisability Sector

This report by the Committee Advising on Professional Education (CAPE) in 1997 is aconsultation document reviewing the state of health sector workforce development. Despite itswide focus the report does identify the need for mental and Maori health sectors to develop theirown workforce strategies.

CAPE acknowledges that the mental health area should be scrutinised as a possible role model orpilot programme for any wider health initiatives.

Following its consultation with the health and education sectors CAPE made recommendations onthe future strategic policy direction for the education and development of the health sector’sworkforce.

3.3.4 Crown Health Enterprise (CHE) sector response to CAPE discussiondocument

This is a response7 to wider health workforce development issues but the points made are highlyrelevant to the mental health sector. The CHE perspective on workforce concerns is also relevant.CAPE views mental health workforce development initiatives currently underway as having auseful pilot role.

The CHEs strongly support a more collaborative and co-ordinated approach to education andtraining, including a nationally co-ordinated workforce ‘planning’ system. Their submission notestheir concern that workforce development can be ‘lost’ among other priorities. They agree thatimproved co-ordination at national level is required to involve stakeholders, co-ordinateinformation, commission or conduct reviews, make recommendations, and so on.

The CHEs note the current system is distinctly unclear about assigning responsibility andaccountability for the appropriate planning, funding and delivery of education and training.

6 The Tertiary Education Review White Paper, November 1998, establishes the Quality Assurance Authority of New

Zealand (QAANZ) to undertake this role. Progressively, NZQA’s other activities (eg. development of unit standards)will be transferred to other bodies.

7 Correspondence between the Crown Health Association and Chairman of CAPE dated 4 July 1997.

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The largely compartmentalised approach to workforce issues by different sectors, and professionalgroups has resulted in a lack of co-operation and consultation on such things as student/traineenumbers, curriculum development and programme reviews. In the absence of an effectiveworkforce development mechanism, the various stakeholders in education and training have beenrelatively free to carve out their territory. This appears to have been the major catalyst behind thedegree of compartmentalisation of education and training in the health sector.

3.3.5 Education and Development of the Health and Disability Workforce:Recommendations from CAPE’s consultation with health, disability andeducation sectors

This report (CAPE, 1997) makes recommendations to Government following consultation with awide range of organisations and individuals involved in health, disability and education services.It has identified similar key issues to those identified in mental health:

• inadequate attention in Government’s health strategies to workforce education anddevelopment

• a preoccupation with short-term financial and service issues by providers and funders tothe detriment of investment in human capital

• the lack of an overall perspective in the allocation of public funds for education in thehealth and disability sector

• the lack of continuity between pre-entry, post-entry and continuing education

• the compartmentalisation of professions, which inhibit innovative service delivery

• the very low percentage of Maori in the health workforce, and deficiencies in other areas,especially mental health

• a lack of consensus on future directions and workforce requirements.

It recommends that the Government embody the following goals for the development andeducation of the workforce in its future health strategy:

To develop and maintain a highly skilled workforce and a network of learningorganisations able to respond to changing requirements and provide world-classservices directed to improving the health, safety and independence of New Zealanders.(p.2)

The report recommends the preferred way forward is to establish a Crown Owned Entity with asmall secretariat. Its approach would be to devolve as much as possible away from the centre. Theproposed Health Education Agency (HEA) would have four primary functions:

• co-ordinate strategy for, and funding of, education and development of the workforce

• encourage the development of learning organisations and networks of co-operation

• promote improvements in the quality of education

• advise on educational aspects of broader policy.

If this recommendation is not adopted, it suggests strengthening the role of the Ministry of Health(or the HFA). They would need, however, to make workforce issues a greater priority.

Government has not adopted these recommendations.

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3.3.6 Report on a Health Industry Training Organisation

In 1995 Godfrey Durham was contracted by the Education Training and Support Agency (ETSA)to develop a plan for a health Industry Training Organisation (ITO). The proposed Health IndustryStandards and Development Organisation (HISDO) was structured with a central board, underwhich would sit four committees responsible for ‘federation management’ and official industryliaison with NZQA. Within these, Sector Standards Groups (SSGs) representing particular sectors,professions or service areas would take responsibility for workforce development in their areas.

HISDO failed to gain widespread approval from the health sector, and it now seems unlikely thatany ITO structure purporting to represent the health sector will be supported.

3.4 Mental health reports

This section summarises the findings of recent relevant reports on mental health services, andparticularly those that mention workforce issues.

3.4.1 Moving Forward, 1997

In 1994 the Government released its mental health strategy. Its main thrust is towardscomprehensive and integrated community-based mental health services. There is special emphasison development of services for Maori, and more recent policy decisions have placed priorities onchild and adolescent mental health services. The strategic plan was updated in 1997 by theMinistry of Health. The goals of Moving Forward are:

• to decrease the prevalence of mental illness and mental health problems within thecommunity

• to increase the health status of, and reduce the impact of mental disorders on, consumers,their families, caregivers and the general community.

The plan provides national objectives for years 4-10 of the mental health strategy and gives stepsalong the way to achieve them. Seventeen principles underlie Moving Forward, 14 identified inLooking Forward (Ministry of Health, 1994) and three additional principles. The list includes:empowerment, full participation, better service specification, Maori involvement, consistent safetystandards, cultural safety, access, best possible outcomes, personal dignity, minimal disruption,sensitivity, cost effectiveness, integration, rights of people, increased control (by individuals,families and communities), supportive social environments, and intersectoral activity. Greaterattention to developing the mental health services infrastructure has been provided through anadditional strategic direction. This includes a specific emphasis on workforce development andperformance targets set by the funding/purchasing body for contracting with providers forworkforce development plans, and consistency in education and training. The plan states thatgreater partnership between and among health providers and education providers is critical if skilldevelopment is to be properly addressed in this area.

Further, specific targets are set to increase the Maori mental health workforce. The planrecognises that before culturally appropriate services can be provided by both mainstream andkaupapa Maori mental health services, Maori workforce numbers need to increase. Similarly,targets are set for increasing the Pacific Islands mental health workforce, particularly mental healthcommunity workers, and for improving the skills and competence of the drug and alcoholworkforce.

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3.4.2 Blueprint for Mental Health Services in New Zealand, 1998

The Mental Health Commission developed the Blueprint as its statement of mental health servicedevelopments required for implementation of the Government’s national strategic mental healthplan. It follows on from the Blueprint Working Document, 1997. The Blueprint is based on the17 guiding principles for mental health services set out in Moving Forward. With its focus onwellness, the Blueprint makes more explicit the need for services to use a ‘recovery approach’ andto tackle discrimination as a major barrier to recovery.

Key service changes needed include:

• Maori, as Treaty partners, have the right of access to both appropriate mainstream servicesand some separate kaupapa Maori services provided by Maori organisations

• the provision and ownership of mental health by Pacific Islands people

• the provision of support for families as part of a continuing care programme

• greater integration of all services at local level and with other (non-health) communityservices

• the provision of services for adults:

– increase in home-based and community-based service options for people in crisis aswell as for those with ongoing severe mental health problems and disability supportneeds as an alternative to admission to an acute service

– wider provision of special crisis response services, early intervention programmes,active outreach and follow-up

– primary care and general hospital liaison for those with mental illness or healthproblems who are not accessing specialist mental health services

– alternative care (planned respite) for family and caregivers

– provision for people with combined alcohol and drug and mental health problems

– an improved ability to respond effectively to the needs of Maori

– increasing service provision ‘by Maori for Maori’

– increasing acknowledgement of the needs of Pacific Islands people

– access to education and employment services, and meaningful activity for people withdisabling mental illness

– family and community advisory services and family-run initiatives

• the provision of services for children:

– many more specialised multi-disciplinary community teams are required. Theseteams need to include services for drug and alcohol problems, and make specificprovision for Maori and Pacific Islands people.

– provision of separate dedicated specialist mental health services in an age-appropriateenvironment and catering for children’s development needs

– where possible, the development of kaupapa Maori services for children and youngpeople

– employment of cultural advisors to work with Pacific Islands families.

– the urgent provision of more day, residential, and respite services, planned inconjunction with the Children, Young Persons and their Families Service (CYPFS)

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• the provision of services for older people:

– appropriate acknowledgement of non-organic mental illness needs

– increased dedicated inpatient services, residential treatment and support services, daytreatment and support services, and multidisciplinary clinical community teams

• the provision of drug and alcohol services:

– the higher prevalence of drug and alcohol problems among Maori must be addressedthrough kaupapa Maori alcohol and drug services

– the provision of specialist, time-limited alcohol and drug counselling and othertherapeutic services to individuals and families

– the provision of intensive and targeted community and residential treatmentprogrammes of varied length of stay and intensity

– the provision of a range of dedicated detoxification services

• the provision of forensic services:

– all levels of service must be effective for Maori

– people in rural areas must receive forensic service equivalent to the resource guidelinelevel

• the provision of other services:

– highly specialised services are needed for people with very complex problems causedby the combination of mental illness and other factors such as a severe drug andalcohol disorder, head injury, severe eating disorders, a disabling personality disorder,profound deafness, or being a refugee, or being a mother with a baby.

The report goes on to emphasise the importance of good co-ordination both of services andbetween sectors, and of significant workforce development to achieve the service changesrequired. It calls for growth in the size and competence of the existing workforce, and newapproaches to develop the Maori workforce.

The National Mental Health Workforce Development Co-ordinating Committee is one of theimplemented strategies. Another has been the development of the National Certificate in MentalHealth (Mental Health Support Work) for the non-clinical workforce, offered since 1998.

The Blueprint indicates several key directions for workforce development including:

• the Clinical Training Agency needs to continue to increase its funding for clinical trainingfor mental health professionals. Target areas for improved workforce expertise arenursing, alcohol and drug (including ‘dual diagnosis’), children and youth, Maori,cognitive therapies, and child psychiatry.

• health providers need to collaborate with tertiary education providers to ensure therelevance of qualifications and access to appropriate clinical practice and training

• major changes are required to training standards, training programmes, and recruitmentand retention to ensure the use of a recovery approach and reduced discrimination againstpeople with mental illness

• workforce development plans are required to provide strategies and programmes toimprove knowledge and skills in early intervention, risk assessment and management,assessment and management of drug and alcohol disorders, psycho-social therapies, Maoriculture, Pacific Islands people’s culture, outcome measurement and evaluation

• training and recruitment programmes are needed to expand opportunities for people withexperience of mental illness to apply for training or positions

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• increases in the total mental health workforce necessary to achieve the resource guidelines

• specific strategies need to be developed to address workforce development and trainingneeds for Maori and Pacific Islands people. These include positive affirmation andfunding to aid recruitment and training for clinical and non-clinical positions.

• acceptance of, and funding for, credible Pacific Islands traditional healers

• facilitating affordable access for smaller mental health service providers to appropriatetraining in business and financial planning, management, and administration and governance

• particular encouragement needs to be given to incentives for recruitment and retention ofskilled staff in rural areas.

3.4.3 Analysis of resource requirements of the Blueprint

The Mental Health Commission carried out an analysis of the ‘gap’ in the resource requirements ofthe Blueprint. The benchmark of workforce requirements shows an extra requirement of 2193.1FTES, made up of 1114.6 clinical and 978.5 non-clinical staff. The monitoring shows:

• significant shortfalls of clinical staff in non-residential community health services

• significant shortfalls of clinical staff for children and young persons’ services and olderpeople’s services

• a shortfall in other areas such as alcohol and drug services, services for dual diagnosis ormultiple problems, illness prevention, home-based support and day activities.

If this is an accurate reflection of what is needed then there is a major challenge in attracting andtraining the appropriate staff or reconfiguring services in such a way as to utilise a wider range ofpeople from outside the service.

3.5 General mental health workforce

This section summarises recent relevant reports on general mental health workforce issues.

3.5.1 Towards Better Mental Health Services, 1996

The report (Ministry of Health, 1996b) of the National Working Party on Mental HealthWorkforce Development, Towards Better Mental Health Services, was published in March 1996.It is viewed as a seminal mental health workforce development document, and has been verywidely reprinted and distributed. It provides a comprehensive analysis of the issues confrontingthe mental health sector, specifically in relation to workforce development and identified strategiesto move the mental health workforce in the directions required for meeting the changing servicedelivery patterns. The Working Party concluded that there are few incentives for mental healthproviders to invest in skill development of staff. Yet changes to mental health workforce skillsare, and will continue to be, required to match the predicted service delivery patterns.

Other key points made were:

• the short-term (ie. one year) nature of many health service contracts creates uncertaintyabout providers’ future roles in health service delivery

• the mobility of staff reduces the organisational gains for providers to invest in skilldevelopment

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• health providers are unable to influence the education sector or be represented in educationsector decision-making processes

• unless addressed, workforce deficiencies will increasingly hinder the achievements ofbenefits for the consumer envisaged by the Mental Health Strategy.

The Working Party advised that incentives for all stakeholders to invest in training programmesneed to be strengthened so that resources are increased and targeted to the type of trainingrequired. It described a workforce model to take services into the 21st century, the maincomponents of which are:

• each skilled worker forms an integral part in the functioning of the service and therelationship of the workers to each other is critical to the success of the clinical care

• standards of training and education are necessary to underpin each of the workers, withmany standards being shared and core to all

• core skills exist for all workers, and it is acknowledged that specific workers havespecialist and unique skills.

The Working Party identified a number of key areas and initiatives needed to produce significantprogress in producing an effective mental health workforce, including the appropriate use of leversby health providers to influence the education sector, better communication and so on. Itconcluded that sole reliance on market mechanisms for workforce issues might not achieve therequired outcomes.

Further, the Working Party found that a major ‘rethink’ of how workforce development issuesshould be dealt with in the future is required. It viewed current problems as an illustration ofunder-investment and the lack of a co-ordinated and sustained approach to workforce development.It strongly recommended the development and ongoing maintenance of an effective nationalmechanism or body to co-ordinate training programmes, set standards and moderate trainingprogrammes.

The report recommended many general and specific actions, including the following overarchingstrategies:

• National and regional workforce development policies need to support health providers inrecruiting and retaining appropriate staff.

• Health and education sectors need to work more closely to ensure that programmes intertiary education institutions reflect the requirements of the health sector.

• A significant increase in investment in workforce training over the next few years will berequired to address the current deficiencies and future requirements.

• More research is required into how efficient mental health outputs and outcomes can bedelivered.

• A destigmatisation strategy for the industry is crucial.

• Health providers should take more responsibility for planning, organising and fundingnational workforce development.

The Working Party’s report has been accepted by the wider mental health sector as relevant andnecessary to the industry, but has not yet been fully implemented.

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3.5.2 Workforce information

There is a shortage of up-to-date workforce information.

There are gaps in the quantitative workforce information available, for example:

• there is little information on non-registered staff numbers

• the HFA collects workforce data as part of its contract monitoring but it is not routinelynationally collated and is not complete

• national data from the education sector on training programmes and student numbers isvery difficult to collect. The Ministry of Education does not collect such data routinely orin enough detail for it to be useful.

3.5.3 Health Workforce Survey Annual Practising Certificate data

The Ministry of Health collects data through an health workforce survey undertaken with theannual invoicing of annual practising certificates/licences to registered health professionals, eg.doctors, nurses, clinical psychologists, occupational therapists and physiotherapists. This data isnot routinely analysed specifically for mental health. The Working Party analysed 1994 APC data,which showed:8

Table 1: Mental health workforce 1994

Occupational group Actual numbers

Psychiatrists 185

Registered nurses 2274

Enrolled nurses 526

Occupational therapists 88

Clinical psychologists 334

TOTAL 3407

3.5.4 Other surveys

A 1995 survey indicated a total of 202 social workers working in mental health, of which 80.2%were employed in CHEs.

The stocktake (Ernst & Young, 1996) collected both actual numbers and full-time equivalents ofsocial workers from providers. The information is important as it is the only workforce datacollected nationally from non-registered staff. However, it excluded forensic services, children,adolescent and family, and drug and alcohol services. A summary of the actual workforcenumbers showed:

8 These numbers are all estimated as national extrapolations made to account for non-responders.

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Table 2: Mental health workforce 1996

Occupational group Actual numbers

Medical staff 389

Nursing 2275

Other clinical staff 830

Non-clinical staff working with patients 1178

TOTAL 4672

3.5.5 Education sector workforce information

The interdepartmental Working Party also collected information on the range of mental healthtraining programmes run in tertiary education institutions.

3.5.6 Report of the Ministerial Inquiry to the Minister of Health, Hon. JennyShipley (Mason Report, 1996)

Judge Mason’s report provided a snapshot of the mental health industry and highlighted many ofthe deficiencies of the mental health service. One of the factors identified was the lack of anorganisation that would accept the responsibility for preparing a strategic plan for workforcedevelopment and then making it work. It strongly endorsed the report of the National WorkingParty. The Mental Health Commission was subsequently charged with making workforcedevelopment a priority.

3.5.7 Final Report on New Zealand’s Mental Health Acute Inpatient Services(National Acuity Review)

This recent Ministry of Health report (Deloitte & Touche Consulting Group, July 1997) concludedthat the core skills and competencies required to accomplish the objectives for mental healthservices have yet to be developed within the current mental health system. The development orincorporation of these skills and competencies urgently needs to be addressed by the funder.

3.5.8 1995 Stocktake of Mental Health Services

This report (Ernst & Young, 1996) concluded:

• considerable progress has been made since 1993 towards the development andenhancement of community-based mental health services

• there are considerable variations in workforce levels. The workforce allocations reflectedthe changes that have been made, but also indicated where there are still opportunities forrealigning resources and services to meet population needs.

• the workforce data does not clearly indicate the availability of teams specifically providingservices for and supporting Maori and Pacific Islands client needs.

The stocktake also identified the need for further work, which included:

• collecting more detailed workforce data to clearly indicate the availability of teamsspecifically providing services for and supporting Maori and Pacific Islands client needs

• reviewing national benchmark targets in light of changes in population, and in the patternof service delivery and purchasing, and to take account of non-clinical staff input intoservice delivery.

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3.5.9 Reviews by the Interdepartmental Working Party

An Interdepartmental Working Party of the Ministries of Health and Education was established in1996 and has been involved in three projects:

• identification of the core functions of the mental health service and the skills required,with a view to assisting the Regional Health Authorities (now the HFA) to analyse skilldeficits and proposals for addressing them within their contractual arrangements

• reviewing the relationships and interfaces between providers of mental health services andeducation providers, the establishment of national standards for mental health education/training programmes and for gaining recognition of prior learning by individuals who wishto enhance their career pathway

• reviewing training priorities of the Clinical Training Agency which has identified the needfor urgency in addressing needs for child and adolescent speciality training, drug andalcohol training, and training in specific psychotherapies at post-entry level.

Key findings from the reviews included:

• a mismatch between the education/training and health opportunities provided, so that theworkforce does not meet the needs of mental health service providers

• education and training for community mental health workers and Maori mental healthworkers as a high priority for mental health workforce development.

3.5.10 Designing Mental Health Training and Education Conference

This conference, organised by the World Federation was held on 30 June/1 July 1997 and broughttogether a wide range of interests from the mental health sector.

The main issues arising from the conference included:

• the need for a mental health workforce strategy

• plurality in service delivery and training

• the need for training standards which also address present gaps in mental health workertraining

• ‘real’ consumer involvement in all mental health initiatives.

3.5.11 A Better Way Forward Workshop, 1 July 1997

Held at the conclusion of the Designing Mental Health Training and Education conference, theworkshop specifically addressed the principles behind a mental health workforce strategy, and theprocesses which are needed to implement them.

The main principles and processes to emerge were:

• the need for a workforce strategy co-ordinating mechanism

• the need for values to guide the principles

• consumer participation

• identification of a mental health ‘industry’

• plurality in services and training

• closer links between health and education sectors

• the need to look closely at training and recruitment and retention.

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The Maori perspective included:

• adherence to the Te Tiriti O Waitangi and all that is included within its articles in thedevelopment of a mental health workforce strategy

• respecting the diversity of Maori culture at the local level

• achieving appropriate Maori representation in the decision-making processes

• systems having an inbuilt plurality and flexibility and professionalism seen as multiplerather than singular

• the need for national standards to be looked at more broadly

• the need for a national Maori database.

The Pacific Islands perspective included:

• principles should be encompassing and inclusive of the diverse taonga of the PacificIslands, and these must address

– an holistic approach to mental health service delivery

– spiritual aspects

– cultural differences

– language issues

– participation-collaboration or otherwise

– traditional versus contemporary processes

– westernised versus non-westernised processes

– Island-born, New Zealand-born, New Zealand-raised ‘island cultures’

– inclusion

• the principles should include the values of:

– independence

– collectivity

– alofa

– participation and collaboration.

• the participants identified the following priorities:

– training and education for “for Pacific Islands people by Pacific Islands people”

– training of non-Pacific Islands people for Pacific Islands people services

– training of Pacific Islands people for mainstream services.

Consumer perspectives included the need for a culture of change towards services and trainingbeing consumer focused and drive. This requires:

• consumers at key points of the process

• consumers with the education required to enable them to be included in the process

• consumers with resources to consult

• families of consumers to be included in the process.

Points raised in relation to processes included:

• multiple standard setting bodies may be required

• there is a need to look at ‘colonisation’ in existing training

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• processes must be cost effective

• the strategy needs to look as much at the process as the goals.

Further, consumer participants wanted a consumer-driven National Advisory Group to look atstrategy in an on-going way. At the same time there was acknowledgement that consumers actingin such roles had difficulty providing representation on behalf of all consumers.

3.5.12 Survey of Mental Health Training Programmes, October 1997

This survey was undertaken as part of the workforce development strategy in the latter part of1997.

The objective was to get as full a picture as possible of training for mental health workers andresources allocated to mental health training programmes in the two years 1996 and 1997 andprojections for 1998.

Key findings9

• Training levels are increasing: Between 1996 and 1997 numbers of mental healthtrainees or workers participating in the training programmes surveyed rose from 1564 to1779. FTE numbers rose from 790 to 1073. Projections for 1998 indicated an increase ofabout 100 trainees, but a few institutions did not give projections because enrolmentstatistics were unavailable when they completed the returns. Thus, the projections for1998 may have slightly underestimate future enrolments.

• A wider range of courses are offered: Training programmes were developing rapidly forsupport workers, new graduate nurses, postgraduate nursing and multidisciplinarypersonnel. There was rapid expansion of advanced practitioner training, and specialistcourses are now offered in Maori mental health, dual diagnosis and eating disorders.While there were slight increases in the numbers of people enrolled in counselling courses,these were offered in more locations, especially in polytechnics in provincial centres.

• $13.5 million allocated to mental health training was identified: 54% was from theTransitional Health Authority (either through the Clinical Training Agency or the regionaloffices of the THA); 36% was funded by Vote: Education; and 10% from trainees’ fees.Education funding tended to be directed toward counselling, alcohol/drug and clinicalpsychology training, and health funding directed toward psychiatric registrar training, newgraduate and advanced nurse training, and specialist courses. In addition, about $2 millionmay be spent by health service providers, but this estimate was speculative. Theboundaries in responsibilities do not appear to be very clear, and these multiple fundingstreams may impede systematic planning and implementation of mental health training.

• Regional distribution of programmes was uneven: The Midland region offered very fewtraining programmes for any groups of mental health workers and the levels of trainingprogrammes in the Southern region were higher.

9 All of these findings reflect only the responses received. No attempt has been made to extrapolate the findings more

generally.

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3.5.13 Information from Clinical Training Agency, February 1997

Psychiatry training

This is a five year plus training programme. In 1996 there were 129.5 FTE registrar trainees. In1997 this had dropped to 125.6 FTEs (132.9FTEs were budgeted by the CTA but not all the placeswere taken up. An incentive payment was offered to each CHE.) Nine trainees were expected tograduate with Fellowships at the end of 1997. Twelve registrars passed Part I. Fourteen left theprogramme of whom 35% were taking ‘time out’, and 28.5% were continuing training overseas.Only 55% of registrars were New Zealand graduates. Of the rest, 40% came from the UK and28% from South Africa.

In 1999 the CTA was funding 137 psychiatry training FTE places, of which 12 were in primarycare and two were in child and adolescent psychiatry.

Nursing training

In 1997, 70 new graduate nurses undertook training, along with 10 funded by Central Division ofthe HFA. Of these, 11% were Maori and 5% were Pacific Islands people. Estimated numbers for1998 were 78.

In 1997 there were 74 nurses in advanced mental health programmes. It is noticeable that theproportion of students in the Midland region was significantly low. Midland accounted for 3.6%of all new graduate nurses in training in 1997 and Midland had no access to advanced mentalhealth training for nurses.

In 1999 the CTA funded 92 FTEs in new graduate nursing programmes and 142 FTEs in advancedmental health programmes.

Other clinical training

Other clinical programmes purchased by CTA:

• Child and adolescent mental health 32 FTEs in 1998

• Dual diagnosis 62 FTEs in 1998

• Cognitive behavioural therapy 36 FTEs in 1998

• Maori mental health programmes 15 FTEs in 1998

• Eating disorders 12 FTEs in 1998

• Total multi-disciplinary programmes 157 FTEs in 1998

Mental health education programmes purchased by CTA:

• Formal teaching – Psychiatry registrars 21.7 EFTs in 1997, 23 EFTs in 1998

• Certificate in Community Mental Health 8.5 FTEs in 1997, 7 EFTs in 1998

• Certificate in Community Psychiatric care 8 FTEs in 1997, 12 EFTs in 1998– adolescent

• Forensic Psychiatric Certificate 15.1 EFTs in 1997, 18.9 EFTs in 1998

• Diploma in Mental Health 14.5 EFTs in 1997, 15 EFTs in 1998.

This training increased from 67.8 places in 1997 to 75.9 in 1998.

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Table 3: Mental health post-entry clinical training volumes for 1999

PECT : Mental Health Programmes 1999 – FTEs/EFTs (1) Comments

Maori mental health 20

Child and youth mental health (2) 60-65 Target 90

Specialist programmes eg.• Dual diagnosis• Cognitive behavioural therapy• Eating disorders

11066395

New graduate nurses (mental health) 92

Advanced mental health nursing 142

Certificate in Forensic Psychiatric Care 40

Certificate in Community Psychiatric Care 7

Diploma in Mental Health 19

Psychiatry (3) 125

Psychiatry in Primary Care 12

TOTAL 6261 Volumes – FTEs are rounded

Actual provision may be lower than contracted volumes2 Includes one programme for adolescent mental health training3 Psychiatry – 14 trainees in final year of training4 Two training centres in child and adolescent psychiatry: Christchurch has two trainees

and Auckland expects to resume this training in 2000.

3.5.14 ALAC Review of Education and Training Needs for the Drug and AlcoholService, 1996

This comprehensive report (Hannifin & Gruys, 1996) recommended that ALAC:

• identify the untapped potential role and contribution of a number of professional groupswho come across alcohol and drug problems in the course of their work

• advise that the skill needs of the specialist alcohol and drug field is widely promoted in theliterature as an area to be developed via improved education and training

• recognise that “... occupational groups do not automatically respond to alcohol and drugproblems in their usual work settings”

• recommend that alcohol and drug education be incorporated into generalists’ training anddevelopment.

The recommendations have not been implemented, however a number of initiatives in line with thereport were planned.

• negotiation of a contractual arrangement with a provider to set up an advanced level coursefor those specialising as drug and alcohol clinicians

• a conference of those involved in the drug and alcohol area

• the establishment of a newsletter

• increasing the drug and alcohol training component in generic education and trainingcourses, eg. nursing and social work.

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Further reports to be commissioned are:

• training requirements for volunteers in the drug and alcohol sector, and care of the elderly

• a further strategy report for workforce development.

3.5.15 Recommendations from the Working Group Considering WorkforceDevelopment Issues, December 1997

In May 1997 the Ministry of Health and the Ministry of Education Joint Working Party convened ameeting of stakeholder group representatives to consider issues relating to the impact ofundergraduate nursing education and post-education support structures on mental health workforceplanning and development.

The paper identified the issues that impacted on the current shortage of experienced mental healthnurses, and made the following recommendations for all the stakeholder groups so that aco-ordinated approach could be taken:

• The nursing profession, through the Nursing Council of New Zealand, should:

– provide professional leadership

– adopt and support national standards of practice for mental health nursing

– monitor competencies for registration

– encourage research initiatives and promote evidenced-based practice.

• Education providers, through Nurse Educators in the Tertiary Sector, should:

– ensure undergraduate curricula prepare graduates to meet beginning practitionermental health nursing competencies and standards

– consult with service providers about health service direction

– offer practice-based postgraduate education.

• Service providers, through CHE and other provider agencies, should:

– provide clinical environments which support workforce development

– implement strategies which retain experienced mental health nurses

– introduce clinical career pathways.

• Government agencies, through the Ministry of Health and the HFA, should:

– protect funding for medium- and long-term workforce development activities

– support workforce planning strategies to ensure there are adequate numbers ofqualified mental health nurses.

• Individual mental health nurses, should:

– commit to national standards

– participate in best practice initiatives

– assume responsibility and demonstrate commitment to their own professionaldevelopment.

Attempts to quantify the actual workforce needs within the mental health sector reinforced the lackof information and lack of understanding of current and future requirements. The Working Groupconsidered that a stocktake should be done to identify whether this lack of resource is a mismatchin levels of resource or skill mix, or both. The stocktake needs to focus on the:

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• current level

• geographic distribution of current gaps

• projected demand.

3.6 Other specific relevant reports

This section summarises recent relevant information on specific categories of the mental healthworkforce.

3.6.1 Maori Workforce Development

Maori have been identified throughout the health policies in New Zealand as being ‘poorlyserved’. At the Oranga Hinegaro Maori-Maori Mental Health Conference 1997, the Minister ofHealth, the Hon. Bill English, acknowledged the “failure of publicly funded services in the past todeal with that problem in a way that makes sense to the Maori community at large and to thosewho are suffering mental illness” (1997, p.1). Maori communities have for many years beenconcerned about the high number of Maori consumers and the very low number of Maori workingin the mental health services.

All the key mental health strategic reports, such as Moving Forward, Blueprint and NationalMental Health Funding Plan 1998-2002, stress the importance of increasing Maori access tomainstream mental health services as well as increasing “Maori for Maori” services.

In developing services which respond to Maori the challenges of Biculturalism andthe emerging Maori/Iwi service providers and Maori Health Workers has beenpivotal. Yet Maori experience of Mental Health Services continues to be one ofexperiencing a cultural void. The rhetoric of biculturalism is inadequate to thepractice of cultural safety without processes which promote and ensure the practiceand protection of an equal partnership with the opportunity for the maintenance ofthe integrity of each participant cultural perspective. Our experience is still that anuneasy and unequal relationship exists between Maori Health and Mental Health,and that the skills and ability to work effectively and transparently at the biculturalinterface remains elusive. (Tangitu, 1996, p.5)

3.6.2 Hui Miria Te Hinengaro

The Hui Miria Te Hinengaro specifically identified Maori workforce development/training issues/key worker developments and the development of a regional strategy as important for the Midlandregion. A report on Maori Mental Health Development in the Midland Region (Tangitu, 1996)was subsequently produced which included the following recommendations:

• that the Treaty of Waitangi be used as the framework for developing and implementingMental Health policies and strategies for Maori

• that Regional Health Authorities consider the establishment of mobile Maori recruitmentand training units, to actively recruit Maori mental health professionals

• that a pilot Maori mental health worker training programme be initiated in the MidlandRegion to assist in the establishment of a nationally recognised programme

• that there be effective and wider Maori representation and participation on those bodiesand organisations responsible for making decisions relating to Mental Health. Especiallythe Mental Health Advisory Board, Mental Health Commission, Ministry of Health,Regional Health Authority

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• that greater inter-agency co-operation be initiated and all stakeholders to increase theeffectiveness of resource allocation and policy development and implementation(pp.10-13).

3.6.3 A Maori Workforce Development: A Discussion Paper

This draft document (Douglas, 1996) identifies that:

• evidence is emerging which indicates that targeted workforce development strategies canlead to a marked gain in health status for the corresponding target client group over time

• identification of all Maori health workers, professionals and other practitioners alike, isrequired so that a comprehensive needs assessment exercise can take place.

The report also suggests that Maori workforce development ought to occur because:

• it has already been identified as a high priority within the sector both in terms of policydevelopment and within the purchasing framework

• it will be effective in contributing to the achievement of better health gains for Maori

• there is a disparity in Maori workforce participation levels in comparison to non-Maorilevels

• there is a need to fill identified gaps in service provision

• there is a need to meet consumer expectations of having a range of choices in health caretreatment

• it recognises Maori as tangata whenua, within the relationship envisaged under the Treatyof Waitangi

• other development initiatives such as new provider development by “Maori for Maori” arebeing hamstrung because of the lack of a critical mass of qualified and recognised Maorihealth workers in the areas concerned

• there is an overall need to plan for long-term goals in order to maintain sustainability inmeeting future demand

• all or a combination of these reasons.

In addition, the report notes:

an increased number of Maori choosing to use by Maori for Maori while encouraging(sic) places a higher impetus on the sector to respond and ensure there are enoughqualified personnel to staff these institutions. Maori clients dealing with mainstreamhealth care services especially CHEs, should where practicable be given this choicealso. (p.22)

3.6.4 Puahou – A Five Part Plan for Improving Maori Mental Health

Durie (1997) identifies five strategies which make up the Puahou Plan:

• access to a secure identity

• active participation in society and in the economy

• aligned services

• accelerated workforce development

• autonomy and control.

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These are derived from the principles of recognition, partnership, options, active protection andautonomy, respectively.10

Within the accelerated workforce development strategy Durie notes “there is a serious need tofacilitate entry into programmes of study so that Maori community workers11 are not trapped orunable to transfer to other work situations and better long term prospect” (p.13). Whileacknowledging the number of agencies working to address the low numbers of Maori in the mentalhealth workforce, Durie comments on the lack of a clear overall plan or mechanisms forco-operation. Nor is there any evidence of Maori health workforce planning being conductedwithin a Maori development needs framework.

Clearly there is a requirement for a specific Maori workforce development focus and Maori mentalhealth workforce development for the development of the generic mental workforce to provideculturally appropriate/safe services.

3.6.5 Mental Health Services for Maori: An Environmental Scan, 1998

The report identifies the current state of the Maori mental health workforce and Maori mentalhealth services for Maori.

It states that training for Maori needs to include kaupapa Maori, as well as mental healthunderstanding and skills. A large increase both in clinical and non-clinical Maori staff and in theskill mix is required. These factors are based on the following major issues affecting mental healthservices for Maori:

• the need for increased kaupapa Maori services and increased access to mainstream servicesfor Maori

• emphasis on early recognition and intervention, and rehabilitative models of care

• increasing services, particularly community-based services (adult and children, youngpersons and family)

• improvement of service quality

• appreciation and consideration of socio-cultural factors and Treaty of Waitangiresponsibilities to support the culture and provide culturally appropriate services forMaori.

Maori health workforce development needs to:

• be aligned with Maori development generally

• have improved incentives for stakeholders to invest in education, training and workforcedevelopment

• recognise the diversity of Maori (including traditional healing) in education and trainingprogrammes for a Maori health and disability workforce

• generate workforce data that identifies barriers to access for education and training forMaori, and the numbers, location and occupations of Maori already in the workforce

10 These principles are earlier described in Durie’s paper, and they are derived from Treaty principles identified in

earlier instrumental reports related to specific legal and Waitangi Tribunal interpretations of the Treaty.

11 Durie (1997) notes Maori community mental health workers have many skills which professionals do not possess andthat there is a tendency to exploit those skills by failing to provide career pathways and not encouraging theacquisition of formal qualifications on top of existing competencies.

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• have information about health services provided by Maori for Maori, culturally effectiveservices that may be provided by non-Maori as well as by Maori, Maori serviceorganisations using non-Maori health professionals, barriers to employment for Maori, andthe effectiveness of current preferential treatment schemes and quotas in increasing theparticipation of Maori in the professional health and disability workforce.

3.6.6 Pacific Islands nations

The Pacific Islands community resident in New Zealand does not consist of a single culture. Thereare six main ethnic groups which originate from the Pacific Islands region and have establishedidentifiable communities in New Zealand. The largest population is from Samoa (51%), followedby Cook Island (23%), Tonga (14%), Niue (7%), Fiji (3%) and Tokelau (2%). (Census data, 1992)

Pacific Islands workers are under-represented in mental health. There is very littleinformation available on the number of Pacific Islands people working in mentalhealth, apart from that of registered health professionals. (Ministry of Health, 1996a,p.62)

3.6.7 Consultation with Pacific Islands People’s Committee of the Mental HealthCommission

The need to have more Pacific Islands workers in the mental health services is a priority. PacificIslands health professionals such as nurses and doctors would take too long to prepare, given theurgency of need. The training of Pacific Islands mental health support workers was seen as anexcellent solution.

The recently developed draft unit standards for mental health support workers were stronglysupported by this advisory group. These standards were seen as a ‘stepping stone’ into the mentalhealth arena as well as into higher level courses. The Pacific Islands People’s Committee hopedthat courses based on these standards would attract more Pacific Islands workers to the mentalhealth area. They also suggested that attention be focused on the retention of Pacific Islandspeople on these courses as well as on initial recruitment. The involvement of Pacific Islandspeople in the development, delivery and assessment of the courses as well as service providerschanging the culture of the workplace so that it is more supportive of Pacific Islands workers,would ensure the success of Pacific Islands people in the courses.

It was suggested that funding and support for these courses could come from a variety of sources,including the Ministry of Pacific Island Affairs.

Support was given for a co-ordinating mechanism for mental health workforce development.Pacific Islands people need to have representation on any mechanism developed.

3.6.8 New Graduate Programme for Entry into Specialist Mental Health Nursing

This report (Hughes and Clark, 1996) evaluates the first year of a pilot programme which began atCapital Coast Health Ltd on 20 February 1995 for nurses beginning practice in mental healthnursing. The course was set up as a response to the significant lack of the specific nursing skillsamong new graduates required to practise competently in modern mental health services.

The model on which the new practitioners’ programme was based provided a developmentalframework that initially ensured an emphasis on theory with some clinical application andprogressively reduced the theory hours as students moved through the programme with moreemphasis on their clinical practice. During this time the students were supported by an identifiedmentor in each clinical area, a skilled practitioner providing professional supervision, and the

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programme co-ordinator. The student was clearly defined as a beginning practitioner who was notexpected to take on the role and responsibility of a staff nurse.

The New Graduate Entry Programme into Specialist Mental Health Nursing (the internprogramme) was 40 weeks long, and aimed at registered comprehensive nurses who werebeginning practitioners in the mental health area. The course funded by the HFA, was based on a‘studentship’ model, with successful students qualifying for a Post-Graduate Certificate in MentalHealth Nursing.

In the first year of the programme 46 students enrolled, and all but one graduated.

The evaluation found that the programme provided valuable education and clinical experience inmental health nursing. It concluded that:

• future programmes adopt the following principles:

– they be based on professional practice standards of competency so that performancecan be measured

– they be part of an ongoing education/career structure, fitting into a recognisedframework for postgraduate professional development

– they be clinically-based and driven, with a strong clinical component and the student,who is largely supernumerary to unit staff, provided with effective clinicalsupervision

– they be delivered in partnership with tertiary education for a sound, educationallybased theoretical component

– they have a minimum of 10-15 students enrolled for economies of scale and good peersupport

• specialist mental health nursing training is desperately needed to build up a national poolof experienced, skilled nurses in mental health

• the comprehensive nursing programme provides an excellent base on which a newgraduate programme like this can build specialist skills at post-graduate level

• the New Graduate Programme for Entry into Specialist Mental Health Nursing was a veryeffective and efficient way of training beginning nursing practitioners.

The Clinical Training Agency surveyed graduates from this first programme in 1997, and foundthat 65% of the respondents were still in mental health.

3.6.9 Report of the Consumer Employment Group Mental Health ConsumerEmployment, February 1997

As part of the Better Life document, the Greater Wellington Mental Health Services Review Teamrecommended increasing consumer involvement in all areas of mental health services. As a resultof this recommendation the then Central Regional Health Authority (CRHA) indicated acommitment to the employment of consumers within the mental health services, and funded theMental Health Consumers Union to investigate consumer employment.

The Consumer Employment Group was set up in mid-1995 and consisted of a project worker andrepresentatives from CRHA-contracted provider services, both Crown Health Enterprise (CHE)and non-CHE.

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The group’s study, completed in February 1997, found overwhelming support for consumeremployment, and made recommendations for the employment, education and support of consumerswithin the mental health services, including a monitoring and evaluation process.

3.6.10 Child, Adolescent and Family Mental Health Services

This report (McGeorge, 1995) is the result of an extensive literature search; a consultative surveyof funders and selected providers; interviews with mental health managers, staff, special education,Child Adolescent and Family Services (CAFS) and Children, Young Persons and their FamiliesService (CYPFS), community-based volunteers and advocates; and national and international‘experts’.

Benchmarks for CAFS and Youth Speciality Services (YSS) reveal a need for 29 CAFS and sevenYSS in the country. Each would require approximately 12 FTEs, comprising one FTE psychiatrist,one FTE psychiatric registrar, one FTE psychologist, one FTE psychology intern, 1-2 FTE nurses,1-2 FTE psychotherapists, two FTE social workers, one FTE occupational therapist, 2-4 FTEcommunity/cultural workers, and two FTE clerical assistants.

Training of mental health clinicians should be co-ordinated to encourage joint participation oftrainees in training modules with different disciplines. Opportunities should be expanded for thetraining of non-clinical workers.

3.6.11 New Futures: A strategic framework for specialist mental health services forchildren and young people in New Zealand

This document (Ministry of Health, 1998b) provides a strategic framework for deliveringcomprehensive mental health services for children and young people 0-19 years inclusive. Itidentifies a lack of skilled experienced personnel as one of the major limiting factors in developingappropriate mental health services for children and young people. The issues of quality serviceprovision need to be balanced with workforce expansion to ensure that safe, appropriate andeffective services are provided. It also highlights the major workforce needs in Maori mentalhealth services, and among the Pacific Islands workforce in areas where there are high PacificIslands populations.

Child and adolescent psychiatrists and psychologists are in greatest demand because the specialistmental health services focus on children and young people with serious mental health problems.

Needs identified are:

• an acceptance that some workers will need to learn on the job and that this training willneed to be resourced and encouraged

• training and development programmes for new and existing staff

• a focus on training Maori to work within either Maori or mainstream services

• good career pathways to encourage the retention of skilled staff.

3.6.12 Child Health Strategy

The Child Health Strategy represents a commitment from the Government, theMinistry of Health and the Health Funding Authority and providers to work togetherto improve, promote and protect the health of children/tamariki and their families andwhanau. (Ministry of Health, 1998a, p.1)

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The report recognises that a highly skilled workforce that is able to meet the special needs ofchildren (aged 0-14) is needed now and into the future. The strategy provides high-level directionfor the child health sector until 2010. Special areas for consideration are the development ofhospital and community-based multi-disciplinary teams to work with children with mental healthproblems. Of concern, is the shortage of a specially trained mental health workforce to work withchildren/ tamariki and their families and whanau.

3.6.13 Through the Eyes of a Child: A National Review of Specialist PaediatricSpecialty Services

The development of the report results from an agreement during 1997 between the PaediatricSociety of New Zealand, the Ministry of Health and the Health Funding Authority to reviewpaediatric speciality services. This report is a summary of completed clinical reports (34) using astandard framework for each speciality group together with recommendations. It forms stage oneof a three stage process intended to cover a period of 5 to 10 years. The review report should beread together with the Child Health Strategy published by the Ministry of Health.

With its overarching principle “that children and young people in New Zealand will have theirneeds treated as paramount” (Health Funding Authority, p.3) the review focused on ninesubsequent principles which would underlie its recommendations. Each speciality report identifiessignificant workforce development issues. One of particular importance to mental health servicesis the child and adolescent psychiatry paediatric speciality service where the need for a majorincrease in financial resource and appropriately qualified staff, is identified.

3.6.14 In Our Hands. New Zealand Youth Suicide Prevention Strategy

In Our Hands (Ministry of Youth Affairs, Ministry of Health, Te Puni Kokiri, 1998) has beenproduced to assist government departments, sector providers, schools, churches and others indeveloping strategies to help prevent youth suicides and to assess how well their communityprovides support for young people at risk from suicide.

Although there are no specific mental health workforce strategies identified in the document, theimplementation of the strategy has significant workforce implications for the health and educationsectors.

3.7 Specific skills required

This section reviews literature and research on skill requirements for mental health workers. Theliterature highlights words such as skills, competencies and tasks, which are often usedinterchangeably. The descriptions of these terms that are often developed reflect what is expectedfrom individuals and team members to carry out their professional duties and to deliver theirparticular service. This information comes from a variety of sources and is based on requirementsfrom:

• discipline/professional requirements

• team performance expectations

• legislation/regulations

• consumers’ requirements.

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3.7.1 Previous general reports on skills required

Stein and Test (1974) recognised in their training programmes in Madison, Wisconsin, that threeactivities were important for mental health workers moving from institution to community:

• developing guidelines for treatment

• working with simulated problems

• becoming familiar with community resources.

Faulkner, Hambridge and Kral (1989) strongly advocated that staff working with the seriously illneed skills in developing psycho-social and positive networks. They drew up a list of skills whichpsychiatrists need to demonstrate to be able to work with this group, including:

• primary care interventions

• education of families

• collaborative treatment planning.

Weir (1994) described the following as core team competencies required by all team members:

• case management

• monitoring of medication

• support counselling

• consultation

• research and evaluation

• liaison

• education

• setting of rehabilitation goals

• functional and resource assessment.

Bloom and Parad (1976) described how each discipline within the mental health workforceprovides specific skills to the team. These need to be clearly understood on entry into the practicearea. While professional colleges and organisations have developed competencies for theirdisciplines, there is as yet no one set of generic requirements of all disciplines within the mentalhealth field.

The requirements for the appointment of Duly Authorised Officers (DAOs) under the MentalHealth (Compulsory Assessment and Treatment) Act 1992 (Ministry of Health, 1995) provide theonly recognised set of competencies for all disciplines in a specific role within the mental heathworkforce in New Zealand. The DAO role is an extension of the clinical duties of mental healthprofessionals, and the following skills are required by all those fulfilling the role, regardless oftheir disciplines. Approval for a health professional to undertake this role is clearly defined withinthe Act.

The DAO role requires competency in three areas: knowledge, skills and attitudes. The skills aredefined as:

• the recognition and assessment of mental disorder

• the use of a mental status examination

• clinical skills in:

– engagement

– interpersonal management

– behaviour management

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• problem-solving

• crisis management and crisis de-escalation

• good written skills and oral presentation skills

• the ability to function as a member of a multi-disciplinary team

• familiarity with calming and restraint, including working in co-operation with the policeand use of breakaway techniques

• the ability to liaise with appropriate community organisations and to work with them in aco-operative manner, including appropriate community organisations which have a culturalbase, eg. marae committees, Pacific Islands communities and church groups

• the ability to deal appropriately with members of the public

• the ability to educate other agencies and the public on the Mental Health Act

• the ability to make decisions and act independently

• the use of supervision, peer review and debriefing procedures for both clinical matters andin the use of the Mental Health Act, as well as seeking specific and specialist advice whenappropriate (Ministry of Health, 1995c, p.15).

The National Health Committee (1996) in Guidelines for the Treatment and Management ofDepression by Primary Healthcare Professionals emphasises in the forward the role of supportivemanagement, and defines this to include:

• education

• problem solving

• supportive counselling

• investigation of lifestyle issues.

Hughes (1993) found in a skill requirement survey of the 512 staff of the regional mental healthservices in Wellington that skills clustered into five groups.

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Table 4: Skill clusters identified12

Skill area Components Skill area Components

Managementskills

VisionConflict resolutionResource managementLegal complianceDecision makingTeam member performanceCommunicationPlanning

Education skills

Cultural skills

TeachingSupervision

Cultural appropriatenessCultural safetyBiculturalism

Clinical skills Crisis interventionEmpowerment of clientsCo-ordination of casesMultidisciplinaryFollow-up/dischargeTherapeutic treatmentsPlanning of treatmentsAssessmentQuality

Communication skills Verbal, computer and/ordatabase

WrittenNetworkingInterpersonal

3.7.2 Central RHA Mental Health Workforce: Skills Analysis, 1996

A comprehensive training needs analysis undertaken by Central Regional Health Authority (Clarkand Hughes, 1996) found:

• there is a clear need for training in cultural assessment for all mental health workers

• a clear set of generic basic skills is needed for all mental health workers. They includeknowledge about mental illnesses, early recognition of illness, assessment, understandingof care processes and working with families.

• there are major deficiencies in family therapy and also in cognitive/behavioural and grouptherapies, and incorporating cultural requirements

• basic skills are required in new graduates entering the mental health services inassessment, therapies and interventions in mental health, and focused training andsupervision by experienced practitioners for their first year of practice

• major training needs are required in the sub-specialty areas where skill needs are highlyspecialist, such as alcohol and drug services. All mental health workers also need a basicknowledge of the key specialist areas so that they can undertake basic assessment andknow when and how to refer clients to specialised agencies.

• few training programmes are available to teach highly specialised clinical skills. Thosethat are run are often poorly advertised and not accessible to many staff who need them.Workers in isolated areas outside of the major teaching centres are particularlydisadvantaged in this regard.

• training programmes are urgently needed for:

– support workers/carers and cultural workers

– new graduate health professionals

– context-specific specialist skills.

12 Hughes, 1993, p.43.

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The report recommended that:

• training offered to workers within the mental health services includes specific kaupapaMaori components

• the mental health workforce has access to cultural assessment training

• training programmes for the mental health services place much more emphasis on issuespertaining to working with families

• programmes are developed to provide basic training for support workers/carers andcultural workers, with particular attention to early recognition of illness, understanding ofthe care processes, and working with families and consumers

• pre-entry training, particularly for nurses and social workers, ensures that graduates havebasic skills in assessment, therapies and interventions in mental health

• ‘intern’ programmes are supported for all new-graduate nurses entering mental healthnursing practice

• further investigation is undertaken into the best way to meet new graduate training needsfor social workers and postgraduate training needs for psychologists

• programmes are developed on a regional basis, particularly for special need areas (eg.Duly Authorised Officers)

• health providers offering specific training (eg. calming and restraint) provide access tomental health workers from other agencies

• specific programmes are developed to address the context-specific needs of sub-specialtyareas (eg. detoxification in alcohol and drug services)

• basic, advanced and context specific programmes on family and cognitive/behaviouraltherapies are developed and made accessible to members of the mental health workforce

• the development and delivery of education/training to the mental health workforceinvolves appropriate and experienced personnel, held in high regard by the mental healthservice

• a regional mechanism is developed to ensure that:

– information about relevant and specific training/education programmes is widelydisseminated among the mental health workforce

– all workers who need training and education have maximum access to relevantprogrammes

– efficient use is made of regional training resources.

3.7.3 Midland Health Mental Health Workforce: Skills Analysis, 1997

Midland Health commissioned a similar project to that undertaken by Central RHA in 1996. Thisreport identifies the core skill deficiencies and training needs of mental health workers within theMidland region and recommends strategies to address them.

Key findings are:

• the study identified a clear set of generic basic skills needed for all mental health workers.They include knowledge about mental illnesses, early recognition of illness, assessment,understanding of care processes and therapeutic interventions, and teamwork.

• specific skill deficiencies identified were mainly clustered in the therapies, assessment andrehabilitation, and teamwork

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• there were specific urgent training needs for support workers and Maori workers

• Maori providers and consumer providers generally identified more deficiencies than thosein other areas, although some specific areas and CHEs demonstrated notable deficiencies,particularly in teamwork skills, crisis intervention, therapies, and rehabilitation skills

• new graduates entering the mental health services need basic skills in assessment, therapiesand interventions in mental health and focused training and supervision by experiencedpractitioners for their first year of practice

• there were few appropriate training programmes available. Those that are run are often notaccessible to many staff who need them. Workers in isolated areas outside of the majorteaching centres are particularly disadvantaged in this regard.

• the work environment needs to support workforce development for its staff through itsservice delivery systems, career development pathways, performance management, andspecific support for and provision of appropriate training

• collaboration of training and health providers is essential to ensure that programmes areboth educationally and clinically sound, and flexible enough to change to meet changingskill requirements. A focus on the development of a pool of training resources to developappropriate training programmes in the Midland region, and proposals which will presentthem in a way to attract the funding is strongly recommended.

Recommendations from the report state that there need to be:

• more effective partnerships developed between education and health providers as a basefor the provision of clinical training

• strategies developed to ensure an infrastructure of training skills which would ensure thatavailable contestable funding (eg. Clinical Training Agency) is accessed, and programmestake place where providers and educators collaborate to maximise the utilisation of expertclinical resources

• measures, including the allocation of resources, taken to ensure that mental health workershave access to training and clinical experience

• encouragement of mental health providers to establish infrastructures that support ongoingmaintenance of competency, including review, monitoring and ongoing development ofmental health workers

• training programmes developed for Maori mental health workers. Such programmes mustinclude both specific kaupapa Maori components and mental health clinical skills, such asassessment and treatment. These programmes should be appropriate and accessible both toupskill current workers and provide initial training to new entrants into the mental healthsector, and be based on clear, national standards, provide national recognisedqualifications and give appropriate recognition to prior learning and experience.

• development of training programmes to provide basic skills for support workers, withparticular attention to assessment skills. These programmes should be appropriate andaccessible both to upskill current workers and provide initial training to new entrants intothe mental health sector, and be based on clear, national standards which are moderatedand audited, provide national recognised qualifications and give appropriate recognition toprior learning and experience.

• reviewed, refined, or developed, training programmes for health professionals (both atbasic and advanced levels) as necessary to ensure that health professionals are proficient inapplying a range of therapies

• inclusion in training programmes for support workers an understanding of the use oftherapies

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• training programmes for mental health workers to increase the emphasis on issuespertaining to working with families

• support for new graduate programmes for all new-graduate nurses entering mental healthnursing practice

• encouragement of health providers offering specific training (eg. calming and restraint), toprovide access to mental health workers from other agencies

• development of relevant programmes on a regional basis, particularly for special needareas, such as Duly Authorised Officers (DAOs)

• development of a regional mechanism to ensure that:

– information about relevant and specific training/education programmes is widelydisseminated among the mental health workforce

– all workers who need training and education have maximum access to relevantprogrammes

– efficient use is made of regional training resources.

3.7.4 Home-based care

The Ministry of Health has developed standards for home-based services (Ministry of Health,1995c). These standards specify that providers must take responsibility for ensuring that theircareworkers have the necessary skills to perform their duties. In particular:

• providers must ensure all workers are trained, supervised and supported in a way thatallows them to fulfil their role in helping people to live at home

• providers should have a performance management system that identifies and monitorscareworkers’ competency levels, training needs and compliance with continuing educationrequirements

• training should be provided on an ongoing basis. Where simple skill levels are required,providers may offer relevant, basic, in-house courses. Careworkers should not be expectedto do tasks they are not trained to do.

• careworkers have a responsibility to know the objectives of the service they provide

• careworkers are expected to be familiar with all aspects of the policy on the rights andresponsibilities of clients

• careworkers are expected to follow written guidelines, set by the provider agency, withregard to:

– the agreed work plan

– the scope and limitations of their responsibilities and activities

– hygiene, health and safety procedures

– administration of medication and drugs

– financial protection (handling money, gifts, bequests, valuables)

– action to take where possible abuse is suspected

• careworkers should respect the privacy of the client’s home and possessions and theclient’s right to determine what takes place in his/her own home.

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3.7.5 Alcohol and drug services

The ALAC review (Hannifin and Gruys,1996) included a survey on training gaps. A survey ofeducation and training issues among managers and employers of staff in the alcohol and drug fieldidentified the gaps in course content, including:

• health promotion

• group work

• Maori issues

• professional writing

• reading and written communication skills

• mental health.

3.7.6 Maori workers

Appreciation and consideration of socio-cultural factors is important for all people inimproving treatment outcomes and the health of the community. In New Zealandthere are Treaty responsibilities to support the culture and provide culturallyappropriate treatment options for Maori. The more the clinician is able to appreciatethe cultural perception of the individual to whom they are offering assistance, thebetter the therapeutic relationship will be. Consequently, compliance with – and theeffectiveness of – the treatment will increase. (National Health Committee, 1996,p.26)

The Maori worker has usually acquired skills while working with Maori people with mentalillness. These skills, however, have not been recognised as formal qualifications, as obtained byothers in the workforce. These people have other skills which are recognised by Maori tikangasuch as “whanau ngatanga, matauranga, mohiotanga and wairuatanga” (Ministry of Health,1996b, p.25).

As a result of the Prime Ministerial Taskforce on Employment, Maori identified the trainingstrategies that need to be included in training processes for Maori within mental health:

• a definition of mental health

• recognition of prior learning

• content that reflects Maori values

• appropriate assessment procedures

• coverage of the range of mental health services from primary (education and prevention)through to tertiary (postgraduate).

Training requirements for Maori mental health workers will require a mix of Maori cultural valuesand politics (eg. de-colonisation and empowerment), and have a consumer focus as well as mentalhealth clinical expertise. Purchasers of training must look for opportunities to merge these skillsrather than seeing them as an either/or situation (Ministry of Health, 1995a).

3.7.7 Cultural assessment

Cultural assessment assesses a person in the context of their culture, in relation to anillness they are suffering, which is integral to their assessment, care and treatment.(Ministry of Health, 1995a, p.11).

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The Guidelines went on to identify that the training requirements for cultural assessors shouldinclude:

• an overview of tikanga Maori, tapu and noa, mate Maori and makutu

• development of interview skills

• knowledge of mental illnesses

• knowledge of drug and alcohol misuse

• knowledge of the cultural assessment process

• specialist areas such as forensic, dual diagnosis, children and young persons (Ministry ofHealth, 1995a, p.27).

The Guidelines raised the issue of provision of training in the area of cultural assessment.According to the report, Auckland is the only area offering such training and it is in modularformat.

3.7.8 Pacific Islands nations

Literature on Pacific Islands skill requirements in mental health was often incorporated under thetotal health concept. In 1985 Parson indicated that there is “a qualitative difference in the wholesickness experience of each cultural group” (Ministry of Health, 1995d, p.11).

Pacific Islands people experience sickness differently from non-Pacific Islands people. In general,Pacific Islands people have a holistic view of health. Mental health is thus not simply seen as aseparate component from physical well-being but is considered an integrated aspect in the matrixof an individual Pacific Islands person’s physical, mental and spiritual health.

The general experience of Pacific Islands professionals is that there is a lack of cultural safety.Cultural advocacy is cited in many reports as an important requirement.

Skill requirements for any health work with Pacific Islands people have been promoted (NationalHealth Committee, 1996) as:

• an appreciation of the different background(s) of the client

• a recognition of the specific ethnic identity/identities of the client, as each of the PacificIslands nations has its own cultural values and beliefs, language(s), lores and laws, verbaland non-verbal codes, customs, practices and protocols

• a willingness to refer to people with specialised knowledge about the various PacificIslands nations’ views of mental health

• an awareness of the health-oriented issues for Pacific Islands communities – such aseconomic survival, unemployment, immigration restrictions, educational opportunities,opportunities to maintain their culture, and collective development

• an ethnic-specific knowledge about a Pacific Islands client which is useful and vital to aPacific Islands healthcare professional – such as language(s) of communication, village(s)of origin, geographical features of the country concerned, relevant family stories, religiousaffiliations and belief, family members and respectful titles of address (p.28).

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3.7.9 Nursing

The New Zealand Nurses Organisation (1997) reported on a survey of its members in mentalhealth. Priority areas for training opportunities and skill development in the community were:

• autonomous working

• working within a multi-disciplinary team

• safety issues

• assessment skills

• crisis intervention

• proficiency in use of computers including laptops.

Other areas identified as priorities were:

• counselling

• self-advocacy for clients

• coping with challenging behaviours

• stress management – maintaining mental health

• effective communication – including active and selective listening

• child and adolescent mental health issues

• Maori mental health issues – spirituality and the role of tohunga

• drug and alcohol issues

• early intervention

• whanau and family interventions

• treatment and behavioural models – including those for dual diagnoses

• conflict solution

• planning workloads

• clinical supervision and kaupapa supervision

• forensic mental health nursing

• rehabilitation

• chronic care.

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4 Strategic Framework for Workforce Development:Competencies for the Mental Health Workforce


A model of core competencies13 advanced core competencies and specialist skills based on currentand future roles for people working in the mental health service has been developed for use by:

• educators in the development of education and training programmes

• regulators in the development of competencies required by applicants for registration andvalidation/accreditation of education programmes

• employers for provision of services, performance appraisals, personal development plansand design of career pathways.

The model is one of several initiatives designed to improve the effectiveness of the mental healthworkforce in mental health service organisations.

Progression through the three core competency levels is dependent upon clearly proscribed andsupported postgraduate and continuing education courses for all workers. Assessment of thecompetencies is the responsibility of employers, educators, regulatory bodies and consumers usingcriterion-referenced processes. The competencies have been developed to promote recovery.

The core competencies and their associated performance criteria have been developed with theassistance of mental health service providers, Maori, Pacific Islands people, professionalorganisations, professional regulatory bodies, and professional education and training providers.

The application of the core competencies in clinical practice will need to be regularly reviewed tomaintain relevance and content specificity. Their inclusion in education programmes, performanceappraisals and development plans, and standards for entry to professional practice, will requireongoing monitoring. Raising the standard of competence in the mental health service workforcewill need not only application of the core competencies but also a sufficient number ofappropriately trained multi-disciplinary teams of workers.

The core competencies can be found in Tables 5, 6, and 7. A strategic framework with prioritiesand targets for achieving the workforce requirements is set out in Table 8.

4.2 Introduction

Employers, consumers and health professionals have raised concerns about the competence ofpeople preparing to work in, or working in, the mental health service. General concern has beenexpressed that education programmes and accrediting authorities (including health professionalregistering bodies) do not appear to be as responsive as they could be to the needs of the service.Others refer to the absence of an interdisciplinary team approach to consumer-focused careplanning and inadequate levels of consultation with consumers, their families/whanau and theircommunities.

13 Competency – a demonstrated ability to achieve a required level of performance.

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Every person working in the mental health services is expected to use a recovery approach in theirwork (Mental Health Commission, 1998a, p.16). The approach requires recognition and initiationof early therapeutic intervention strategies, and is consistent with the guiding principles of theNational Mental Health Plan (Ministry of Health, 1997a) and the National Mental HealthStandards (1997b). Stopping discrimination and promoting respect, rights and equality for peoplewith mental health illness is also important.

With these concerns in mind a set of core competencies has been developed as a requirement forall people working in the current and future mental health service. Specific competencies andskills required by individual health professionals in order to be able to practise in their particularprofession, eg. psychometric testing by clinical psychologists, are additional to the core competenciesdescribed.

The core competencies are based on already published competency and standards material from anumber of professional regulatory and non-regulatory bodies, on unit standards registered on theNational Qualifications Framework for mental health support work, and published andunpublished reports on New Zealand mental health services.14 They have not been developed toidentify a generic multi-skilled mental health worker,15 but rather to demonstrate that there are setsof core competencies that need to be demonstrated by all mental health service workers, whatevertheir occupational discipline, at different stages of their careers.

The advanced competencies, although more clearly defined in the appendices than in some of thereferenced material, are in fact, included amongst the competencies and performance criteriaexpected at entry to practise of most of the health occupational groups who practice in NewZealand’s mental health services. They are also complementary to, and should be used togetherwith, such publications as the Blueprint and the National Mental Health Standards.

Key threads link the basic, advanced and specialist competencies. These are set out in thecompetency descriptors and performance criteria. An example is the use of counselling (usedwidely and generally to include budget advice and therapeutic counselling), which can beconsidered as ‘general advice’ at the basic level and a content-specific skill at an advanced orspecialist level.

4.3 Preamble

The mental health area has been one of major change over the last 10 to 20 years. Medicalscience, technology and societal demands predict further significant change occurring in the future.Services will be culturally appropriate and consumer focused and will be delivered in partnershipwith the consumer, their family/whanau and their communities.

Members of the mental health workforce must be willing to upgrade their knowledge and skills tomeet the expected evolutionary changes in work practices and disease manifestations. Therapeuticoptions will continue to evolve, placing greater demands on the need for advanced competence in ahighly specialised service staffed by highly competent workers.

14 The resources referred to are included in the reference list.

15 Workers – this generic term has been used deliberately throughout the chapter to describe all persons who worktherapeutically with consumers of mental health services. It fits within the use of the term ‘workforce’, and covers allmental health workers and other health professionals such as registered nurses, doctors, occupational therapists,clinical psychologists, social workers, psychotherapists and physiotherapists.

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Linkages need to be improved to enhance integration between general medical practitioners,primary and other health services, schools, Maori health and Pacific Islands health groups andcommunities. Services sitting outside the health services (eg. prisons), will need consultation/liaison links with the mental health services.

There is general agreement internationally that mental health services are best delivered toconsumers by teams of multi-skilled16 and multi-disciplinary workers.17 Members come with avariety of personal and professional competencies and experience. Teams of such workers needmembers with core skills and competencies representing generic as well as shared skills andknowledge to enable them to work with people accessing the services in a variety of therapeuticsettings. They also need access to people with additional specific clinical skills.

Literature and experience supports the need for collaborative planning in the mental health service.Service delivery using collaborative approaches is frequently described as trans-disciplinary18

and/or inter-disciplinary.19 Consumers, their families/whanau and their communities must beincluded in the consultation process where planning affects the services they will receive.

4.4 Competence

There are several perspectives on the nature of competence. Those generally used in the referencedocumentation and in health professional practice in New Zealand marry the general attributes(knowledge, attitudes and skills) in an integrated approach to realistic tasks. These attributes areused in combination to bring together disparate things (abilities of individuals derived fromcombinations of attributes) and the tasks that need to be performed in particular situations (Gonczi,1994). They also incorporate professional judgement.

A good set of competency standards will provide a clear statement of what is considered to beimportant in competent performance for the workforce (Hager, 1992). Partial demonstrationcannot be considered adequate.

While the relationship between competency standards and education curricula needs to be flexible,the relationship should be one of overall coherence of an educational programme and thecompetency requirements required by an occupation. If curricula are conceived this way, it will bepossible to overcome some of the fragmentation and lack of integration that currently characteriseaspects of the initial education and training of clinical staff.

The use of competency based standards enables competence to be achieved in a recognised way.Clear public standards help to maintain public confidence, and give occupational groups a clearerunderstanding of their work and what constitutes good practice (Gonczi, 1994). Relationshipswith other occupations are also clarified. Their use potentially provides a more rational basis forinitial and continuing education and for objective assessment of achievement (outcome) in thework setting. Emphasis can be applied to the application and synthesis of knowledge and the

16 Multi-skilled – skilled in a wide range of tasks.

17 Multi-disciplinary team – a team of workers from a variety of backgrounds or disciplines. Each member tends topractise independently within the team framework.

18 Trans-disciplinary – with agreement, members of the team may use skills that traditionally incorporate recognisedprofessional practice of disciplines other than their own, to provide a unified treatment approach. The ‘owner’ of theprofessional practice skill retains overall authority and accountability for its use by other team members.

19 Inter-disciplinary – workers from a variety of backgrounds (or disciplines) working collaboratively together for acommon approach.

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integration of theoretical and practical knowledge in professional judgements. This is the heart ofsuccessful practice.

Competencies and their performance criteria, should not be used as an unqualified checklist, ontheir own. Because each competency relates to another, the set of competency standards needs toread as a whole. The performance criteria provide guidance and background on what areconsidered the important components for competent practice in the mental health service.

The core competencies described in Tables 5, 6, and 7 encompass the comments, additions andrefinements offered by the following individuals and groups:

• mental health service providers

• professional associations representing health professional groups working in the mentalhealth service

• education providers for all relevant health professional groups and mental health supportwork

• relevant professional regulatory bodies

• Maori and Pacific Islands people.

The majority of providers and professionals view very positively the initiative of requiring corecompetencies for all members of the mental health workforce. Strong support has been given forthe use of specified competencies as a focus for education and training programmes and forperformance appraisals for staff. The negative views indicated that professional competency andstandards documents are already available, and that there is no need for a further set.

Standards of practice and competencies in mental health nursing, knowledge and skill-basedcompetencies for clinical psychologists, and mental health training for psychiatrists and generalpractitioners have been defined. Other competency standards are currently immersed in genericcompetencies for a formal qualification and/or for registration with the respective professionalregulatory bodies, and are not clearly identifiable as being the specific competencies required forpractice in the mental health service.

4.5 Clinical experience/practice

Practice in the workplace setting is an essential and integral part of education and training. Itencompasses direct and indirect consumer contact, including assessment, management of plannedcare, evaluation, and consumer focused family/community interactive activities. Observation, whilean acceptable learning technique, is not interchangeable with clinical practice (Physiotherapy Board,1988). It is essential that education and training programmes provide students with the mostappropriate exposure to workplace clinical practice opportunities to enable students to achieve thecompetencies described. Access to such exposure requires the co-operation and resource support ofmental health service providers.

4.6 Core competencies

4.6.1 Basic competence

The following core competencies are expected to be held by all mental health workers practising inthe mental health sector. Actual practice frequently involves several of the following intentionalactions simultaneously, and the competencies need to be considered as a whole.

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The mental health worker (including support worker) will be able to:

• demonstrate knowledge and understanding of mental health, mental illness and mentalhealth services20

• communicate effectively

• demonstrate culturally appropriate practice

• assess the client’s health needs

• provide appropriate intervention for consumers

• keep records in a clear, concise and accurate format

• practise safely and ethically

• comply with legal responsibilities

• promote the health and wellness of consumers, families and communities

• promote individual professional growth.

The competency standards include the concept that the practitioner must take account of varyingcontexts in which they are operating (eg. residential, community, and alcohol and drug services).The holistic character of each competency represents complex tasks and behaviours that are notdiscrete and independent but are integrated within other competencies in a matrix. Details of thecompetencies and expected performance criteria are described in Table 5.

Basic-level competency standards should offer guidance for longer-term advancement and careerdevelopment. The clear specification of what a competent mental health worker needs to be ableto do will provide a sharper focus for continuing education and specialisation (Hager and Gonczi,1991).

4.6.2 Advanced competence

The competencies in this model (see Table 6) build on the strengths derived from the basic corecompetencies to provide services at an advanced generic level. They are expected to be held bymental health workers who may have no formal qualifications at entry but who have gainedexperience and expertise while working in the mental health sector, and are supported by formaleducation and training programmes.

Practitioners entering the mental health sector with a formal health professional qualificationwould be expected to be able to practise at this level within 12 months of commencing work in themental health service. This expectation applies not only to new graduates but also to thosegraduates transferring from other areas of practice (eg. medical services), to work in the mentalhealth service. House surgeons would be expected to meet the advanced competencies at thecompletion of a three-month attachment to a mental health service.

Although health professional education and entry-level programmes prepare graduates for work ina range of professional practices, many new graduates entering the mental health workforce needextensive supervision and further training before they can practise effectively. Such supervisionand training requirements also apply to experienced practitioners changing their practice setting(eg. general medical/surgical to mental health).

20 Includes alcohol and drug services.

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There is a strong feeling among many practitioners that there is a good case for limiting caseloadcomplexity during the first year of mental health service practice (Clark and Hughes, 1996; Evert,1993). Regular and ongoing supervision from experienced staff is therefore critical. The type ofsupervision required for post-entry practice – such as close, routine, general, and minimalsupervision – also needs to be addressed for workers shifting to another area of specialisation or tomanagement, or for workers returning to practice after a break in their career.

The establishment of a formal one (academic) year post-entry mental health nursing programmeusing a model of collaboration between employers and an associated tertiary education provider isan example of a training initiative to upskill newly graduated registered comprehensive nurses forwork in the mental health sector.

The advanced mental health practitioner will hold the basic core competencies (described inTable 5), basic competencies that are more complex, and additional competencies that incorporateleadership, management, research and education (Table 6).

The mental health worker will be able to:

• demonstrate knowledge and understanding of mental health, mental illness and mentalhealth services21

• communicate effectively

• demonstrate culturally appropriate practice

• evaluate the consumer’s health needs

• manage therapeutic interventions

• keep records in a clear, concise and accurate format

• practise safely and ethically

• comply with legal responsibilities

• promote the health and wellness of consumers, families and communities

• promote individual professional growth.

(Note: The requirements for the Duly Authorised Officers (DAOs)22 provide a useful recognisedset of competencies. They are also a required extension of the clinical duties for any healthprofessional fulfilling the role, regardless of their occupation.)

4.6.3 Specialist competence

Specialist core skills that are additional to the generic core competencies and skills required forworking in the mental health service and for advanced competence for the following specialistareas, are described in more detail in Table 7:

• acute clinical services

• anxiety and eating disorders

• children and young people

• alcohol and drug services

• forensic psychiatry


22 Appointed by the Director of Area Mental Health Services under the Mental Health (Compulsory Assessment andTreatment) Act 1992.

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• consultation liaison psychiatry

• Maori health

• Pacific Islands health

• psychogeriatrics

• residential care

• rehabilitation.

Estimates of dual diagnosis patients in New Zealand are substantial, and range between 35% and85% of psychiatric patients. Close working relationships should be promoted between the alcoholand drug sector and the mental health services.

The specialist individual professional practitioner’s clinical competencies (eg. occupationaltherapist, psychiatrist) have not been included, as these are specific to those disciplines and are notcore competencies required by all mental health workers. Nursing and medical (general practice)mental health competencies (which include many of the core competencies) have been published.Specialist psychiatric requirements are available while others have yet to be defined by theprofessions. In addition, the Nursing Council has published guidelines and competencies for post-registration nursing and specialisation.

A wide range of specialised courses are being offered for Maori mental health, dual diagnosis,eating disorders and counselling although the regional distribution is uneven. It is estimated thatthe HFA probably contributes about 50% of the money allocated for mental health training.23

Approximately 35% is estimated to be funded by Vote:Education. Education funding tends to bedirected towards counselling, alcohol/drug and clinical psychology training. Health funding isdirected towards psychiatric registrar training, new-graduate and advanced nurse training, andspecialist courses.

4.6.4 Consultation on the competence model

The draft competencies were distributed widely for feedback and redrafted to include the specificcontent provided. The development of a defined three-level core competency model for all peopleworking in the mental health service has received strong support from education and trainingproviders, regulatory bodies and the majority of service providers. Some professional bodiesexpressed concern about the role and relationship of core generic competencies to their ‘discipline-specific’ standards.

Education providers generally considered that the competency framework was useful in settingcurricula and some health professional educators commented that their graduates would alreadymeet most of the advanced competencies. Several made comments similar to the following:

Documents such as the core competencies will be of considerable use to ourprogramme. Since all academic programmes must undertake regular review anddevelopment, the document will reinforce where important areas are being addressedand highlight those areas that need further development.

Health professional groups varied from agreement that these competencies reflected their ownprofessional standards to concern about the concept of generic competencies and the use of thesecompetencies in relation to their professional practice. There was little disagreement on actualcontent.

23

An estimate in late 1997 found that the then Transitional Health Authority (THA) either through the CTA or theregional offices of the THA, contributed 54% of the $13.5.million allocated to mental health training.

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Regulatory bodies confirmed that the competencies reflected their own requirements. The NursingCouncil, Occupational Therapy Board and Physiotherapy Board all confirmed that the advanced-level core competencies matched, or were compatible with, their generic and mental healthperformance criteria competency requirements for registration. The Medical Council confirmedthat psychiatrists would demonstrate the advanced competencies.

4.7 Detailed competencies

Table 5: Basic core competencies

Every mental health worker will be able to:

1 Demonstrate knowledge and understanding of mental health, mental illness and mental healthservices24

Performance criteria

1.1 Demonstrate knowledge of mental health and illness, treatments and services including alcohol anddrug services.

1.2 Integrate knowledge of societal, cultural, psychological, environment, spiritual and belief systems thatinfluence mental health and illness into practice.

2 Communicate effectively


2.1 Use language and terminology appropriate to the needs of the consumer, the group and the setting.

2.2 Use appropriate communication style, level and medium for the consumer, the group and the setting.

2.3 Be sensitive to and modify approaches for situations in keeping with cultural differences.

2.4 Give and receive verbal and non-verbal communication in individual and group settings, with teammembers and others.

2.5 Maintain objectivity and minimise bias.

2.6 Respect the rights of the individual, their families and/or significant others.

2.7 Apply the principles of informed consent.

2.8 Recognise the availability and role of health consumer advocates/interpreters and use themappropriately.

2.9 Provide supportive relationships.

2.10 Liaise with family members and other resource persons/agencies.

2.11 Participate as a team member in a consumer-focused/goal-directed inter-disciplinary approach to clientcare.

2.12 Demonstrate empathy with consumer, family/whanau, team members and appropriate others.

2.13 Seek and accept critical feedback on understanding of imparted information from consumer,family/whanau, colleagues and others.

2.14 Use reflective practice techniques in order to alter practice when indicated.


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3 Demonstrate culturally appropriate practice


3.1 Apply the principles of the Treaty of Waitangi to mental health services.

3.2 Recognise the impact of the mental health service on a consumer’s belief system.

3.3 Establish and maintain a supportive relationship with consumers and their families/whanau orsignificant others.

3.4 Evaluate own practice in relation to cultural appropriateness.

3.5 Identify own cultural value base and its impact on that of the consumer.

3.6 Avoid imposing own belief system on to consumers and others.

3.7 Recognise and respect the differing values and beliefs of individual consumers and groups.

4 Assess consumer health needs


4.1 Undertake a basic mental health assessment.

4.2 Assess and acknowledge the needs of everyone affected by mental illness.

4.3 Assess risk of harm to self and others.

4.4 Treat the consumer and his/her family/whanau/resource group with respect.

4.5 Practise holistically.

4.6 Elicit pertinent data.

4.7 Apply observation skills to assess appearance, behaviour, speech, mood, thinking, perception,cognitive function, content of thought, insight and judgement of the consumer.

4.8 Recognise the presence of alcohol and drug problems.

4.9 Recognise the presence of co-existing disorders.

5 Provide appropriate intervention for consumers


5.1 Use recovery approach as the guiding principle for planning of care and practice.

5.2 Work with consumers with a dual diagnosis/co-existing disorders.

5.3 Manage difficult behaviour.

5.4 Administer calming and restraint techniques when encountered by challenging and threateningbehaviour.

5.5 Recognise and respond to changes in the consumer, self and the environment.

5.6 Provide interventions that achieve agreed goals.

5.7 Utilise the skills of other mental health workers.

5.8 Administer cardiopulmonary resuscitation.

6 Keep records in a clear, concise and accurate format


6.1 Keep and maintain consumer records that are accurate, timely, objective and legible.

6.2 Meet legal, organisational and consumer management requirements.

7 Practise safely and ethically


7.1 Ensure the consumer’s and his/her family’s right to privacy.

7.2 Recognise ethical and safety dilemmas as they arise.

7.3 Consult with experienced mental health workers and appropriate others to resolve ethical and safetyissues.

7.4 Participate in regular ongoing supervision and support forums.

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8 Comply with legal responsibilities


8.1 Apply relevant legislation, statutory regulations, policies and protocols that influence mental healthpractice.

8.2 Work in accordance with relevant legislation and codes.

8.3 Respect a consumer’s right to complain, or refuse treatment or any part of any care without instillingfear of recrimination, penalty or withdrawal of emotional and physical support.

8.4 Recognise and support the consumer’s and his/her family’s/whanau/resource group’s right to accessinformation.

8.5 Recognise the rights of family/whanau and/or significant others.

9 Promote the health and wellness of consumers, families and communities


9.1 Support the implementation of individual lifestyle planning in accordance with Treaty of Waitangipartnership principles.

9.2 Support the implementation of family/whanau-inclusive mental health services.

9.3 Ensure that consumers and their families/whanau/resource group have access to relevant information,pertinent education, and support in relation to the diagnosis, illness and mental healthcare optionsavailable.

9.4 Use communication skills appropriate to the individual or group.

9.5 Apply the recovery approach.

9.6 Ensure that consumers and their families/whanau are made aware of, and have access to, relevant staffin relation to their mental health care.

9.7 Consult with alcohol and drug agencies.

10 Promote individual professional growth


10.1 Identify own role and the roles of others in the mental health team.

10.2 Demonstrate self-awareness.

10.3 Recognise own learning needs.

10.4 Recognise limitations of own abilities and refer to other team member or specialist resource whenappropriate.

10.5 Seek peer review annually.

10.6 Participate in career development strategies

10.7 Participate in continuing education activities.

10.8 Participate in regular ongoing clinical supervision.

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Table 6: Advanced competencies

Every mental health practitioner will be able to:

1 Demonstrate knowledge and understanding of mental health, mental illness and mental healthservices


1.1 Identify normal and abnormal patterns of human development.

1.2 Describe the societal, cultural, psychological, environmental, spiritual and belief systems influencinghuman development and behaviour.

1.3 Describe how human development can be affected by common mental health disorders.

1.4 Demonstrate a working knowledge of the dynamic changes in behaviour related to mental health.

1.5 Demonstrate a working knowledge of the epidemiology of mental health and mental illness in NewZealand.

1.6 Demonstrate an understanding of the natural history of mental disorders and the value of earlyintervention.

1.7 Describe the effects of common mental health disorders and impaired intellect on human behaviour.

1.8 Describe the effects of mental illness/substance abuse on family/whanau.

1.9 Demonstrate knowledge of current psychiatric medical diagnosis classification systems.

1.10 Demonstrate knowledge of treatment modalities used in primary, secondary and tertiary mental healthcare.

1.11 Use the mental health service and intersectoral agency linkages.

2 Communicate effectively


2.1 Use language and terminology appropriate to the needs of the individual, the group and the setting.

2.2 Use appropriate communication style, level and medium for the individual, the group and the setting.

2.3 Be sensitive to and modify approaches for situations in keeping with cultural differences.

2.4 Give and receive verbal and non-verbal communication in individual and group settings.

2.5 Apply assertiveness skills.

2.6 Apply interviewing skills.

2.7 Maintain objectivity and minimise bias.

2.8 Respect the rights of the individual, their families and/or significant others.

2.9 Apply the principles of informed consent.

2.10 Recognise the availability and role of health consumer advocates/interpreters.

2.11 Use leadership skills and group interaction effectively.

2.12 Provide a supportive environment to support communication and foster motivation.

2.13 Provide supportive counselling.

2.14 Liaise with appropriate family/whanau members and other resource persons.

2.15 Participate in team approach to consumer/family/whanau/resource group interventions.

2.16 Demonstrate empathy and respect for consumer, families/whanau team members and others.

2.17 Empower consumers, families/whanau, groups, team members and appropriate others.

2.18 Use appropriate physical and environmental setting for the individual or group.

2.19 Recognise situations where information should be imparted to appropriate others.

2.20 Seek and accept critical feedback on understanding of imparted information from consumer, families/whanau, colleagues and others.

2.21 Evaluate communication skills of self and others.

2.22 Use reflective practice techniques to alter practice deficiencies.

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3 Demonstrate culturally appropriate practice


3.1 Maintain the cultural identity of clients, consumers and others in relation to their culture, gender,marital status, age, disability, beliefs, sexual orientation, employment or family status.

3.2 Facilitate consumer’s access to appropriate support, systems, services and resources.

3.3 Recognise the impact of a consumer’s culture when providing mental health services.

3.4 Recognise the impact of the mental health service on a consumer’s belief system.

3.5 Establish and maintain a supportive relationship with consumers and families/whanau.

3.6 Evaluate own practice in relation to cultural appropriateness principles.

3.7 Evaluate own belief system and refrain from imposing beliefs on to consumers and others.

3.8 Practise safely and effectively in in-patient, home-based care, community and rehabilitation settings.

3.9 Demonstrate a commitment to Maori and acknowledge them as tangata whenua.

3.10 Demonstrate a commitment to Pacific Islands people’s, refugees’ and migrants’ health.

4 Evaluate consumer health needs


4.1 Treat the consumer(s) and their family/whanau/resource group with respect.

4.2 Use an holistic approach.

4.3 Elicit pertinent data.

4.4 Apply observation skills.

4.5 Conduct a subjective mental health status examination that includes an assessment of presenting issues.

4.6 Select and conduct an objective mental health status examination.

4.7 Assess the risk of harm to self and others.

4.8 Interpret and synthesise findings.

4.9 Recognise the need for early therapeutic intervention.

4.10 Recognise alcohol and drug problems.

4.11 Set treatment/rehabilitation goals with the consumer.

4.12 Evaluate, and be involved in, strategies for relapse prevention and a care management plan.

4.13 Re-evaluate and modify accordingly.

4.14 Recognise when advocacy is required.

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5 Manage therapeutic interventions


5.1 Implement planning and mental health therapeutic management of care in partnership with theconsumer, their family and significant others as required by the recovery model.

5.2 Use a range of appropriate therapeutic modalities such as individual therapy, group therapy, familyintervention/education, and pharmacology as described in the care management plan.

5.3 Recognise the commonly used psychotropic medications and their side effects.

5.4 Manage anger and other challenging and threatening behaviours.

5.5 Apply crisis management and de-escalation skills.

5.6 Provide appropriate therapeutic management for consumers with co-existing disorders.

5.7 Identify hazards and implement safe practices.

5.8 Recognise and respond to changes in the consumer, self and the environment.

5.9 Apply cost-effective and efficient management skills.

5.10 Practise effectively in in-patient, home-based care, community and rehabilitation settings.

5.11 Provide professional leadership when required.

5.12 Effectively supervise delegated tasks.

5.13 Provide safe and effective intensive case management when indicated.

5.14 Set measurable and achievable rehabilitation goals with consumer, family and relevant team members.

5.15 Use research and educational material to improve service delivery.

5.16 Develop discharge plans with consumers, family and other team members.

5.17 Demonstrate effective problem-solving skills.

6 Keep records in a clear, concise and accurate format


6.1 Keep and maintain consumer records that are adequate, accurate timely, objective and legible.

6.2 Meet legal, organisational, research and consumer management requirements.

6.3 Use accurate and factual language with professional terminology.

6.4 Complete a consumer’s discharge summary.

6.5 Demonstrate organisational skills.

7 Practise safely and ethically


7.1 Incorporate the concepts of professional independence, interdependence, authority, accountability andpartnership into practice.

7.2 Ensure the consumer’s and their family’s right to privacy.

7.3 Use ethical reasoning strategies to resolve ethical dilemmas and problems arising in mental healthpractice.

7.4 Consult with experienced mental health workers when an ethical dilemma arises.

7.5 Ensure that each consumer of mental health services and their family/whanau is fully informed so thatthe consumer can optimise their decision making and options of choice.

7.6 Appropriately challenge mental health care practices which could compromise patient safety, privacyor dignity.

7.7 Provide appropriate supervision for delegated tasks.

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8 Comply with legal responsibilities


8.1 Ensure familiarity with relevant legislation, statutory regulations, policies and protocols whichinfluence mental health practice.

8.2 Practise in accordance with relevant legislation and codes.

8.3 Respect a consumer’s right to complain, or refuse treatment or any part of any care without instillingfear of recrimination, penalty or withdrawal of emotional or physical support.

8.4 Recognise the consumer’s and their family/whanau’s right to access information.

8.5 Recognise the rights of family/whanau and/or significant others.

9 Promote the health and wellness of consumers, families and communities


9.1 Support the implementation of individual lifestyle planning in accordance with partnership principles.

9.2 Support the implementation of family-inclusive mental health services.

9.3 Assess and acknowledge the needs of everyone affected by the mental illness.

9.4 Ensure that consumers and their families/whanau have relevant and current information about theirmental health care, including available treatment options.

9.5 Select and use appropriate mental health education promotion programmes to meet the needs of theconsumer, their families/whanau and their communities.

9.6 Use formal and informal learning and teaching methods, strategies and resources.

9.7 Evaluate consumer learning and understanding when appropriate.

9.8 Liaise effectively with community groups.

10 Promote individual professional growth


10.1 Identify own role in the mental health team.

10.2 Apply self-awareness strategies.

10.3 Recognise own learning needs.

10.4 Recognise professional limitations and refer to another team member or specialist resource whenappropriate.

10.5 Seek peer review annually.

10.6 Participate in career development strategies.

10.7 Participate in continuing education activities.

10.8 Participate in professional activities.

10.9 Participate in regular ongoing clinical supervision and peer review.

10.10 Acknowledge professional debate on mental health issues.

10.11 Promote quality improvement strategies.

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Table 7: Specialist competencies

Mental health professional practitioners are expected to hold relevant additional qualifications andwill practise at a level of advanced competence or better, with the following additional skills:

Acute clinical services

• Assess mental and physical health status, and developmental history.

• Administer a mental health status examination.

• Demonstrate in-depth knowledge of mental illnesses.

• Apply specific experience and skills in in-patient assessment and treatment of adults, children and youth.

• Develop care plan for action/follow-up.

• Support consumers on an intensive therapy programme.

• Provide crisis management and de-escalation skills.

• Use conflict resolution skills.

Anxiety and eating disorders

• Assess mental and physical health status.

• Educate and support consumers in stress management techniques.

• Demonstrate in-depth knowledge of eating disorders.

• Ensure consumer’s physical safety.

• Provide therapeutic intervention and treatment plan.

Children and young people

• Communicate effectively with children and young people at different age levels.

• Conduct a comprehensive developmental assessment.

• Identify developmental needs of children and young people.

• Apply in-depth knowledge of developmental stages of childhood and adolescence, ‘at-risk behaviour’ andpotential ‘at-risk groups’.

• Identify and offer treatment for children and young people with substance abuse.

• Identify and treat illnesses that are likely to be an issue for children and young people (eg. pervasivedevelopmental childhood disorder, psychiatric illness and early intervention psychosis).

• Use comprehensive biopsychosocial assessment and risk management techniques to identify and manageyoung people and children at risk of suicide.

• Use cognitive behavioural therapy and other behavioural therapies appropriate to developmental stage ofgrowth.

• Identify patterns of learning, any learning disorders and educational history in liaison with child’s schooland Specialist Education Service (SES).

• Effectively liaise with both child and adult mental health services and other agencies to ensure the mostappropriate supports and treatment processes are put in place for each service consumer.

• Effectively work with families/whanau.

• Meet cultural needs of Maori and Pacific Islands people.

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Alcohol and drug services25

• Use a range of strategies to a) accurately identify and assess alcohol and drug problems, b) negotiateappropriate goals and c) plan relevant interventions with the client or client group.

• Intervene appropriately in alcohol and drug related issues and problems presented by a client, family,whanau, group or community.

• Work effectively with communities, groups, families, whanau and other significant networks in reducingthe harms associated with alcohol and drug use.

• Use appropriate strategies to educate others on alcohol and drug related issues.

• Assist other workers to identify and deal effectively with people experiencing issues and problems relatedto alcohol and drug use.

• Formulate a suitable intervention and management plan.

• Manage a prescribed detoxification process.

• Assess consumer’s suitability for home-based/residential care.

• Provide a consumer with supportive counselling, education and information on relevant issues, andavailable resources.

• Understand human biochemical processes relating to the use of drugs and alcohol.

• Work effectively within community mental health teams.

• Provide alcohol and drug information and harm-reduction strategies.

• Liaise effectively with other alcohol and drug services, including dual diagnosis specialists.

• Liaise effectively with Maori, Pacific Islands people and other cultural groups.

• Work according to a Maori kaupapa.

Forensic psychiatry

• Demonstrate specialist knowledge of intense pharmacological interventions for patients with behaviouralproblems and mental illness.

• Demonstrate knowledge of psychopathology.

• Demonstrate a working knowledge of relevant health and justice legislation.

• Use conflict intervention/resolution strategies in the management of high-risk behaviours exhibited byconsumers.

• Manage an intensive supervision programme in a community setting.

• Contribute to the preparation of prison and court reports and recommendations.

• Provide consultation and support for prison services staff.

• Liaise effectively with public and private sectors, health providers, court personnel, prison staff and legalofficers.

• Demonstrate an advanced level of ethical practice in forensic psychiatry.

Residential care

• Assess consumer’s suitability for home-based/residential care.

• Evaluate suitability of home/residence for the management of home-based care.

• Manage a range of individual therapeutic intervention programmes.

• Demonstrate familiarity with specific cultural, socio-economic issues relevant to home-based/residentialcare.

• Manage home-based detoxification.

• Provide alcohol and drug information and harm-reduction strategies/risk management.

• Work according to a Maori kaupapa.

25 The following are interim competencies as the ALAC sponsored Alcohol and Drug Treatment Workforce

Development Advisory Group is currently co-ordinating a national consultation process to develop competencies atboth the advanced and specialist levels for workers in the alcohol and drug treatment field. The list includes draftcompetencies developed by ALAC.

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Maori health

• Provide culturally effective and appropriate services to Maori.

• Acknowledge the positive impact culturally based treatments have on the healing process for Maori.

• Provide clinical treatment which integrates with Maori development.

• Promote tikanga Maori.

• Seek and ensure active Maori participation in the management and implementation of mental healthservices for Maori.

• Recognise the need for, and support the development of, relevant standards, policies and practicestargeted at delivery of services for Maori.

• Ensure Maori priorities have equal consideration in the mental health services.

• Commit to non-discriminatory practice.

• Provide measures that promote wellness with a focus on whaiora and their whanau.

Pacific Islands peoples health

• Seek and ensure active participation with Pacific Islands people in the design, implementation andmanagement of mental health services for Pacific Islands people.

• Provide culturally effective and appropriate services to Pacific Islands people.

• Use action research and evidence-based practice to actively monitor and evaluate service delivery toPacific Islands people.

• Provide culturally appropriate community mental health education programmes within Pacific Islandscommunities to promote good health for Pacific Islands people and destigmatisation of mental illness.

Consultation liaison psychiatry

• Demonstrate knowledge of general medicine and surgery.

• Effectively liaise with other general hospital medical services.

• Assess and offer opinions for patients in consultation with their attending medical specialists.

• Diagnose and manage psychiatric illness in the medically ill.

• Assess suicidality.

• Demonstrate pharmacological knowledge of antidepressant, antipsychotic and analgesic medications,including their side effects and interactions.

• Apply psychotherapeutic management strategies for grief, adjustment reactions and abnormal illnessbehaviours.

• Communicate basic and relevant psychiatric knowledge in a succinct and competent manner.

• Demonstrate clinical competency when dealing with terminally ill patients (and their relatives).

• Portray the specialty of psychiatry to the hospital community appropriately.

Psychogeriatric

• Apply knowledge of the ageing process and its effects.

• Apply knowledge of mental illness associated with ageing.

• Apply skills in the psychiatry of older adults.

• Use the assessment, treatment and rehabilitation process appropriately.

• Formulate achievable and measurable rehabilitation goals in consultation with the consumer, familyand/or caregiver.

• Liaise effectively with the consumer, their workplace and the community.

• Provide a therapeutic intervention.

• Apply knowledge of pharmacology specifically used with older people.

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Rehabilitation

• Demonstrate an understanding of the various models and goals for rehabilitation.

• Select and conduct appropriate objective assessments.

• Determine consumer’s level of functioning in all domains.

• Consult with other team members and consumers to determine treatment and a management plan.

• Formulate achievable and measurable rehabilitation goals.

• Liaise effectively with consumer(s), significant other(s), their workplace and the community.

• Provide a therapeutic intervention with a specified review date.

• Provide a continuing-care plan to support ongoing maintenance of wellbeing.

4.8 Role of regulatory bodies

Entry to the mental health workforce for a number of clinical professional groups is controlled byregulatory/registration bodies and specialist medical colleges.26 The registration bodies have theirfunctions and responsibilities defined in legislation. As standard setters, these bodies need to beresponsive to consumer, employer and professional requirements.

The accreditation/validation of education programmes is a compulsory external audit process todetermine whether a particular education programme meets the principles, pre-determinedstandards, competencies and any other requirements set by a regulating body. The ‘regulator’ maybe a professional statutory registration body, a non-statutory professional body, a funder (eg.Clinical Training Agency) and/or the NZQA.

The accreditation process requires each education institution and its staff to be accountable, tomeet the competency standards set in terms of outcomes, and to provide evidence of means bywhich competencies are assessed, evaluated and achieved (eg. criterion-referenced).

The two activities, competence and accreditation/validation, together form a process which shouldmeet the needs of the mental health service and its consumers.

The requirement for all mental health workers to hold the core competencies described will needthe ongoing co-operation of the above regulatory bodies and the relevant education providers.

4.9 Strategic direction

Table 8 sets out a strategic framework for the achievement of a competent mental health workforceby the year 2002. A process for monitoring the inclusion and assessment of the core competenciesin continuing and formal educational programmes, by regulatory bodies, and their application instaff performance appraisals in the workplace will be required.

Skill deficiency is the one strategic issue that needs to be grappled with to achieve the objective ofa competent mental health workforce by the end of the year 2002. A major component is the needto upskill the current mental health workforce. The second is to recruit and retain the employmentof an appropriate mix of competent staff.

26

Medical Council of New Zealand, Nursing Council of New Zealand, Occupational Therapy Board, PsychologistsBoard, Physiotherapy Board, and Royal Australian and New Zealand College of Psychiatrists.

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A survey of mental health training programmes was undertaken for the Mental Health StrategyProject in the latter part of 1997. The key findings showed that the number of workersparticipating in training levels is increasing, a wider range of courses is being offered; multiplefunding streams may be impeding systematic planning; and implementation of mental healthtraining courses and the regional distribution of training programmes is uneven (Mental HealthStrategy Project, 1998).

Upskilling alone will not meet the needs of the mental health service. Analyses of the 1998 healthworkforce survey data for nurses, medical practitioners, occupational therapists and clinicalpsychologists show significant growth in the numbers of each category of registered staff (exceptoccupational therapists) working in mental health services over the last two- and four-year periods.There are, however, a number of significant workforce gaps in key clinical areas. Overall there arelow numbers of Maori and Pacific Islands people in all occupational groups, and an unevendistribution of psychiatrists, registered clinical psychologists and registered occupational therapistsparticularly in areas away from the main centres. The analysis also indicates an ageing workforceacross all groups. For example, 15% of specialist psychiatrists are over 60 years of age. Asummary of important findings can be found in the appendices.

Table 8: Strategic directions

Key goals Action points Timeframes forimplementation

Mental health service providers have workforce developmentplans that are operational.

Immediate(3-6 months)

To upskill thecurrent and futuremental healthworkforce The training status of all mental health support workers in the

mental health service is surveyed.Immediate

(3-6 months)

Formal post-entry and post-graduate clinical training needsfor all mental health workers will be assessed.


Individual annual performance appraisals and performancedevelopment plans based on the basic, advanced andspecialised Core Competencies for the Mental HealthWorkforce are in place for every mental health worker.

Short term(6-12 months)

There is regular ongoing supervision and peer review forevery mental health worker.


Employers commit sufficient current and future resources toupskill all

• untrained mental health workers to enable them todemonstrate basic core competencies

• trained mental health workers to enable them todemonstrate specialist core competencies

• mental health staff working in specialist mental healthservices to enable them to demonstrate specialist corecompetencies.


Mental health service providers will promote teamwork andcollaborative planning as important tools for the provision ofconsumer-focused/goal-directed/inter-disciplinary mentalhealth services.


Postgraduate programme(s) will be established for mentalhealth social workers.


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All relevant education providers preparing graduates forpractice in the mental health service will include the relevantlevel of Core Competencies for the Mental Health Workforcein their programme curricula.


To upskill thecurrent and futuremental healthworkforce(continued)

All pre-entry, post-entry and specialist educationprogrammes preparing clinical and non-clinical staff forpractice in the mental health services, and/or upskillingcurrent mental health workers, will include the recoveryapproach and competencies intended to destigmatise mentalillness in their curricula.


Mental health service providers will have increased clinicalpractice resources and established partnerships with relevanteducation providers so that students in mental health supportwork and health professional training programmes haveaccess to appropriate, quality clinical practice opportunitiesin mental health services.


All education providers will be assessed to determine theextent to which their students will graduate with the basic andadvanced Core Competencies for the Mental HealthWorkforce.

Medium term(12-18 months)

All relevant regulatory bodies will ensure that all successfulapplicants for registration will demonstrate the advancedcompetencies of the Core Competencies for the MentalHealth Workforce at a beginner practitioner level.


All newly graduated registered comprehensive nurseswanting to enter mental health nursing will participate incertificated mental health nursing programmes that aredesigned to provide nurses with the advanced corecompetencies and specialist nursing competencies as set outin the Core Competencies for the Mental Health Workforceand the Standards of Practice for Mental Health Nursing inNew Zealand.


The Core Competencies for the Mental Health Workforce arereviewed for relevance and content specificity.

Medium-long term(2-4 years)

Implement plans to increase the number of Maori recruitedinto training programmes for mental health support work.


To ensure adequatenumbers ofappropriatelytrained staff areavailable.

Implement plans to increase the number of Pacific Islandspeople recruited into training programmes for mental healthsupport work.


Implement plans to increase the number of Maori recruitedinto health professional training programmes.


Implement plans to increase the number of Pacific Islandspeople recruited into health professional trainingprogrammes.


Complete a comprehensive graduate survey and analysis ofoccupational therapists from 1993 to identify cohortremainder rates and detailed worktypes and employmentsettings.


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Complete a comprehensive workforce survey of registeredclinical psychologists and occupational therapists practisingin mental health services, focusing on recruitment andretention issues.


Complete a comprehensive workforce survey of all clinicaland mental health support workers practising in mental healthservices, focusing on recruitment and retention issues andbroken down into specialised worktype sub-categories suchas forensic services and child and youth services.


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5 Guidelines to Improve Workforce Effectiveness inMental Health Service Organisations


To meet the Government’s aim in Moving Forward for more and better services, more people mustbe attracted to and retained in the wide range of services for mental health consumers. Therecruitment and retention of a competent and skilled workforce is critical to the delivery of aquality service. In addition, patient care is enhanced where good workforce practices are found atall levels throughout an organisation.

Historically mental health services have been poorly funded. The tendency in the recent past tofund by means of short-term contracts has worked against workforce development and effectiveplanning for services. Money has been directed at mental health services without consideration ofthe need to invest in training and upskilling of the clinical workforce. In addition, educationalinstitutions have not always met the needs of the mental health service.

In developing strategies to improve the effectiveness of the mental health workforce, workforceutilisation practices and issues were examined and analysed across a range of HHSs and NGOs.

While HHSs and NGOs are working and need to continue to work on local solutions based on theirpriorities, a number of effective activities have been identified to assist their processes. Theseinclude collaboration for overseas recruitment through the establishment of a central agency;multi-directional open communication channels between senior management and staff; focusedstaff development programmes; flexible staff management and working conditions; utilisation ofclinical expertise in multi-disciplinary teams; collaboration with other providers over staffdevelopment training programmes and relevancy of course content; promotion of a learning andresearch culture; promotion of evidenced based practice; and an understanding of the implicationsof HFA contract and service specifications.

This report also identifies a number of health and education organisations, and allocatesresponsibilities for a number of initiatives.

5.2 Introduction

The National Mental Health Workforce Development Committee was established to develop andimplement a workforce plan to support the HFA’s National Mental Health Funding Plan 1998-2002, the Ministry of Health’s Moving Forward and the Mental Health Commission’s Blueprintfor Mental Health Services.

It has been acknowledged by many in the sector that:

• mental health services have historically been poorly funded

• short-term funding has worked against workforce planning, as it can take several years totrain some groups of staff

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• educational training organisations have not always met the needs of the mental healthworkforce or mental health services

• money has been directed solely at patient care without consideration of the need to investin training and upskilling the workforce to provide care.

The prime focus of this project has been to examine and promulgate workforce utilisation practicesto improve the quality of services for consumers. It has been prepared following an analysis ofworkforce practices and issues in a range of HHSs and NGOs.

Consumer care is enhanced in organisations where good practices are found at all levels.

This report has relevance for all organisations providing mental health services. It recognises thatthe priorities of each organisation will differ depending on its focus and size. This projectidentifies organisational practices that enhance workforce effectiveness.

5.3 Background

In recent years there has been a limited commitment to workforce development by health serviceproviders and funders, primarily because of resource constraints. As a result, and despite thecommitment of individuals and services, there exist shortages in both the skills and numbers ofstaff required by mental health service providers.

Since mental health was identified as a priority health area in 1994, strategies and actions todevelop the workforce have been sought. However, the rate of service expansion has been limitedby the shortage of sufficient numbers of staff.

It is not solely a matter of requiring more staff but of attracting staff with the appropriate skills toprovide safe services within the context of the recovery model across the continuum of serviceproviders that work together to provide care to a consumer.

Strengthening the workforce will ensure services have available a pool of well trained, up-to-datepeople who are motivated and accountable. In addition, where good employer-employee relationpolicies exist, the workforce is likely to be retained in the organisation. It is well known in NewZealand that some organisations are better to work for than others. Anecdotally, the majorvariable appears to be the level to which staff feel valued. Where staff feel valued, there is anexpectation that this will have a positive impact on the quality of care provided for consumers.

Mental health service provision can be enhanced by effective workplace practices which ensurestaff perform at their optimum. In particular, services should be organised to:

• ensure there is leadership and a vision upon which consumer care is focused, and that theorganisation is structured to deliver this vision

• show clear lines of accountability

• improve the organisation’s culture of training, research and development

• improve recruitment and retention of staff to ensure excellence in practice

• support innovation

• pro-actively manage risk

• align individuals’ training and performance to agreed core work practice competencies.

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Co-operation between the many services which provide care for people with a mental illness isessential to meet a consumer’s needs. Integration of the various aspects of a consumer’s life mustbe addressed concurrently so that maximum health gain can be achieved. Services such ashousing, employment and social welfare are provided by other government agencies.

Mental health service providers should also:

• foster liaison, particularly where supervision is shared

• share common forms of in-service and other training, eg. workshops on service-relatedtopics by visiting speakers

• provide mutual mentoring at both an individual and organisational level

• support each other, especially if they are larger or more established services which canassist smaller or newer groups to become established, eg. new specialist child and youthservices, or Maori, or Pacific Islands people’s providers

• negotiate and document transparent inter-agency case management processes.

5.4 Characteristics of an ideal organisation providing mental healthservices

In any ideal organisation a combination of factors will prevail in supporting staff to achieve theirprimary purpose and the organisation’s goals. Factors listed below are based on general humanresource and management literature, and identify the characteristics of an ideal organisation.These provide a guide for mental health service providers in New Zealand:

Table 9: Characteristics of an ideal organisation

Ideal organisation Examples of strategies to achieve this

Strong vision –leadership

Mental health services are led by staff who are focused on achieving the bestquality of service and supported by realistic contracts.

Leaders recognise in service development, that the culture of the organisation is‘consumers first’.

Mental health services extend beyond the individual organisation into the sectorand across multiple agencies.

Family/caregiver involvement is supported.

The partnership between clinicians and managers is robust and focused.

Maori and consumers are represented at management level.

The organisation demonstrates openly that it exists for consumers and for theirtreatment and wellness.

Leadership adopts best practice and notes the needs of Maori, Pacific Islandspeople, refugees and other groups.

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Commitment of staff toorganisational goals

Staff are encouraged formally and informally to commit to the organisationalgoals.

There is clear understanding and ‘buy–in’ of mental health service goals.

Compulsory induction and orientation courses that offer an opportunity for staffto understand the organisation as well as their areas of accountability.

Services and individuals share responsibility for understanding theorganisation’s goals, understanding the national strategy, working to theNational Mental Health Standards.

Clarity of roles andunderstanding ofcompetencies/roles –what they are there todo

All organisations, including central organisations (Ministry of Health, CrownCompanies Monitoring Audit Unit, Mental Health Commission, HFA) are clearon their roles and accountabilities to the mental health sector, and liaise with andsupport mental health service providers.

Staff understand the purpose of their service and the tasks required of themwithin the context of the National Strategy for Mental Health Services and theNational Mental Health Standards.

Services and individuals are clear on the tasks, the skills and training required,and these are consistent with the contracts, the national strategy and the NationalMental Health Standards.

Clear policies andprocedures/accountability

Policies and procedures are developed and understood by all staff, consistentwith the National Mental Health Standards and Ministry of Health policy.

Individuals understand their areas of accountability and their responsibility forthe service attaining the National Mental Health Standards.

Good management/employee relationships

Resources are utilised with greatest effect to improve the quality of services forthe consumer.

All staff work towards this goal in a collaborative manner, encouraging positivecommunication channels.

Up-to-date material from the sector and developments in the treatment of mentalillness are available to staff (via circulation lists); and, where submissions areinvited, individuals and the service are encouraged to respond.

Best practice humanresource managementsystems – value,reimbursement,appraisal

Regular performance appraisal is in place which links expectations to contracts,organisation goals and values, and professional code of ethics.

Exit interviews are carried out and comments valued.

The employer initiates a proactive approach to employee/industrial relations andnegotiates employment contracts in good faith.

Supervision andsupport

The importance of supervision and support, including the provision of clinicalsupervisors and the training of a sufficient number of supervisors is recognised.

Individuals are obliged to participate in both formal and informal clinicalsupervision.

As a minimum, peer/group supervision should be available to all staff.

Opportunities exist to reduce the isolation felt by staff in sole positions.

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Innovation, evaluationand research

Innovation is important to job satisfaction.

Job satisfaction is recognised as an important driver in the retention of staff.

Opportunities exist for staff to influence the development and purchase ofservices through involvement in business planning and in the contract processes.

Clinical judgements and advice given by the service to the HFA areacknowledged as possessing safety and risk management value. Where suchadvice is ignored, a system should be in place to support independent arbitratorsto resolve the conflicts.

Strategies are in place to openly review and assess the service’s progress,including access to the service, care planning and discharge planning.

Learning and research opportunities are endorsed and may include a Centre ofResearch which encourages the participation of the less experienced to gaincritical skills.

Skill development – staff are encouraged to bring their specialist skills ordevelop individual areas of interest to the workplace.

Innovation and change is supported by contracts that include realistictimeframes and start-up costs to assist better planning and gain staff buy-in.

Services identify impediments to service delivery and actively seek to find asolution.

Consumers/caregivers and families are involved in evaluation.

Intersectoral liaison/co-operation

Co-operation is essential for good consumer care, and funding incentives shouldsupport this rather than the competitive model.

There is a clear expectation that liaison and co-operation will exist and thatcommercial competitiveness will erode such an expectation.

Opportunities to improve inter-sector co-operation are sought and funded, andexternal arbitrators are engaged to resolve issues of poor co-operation.

Promoting successes,collaborating andsharing achievements

There is a culture of sharing the successes of teams with others to promote bestpractice. Such collaboration can be internal or with other providers, and mayinclude teaching and public relations.

Staff attitude –continual improvement

Explicit expectations that the consumer comes first and that attitudinal changesare required to enable a service to reach its potential as a good provider whichoptimises best outcomes for consumers.

Consumer‘connectedness’

Mental health services explore and employ practices that create closerunderstanding of the needs of consumers individually and as a whole.

No stigma The HFA, services and staff understand the issues of discrimination and supporttraining initiatives that are consistent with the National Mental Health Standards(Standards 5, 8, 9, 11, 20) and the Health and Disability Services Code ofConsumer Rights and other regulations.

The recovery philosophy shall be encapsulated in the service delivery practicesof all organisations.

From discussions with a range of mental health organisations, it is clear some of the abovestrategies have been adopted. Common areas in which many organisations struggle to ensure thebest environment for their staff are:

• retention of staff

• recruitment of staff

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• training

• research

• development of services.

5.5 Strategic plan

5.5.1 Recruitment of staff

The focus on mental health as a key development area has given rise to the need for more staff.The lack of investment in mental health staff development in the 1970s and 1980s and the lengthof time it takes to train individuals have meant that the recruitment of skilled staff is not easy.Moreover, health professionals have not seen mental health as an attractive area in which to work,especially in light of continued adverse media and political attention. Recruitment of professionalsfrom overseas has been successful in some areas, but cultural differences do not always makeoverseas recruitment a viable option. Furthermore, professionals like psychiatrists are in shortsupply worldwide, and this compounds the problem. Pay and conditions in mental healthorganisations have historically been industrially focused and only in recent years havemanagement and clinicians/staff begun to work together to address pay and other conditionsproactively.

HHSs and NGOs need to continue to work on local solutions based on their priorities.

5.5.2 Retention

Job satisfaction is recognised as an important component in retaining staff. It is frequentlyreported that job satisfaction in mental health service organisations is low and that staff arereluctant to work in such organisations.

Organisations improve by valuing both institutional knowledge and accumulated ‘wisdom’ ofexperience. In this climate innovation can be supported.

5.5.3 Training

To improve services a culture of training needs to exist in mental health organisations. Thisshould include a continuing programme of upskilling staff to meet consumer needs, as well astraining of new staff to enter the mental health services

The CTA has done much in recent years to improve training opportunities for some occupationalgroups. There remain concerns about the mental health component of undergraduate healthprofessional training programmes, and access to training programmes by organisations on the basisof cost and distance. Organisations often complain that funding does not take into account the costof replacing staff while other staff are on training programmes.

5.5.4 Research

The effectiveness of mental health organisations can be improved even in a small way if theybecome involved in some research. This can be as simple as looking at the consumer outcomes oftheir services or may involve working with other organisations (or family) involved in aconsumer’s care.

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5.5.5 Development

Many mental health staff feel isolated from service planning and confused about how the currenthealth system works following changes from the ‘competitive’ health model initially proposed in1993. When staff who know ‘the system’ are involved in service planning, they contribute to itsimprovement and help ensure that the system reflects consumer needs.

Table 10: Plan to improve recruitment

Key goals Action points

An effective workforce will berecruited. The organisation willbe perceived as a sought-afterplace of work.

All staff undertake an induction and orientation process to ensure theyare familiar with the organisation’s goals and their own areas ofaccountability.

Rigorous recruitment and appointment systems are in place whichinclude consumer participation.

An increased percentage of newhealth professional graduateswill be recruited into mentalhealth services.

Incentives (eg. funding support in the form of bursaries andsponsorships) are in place to attract new graduates to the mental healthservice.

Ensure pre- and post-entry students have access to quality clinicalpractice experiences in the mental health sector during training.

Encourage a training culture within the service.

Ensure recruitment isundertaken economically,particularly if it is fromoverseas.

Collaboration is undertaken for overseas recruitment, eg. establishmentof a central recruitment agency.

Table 11: Plan to improve retention


Effective communication occursbetween all levels of staff

Communication channels between senior management and staff aremulti-directional and open.

Staff receive timely information about change within the organisation.

Staff accept their responsibility to be informed of service developments.

Staff development programmesare relevant and reflectindividual development goals.

Opportunities exist for new graduates to experience a range of serviceswith appropriate supervision and support.

Staff who attend education programmes at the organisation’s expense arebonded for a period of time.

Realistic training opportunities exist and are reflected in the funding.

Ensure that incentives and support are in place, eg. supporting registrarsto succeed in their training and continue employment with the provider.

Mentoring and succession planning training are available for experiencedstaff.

Consumer care is enhancedthrough well-balanced multi-disciplinary teams whichrecognise the contribution ofeach member.

Co-ordination and utilisation practices occur – skill mix, opportunitiesfor cross team work, practices that use skills appropriately and enhancejob satisfaction.

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Flexibility occurs in staffmanagement and workingconditions to reflect theindividual’s contribution to theorganisation.

Employee’s family commitments are recognised eg. appropriate use ofspecial leave/leave without pay.

Work-related accidents are dealt with proactively.

Regular organisational climate surveys are carried out.

Table 12: Plan to improve training


Cost effective relevant staffdevelopment training packagesare available.

A collaborative approach is recommended and may prove economical, asthere would be economy of scale. This is particularly relevant for thesmaller organisations which could develop functional relationships withthe larger or tertiary organisations.

Reduce academic capture by increasing the incentives for trainingorganisations to provide appropriate training for the sector.

Identify those areas that require accelerated training packages, andpromote those programmes, eg. training in mental health assessments byalcohol and drug staff or training in substance abuse assessments bymental health services staff.

Involve consumers in staffdevelopment.

Initiate consumer-run training and research the results.

Ensure training courses addressorganisational and teampriorities.

Organisations need actively to support staff attending training.Encourage staff attendance by asking teams to prioritise the courses thatoffer the skill development most needed in their teams.

When staff are released to attend training, actual course costs and coststo the provider are incurred. Funding sources need to be assured.

Table 13: Plan to improve research


Promote a research culture as adesirable attribute of a mentalhealth service.

As part of a culture of learning and research, staff should be supported topursue some areas of interest.

Staff who are inexperienced in research should be introduced to the valueof evidence-based research and acquire the skills to be critical ofevidence. Critical thinking is an essential skill for the development ofevidence-based practice.

Organisations establish either a budget for research or a ‘centre ofresearch’ that is overseen by a multidisciplinary team and management.

Promote evidence basedpractice.

Practice-based research is pursued by all teams.

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Table 14: Staff development plan


Ensure all staff understand theimplications of HFA contractsand service descriptions.

Staff development programmes focus on developing an understanding ofthe contracts and service descriptions. Services will then be in a betterposition to develop proposals for new services or improved funding.

Negotiate appropriatetimeframes for the introductionof new services to enableadequate preparation.

New services should be introduced within a project framework which hasestablished time-lines and an implementation plan. HFA contractsshould reflect this.

The HFA must proceed in a collaborative manner with providers. Thecontracting environment is an important driver in developing services.Where services cannot develop, because of a breakdown in thisrelationship, an independent arbitrator(s) should be appointed to resolvecontractual issues eg. Mental Health Commission and CCMAU.

Existing services should be strengthened before additional services arepurchased.

5.6 Views of current mental health providers

This document has been reviewed by a number of HHSs and NGOs. They report that manyindividual initiatives (like those in section 5.4) are underway to improve their workforceeffectiveness.

They note how long it takes to make sustainable changes to workforce practices. While theyindividually work towards becoming ‘an ideal organisation’ more co-ordination is needed acrossthe sector to make this possible. Their ideas are incorporated into the recommendations below.

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5.7 Recommendations

To improve and sustain the effectiveness of the mental health workforce, the followingorganisations should focus on specific initiatives.

Table 15: Recommendations for agencies

Ministry of Health Ensure consistency in mental health strategy, with little or no change of LookingForward/Moving Forward policy.

Monitor mental health standards and amendments to standards over a period oftime, following consultation with sector.

Mental HealthCommission

Provide sustained support of the workforce goal.

Provide a forum to bring providers together to progress workforce issues, eg.‘learning sets’.

Health FundingAuthority

Funding intentions cannot be delivered unless the HFA works with providers toimprove workforce skills and numbers.

The costs of releasing staff for training purposes must be acknowledged in contractprices.

Special programmes may be needed for Maori and Pacific Islands people.

HHS, NGOs,IPAs27

Incorporate ideal organisation values.

Be ‘good employers’.

Involve consumers and families.

Participate in national and local strategies to address issues.

Collaborate with education providers so they understand what is needed.

Clinical TrainingAgency

Respond to needs of providers.

Give recruitment and retention a high priority in training whether the funding isthrough the CTA or HFA.

Others –educational andprofessional bodies

Work with providers to offer training consistent with their expectations.

Assist employees to understand the nature of their role.

Adapt education programmes to fit nationally accepted competencies for mentalhealth workers.

27

IPAs – Independent Practitioner Associations.

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6 Workforce Development for Child and Youth MentalHealth Services


The current level of mental health services for children and young people is significantly below theMental Health Commission benchmarks. Expansion and strengthening of services is a nationalpriority. Access levels, currently estimated to be at 1% for the age range adopted for the provisionof specialist child and youth services (0-19 years inclusive), are expected to increase to 1.6%nationally by 2002.

The greatest single barrier to proposals to expand child and youth mental health services is theshortage of skilled clinicians to work in these services. The most critical shortages are child andadolescent psychiatrists and Maori clinicians.

In order to maximise the benefits of the proposed service expansion there is a clear need toprioritise child and youth workforce development initiatives so that these are aligned with fundingplans and service provision policy.

The Committee, while consulting with the sector for this project, identified a number of keyworkforce development strategic issues:

• lack of national co-ordination and leadership

• limited capacity of the child and youth sector to provide training opportunities

• shortage of experienced child and youth mental health clinicians across all professionalgroups

• critical shortage of child and adolescent psychiatrists

• critical shortage of Maori workforce

• shortage of Pacific Islands peoples workforce

• limited opportunities for training and development of support worker roles

• lack of national co-ordination for overseas recruitment of clinicians.

To support the level of child and youth mental health services expected in the future a number ofkey goals have been developed. The goals and action points identified should ensure that a skilledworkforce is available to match service development in both the short term and long term.

6.2 Introduction

In recent years there has been greater recognition of the specific mental health needs of childrenand young people, with greater national focus on expanding and strengthening services providedfor these groups across primary, secondary and tertiary services.

The greatest single barrier to proposals to expand and strengthen the workforce is the shortage ofskilled clinicians. There currently exists in New Zealand a serious deficit, across all healthprofessional groups, of people able to work with children and young people with mental health

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problems. The present situation in which service providers are struggling to provide qualityservices while concurrently developing the specialist skills of the workforce cannot continue.

This report has been prepared following an analysis of the workforce development needed. Theaims were to:

• understand the requirements of the sector through broad based consultation includingintersectoral links with people working outside the mental health sector

• develop specific workforce development frameworks for child and youth services.

The prime focus has been on the workforce development needs of services providing specialistmental health services for children and young people because:

• specialist child and youth mental health services are a priority area for funding and will bethe focus of significant service expansion over the next two to three years

• the National Mental Health Strategy focuses on the needs of those with the most seriousproblems

• there is a need for balance across the primary, secondary and tertiary components of thesector to facilitate early identification, appropriate treatment, and recovery for children andyoung people

• insufficient treatment services are available to deal with children and young people withserious mental health problems

• the non-specialist child and youth workforce is currently receiving focus from a range ofgovernment initiatives.

This chapter presents an overview of the current need. Initiatives in non-specialist and specialistservices are identified to provide the basis for a framework for workforce development.

6.3 Background

Throughout New Zealand there are insufficient dedicated mental health services provided forchildren and young people. The current level of services is significantly below the Mental HealthCommission benchmarks although considerable effort is being invested in expanding andstrengthening the services available. Expansion and strengthening of services is a national priorityin line with the HFA Mental Health Plan 1998-2002, Ministry of Health New Futures and theMental Health Commission Blueprint for Mental Health Services in New Zealand.

Youth are more affected by mental health problems than any other age group. Although theycomprise only 7% of the population they account for almost 12% of those who have a mentalillness requiring treatment (Mental Health Commission, 1998). The complexity of their problemsmay be compounded by the effects of alcohol and/or substance abuse.

The HFA estimates the current (1999) level of access to specialist mental health services as 1% ofchildren and young people. Although the level is well below the national target of 3%, it reflectsan expected increase in access from 0.7% in 1997. The HFA anticipates that by 2002, with theplanned service expansion, the level of access will have risen to 1.6% nationally, with somevariation between regions.

The age range which has been adopted for the provision of specialist child and youth mental healthservices is from 0-19 years inclusive. There are approximately 1.13 million children in this agegroup in New Zealand.

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Table 16 below summarises the population of New Zealand children and young people by agegroup, ethnicity and HFA region.28

Table 16: Population of New Zealand children by age group, ethnicity and HFA region

Age HFA region TOTAL

North Midland Central Southern

0-9 Maori 48,750 47,520 35,710 14,680 146,660

Pacific Islands 34,650 2,680 8,340 2,600 48,270

Other 124,300 74,700 96,950 93,220 389,170

10-14 Maori 19,350 20,310 14,850 6,380 60,890

Pacific Islands 12,740 1,160 3,370 1,200 18,470

Other 61,510 39,030 48,580 47,220 196,340

15-19 Maori 17,520 17,990 13,830 6,280 55,620

Pacific Islands 12,410 1,170 3,420 1,180 18,180

Other 61,870 35,440 48,150 51,040 196,500

TOTAL 393,100 240,000 273,200 223,800 1,130,100

As can be seen, Maori have a young demographic profile. They constitute 23.3% of the child andyouth population, with 55.72 % of them in the 0-9 age group.

The population of Pacific Islands people is the fastest growing in New Zealand, and includes arelatively large number of children and young people. The proportion of Pacific Islands childrenin New Zealand is currently 7.5%, with 57% of these between 0-9 years.

The population of children and young people in New Zealand varies by region and ethnicity. Theservices provided thus need to reflect the demographic characteristics of each region.

Because the need for mental health services varies enormously within the 0-19 age range, it hasbeen further broken down into three categories of 0-9 years, 10-14 years and 15-19 years. Thereare workforce and service configuration ramifications for any age categorisation system. This isparticularly evident for those young people who cross boundaries between youth and adult servicesfor example, from 18 – 24 years as the incidence of serious mental illness increases with age.

6.3.1 Non-specialist mental health services

The initial first point of contact for children and young people may be youth workers, schoolteachers, guidance counsellors, general practitioners, social workers, practice nurses, schoolattendance officers and Police Youth Aid officers. The context for the contact is varied, andranges from school, to community activities, to formal contact with services such as the Children,Young Persons and their Families Service (CYPFS).

There is a range of national programmes addressing aspects of child and youth mental health.These include the New Zealand Youth Suicide Prevention Strategy, the Strengthening Familiesproject and Special Education 2000 (SE2000). Each of these includes a workforce developmentcomponent. All have the potential to enhance the understanding and capability of the communityto recognise and respond effectively to the needs of young people.

28

Mental Health Commission (1998, p.30) based on Department of Statistics revised population estimates for 1998.

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A draft specification for the minimal training needs of non mental health workers involved withchildren and young people has been developed under the Strengthening Families programme. It istargeted at groups including SE2000 Resource Teachers in Learning and Behaviour, guidancecounsellors, social workers both in schools and CYPF services, youth workers, Youth Aid officers,attendance officers, and Maori and Pacific Islands people. As a result a range of learning packagesand programmes may be developed.

Workforce development issues relating to service provision for children and young people withsevere mental health needs, disabilities and/or behavioural problems are currently being addressedby Health, Education and Welfare officials.

6.3.2 Specialist mental health services

In June 1998 the Ministry of Health developed a broad strategic framework for specialist child andyouth mental health services (New Futures).

New Futures states that two key roles in specialist mental health services should be available forthe 0-19 age group:

• the provision of specialist assessment and treatment services to young people withmoderate to severe mental health problems, with priority given to those with the highestlevel of need

• the provision of consultation and liaison services to other agencies who work with childrenand young people.

The spectrum of services includes:

• community teams (including youth specialty services and Maori mental health services)

• crisis respite options

• drug and alcohol services

• day treatment programmes

• acute in-patient services

• supported accommodation/residential services.

Currently community based teams are available in each HHS area, although the size of the teamper 0-19 population varies considerably around the country. Specialist child and youth mentalhealth in-patient units are also available in Auckland and Christchurch, and there are a smallnumber of the other types of services available.

Planned service expansions

The HFA has prioritised funding for the expansion of specialist child and youth mental healthservices throughout the country. The focus of the expansion is likely to be on community teamsand it is estimated that an additional 199.5 FTEs29 will be required to fill the expanded places.

29

Mental Health Commission, 1999, p.13.

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Despite the proposed additional funding, the level of service availability in 2002 is predicted to fallsignificantly short of benchmark levels. If service capacity is to reach these levels, furthersignificant expansion of the services will be required after 2002.30

There are limited kaupapa Maori services available nationally to meet the needs of those childrenand young people and their whanau who would choose this option for service. A major barrier tothe expansion of these services is the critical shortage of a suitably qualified Maori workforce withboth cultural and clinical knowledge and expertise.

6.4 Workforce development for specialist child and youth mental healthservices

6.4.1 Overview

The biggest single barrier to the success of proposed plans for the expansion of child and youthmental health services is the shortage of clinicians to work in these services. There is a shortage ofexperienced child and youth mental health clinicians across all professional groups with the mostcritical shortages being child and adolescent psychiatrists, and Maori clinicians. Most servicesalready experience serious problems recruiting appropriately skilled and trained staff, and thisproblem is likely to increase significantly as further service expansion occurs over the next threeyears.

In order to maximise the benefits of the proposed service expansion, there is a clear need toprioritise child and youth workforce development initiatives so that these are aligned with fundingplans and service provision policy.

The focus of specialist child and family services is on the children and young people with the mostserious mental health problems. This requires a specialist workforce who can work with children,young people and their families in an intersectoral way, liaise and ‘broker’ all the elements of achild’s or young person’s life.

Furthermore, the skill sets required to work with children and youth differ. The complex needs ofyoung people with mental health problems, and the likelihood that these may be compounded bydrug and alcohol use, make them a particularly challenging client group. Effective consultationand liaison is required where young people’s needs intersect with adult services. To meet thesechallenges the workforce also needs skills and expertise in working with children and youngpeople using drugs and alcohol.

Many non-Maori clinicians working within mainstream services are required to work with Maoriclients. There are very limited opportunities for these clinicians to access training in respect ofsafe and appropriate ways to work with Maori young people and their whanau

Many services report that workforce constraints make it difficult for them to maintain a balancebetween safe and effective service delivery and expanding services to meet their contractualrequirements and the needs of the community. It appears a self-perpetuating cycle exists, withrecruitment, retention and burnout significant issues until a critical workforce mass can beachieved.

30

Mental Health Commission, 1999, p.13.

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New Zealand is not currently training enough child and youth mental health professionals to meetthe needs of the sector. A review of health professional education found that there is limitedliaison between representatives of professional groups and those people running pre-entry trainingprogrammes for health professional groups. Furthermore, the majority of pre-entry healthprofessional training programmes do not provide a sufficient foundation on which to base thespeciality practice required for these services. A limitation on the development of skills at a pre-entry level is the availability of sufficient quality clinical placements for students to gain anunderstanding and initial experience of the challenges within the specialty. In addition there haveuntil recently been only limited opportunities to gain specific post-entry qualifications andexperience in child and youth mental health.

There are enormous demands on key service personnel, who not only provide the services but alsosupervise students in training and teach courses designed to upskill the workforce. A consequenceof this is a shortage of skilled people to provide the volume of training required for the workforceand services to expand.

The underlying workforce direction has been based on the composition of multi-disciplinarycommunity mental health teams which assume effective use and mutual valuing of the uniquecontribution of each team member. The composition and management of multi-disciplinary teamsvaries nationally. Those involved in the consultation indicated strongly that specialist servicesrequired a multi-disciplinary specialist health professional workforce.

It is vital that any plan developed to expand the workforce recognises the difference between short-and long-term requirements. The short-term focus is to obtain a critical mass of skilled cliniciansto enable the establishment and safe provision of services. The long-term focus is on thedevelopment of a sustainable workforce that is broadly based and capable of providing excellentspecialist mental health services for children and adolescents.

There is general agreement that in order to develop a critical mass of experienced clinicians overthe next three to five years workforce development initiatives will need to have a dual focus thatincludes:

• recruitment of experienced clinicians from overseas

• training of clinicians within New Zealand.

There is, however, concern that the current systems in both of these areas are not adequate to meetthe needs of the sector. There is a clear consensus that if specialist child and youth services are tobe expanded and strengthened in line with national policy, a greater emphasis on addressingworkforce development issues at all levels of the sector will be necessary.

6.4.2 Summary of key strategic issues

The following key strategic issues have been identified:

1. lack of national co-ordination and leadership with respect to child and youth workforcedevelopment

2. limited capacity of the child and youth mental health sector to provide training

3. shortage of experienced child and youth mental health clinicians across all professionalgroups

4. critical shortage of child and adolescent psychiatrists

5. critical shortage of Maori workforce

6. shortage of Pacific Islands peoples workforce

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7. limited opportunities for training and development of support worker roles

8. lack of national co-ordination with respect to overseas recruitment of clinicians.

A summary of the workforce development issues and possible solutions follows.

6.5 Framework for action

6.5.1 Co-ordination and leadership

Responsibility for workforce development within child and youth mental health services rests witha number of different agencies within the mental health and education sectors. No one agencyholds overall accountability for ensuring that the workforce requirements of the child and youthmental health sector are met. Consequently, there has been a lack of co-ordination and leadershipwith respect to workforce development in the sector. This lack of co-ordination occurs within thehealth sector, and between health and education.

6.5.2 Enhancing the capacity and status of the sector

There is a significant shortage of specialist child and youth mental health services in New Zealand,with service capacity below 50% of benchmark levels in all four regions. As a result, there is verylimited capacity within the sector to provide opportunities for workforce development.

Services have difficulty finding a safe balance between service expansion and workforcedevelopment, and experienced clinicians are in demand both to provide clinical services and tosupervise and train new staff and students. There is also a limited capacity within the sector toprovide clinical placements for students at pre- and post-entry level.

6.5.3 Increasing the health professional workforce

There is a shortage of experienced child and adolescent mental health professionals across all ofthe major health professional groups including:

• child and adolescent psychiatry

• clinical psychology

• nursing

• occupational therapy

• social work

• child psychotherapy.

New Zealand is not currently training enough clinicians to meet the needs of the mental healthsector. In addition, opportunities for specialist training in child and youth mental health are verylimited. Consequently, initiatives to increase the number of child and youth mental healthprofessionals being trained within New Zealand will need to be aimed at both pre- and post-entrytraining programmes for all of the major health professional groups. Most services also report thatthey have difficulty retaining experienced clinicians, as they are often attracted into other sectorssuch as education and justice by higher salaries and ‘better working conditions’. Clinicians whodo work in specialist child and youth mental health services report high levels of burn-out becauseof the demands of working in services which are well below benchmark levels.

The shortage of experienced child and youth mental health clinicians means that many serviceshave had to recruit less experienced staff and to develop their own in-house training programmes

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for them. This creates an additional burden for the services, and particularly for the moreexperienced staff who are required to supervise and train new staff whilst still providing the bulkof the service delivery. The groups of health professionals most commonly being recruited forthese programmes are:

• new graduates

• clinicians who have experience working with children and youth but not within mentalhealth services (eg. nurses and social workers who have worked in general health/paediatric services)

• clinicians who have experience of working in adult mental health services but noexperience or training in child and adolescent mental health.

The unique challenges of working with children and young people with mental health problemsrequire a comprehensively skilled workforce who can work not only with the child or youngperson but also in the context of their family.

Pre-entry training

There are a number of issues in pre-entry preparation of health professionals common to theprofessional groups employed in specialist child and youth mental health services.

The majority of pre-entry programmes are generic providing the foundation for later specialisation.For example, pre-entry nursing, social work and occupational therapy programmes are designed toprepare beginning practitioners across a broad range of practice settings. Of these, occupationaltherapy clearly provides a sufficient basis for entry into this specialty as a beginning practitioner.

There are insufficient clinical placements available for pre-entry students in child- and youth-focused settings. As a result many students are unable to gain an understanding of the scope ofthis specialty which may influence later recruitment.

A limited number of placements are available for final-year occupational therapy students to gainexperience in the specialty. Anecdotally, these placements are seen as attractive to final-yearstudents.

The lack of sufficient specialist placements is an issue within child psychotherapy and clinicalpsychology programmes along with a concern that some clinical psychology programmes do notplace sufficient emphasis on serious mental health problems/illness despite the fact that this is thefocus of service delivery in specialist child and youth mental health services.

The number of practitioners available to provide support for new graduates entering this specialtyfield is limited. For example, whilst nurses make up the bulk of the workforce in in-patient childand youth mental health services, there has been a decrease in the number of nurses working inspecialist child and youth community services in recent years. Consequently, there are fewexperienced nurses to provide support and supervision to nurses who want to work in community-based specialist child and youth mental health services.

Expectations of pre-entry training requirements in child and youth mental health have not beenclearly specified by the professions, so there may be a lack of clarity about the role andexpectations of new graduates. New graduates employed may be isolated from their professionalpeers and unable to access the level of supervision and support they require.

Services employing new graduates, for example occupational therapists, need to consider flexibleand innovative arrangements for professional supervision and support. These may be external as

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well as internal. New graduates do not stay working in child and youth mental health services ifthey feel professionally isolated.

The recognised entry point for nurses into specialist mental health services is through a new-graduate programme funded by the Clinical Training Agency which provides support and trainingfor beginning practitioners working in mental health services. However, these new-graduateprogrammes have a focus on adult services, and do not include a specific child and youthcomponent.

Post-entry multi-disciplinary training

Until recently there have been few options for mental health professionals to undertake specificpostgraduate training in child and youth mental health. This has been addressed to some degreewith the development of the Clinical Training Agency-funded programmes for child and youthmental health professionals established in 1998. There are currently 65 funded places on theseprogrammes and there are plans to expand this to 120 FTE places. Programmes are presentlyoffered in Auckland and Wellington and have recently commenced in Christchurch.

The Clinical Training Agency-funded positions are available to health professionals employedwithin a HFA funded mental health service. In reality, the skills and experiences of peopleentering these programmes vary considerably, and this can create difficulties for the trainingproviders. Feedback indicates that the content and level of training provided also varies fromprogramme to programme, although these variations are not formally specified. The effectivenessof these courses is yet to be evaluated, but they are strongly supported by the child and youthmental health sector.

The options for clinicians to attend training programmes relating specifically to child and youthmental health are few. This makes it difficult for experienced clinicians to continue developingtheir skills and expertise and to ensure that they are up to date with current best practice. This is aparticular concern for clinicians working in smaller services outside of the main centres.

6.5.4 Increasing the number of child and adolescent psychiatrists

There is a critical shortage of child and adolescent psychiatrists in New Zealand. In 1996,28 medical practitioners identified as working in child and adolescent psychiatry. By 1998 thisnumber had increased to 36.

There are accredited child and adolescent psychiatry training programmes in Auckland andChristchurch. However, there are currently no trainees in Auckland and only two in Christchurch.In recent years a few New Zealand registrars have been accepted into the training programme inMelbourne. There is no guarantee that they will return to New Zealand once they have completedtheir training.

There appears to be a reasonable level of interest amongst psychiatric registrars in undertakingtraining in child and adolescent psychiatry (including three or four registrars currently in thegeneral psychiatry programme in Auckland). However, there are a number of barriers whichprevent registrars from moving into child and adolescent training programmes. These include:

• difficulties obtaining funding for senior trainee positions

• the extended length of time in training

• the limited capacity of the sector to develop and co-ordinate training programmes andplacements.

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6.5.5 Increasing Maori staff

There is a critical shortage of Maori staff in child and youth mental health services throughout thecountry. The shortfall exists in two areas:

• clinicians from all professional groups

• cultural advisers/support workers with skills and knowledge in the area of child and youthmental health.

In order to prepare Maori mental health professionals to work in child and youth mental healthservices, training programmes need to have a dual focus, incorporating both clinical and culturalcomponents. This would enhance the development of kaupapa Maori child and family services.

To date, pre-entry training programmes for health professionals have not succeeded in attractingsufficient numbers of Maori students. As a result, Maori are significantly under-representedwithin each of the health professional groups working in child and youth mental health services.Consequently, there are enormous expectations placed on those few Maori mental healthprofessionals who do work in the area, with few opportunities for networking and support withinthe group.

6.5.6 Increasing Pacific Islands people working in child and youth mental healthservices

There is a critical shortage of Pacific Islands people working in specialist child and youth mentalhealth services. This is of particular concern, because this is the fastest-growing population groupwithin New Zealand, with a high percentage of children and young people.

To date, pre-entry training programmes for health professionals have not succeeded in attractingsufficient numbers of students from Pacific Islands nations. As a result, they are significantlyunder-represented within each of the health professional groups working in specialist child andyouth mental health services. This places enormous expectations on those few Pacific Islandspeople who do work in these services.

Because the number of Pacific Islands people working in the child and adolescent mental healthsector is so low, it is important that training programmes are available to offer health professionalsfrom other cultural groups a better understanding of Pacific Islands people’s needs. This wouldensure that services are provided in a way that is culturally safe.

6.5.7 Increasing training and support opportunities for child and youth supportworkers

Within child and youth mental health services there are several distinct roles for support workers.These include:

• cultural support workers

• peer support workers – young people providing support to other young people

• consumer support workers – young people and/or families of children/young people whohave themselves experienced a mental health problem

• mental health support workers – to work in rehabilitation and support services.

Young people may feel more comfortable about using a mental health service if they have accessto people of their own age who can support them through the process. It can also be enormouslybeneficial for them to have contact with other young people who are themselves recovering from

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mental health problems. These types of peer and consumer support programmes are not welldeveloped in New Zealand and are offered by very few specialist child and youth mental healthservices. Adequate training and support for the peer support workers is crucial to the success ofthese programmes.

Similarly, parents and families of children and young people who use mental health services canbenefit from access to support services provided by families who have experienced similarproblems. At present, these types of support networks exist only for a few specific problems, areassuch as ADHD and autism. There are no formal programmes to assist in the development andsupport of these networks.

The majority of specialist child and youth mental health services have a clinical treatment focus.However, the HFA has signalled its intention to fund a limited number of rehabilitation/supportservices for children and young people with serious mental health problems. Services that willhave a rehabilitation/support focus include respite and residential services, as well as some earlyintervention services for young people with newly diagnosed psychosis. It is likely that theseservices, once established will employ support workers as well as clinicians. While trainingprogrammes for mental health support workers have been established in recent years, these areadult focused and do not have a specific child and youth component.

The need for a clear definition of the role of the cultural support worker has been discussed inabove. It is important that cultural support workers for child and youth mental health servicesreceive on-going training and support which is specific to their role.

6.5.8 Co-ordination of overseas recruitment

Efforts to increase the number of child and youth mental health professionals trained in NewZealand will not in themselves be sufficient to meet the workforce requirements of the sector overthe next three to five years. There will need to be some recruitment of experienced clinicians fromoverseas.

Most child and youth mental health services report that they have had to invest in overseasrecruitment drives in order to fill vacant positions. In many cases, filling vacancies with peoplefrom overseas has been the only option to ensure that services remain viable. Currently this ismanaged on an individual basis by each service, and it is often time consuming and expensive. Inaddition, there are difficulties with clinicians recruited from overseas, and services need to ensureclinicians’ familiarity with the culture and environment within New Zealand, particularly inrelation to provision of services for Maori and Pacific Islands people. Moreover, many contractsare of a short-term nature, resulting in high turnover and lack of consistency in staff.

Table 17: National co-ordination of child and youth workforce development

Key goal Action points Timeframe forimplementation

Implement the plan for child and youth workforcedevelopment which is agreed by all the key agencies inthe mental health and education sectors.


Appoint one agency/group to co-ordinate and overseeimplementation of the workforce development plan.


A nationally co-ordinatedapproach to child andyouth mental healthworkforce development,which is activelysupported by all the keyagencies within the mentalhealth and educationsectors.

Identify designated personnel responsible for child andyouth mental health issues (including workforcedevelopment) within each of the key national mentalhealth agencies.


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Table 18: Plan to co-ordinate overseas recruitment


Establish a nationally co-ordinated overseas recruitmentprogramme for child and youth mental healthprofessionals.


The development ofeffective mechanisms forthe national co-ordinationand management ofrecruitment of experiencedchild and youth mentalhealth professionals fromoverseas.

Develop nationally consistent criteria and processes forassessing the credentials of mental health professionalsfrom overseas.


Table 19: Plan to enhance the capacity of the sector


Include clauses in HFA contracts for specialist child andyouth mental health services, that identify workforcedevelopment as a priority area for service providers.


The development of arobust child and youthmental health sector whichis able to support andclinically train its ownworkforce.

Develop centre(s) of excellence for child and youthmental health which have a multi-disciplinary focus andundertake the following roles:

• work with training institutions to ensure that corecompetencies with respect to child and youth mentalhealth training are developed and instituted

• work with the mental health sector to maximise thenumber of clinical placements available for studentsin child and youth mental health services

• raise the profile of child and youth mental health

• provide mobile on site training, support andsupervision to child and youth mental health services

• develop best practice guidelines

• develop a national register of child and youth mentalhealth expertise

• support and encourage relevant research anddevelopment.

Medium term(1-3 years)

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Table 20: Plan to increase training and support opportunities for child and youth support workers

Key goals Action points Timeframe forimplementation

Cultural support workers inchild and youth mentalhealth services receiveappropriate training andsupport.

Develop appropriate training and supportprogrammes for cultural support workers.

Short term (6-12 months)

Families and young peoplewho use child and youthmental health services areable to access appropriatepeer/consumer supportnetworks.

Develop a training and support programmes forpeer/consumer support workers in child and youthmental health.

Medium term (1-3 years)

Child and youthrehabilitation and supportservices are able to recruitsupport workers withspecific knowledge ofchild and youth mentalhealth issues.

Develop a child and youth component in themental health support workers’ trainingprogramme.

Medium term (1-3 years)

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Table 21: Plan to increase the health professional workforce


Develop appropriate core competencies for allpre-entry health professional programmes.


Increase liaison and co-ordination betweenprofessional groups and education providers, toraise the profile of child and youth mental healthin health professional training programmes.


To ensure that pre-entrytraining programmes forhealth professionalsprepare students to work asbeginning practitioners inchild and youth mentalhealth.

Develop mechanisms to maximise the number ofclinical placements available to pre-entry levelstudents in child and youth mental health services.


Continue expansion of CTA funded post-graduateprogrammes, with the type and level of trainingthat is offered more clearly specified.


Formal evaluation of each of the CTA fundedprogrammes.


Ensure that multi-disciplinary post-graduatetraining programmes inchild and youth mentalhealth are availablenationally.

Establish distance learning options for staff inrural or more isolated services.


Establish a specialty stream in child andadolescent clinical psychology, eg. within theprofessional doctorate.


Ensure that post-entryspeciality programmes formental health professionalsinclude a child and youthcomponent. Develop a specific child and youth component in

new-graduate mental health nursing programmesand advanced mental health nursing programmes.


Allocate funding for child and youth mental healthservices to use for workforce developmentprogrammes. This should include a range ofoptions, such as funding for staff to attendexternal training programmes or the developmentof in-service training modules.

Immediate - short term(6 months - 2 years)

Ensure that mechanismsare in place to attracthealth professionals towork in child and youthmental health services, andto ensure that experiencedclinicians are retainedwithin the sector. Develop short-term training modules for child and

youth mental health clinicians eg. working withyoung people with alcohol and drug problems,family therapy, and other specific models oftherapy such as cognitive behavioural therapy.


Develop bridging programmes for healthprofessionals working in other areas of servicedelivery.


Establish specified intern positions in child andyouth mental health services for graduates fromall professional groups.


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Table 22: Plan to increase the number of child psychiatrists


The establishment ofsustainable trainingprogrammes for childand adolescentpsychiatrists in Aucklandand Christchurch.

Make funding available for a director of training for eachtraining programme. The director of training would haveresponsibility for developing and co-ordinating trainingprogrammes as well as recruiting registrars nationally intochild and adolescent psychiatry. It is anticipated that thiswould require 2/10 psychiatrist salary in each centre.


Allocate funding for dedicated senior trainee positions forchild and adolescent psychiatry in Auckland andChristchurch (2-4 places in each centre).


Develop mechanisms to allow psychiatry registrars to ‘fast-track’ their training by beginning their child and adolescenttraining pre-Part I.


Develop fast-track training programmes to allowpaediatricians to undertake training in child and adolescentpsychiatry.


Develop joint paediatric/child and adolescent psychiatrytraining programmes.


Table 23: Plan to increase Maori staff

Key goal Action points Timeframes forimplementation

Develop national training and support programmes whichhave a dual clinical and cultural focus for Maori mentalhealth professionals working in child and youth mentalhealth services.


Development of asustainable Maoriworkforce in child andyouth mental healthservices.

Pre- and post-entry training programmes for mental healthprofessionals adopt an affirmative action policy withrespect to the recruitment of Maori students.


Develop scholarships to assist Maori students in clinicaltraining programmes.


Develop training and support programmes for Maoricultural advisers/support workers working in child andyouth mental health.


Develop and provide kaupapa Maori training programmes.

Kaumatua develop training and support programmes forKaumatua working in child and youth mental healthservices.

Develop workforce training to support Maori models ofservice delivery, eg. ‘buddy’ training.


Ensure that mainstreamservices provide safe andeffective services fortheir Maori clients.

Develop effective cultural safety programmes for non-Maori clinicians working in child and youth mental healthservices.


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Table 24: Plan to increase Pacific Islands workers


Develop scholarships to assist students from PacificIslands nations to enter health professional trainingprogrammes.

Develop training and support programmes for culturalsupport workers working in child and youth mental healthservices.



Development of asustainable PacificIslands people’sworkforce in child andyouth mental healthservices.

Develop training and support networks for clinicians fromPacific Islands nations working in child and youth mentalhealth services.

Develop effective relationships between existing PacificIslands health professionals and leaders in both theeducation and mental health sectors.

Develop workforce training to support Pacific Islandsmodels of service delivery.


Ensure that mainstreamservices provide safe andeffective services forconsumers from PacificIslands nations.

Develop effective cultural safety programmes for cliniciansworking in mainstream child and youth mental healthservices.


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7 A Development Framework for the Maori MentalHealth Workforce


Major disparities exist in the health status of Maori and non-Maori in the field of mental health.For gains to be achieved in the areas of mental health, and drug and alcohol specifically, key issuessurrounding the Maori mental health workforce need to be addressed.

A strategic framework for the development of a Maori mental health workforce has beendeveloped, with key issues and goals that can be addressed in a planned way. The goals areunderpinned by a number of guiding principles that confirm Maori aspirations and goals fordevelopment; education and training that is relevant to tangata whaiora (mental health consumers)needs; competencies and skills which complement Maori health approaches; incentives fortraining; and sustainable resourcing for training initiatives.

Key goals identified include increasing the number of Maori working in mental health services sothat it proportionally represents the number of tangata whaiora using mental health services; Maorimental health workers with essential mental health skills and competencies; increasing the numberof trained Maori mental health support workers; developing more and better mental health servicesfor Maori in a range of settings; providing tangata whaiora with a choice of mainstream or Maoriclinical staff in clinical settings; ensuring a competent Maori primary mental health workforce;supervision and mentoring to support and retain the Maori workforce; and providing relevant,timely and accurate data on the Maori mental health workforce that is managed to supportworkforce initiatives.

7.2 Introduction

The Maori mental health workforce comprises Maori people with a variety of skills, knowledgeand experience who contribute culturally, clinically and socially to improving the mental health ofMaori individuals, whanau and communities. The number one health concern for Maori is themajor disparity which exists between Maori and non-Maori health status. In order for health gainsto be made for Maori in the priority areas of mental health and drug and alcohol, key issuessurrounding the Maori mental health workforce must be addressed.

This chapter presents a strategic framework for the development of the Maori mental healthworkforce. It has been developed so that key issues and goals can be prioritised and addressed in aplanned way. It is recognised that a range of strategies will be required and it will take time for all ofthe issues to be addressed. For example, in the medical profession it takes up to 12 years for oneperson to complete the training as a consultant psychiatrist. It is envisaged that implementation of thestrategic framework will benefit Maori in the short-, medium- and long-term.

Improving the status of Maori mental health will require a major focus on the Maori populationwho experience mental illness across the spectrum from mild to moderate to severe. A skilledMaori workforce is required to work in and across the primary, secondary and tertiary mentalhealth sector.

A number of major policy documents impact on the development of the Maori mental healthworkforce. Of particular relevance are the Ministry of Health’s Moving Forward and Towards

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Better Mental Health Services, the Mental Health Commission’s Blueprint for Mental HealthServices in New Zealand, and the Health Funding Authority’s National Mental Health FundingPlan 1998-2002.

All of these documents see development of the mental health workforce and the Maori mentalhealth workforce as a priority. The strategic framework is aligned with these major documentsbecause they have broadly determined future directions and, in the case of Moving Forward, areGovernment policy. Relevant targets and action points from these documents have beenincorporated into the strategic framework.

However, because these documents are not solely about Maori mental health and some are broadand general in their nature, the strategic framework was also developed from reports, researchinformation and policy documents concerning Maori health, mental health, employment anddevelopment.

7.2.1 Key issues

The key issues facing the development of the Maori mental health workforce are:

• increasing the number of Maori working in mental health services (current workforcestatistics indicate a significantly low ratio of Maori staff to tangata whaiora)

• improving the mental health status of Maori through:

– facilitating effective communication and intervention

– developing appropriate mental health information for Maori communities

– supporting culturally effective service delivery that lowers barriers to access andencourages the early uptake of service

– developing health worker leadership roles to provide role models and to aid thecommunity in the destigmatisation of mental illness

• identifying the skill requirements in the current workforce, eg. skill attainment incommunication and counselling (including cross-cultural skills), administrative andorganisational expertise, and clinical and best practice competence

• increasing Maori responsibility for the delivery of mental health services to Maori willensure the services are more appropriate and responsive to tangata whaiora

• recognising and making better use of the Maori voluntary and community health workforce

• developing better co-ordination and liaison of Maori health service providers and theMaori workforce so they are able to work within and across a range of settings andprovider groupings

• ensuring the availability of an experienced, skilled, knowledgeable and qualified Maorimental health workforce to staff existing and new Maori services including across theprimary mental health sector

• developing information systems that will provide meaningful, up-to-date and accurateinformation about the Maori mental health workforce

• focusing on the Maori population who experience a mild to moderate/moderate to severemental illness.

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7.3 Maori mental health workforce principles and goals

The following goals are intended to address the key issues for the existing and future Maori mentalhealth workforce. They are underpinned by a number of guiding principles. The principles areintended to guide stakeholders when implementing the framework, provide the basis for inclusionof specific goals, and demonstrate that achievement of the goals will contribute positively to Maorihealth outcomes, lifestyles and economic independence.

The guiding principles are:

• consistency with Maori aspirations and goals for development

• training and education relevant to tangata whaiora needs

• educators and trainers experienced, skilled and knowledgeable in mental health and inworking with Maori

• skills, knowledge and competencies that complement Maori health approaches

• encouragement and support for professional development and career advancement ofMaori

• recognition of Maori mental health competencies

• incentives for attracting Maori into health education and training

• maintaining sustainable resourcing for Maori mental health initiatives

• intersectoral collaboration as a central component of Maori mental health workforcetraining and service delivery.

The key goals identified are:

• the proportion of Maori in both the professional and non-professional mental healthworkforce represents the numbers of tangata whaiora using mental health services

• all Maori working in mental health services have essential mental health knowledge andskills, and have the opportunity to develop knowledge and understanding relevant to Maoridevelopment and cultural competencies

• education and training opportunities for Maori mental health support workers continue tobe offered, and new initiatives developed across New Zealand

• provide incentives for clinically trained Maori, especially Maori registered nurses, to movefrom a hospital setting to the community, and particularly to Maori mental health serviceproviders

• more and better services for Maori are developed in a range of settings, particularly in theareas of early intervention; child, adolescent and family; and dual diagnosis (drug andalcohol), through the accelerated development of effective and appropriate training andeducation programmes for Maori working in these areas

• tangata whaiora are provided with a choice of mainstream or Maori clinical staff

• strategies are developed to increase the retention of Maori mental health workers in mentalhealth services

• Maori primary health services have skilled and competent workers who are able to provideprimary mental health services in conjunction with specialist mental health services

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• relevant, timely and accurate data which does not compromise individual confidentiality iscollected annually on all Maori working in mental health services. It includes type ofservice, work type, region, paid or unpaid work, and training priorities.

• information collected will be managed to support workforce development initiatives.

7.4 Background

An environmental scan was undertaken to gain an understanding of developments in the healthsector that may impact on the Maori mental health workforce and development of the workforcestrategy.

Key issues identified through the scan were:

• the future development of Maori mental health services hinges on the availability of askilled, qualified and experienced workforce

• there is a paucity of Maori in certain mental health workforce groups

• growth in and development of a Maori mental health workforce will aid in addressing themajor mental health concerns that confront Maori

• Maori have high admission and re-admission rates to mental health services. In general,Maori present at a later stage of their illness. A high number enter mental health servicesas a result of court referrals for assessment and/or treatment. Maori have high rates of dualdiagnosis involving illicit drugs and/or alcohol.

• the Maori mental health workforce requires cultural competencies as well as mental healthcompetencies for working in both mainstream and Maori mental health services.

7.4.1 Maori mental health services

There has been a marked increase in the number of Maori mental health service providers over thelast six years. In 1989 there were no Maori mental health services outside of the then Area HealthBoards, and only two within them. By 1995 this had grown to 23 kaupapa Maori mental healthservices. From the recent workforce survey undertaken by the workforce project team (March1999), there are approximately 95 kaupapa Maori mental health services, including services in 21of the 23 HHSs.

However, the growth in Maori service providers has not been matched by a growth in the Maorimental health workforce, particularly in a number of the workforce groups.

7.4.2 Maori mental health workforce

In 1998 there were 10 Maori medical practitioners working in psychiatry in New Zealand and 208Maori registered nurses (7.34% of the total registered mental health nursing workforce) working inmental health services and 54 enrolled nurses (14.67% of the total enrolled nurse mental healthworkforce).

There is very little information about the number of Maori community mental health workers,Maori health workers working in mental health services, or voluntary workers.

A telephone survey of Maori mental health service providers in early 1999, was designed todetermine the approximate numbers and skill mix of Maori working in mental health services inNew Zealand. Although it is an incomplete snapshot of the Maori mental health workforce, it

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provides a picture of the current Maori mental health workforce and a benchmark against whichthe future Maori mental health workforce can be measured.31

The survey was undertaken over a three-month period and provides a ‘snap shot’ of Maori workingin mental health services at this time. The survey represents an 88.6% response rate. Of thesample obtained, 74.7% were employed on a full time basis and 25.3% part time. The Maorimental health workforce is made up of support workers, including Maori mental health workers,(45.9%); registered nurses (17.3%). The proportion of health professionals comprising socialworkers, psychiatrists, therapists, counsellors, psychologists, occupational therapists, and nurses inthe sample is 31.4%. The survey demonstrated a balance between mainstream services and Maoriservices. The major services where the Maori workforce are employed are residential services,adult community services, acute/sub-acute in-patient services and alcohol and drug services.

7.5 Strategic framework for workforce development of the Maori

A strategic framework has been established for the sustained development of the Maori mentalhealth workforce by mapping out the goals, targets and actions required over a 12-year period.

In order for the Maori mental health workforce to contribute safely and effectively to the mentalhealth of tangata whaiora as they work towards recovery, funders and providers of mental healthservices need to agree to:

• incorporate and adhere to the guiding principles

• work toward achieving the development framework’s goals, targets and action points.

7.6 Strategic issues and goals

Good outcomes for Maori within the mental health sector will be enhanced when goals and targetsare achieved. The following goals are to be applied universally, and each is to have the samepriority. No one goal is more important than the other. However, it is recognised that achievementof these goals must occur over a period of time, and short-, medium- and long-term priorities needto be established. Indicative timeframes are provided for each action point.

7.6.1 More Maori working in mental health services

Maori are under-represented in the mental health workforce. Ministry of Health national objectivetarget 6.4.1 requires that by July 2005, the Maori mental health workforce (including clinicians)will have increased by 50% from the baseline in 1997/98.

An increased Maori mental health workforce, including clinicians (psychiatrists, psychologists,nurses) and community support workers, will mean more culturally effective mental healthinterventions. An increase will also reduce barriers to access, facilitate more effectivecommunication and treatment, provide positive role models in the community and encourage theearlier uptake of services.

Maori who are considering entering the medical or nursing profession must be encouraged to workin the mental health field. Appropriate incentives should be made available to them. Theresponsibility for providing these incentives lies with the industry as well as with Maori throughagencies like iwi or urban authorities. Maori working in allied professions (ie. social workers,

31

See Appendix 6 for the report of the survey.

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occupational therapists) also need incentives to gain skills, knowledge and expertise in the mentalhealth sector.

A committed and co-ordinated approach is urgently needed to develop the Maori mental healthworkforce, both intersectorally and intrasectorally. There must be ongoing co-ordination of thehealth and education sectors to offer continued training and educational opportunities for Maoriwishing to pursue a career in mental health. The education sector must recognise the training andeducational needs of the mental health sector, especially as they relate to training of the Maorimental health workforce.

7.6.2 A skilled, knowledgeable and competent Maori mental health workforce

National objective target 2.2.1

By July 1999, all mental health services will be using cultural assessment proceduresfor Maori tangata whaiora. In order to meet this target, training programmes mustbe in place to ensure the appropriate mental health staff have the knowledge andskills to undertake cultural assessments.

National objective target 6.1.2

By July 2001, education and training for the mental health workforce will beconsistent across New Zealand.

The Maori mental health workforce reflects a wide range of skills, knowledge and experience.The Maori mental health worker of the future will be multi-skilled, and be able to work in andacross a range of settings and with a range of multi-disciplinary teams.

An effective strategy would incorporate the development of national standards and curricula forrelevant training programmes, and would aim to ensure that the culture of organisations reflects astrong commitment to staff by paying attention to employment conditions and remuneration, andresearch and training opportunities.

A review of the interface and relationships between mental health service providers and educationproviders identified a need for education and training programmes which are culturally focused,which prepare professionals and non-clinical workers for community mental health practice, andprogrammes which also focus on sub-specialities and on administrative and management skills.

Greater opportunities for post-entry clinical training for Maori are a priority. Programmes need tobe more accessible and to meet the needs of Maori clinicians and their clients.

The number of Maori professionals and managers in the health and disability support sector needsto be increased. Particular areas in which management skills are required include contractnegotiation, relationship/people management, and financial management.

The roles and skills of voluntary community workers need to be acknowledged. The significantvoluntary participation by Maori is of considerable benefit to the health and disability sector.Voluntary work provides work experience and acts as a bridge to formal employment or furthereducation and training in the sector. The amount of voluntary work also reflects a lack of availableresources and does not provide an incentive for long-term commitment to the service by workers.As a result skills and experience are lost.

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Voluntary work is also an indicator of the level of support and commitment that exists forcommunity services. This support may be used to mobilise Maori communities to participateactively in health services, and to enable Maori to take a greater level of responsibility for Maorihealth status.

There are kaumatua, kuia or whanau support workers working in mental health services who havenot had any formal training in the care and treatment of people with a mental illness. Whilst itmay not be necessary for them to undertake formal training, it is important that they are providedwith the opportunity to access suitable training.

In most of the major centres of the country educational opportunities are offered for supportworkers to gain a national qualification. Opportunities such as these need to continue and to beexpanded.

7.6.3 Range of settings to meet tangata whaiora needs

Maori working in mental health services work across a range of settings. These include acutepsychiatric wards, other hospital settings, residential housing in the community, consumers’homes, day programmes, District and High Courts, prisons, schools, Maori health services, anddrug and alcohol services.

Traditionally, clinically trained mental health staff, including Maori, have worked in the hospitalsetting where the majority of mental health services were provided. As mental health serviceshave become more community focused, Maori clinical staff need to be accessible to communityhealth providers and other non-traditional providers, such as prisons and schools.

Despite the development of services outside the HHSs, there has not been a dramatic shift ofclinical staff to NGOs. In the main, the concentration of clinical expertise has remained in theHHSs where many health professionals consider their expertise can best be utilised.

One of the major issues for Maori is providing incentives for clinical staff to move from the HHSsto other settings. As the number of Maori providers of mental health services increases so too doesthe need for clinically trained Maori staff to work in NGO services. One short-term solution is toencourage Maori staff to move from the HHS to Maori NGO services while enabling them tomaintain their clinical expertise.

This does not resolve the critical shortage of Maori staff in all settings, including hospitals, in theshort-, medium- and long-terms.

Other specific mental health services, such as early intervention, child, adolescent and familyservices, and dual diagnosis (drug and alcohol) services, require specially trained staff. There is agreat need for Maori to work in these areas, because the number of Maori who require theirservices is high. More of these speciality services are required and Maori providers of theseservices will need appropriately trained staff.

7.6.4 Maori working in mental health services are accessible to Maori tangatawhaiora

Maori tangata whaiora will benefit from increased access to culturally effective mental healthworkers, including Maori mental health clinicians such as psychologists, psychiatrists and nurses.An increase in the number of Maori mental health service providers has meant an increase in theopportunities to deliver effective and acceptable services to Maori.

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Primary health services are now starting to recognise they have a role to play in the earlyrecognition and detection of some mental illnesses. These services must employ staff competent toassess and treat tangata whaiora with mental health problems, and to consult and liaise withsecondary mental health services where necessary.

Increased co-ordination of services through innovative contracting, provider groupings or similarapproaches will benefit tangata whaiora by ensuring effective liaison and referral processes amongdifferent providers and will assist tangata whaiora to gain better access to Maori clinicians.

7.6.5 Retention of the Maori mental health workforce

Maori who work in mainstream services may feel isolated and lacking in peer and cultural support.Mental health services providers and training organisations must ensure they support Maori staffwho seek peer and cultural support from other Maori professionals, professional bodies or personalnetworks.

Opportunities for ongoing training at all levels must be offered to Maori already working in mentalhealth services. This will ensure a continuum of education and training for those who wish toupskill or develop more specialised knowledge and skills.

7.6.6 Primary health services workforce

An improvement in the status of Maori mental health will require a major focus on those membersof the Maori population who experience mental illness across the spectrum from mild to moderateto severe. It will require a Maori mental health workforce that is skilled, knowledgeable andexperienced in primary mental health.

Primary health services provided by Maori are developing throughout New Zealand and are a keypoint of referral to secondary mental health services. It is therefore important that these servicesemploy skilled and experienced staff, including general practitioners, registered nurses andcommunity health workers, who are able to screen, detect, assess and treat people with mild tomoderate mental illness. They must also establish consultation and liaison relationships withsecondary mental health services.

7.6.7 The management of workforce information

An information system that supports workforce development initiatives is critical. Unlessworkforce progress can be monitored effectively, there is a risk that funding will be given toinitiatives that do not deliver the required outcomes.

Effective monitoring requires a process that is consistent and reliable from year to year. It isrecommended that a standardised collection form and a standardised monitoring schedule are used.

The information collected must be relevant, timely, accurate and reliable and must maintain theconfidentiality of individuals. Accurate annual collection of ethnicity information on the Maorimental health workforce is required.

The information collected must be able to inform the sector of progress toward achieving theresource guidelines identified in the Blueprint and in National objective target 6.4.1 of MovingForward, that:

By July 2005, the Maori mental health workforce (including clinicians) will haveincreased by 50% from the baseline in 1997/98.

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Strategies need to be developed to ensure reliable and comprehensive annual collection ofworkforce data. This can be achieved by establishing effective relationships with the relevantprofessional and registration boards and councils, so that workforce data can be collected at thesame time as annual practising certificates and registration certificates are issued. Ensuringcomparability of data gathered by the different bodies and good survey return rates are key issues.

Table 25: Plan to increase Maori working in mental health services

Key goal

The proportion of Maori in both the professional and non-professional mental health workforce representsthe numbers of tangata whaiora using mental health services.

Who is involved What needs to be done Indicativetimeframe

Intersectoral collaboration in developing short-, medium- andlong- term strategies for Maori mental health workforceeducation, and specifically for the provision of programmesand incentives for the recruitment of Maori students.

30 June 2000

Strategy identified for the collection and sharing ofinformation relating to the number of Maori working in mentalhealth services, ensuring that agencies collect ethnicity data.

30 June 2000

HFA including ClinicalTraining Agency.Ministry of Education,educational institutes

HFA implements plan for Maori mental health strategy.

CTA purchases additional training programme for Maorimental health workforce.

Benchmarks are developed for the Maori mental healthworkforce.

The development of targets, in collaboration with the sector,for the ongoing implementation of Moving Forward.

OngoingMinistry of Health,Mental HealthCommission

Collection and sharing of information relating to the numberof Maori working in mental health services.

Monitoring the implementation of Moving Forward.

Ongoing

Development of incentive schemes for Maori to enter clinicaltraining in mental health.

December2000

Development of a plan to ensure that the retention rate ofMaori students studying to obtain medical qualifications ismaintained.

June 2001

Incentive schemes for Maori recruitment are in place in eacheducational institute, especially, for social workers,psychologists, psychiatrists, occupational therapists andregistered nurses.

June 2001

Educational institutesincluding universitiesand polytechnics, iwiand urban Maoriorganisations, Ministryof Education, Ministryof Health

Educational institutions ensure they can meet goals by havingskilled, knowledgeable and qualified trainers, perhaps throughproviders of mental health services.

June 2001

Provide placements for Maori students. OngoingMental health serviceproviders (HHSs,community mentalhealth services, Maorihealth services)

Provide environmental support through collegial mentoring,study leave, iwi support

Ongoing

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Table 26: Plan to increase the competence of the Maori mental health workforce

Key goals

All Maori working in mental health services have essential mental health knowledge and skills, and havethe opportunity to develop knowledge and understanding relevant to Maori development and culturalcompetencies.

Education and training opportunities for Maori mental health support workers continue to be offered andnew initiatives developed across New Zealand.

Who is involved What needs to be done Indicativeframework

Develop training programmes for cultural assessment. July 2001HFA, educationalinstitutes, mental healthservice providers,mental health consumergroups

Develop a plan whereby the Maori mental health workforce isable to access training pertinent to Maori development andincludes Te Ao Marama and Te Ao Turoa.

July 2001

Develop career pathways for Maori mental health workers,including those in the voluntary sector, who do not haveclinically based skills.

July 2001

Ensure that Maori mental health workers have nationwide accessto appropriate information and core mental health knowledgeand skills, through education programmes and in collaborationwith iwi and urban Maori organisations.

July 2000

Increase the funding of training and education providers, wharewaananga, universities and polytechnics for post-entry clinicaltraining which particularly relates to Maori clinicians in mentalhealth services.

July 2000

Table 27: Plan to increase access to Maori workers

Key goal

Tangata whaiora are provided with a choice of mainstream or Maori clinical staff.


HFA, Maori healthproviders and/ororganisations providinghealth services

Ensure that contractual arrangements with Maori healthproviders or Maori organisations which provide health servicesinclude:

• the provision of mental health services, includingconsultation and liaison

• the provision of Maori clinical staff within the primarysetting.

July 2001

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Table 28: Plan to increase access to a range of services

Key goals

Provide incentives for clinically trained Maori, especially Maori registered nurses, to move from a hospitalsetting to the community, particularly to Maori mental health service providers.

More and better services for Maori are developed in a range of settings, particularly in the areas of earlyintervention; child, adolescent and family; and dual diagnosis (drug and alcohol), through the accelerateddevelopment of effective and appropriate training and education programmes for Maori working in theseareas.


Clinical TrainingAgency, mental healthservice providers (bothmainstream andkaupapa Maori), Maorinurses’ organisations

Development of incentives for Maori registered nurses withknowledge, skills and experience in mental health care to movefrom the hospital setting to community settings, and particularlyto Maori providers of mental health services and Maori primaryhealth services.

Phased infrom July

2000 to June2002

Clinical TrainingAgency, mental healthservice providers (bothmainstream andkaupapa Maori),educational institutions

Develop a strategic plan for the training of Maori working in arange of settings, including schools, and particularly in earlyintervention, dual diagnosis, and child and youth services.

July 2001

Clinical TrainingAgency, Department ofCorrections,educational institutes,mental health workersin forensic psychiatryincluding psychiatristsand court liaison nurses

Develop an agreement whereby Department of Corrections staff,especially probation and prison officers, have some training inmental illness, drug and alcohol disorders and dual diagnosis,and in referral processes to Maori service providers ormainstream specialist mental health services.

July 2001

Table 29: Plan to increase retention of Maori workers

Key goal

Strategies are developed to increase the retention rate of Maori mental health workers in mental healthservices.


Mental health serviceproviders

To ensure retention of Maori staff in mental health services,contractual arrangements with providers include:

• ongoing training opportunities

• workplace support for Maori mental health workers throughcollegial mentoring, study leave, iwi support.

December2000

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Table 30: Plan to strengthen primary health service

Key goal

Maori primary health services have skilled and competent workers who are able to provide primary mentalhealth services in conjunction with specialist mental health services.


Clinical TrainingAgency, educationalinstitutions, healthproviders

Develop a plan to increase the number of skilled clinical staffworking in Maori primary health services who are able toundertake early detection of mental illness and drug and alcoholdisorders.

July 2001

Educationalinstitutions, child andfamily mental healthservice providers

An accelerated learning programme for people working outsideof specialist child and youth mental health services (eg.teachers) to be trained in working in this area.

July 2002

Educationalinstitutions, alcohol anddrug service providers,mental health serviceproviders

Ongoing development of a qualification in dual diagnosis forMaori working in mental health services, primary health servicesor alcohol and drug services.

Ongoing

Maori health andmental health providers

Develop a plan for the education and training of peer educatorsto work with young Maori in the area of mental illness and drugand alcohol disorders.

July 2002

Educationalinstitutions, Maorihealth and mentalhealth providers

Develop training programmes in mental illness and drug andalcohol disorders for general practitioners working in Maoriprimary health services.

July 2000

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Table 31: Plan to ensure continued access to workforce information

Key goals

Relevant, timely and accurate data which does not compromise individual confidentiality is collectedannually on all Maori working in mental health services. It includes type of service, work type, region,paid or unpaid work, and training priorities.

Information collected will be managed to support workforce development initiatives.


Ministry of Health,mental health serviceproviders, NewZealand HealthInformation Service,Clinical TrainingAgency

Develop standard collection form.

Arrange with boards and councils to incorporate collection formwith annual practising certificates and registration certificates.

Make collection form available to all mental health providers foruse by their workers, especially non-clinical staff.

Investigate the feasibility of conducting a survey of the non-clinical, community and voluntary workforces.

July 2002/03

Ministry of Health,mental health serviceproviders, NewZealand HealthInformation Service,Clinical TrainingAgency

Develop the standard monitoring schedule.

Implement regular use of the monitoring schedule.

Determine 1997 baseline workforce information.

Measure same 2004/05 baseline workforce information.

July 2002/03

HFA Develop a national directory of mental health providers andMaori health providers providing mental health and drug andalcohol services.

July 2000

Clinical TrainingAgency

Collect information to determine the number of Maori staff inmental health services as the basis of a benchmarking exercise.

July 2000

Mental health serviceproviders

Develop workforce information pamphlets as part of arecruitment drive to get more Maori working in mental healthand drug and alcohol services.

July 2000

Clinical TrainingAgency, Mental HealthCommission

Work closely with Statistics New Zealand to determine anethnicity definition.

July 2000

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8 A Development Framework for the Pacific IslandsPeople’s Mental Health Workforce


This chapter describes the issues confronting the development of a robust and sustainable PacificIslands mental health workforce, and the guiding principles which underlie that development.

The most critical priority identified is the need to rectify the relative absence of appropriatelyskilled Pacific Islands mental health professionals in the mental health sector. Strategies havebeen developed that will begin to address the current deficiencies and put in place mechanisms toensure the Pacific Islands mental health workforce grows in size and skills in a sustained and co-ordinated manner. The strategies, with key goals, action points and a timeframe forimplementation are focused on the need for:

• more Pacific Islands mental health workers

• a more skilled and competent Pacific Islands mental health workforce

• upskilling of current mainstream workers in Pacific Islands mental health issues

• national representation

• a definition of future Pacific Islands mental health service specifications

• a supported and sustainable Pacific Islands workforce.

8.2 Introduction

The Government’s national mental health plan for more and better mental health servicescontained in Moving Forward and the Blueprint clearly identify the priorities for improving thedelivery of mental health services and the overall mental health status of Pacific Islands people.

A scan of the mental health sector by the Mental Health Commission identified the absence ofcomprehensive mental health workforce information, particularly for Pacific Islands people. As aresult, a Pacific Islands workforce database funded by the Mental Health Commission will becompleted by mid 1999.

This database will enable clear identification of the current state of the Pacific Islands mentalhealth workforce, and allow appropriate planning and targeted funding to improve on thedeficiencies that are already known to exist. More important, however, is the need to developconcrete mechanisms that will be successful in the recruitment, retention and training of thePacific Islands mental health workforce and complement the existing national policies.

8.3 Background

The large scale immigration of Pacific Islands peoples to New Zealand began in the 1950s, andaccelerated dramatically with the economic boom of the 1960s and early 1970s. There is now aconsiderable Pacific Islands population in New Zealand, with the largest concentration in theSouth Auckland region. The 1991 Census found there were 47,435 Pacific Islands people in thegreater South Auckland region, and the numbers have increased since then. Other regions that

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contain relatively large Pacific Islands populations include the greater Auckland area, and Poriruaand other parts of Wellington. Smaller populations are concentrated in Northland, Tokoroa,Gisborne, Christchurch, Dunedin and Invercargill.

Unemployment, low income, poor housing, the breakdown of extended family networks, culturalfragmentation, and rising alcohol and drug problems are having an increasing impact on the mentalhealth of Pacific Islands people. Growing numbers of them are accessing mental health services,where they are frequently faced with insensitive institutionalised work practices, staff who misreadnormal cultural behaviour as signs of illness, and (despite the release of the National MentalHealth Standards) mainstream mental health services that fall well short of providing culturallysafe and sensitive care to Pacific Islands people. Data on rates of mental illness among PacificIslands people is inadequate. Rates of hospital admissions provide a skewed perspective of oneaspect of mental illness among Pacific Islands people.

One of the striking features of the Pacific Islands population is its age structure and regionaldistribution. In comparison with the national population, the Pacific Islands population, isrelatively young, and lacks the relatively high proportion of people over the age of 60 years typicalof the national population.

Table 32: Age structure of the Pacific Islands peoples and national populations (rounded)32

Age group Pacific Islands peoples(%)

TotalNew Zealand (%)

0-9 25.1 15.5

10-14 9.6 7.3

15-19 9.5 7.1

20-64 52.4 58.4

65+ 3.3 11.6

Total 100.0 100.0

This means that Pacific Islands peoples mental heath service requirements will increasingly needto be directed at child and adolescent mental health services.

These factors have led to difficulties in planning the right number of services for Pacific Islandspeoples, and ensuring their location in the right places, and their staffing by the right people at theright times.

8.4 Guiding principles

The following principles underlie the development of a Pacific Islands mental health workforcestrategy.

8.4.1 Overriding values

In the development of a strong and robust Pacific Islands mental health workforce, the core beliefsof Pacific Islands people must never be marginalised. The holistic approach to mental health careincluding spirituality, language, established traditions and protocols, and the involvement of

32

Source: Department of Statistics, revised population estimates for 1998.

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extended family and community, will be strengthened by increased numbers of Pacific Islandspeople working in mental health.

8.4.2 Equitable resourcing

The mental health sector will demonstrate equitable resourcing of Pacific Islands mental healthservices, according to demonstrable needs. Government agencies responsible for policy-makingand the allocation of resources should be directly accountable.

8.4.3 Ownership

Where appropriate, Pacific Islands people will be given ownership of the design, management,staffing and implementation of Pacific Islands mental health services in areas with large PacificIslands populations. These services should be delivered in a context of continual learning,consistent with demonstrable, current, acknowledged best practice.

8.4.4 Community links

Strong links with Pacific Islands communities in areas with large numbers of Pacific Islandspeople will be established and maintained by all mental health service providers to ensurecommunity participation.

8.4.5 Training

Education relating to Pacific Islands mental health and culturally appropriate safe practice needs tobe nationally consistent and of a high quality.

8.4.6 Sustainability

Mechanisms will be in place so that Pacific Islands individuals in the mental health sector willhave the opportunity to update and upgrade their skills throughout their working lives. Theinitiatives designed to develop a robust and well-trained Pacific Islands mental health workforcewill be sustainable into the future.

8.5 Pacific Islands mental health workforce requirements

8.5.1 Traditional healers

Specific information about how many Pacific Islands people choose to access traditional healersfor their mental health needs is not available. The consultation process identified that a largepercentage of Pacific Islands people are using traditional healers and there are examples ofsuccessful shared care between mainstream mental health services and traditional healers.

The challenge facing the Pacific Islands mental health sector is to formalise processes allowingPacific Islands service users and their families the right to access traditional forms of treatment. Anumber of ethical and safety considerations need attention before mainstream mental healthservices can effectively work with traditional healers, but the Pacific Islands community is sendingclear signals to mainstream services that they would like the choice.

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8.5.2 Management

Successful progress towards increasing the number of sustainable Pacific Islands mental healthservices is dependent on these services being led by competent and well-trained managers. Theadoption of the business model in the health sector and the competitive nature of health carepurchasing and service delivery, have increased the need for sound business planning skills andacumen.

There is already a large amount of anecdotal evidence about the difficulty experienced by manypotential Pacific Islands mental health providers in attracting funding for various initiatives thatwould contribute to the current range and number of Pacific Islands mental health servicesavailable. The major reason for this problem is that the proposals received by the HFA do notdemonstrate sufficiently sound operational and procedural systems to warrant funding. This is notto say that the Pacific Islands mental health community does not have the skill and the knowledgeto deliver the necessary services. The main limiting factor is the lack of knowledge and skill intendering, writing proposals, and the accounting and financial aspects of mental health servicedelivery.

Clearly, where management skills are required, mechanisms whereby Pacific Islands mental healthservice providers can access appropriate level managerial training are important, and externalexpertise is made available to these small organisations.

8.5.3 Research

The most obvious problem facing the Pacific Islands research community is the lack of qualifiedPacific Islands researchers. Without them there is an absence of leadership and the Pacific Islandscommunity is unable to participate in research into its own mental health issues. Instead, it relieson research carried out by the dominant research community. There is ample evidence ofinsensitive research practices, at times dubious research conclusions and a perception in the PacificIslands community that researchers take a lot and give little back in return.

The current policy of the Health Research Council of New Zealand (HRC) identifies PacificIslands mental health research as a priority. Unfortunately, many of the funded research projectsare in special interest areas and they are undertaken by Pacific Islands individuals or small groups,in addition to their other work. This has limited value in terms of producing career Pacific Islandsresearchers.

There are currently a few Pacific Islands research academics in the health sector but none have amental health background. These individuals carry the burden of having to contribute to numerousrequests for involvement in generic Pacific Islands health issues as well as mental health issues.The absence of a high-profile, highly trained Pacific Islands mental health researcher is a limitingfactor in the attraction of other Pacific Islands people into the field.

The Pacific Islands mental health sector and the HRC are required to identify and support PacificIslands people to become career researchers in mental health. These individuals will become themental health research leaders who enable full and equal partnership between the Pacific Islandsand mainstream mental health researchers in the future. Acting as Pacific Islands role models willgreatly assist the ongoing recruitment and training of Pacific Islands mental health researchers.

The major obstacle to recruiting Pacific Islands people of the calibre required is the cost involvedin training.

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8.5.4 Psychiatrists

Currently there are no qualified Pacific Islands psychiatrists in the country and there are numerousobstacles in the way of recruitment and training of Pacific Islands psychiatrists in the future.Obstacles include:

• a very small pool of Pacific Islands medical undergraduates to choose from. While thepool remains so small, psychiatry competes with the other medical specialties for recruits.

• psychiatry being seen as a low status medical specialty in comparison with surgery,paediatrics, obstetrics and gynaecology. There is also a stigma attached to working in themental health sector.

• the length of postgraduate training programmes

• difficult exam processes, with low pass rates across all candidates in training

• a lack of support and mentors to assist candidates

• the difficulty experienced by Pacific Islands medical undergraduates as a whole in copingwith the undergraduate course so that the prospect of specialising, especially in psychiatry,can be quite daunting.

There are a number of positive developments that will go some way towards overcoming theobstacles identified.

The Auckland School of Medicine’s Department of Maori and Pacific Islands Studies hasintroduced two new programmes as part of Vision 20/2033 which are designed to increase thenumber of Pacific Islands students gaining entry into medical school and other health sciencesprogrammes such as occupational therapy, physiotherapy, clinical psychology, and counselling.These are the Wellesley Programme and the Certificate in Health Science. The programmes aredesigned to take students who have performed well in their Bursary year but not sufficiently wellto gain entry into medical school. Students are able to take the Certificate in Health Science andare given extra support and tuition. They can then reapply at the completion of the certificate (aone-year course).

In their first year of running, these programmes have already been successful in increasing thenumbers of Pacific Islands students gaining entry into medical school. There are close to40 students enrolled in 1999 for the Certificate in Health Science. Vision 20/20 is targeting up to100 students per year in the future.

A number of strategies which could increase the number of Pacific Islands doctors choosingpsychiatry, include mentoring programmes, support networks, mental health careers day,conference funding and placement with Pacific Islands mental health providers and summerstudentships.

8.5.5 Registered nurses

There is a relatively large pool of experienced Pacific Islands mental health nurses in the mentalhealth sector, mainly in the Porirua area of Wellington. In 1998 there were 60 registered nurses(2.1% of all registered nurses working in mental health) and 16 enrolled nurses (4.3% of allenrolled nurses working in mental health). A number of these experienced nurses were trained atPorirua Hospital under the old apprenticeship model that allowed many Pacific Islands males to

33 Vision 20/20 is a programme at the Auckland Medical School aimed at increasing the number of Maori and Pacific

Islands students entering medical training.

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receive psychiatric nursing training. As a result there are a number of Pacific Islands malepsychiatric nurses.

The change to polytechnic education for nurses has resulted in a dramatic reduction in the numberof male Pacific Islands nurses entering the mental health field. Many Pacific Islands males are notprepared to go through a generic comprehensive nurse training programme. This change intraining for nurses is also affecting the number of Pacific Islands female nurses choosingpsychiatry. Overall numbers of Pacific Islands nurses in training has steadily increased, but thenumber choosing mental health is dropping.

The other significant issue for the Pacific Islands mental health sector is that there is littleinformation on where and how these nurses are working. Anecdotal evidence suggests that themajority are employed in mainstream organisations which continue to utilise these nurses’ specialcultural expertise ineffectively.

Two major issues therefore need attention:

• how to utilise better the current Pacific Islands nursing staff in the sector

• how to increase the numbers choosing mental health nursing (especially male nurses).

In order to attract Pacific Islands nurses into careers in the mental health sector, a number ofindividuals and organisations have identified the need for good mentoring. This can be achievedthrough placement with credible Pacific Islands mental health providers which have experiencedPacific Islands mental health nurses, and through selecting Pacific Islands nurses in mainstreamorganisations for students to work with. This requires close collaboration between the educationand mental health sectors.

Other recommendations include more effective marketing of mental health as a career, careersdays, scholarships, conference funding for undergraduates, and foundation programmes as anavenue for entry to the mental health sector for Pacific Islands nurses who are wanting a careerchange.

Improving the effectiveness of mainstream Pacific Islands mental health nurses is theresponsibility of service providers. With the release of the mental health standards, all mentalhealth providers will be obliged to make better use of their Pacific Islands staff to achieveaccreditation standards.

8.5.6 Social workers

Many Pacific Islands people are currently being attracted to the social work profession. Theymake up a large percentage of undergraduate social work students, especially at Manukau Instituteof Technology in South Auckland and Whitireia Polytechnic in Porirua. By contrast with doctorsand nurses, anecdotal evidence also suggests that the mental health field is a preferred careeroption for social workers. This provides an opportunity for the Pacific Islands mental healthsector, and one of its challenges lies in effectively utilising this growing resource.

A focus on postgraduate training for Pacific Islands social workers is the single most effectivestrategy that would benefit the Pacific Islands community, and to a certain extent it is alreadyoccurring in the sector. The upgrading of social work training to degree level, teaches betteranalytical skills and thinking. This better prepares social workers to undertake postgraduatetraining in specialised areas like child and adolescent mental health and alcohol and drugrehabilitation which are priority areas for Pacific Islands people.

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The Clinical Training Agency and the HFA are responsible for the purchasing and allocation oftraining. Post-entry funded training for Pacific Islands social workers would be a cost-effectiveand timely means of upskilling the Pacific Islands mental health workforce.

Although the social work group makes up a relatively large percentage of the Pacific Islandsmental health workforce it is still small in real numbers. The effectiveness of these workers in thesector would be greatly increased if they organised a Pacific Islands mental health social workcollective which could be more proactive in recruitment and postgraduate training. It has beensuggested that all the Pacific Islands people working in the mental health sector should form anassociation which would act in many capacities for the advancement of Pacific Islands mentalhealth.

8.5.7 Clinical psychologists

There are very few Pacific Islands clinical psychologists currently working in the sector and only avery few in training. Despite the fact that a career in clinical psychology is well remunerated andpersonally rewarding with numerous specialty areas of practice, Pacific Islands people are notchoosing it as a career option.

It appears that the major problem in recruiting Pacific Islands people into the field is the lack ofawareness in the Pacific Islands community of what a clinical psychologist actually does. Theprofession does not have the same profile as social work, nursing or medicine. Occupationaltherapy and counselling have similar profile problems and few Pacific Islands people choose theseoccupations as career options. The major drive initiated by the Auckland School of Medicine toincrease the number of Pacific Islands medical students, may have a flow-on effect into theseallied health professions which should lead to a marked increase in the number of Pacific Islandspeople training in clinical psychology in the next few years. It would assist this process greatly ifthe Pacific Islands clinical psychologists currently in the sector were actively involved in therecruitment and support of these students.

A high-profile recruitment drive for clinical psychology and other less well known professions andoccupations in mental health could prove successful.

8.5.8 Mental health support workers

The mental health support work initiative is relatively new in the mental health sector and nowplays an important part in the comprehensive delivery of mental health services.

From a Pacific Islands perspective the mental health support worker initiative has provedextremely valuable. The types of Pacific Islands people who have entered the sector have beenmore mature, have represented a good gender mix, and have demonstrated a range of lifeexperiences and strong community links. They are very knowledgeable in cultural matters, andsome are not just bilingual but multilingual.

Mainstream services find working with Pacific Islands service users difficult at the best of times,and having access to culturally appropriate mental health support workers has greatly improved thedelivery of mental health services. The other benefit is that following the relatively short trainingtime, these mostly mature Pacific Islands people are actively participating in the mental healthsector and doing valuable work.

Almost all the Pacific Islands people training for the National Certificate in Mental Health (MentalHealth Support Work) are staff with mental health service providers. If more Pacific Islands

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people are going to train in this programme, a greater number of Pacific Islands mental healthsupport worker positions need to be supported by the HFA.

The Pacific Islands mental health sector has benefited from the entry of Pacific Islands mentalhealth support workers in the sector, and priority for funding for FTEs in this area isrecommended.

8.5.9 Occupational therapists

A scan of the mental health sector revealed that in the last five years only one Pacific Islandsperson has graduated from the Auckland Institute of Technology occupational therapy course.Figures from Otago were not available. The low profile of occupational therapy within the PacificIslands community is put forward as the major reason for its failure to attract Pacific Islandsstudents. This is unfortunate as Pacific Islands people have talents that lend themselves naturallyto occupational therapy. It is also noted that mental health is a preferred career option foroccupational therapists at the completion of their training.

8.5.10 Counsellors

Counselling is another area in which Pacific Islands people are poorly represented, even thoughthere is increasing demand for quality Pacific Islands counsellors. High-quality, culturallyappropriate marriage and relationship counselling, and grief, anger, sexual abuse and self-identitycounselling for Pacific Islands people are in great demand. Again it appears that the avenue ofentry into training and the rewards of this occupation are not well known in the Pacific Islandscommunity. In addition Pacific Islands people need to integrate current accepted theories ofwestern counselling practice with Pacific Islands approaches to counselling. This is an academicprocess, but a very important one in which organisations like the Family Centre in Wellington arealready involved.

A high-profile advertising and recruitment campaign is needed to lift the Pacific Islandscommunities’ awareness of these occupations. Focused campaigns need not be expensive, and iffunding for training is made available, successful recruitment of Pacific Islands people into theseoccupations would be reasonably assured.

8.6 Issues

8.6.1 National representation

There is a view in Pacific Islands communities that no one individual can adequately represent thevarious Pacific Islands nations and their perspectives at a national level. A national Pacific Islandsbody (similar to the Pacific Islands Peoples Advisory Committee) funded by the Mental HealthCommission, is therefore required in the mental health sector.

There also needs to be a Pacific Islands mental health position created in both the HFA andMinistry of Health. This will not only demonstrate a greater commitment to the health needs ofPacific Islands people but will also recognise that there is a tremendous amount of work that needsto be done in both these organisations.

8.6.2 Socioeconomic factors

In terms of socioeconomic status, Pacific Islands communities in New Zealand are expected tobecome the biggest at-risk group in New Zealand in the new millennium. This will have a

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corresponding negative effect on the mental health of Pacific Islands peoples, who will place anever-increasing demand on mental health services. This will reinforce the need for even greaternumbers of Pacific Islands people in mental health services.

8.6.3 Training

The Blueprint, Moving Forward, Making a Difference and the HFA National Mental HealthFunding Plan 1998-2002 discuss training issues in great detail and essentially identify similarproblems and solutions. For Pacific Islands people, increased mental health support workertraining is clearly identified as a priority, but this does not mean that attention and strategiesshould not be implemented for the other human resources required. Positive affirmation andincreased funding to attract Pacific Islands people into the mental health sector and the importanceof training competent managers are identified too. The role of traditional healers is alsoconsidered, and there is a need here to formalise relationships between mainstream serviceproviders and traditional Pacific Islands healers.

The issue of standardised Pacific Islands training packages across all mental health programmeshas been discussed, with a particular emphasis on cultural safety. There is a need for a PacificIslands focus group to review the current curricula of mental health training programmes, forquality and content that reflects current opinion and understanding of Pacific Islands mentalhealth.

Programmes to destigmatise and to combat discrimination against all people with mental illnessmust continue in the sector. Pacific Islands people face double discrimination when theyexperience mental illness. Before wider community prejudices can be addressed, the mental healthworkforce must be trained to be less discriminatory in its attitudes and behaviour.

8.6.4 Models of service delivery and service specifications

Future models of mental health service delivery and Pacific Islands mental health servicespecifications need to be clearly identified so that Pacific Islands workforce development can beappropriately planned. The services Pacific Islands mental health service providers should belooking to provide and the way they are to be delivered both require clarification. A nationalPacific Islands focus group meeting, attended by all significant stakeholders should be organised toenable strategic planning around future Pacific Islands mental health service specifications andappropriate models of service delivery. Small Pacific Islands mental health providers who lackessential managerial and financial skills may need to be supported by the funder.

It is important that the differences between the various Pacific Islands nations are recognised andthat the perspective of the smaller Pacific Islands nations is acknowledged.

Increasing resources will be required for child and adolescent mental health, youth suicide anddual diagnosis (alcohol and drug, and mental illness) in the Pacific Islands context in the future.Resources must be allocated to assist Pacific Islands families caring for mentally unwell relativesin the home.

There is a clear demand from Pacific Islands service users and their families that their spiritualneeds must be catered for. Mechanisms are required that allow for these needs to be addressedwithin mainstream services. There are models for how this may work. The incorporation ofgeneral hospital chaplaincy services into community care is an example of one such model.

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8.6.5 Evaluation and monitoring

Evidence based Pacific Islands best practice initiatives that have in-built mechanisms of evaluationare important for the development of a culture of learning that would allow the Pacific Islandsworkforce to operate in an environment of continuous learning.

Monitoring and evaluation of Pacific Islands mental health providers requires the development of aculturally appropriate audit tool.

8.6.6 Information collecting systems

Collection of all significant data about Pacific Islands people’s use of mental health services is apriority. A national review of the prevalence of mental illness in Pacific Islands communities anda Pacific Islands people’s national needs assessment must also be undertaken.

A national database of all Pacific Islands people working in the mental health sector would beinvaluable for identifying gaps and achieving more co-ordinated Pacific Islands workforceplanning.

8.6.7 Recruitment and retention

The reports reviewed make constant reference to the importance of strategies to increase therecruitment and retention of Pacific Islands people in the mental health sector. No concretestrategies for how this can be achieved have been clearly articulated.

8.6.8 Intersectoral collaboration

The need for increased collaboration between the education and health sectors is viewed as anecessary development to ensure that Pacific Islands people are recruited into training programmesand that Pacific Islands issues are included in curricula.

8.7 Essential service components

The Pacific Islands mental health sector is currently not in a position to staff and fully operate themany services that make up the mental health sector. Current and future Pacific Islands mentalhealth service planning must be based on what is realistically achievable.

Within the larger HHSs, especially in Auckland and Wellington, there are significant numbers ofPacific Islands staff working in mainstream positions. However, they work with Pacific Islandsservice users only as they come into contact with them.

All the various mental health services should have access to Pacific Islands expertise so that itenhances the service they deliver and makes it more responsive to the needs of Pacific Islandspeople. This will mean stand-alone Pacific Islands services in areas where there are large numbersof Pacific Islands people. In other areas, more imaginative models of service delivery that utiliseindividual Pacific Islands staff within the organisation will be required.

Where the expertise does not exist for Pacific Islands services to work independently (in areas withlarge populations of Pacific Islands people), there needs to be a clinical/cultural Pacific Islandsliaison service that mainstream mental health services must access when Pacific Islands serviceusers and their families engage the service.

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In the areas with large Pacific Islands populations, there should be a movement towards theavailability of:

• crisis teams with 24 hour access to a Pacific Islands clinical liaison service

• Pacific Islands crisis respite

• Pacific Islands acute inpatient liaison services

• Pacific Islands child and adolescent liaison services

• Pacific Islands chaplaincy services

• Pacific Islands early intervention service or liaison service

• Pacific Islands maternal mental health service or liaison service

• general hospital liaison

• Pacific Islands case management services

• Pacific Islands dual diagnosis services (alcohol and drug, plus mental illness).

The demography of the Pacific Islands population, with 44% of the Pacific Islands population lessthan 20 years of age, creates an urgent need for increased child and adolescent services.

Over-representation of Pacific Islands people in forensic services and increasing drug and alcoholproblems also causes concern. Future service planning for Pacific Islands people will need to befocused in these areas.

8.8 Strategic framework

The purpose of the strategy is to outline short-, medium- and long-term goals and targets, and themechanisms to achieve these. Achievement of the strategy should result in the mental healthsector having access to a sufficiently large, sustainable and well-trained workforce.

The first strategy looks at increasing the number of Pacific Islands mental health professionals andincludes the need for Pacific Islands people to access traditional forms of treatment if this isappropriate. The second and third strategies focus on upskilling and improving the competence ofthe Pacific Islands and mainstream workforce to make mental health services more responsive tothe needs of Pacific Islands people. There are also important strategies concerning the nationalrepresentation of Pacific Islands people at a policy-making level, the need to define models ofservice delivery for Pacific Islands people, and ways of supporting the Pacific Islands mentalhealth workforce and ensuring its sustainability.

8.8.1 Increase Pacific Islands mental health workers

The deficiencies in the Pacific Islands mental health workforce exist across all the professionalgroups. There are a number of obstacles to overcome in recruiting Pacific Islands people into themental health sector and the best way of achieving this is the active involvement of current PacificIslands mental health workers in the recruitment process.

Table 33 looks at the core mental health professions, and suggests targets and concretemechanisms for recruitment and support of interested Pacific Islands people. It is difficult toprioritise the professions, as they are equally important in the overall delivery of comprehensivemental health services. It is important to note that Pacific Islands mental health support workershave been identified as the category of staff that should be given priority funding. Mental healthsupport workers enter the workforce after the shortest and least costly training process, andanecdotal evidence shows that competent, more mature Pacific Islands people with sound culturalknowledge and life experiences are entering the mental health sector via this profession.

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There is currently no Pacific Islands psychiatrist in New Zealand. This is clearly a deficiency thatneeds rectifying in the medium term. Other professions are also under-represented, and need theurgent introduction of proactive initiatives.

The key to the successful recruitment of Pacific Islands people is to develop initiatives that allowfor current Pacific Islands mental health workers to play an active role in mentoring Pacific Islandsundergraduate students and to participate in high-profile mental health career promotionalactivities.

8.8.2 Increase the competence of the Pacific Islands mental health workforce

This strategy outlines mechanisms that will ensure that the Pacific Islands mental health workforcehas the appropriate core competencies to deliver mental health services to the highest standards.To achieve this, Pacific Islands mental health services throughout the country should have stronglinks with education training providers and universities to ensure that their practice is based on thebest available mental health information. This information should then be disseminated to themental health sector as a whole.

The National Committee has worked with education and health service providers to develop thebest ways to achieve this and an approach is being trialled by one Pacific Islands mental healthservice provider which has set up a direct relationship with the local Polytechnic. Current reportsindicate favourable outcomes both for the service itself and the education providers involved.

8.8.3 Upskilling current mainstream workers in Pacific Islands mental health issues

Mainstream, non-Pacific Islands mental health staff should be upskilled to improve their ability torespond appropriately to the needs of the increasing number of Pacific Islands people who areaccessing mainstream mental health services.

As a result of efforts made by the National Mental Health Workforce Development Co-ordinatingCommittee a Working Party, funded by the HFA, has been established in the Pacific Islands mentalhealth sector to look into this issue. The content of these training sessions and workshops is beingdeveloped.

8.8.4 National representation

Pacific Islands people must have representation at the highest levels of decision-making andpolicy-making to ensure that adequate co-ordination and monitoring of the sector from a PacificIslands perspective occurs. This will be especially crucial in relation to Pacific Islands people’sfuture mental health workforce development, as the success of many of the initiatives outlined isdependent on access and rapport with the Pacific Islands mental health workforce and communityat large.

The National Mental Health Workforce Development Co-ordinating Committee representativeshave liaised with the National Pacific Islands Advisory Board to the Mental Health Commission asa forum for discussing national workforce development issues and the best solutions.

8.8.5 Define future Pacific Islands mental health service specifications

The Pacific Islands mental health sector must clearly identify both its future capacity to deliverservices and what these services are. Pacific Islands mental health workforce developmentdepends on this occurring.

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The National Mental Health Workforce Development Co-ordinating Committee has beeninstrumental in co-ordinating discussions on the organisation of a national meeting of key PacificIslands stakeholders. The expected outcome of this meeting, scheduled for August 1999, is aclearer definition of the future direction and specifications of Pacific Islands mental healthservices.

8.8.6 Supported and sustainable Pacific Islands workforce

Ensuring the sustainability of the Pacific Islands mental health workforce is an importantconsideration. The Pacific Islands mental health sector has identified the need for a coalition ofPacific Islands mental health workers, and support for this is a concept gaining increasingmomentum. If such a coalition came into existence, it would be in a position to co-ordinate manyof the activities outlined.

Following the completion of the Pacific Islands mental health workforce database, correspondencewith all the Pacific Islands mental health workers identified will be needed to establish the demandfor a coalition.

Table 33: Increase Pacific Islands mental health workers


Effective marketing of mental health as a career option. Immediate(3-6 months)

Heighten the profile and awareness of these occupationsin the Pacific Islands community.


Establish careers information days in schools with theassistance of mental health service providers and currentPacific Islands mental health workers.


Increase number of FTEs funded to undertake theNational Certificate in Mental Health (Mental HealthSupport Work).


Recruit at least one Pacific Islands person into medical,occupational therapy, clinical psychology andcounselling training each year.


Establish appropriate funding support for students intraining.


Increase and sustainnumbers of PacificIslands people:

a) in mental healthsupport work trainingprogrammes

b) in health professionalpre-entry and post-entry trainingprogrammes, inparticular, medicine,occupational therapy,and clinicalpsychology

c) as male nurses.

Education and mental health service providers establishmentoring programmes and support networks for PacificIslands people in the mental health workforce.


Use experienced Pacific Islands people in the mentalhealth workforce to provide supervision for students intraining and for new staff.


Establish clinical placements with Pacific Islands mentalhealth services.


Provide funding support for attendance at conferencesand postgraduate training programmes.


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Create a Pacific Islands social work collective to beactive in recruitment.


Increase proportion ofPacific Islands socialworkers choosing mentalhealth as a career. Fund post-entry training for Pacific Islands social

workers.Medium term(1-3 years)

Identify appropriate funding support. Medium term(1-3 years)

Target and mentor possible candidates. Medium term(1-3 years)

Recruit one career mentalhealth researcher fromeach of the main PacificIslands nations.

Establish research scholarships/salaries. Medium term(1-3 years)

Attract quality Pacific Islands managers into the mentalhealth services.


Ensure that a trainedPacific Islands manageris in situ for each PacificIslands mental healthservice.

Target and support Pacific Islands people to undertakeappropriate management training for work in the mentalhealth sector.


As noted above, the Mental Health Commission has instigated the development of a nationalPacific Islands mental health workforce database.

Table 34: Increase the competence of the Pacific Islands mental health workforce


Develop a culture oflearning amongst PacificIslands mental healthworkers.

All Pacific Islands mental health workers will adopt aculture of evidence-based mental health care bestpractice.


Sharing of Pacific Islandsinformation on mentalhealth issues will beenhanced.

Establish a website to facilitate information sharing ofPacific Islands mental health service issues.


Pacific Islands services must have a strong educationfocus and allocate appropriate resources to facilitateaccess to clinical practice opportunities for students.


Establish appropriateclinical placements withPacific Islands serviceproviders for PacificIslands students intraining.

Mainstream services should allocate resources to permitcurrent Pacific Islands staff to provide supervision forPacific Islands students during clinical placements.


Promote Pacific Islandspostgraduate trainingopportunities, especiallyin child and adolescentservices and dualdiagnosis.

Identify funding resources for five postgraduate PacificIslands students annually.


Facilitate Pacific Islandsattendance at relevantconferences.

Identify funding sources to assist Pacific Islands workersto attend relevant conferences.


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All Pacific Islandsmental health servicesshould be managed by amanagement trainedPacific Islands person.

Pacific Islands mental health organisations shouldidentify and promote an appropriate Pacific Islands staffmember to undertake management training at theappropriate level.


Table 35: Upskilling current mainstream workers in Pacific Islands mental health issues


There will be culturallyappropriate and safeprofessionalpractitioners.

Professional organisations, relevant regulatory bodiesand employers will ensure Pacific Islands culturally safepractice by all mainstream clinical and non-clinical staff.


All mainstream staff willbecome Mental HealthStandard 2 proficient.

A Pacific Islands mental health workshop/trainingpackage is developed and delivered to all mainstreamstaff so that participants become Mental HealthStandard 2 proficient.


Table 36: National representation


Establish a nationally representative Pacific Islandspeople’s mental health forum for the mental healthsector.

Long term(3-5 years)

Pacific Islands peoplesare represented atnational policy decisionmaking levels.

Create a senior Pacific Islands advisory position in themental health service policy sections of the Ministry ofHealth and the HFA.

Long term(3-5 years)

Table 37: Development of a sustainable Pacific Islands workforce


Pacific Islands mentalhealth workers aresupported and retained.

Pacific Islands mental health workers are paidcompetitive rates of remuneration.

Pacific Islands mental health workforce retention policiesare established and activated.

Pacific Islands support networks are established andresourced.

A coalition of Pacific Islands workers is established.


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Table 38: Define future Pacific Islands mental health services


Identify future workforcedevelopment needs.

Formulate a workforce development plan based on clearlydefined future Pacific Islands mental health services.


Establish a database ofinformation on thecurrent Pacific Islandsmental health workforce.

Undertake a comprehensive survey of the current PacificIslands workforce.


Determine and prioritisePacific Islands child andadolescent serviceworkforce requirements.

Develop a Pacific Islands service workforce developmentplan for child and adolescent services which identifiesPacific Islands recruitment strategies in this area.


Determine the need for,and numbers of, PacificIslands mental healthsupport workers.

Identify training requirements and get agreement for priorityfunding of a defined number of Pacific Islands mental healthsupport workers.


Increase the number ofPacific Islands mentalhealth workers trained inthe treatment of PacificIslands people with dualdiagnosis.

Get agreement for priority funding of an increased numberof Pacific Islands mental health workers training in this sub-specialty.


8.9 Conclusion

For the strategies outlined to be successful the current Pacific Islands mental health workforcemust be utilised effectively in planning, recruitment, support and training in all aspects of PacificIslands mental health work force development. Funding needs to be made available to allow thisto happen.

The current Pacific Islands workforce deficiencies will be identified by the current audit beingundertaken by the Mental Health Commission and will be available mid 1999. This informationwill enable better planning and targeted funding for the Pacific Islands mental health workforce.

Pacific Islands mental health services must also work closely with education providers in theirlocalities. A successful example of such an activity is the current relationship between SouthAuckland Health and the University of Auckland and Manukau Institute of Technology, initiatedby the Committee. The benefits for all parties have to date far exceeded expectations. Thesebenefits need to be passed on to other Pacific Islands mental health providers developing similarinter-agency activities in other parts of the country.

The numbers of Pacific Islands mental health workers and social workers are increasing.

The Pacific Islands members of the National Mental Health Workforce DevelopmentCo-ordinating Committee have been assisting in the development of Pacific Island mental healthservices. Currently, there is a separate Pacific Islands mental health service in Auckland HealthCare. South Auckland Health’s Pacific Islands Mental Health Team is operational. Pacific Islandsmental health services are being set up in Waitemata Health in West Auckland; negotiations aretaking place in Wellington; and funding has been allocated for a Pacific Islands mental healthservice in Christchurch. The result of the initiative has been close collaboration across the various

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services allowing consistent philosophies, values and models of service delivery for Pacific Islandspeople nationally.

This close collaboration between Pacific Islands services will allow any newly developedresources, training packages, or successful programmes or models of service delivery to be sharednationally which enables work to build on that already done and avoids wasteful duplication.

The net result of the implementation of the strategies already initiated by the Committee and thoseoutlined will result in New Zealand having a Pacific Islands mental health workforce large enoughand skilled enough to meet the needs of Pacific Islands service users and their families.

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Appendix 1: Terms of Reference of the National Mental HealthWorkforce Development Co-ordinating Committee

February 1998

Introduction and background

This report describes the mental health workforce strategy envisioned and approved by a MentalHealth Workforce Development Steering Group established by the Mental Health Commission, theMinistry of Health and the former four regional health authorities (now Health Funding Authority).

In May 1997 the Steering Group was established to address two issues.

1. Development of an overall mental health workforce strategy which will ensure a mentalhealth workforce is available on an on-going basis which is appropriately educated andtrained and of sufficient numerical strength to achieve the long term planning objectives ofthe central agencies.

2. Development of training standards for mental health support workers. These have beencompleted.

National mental health workforce development strategy

It has been decided that the establishment of a national co-ordinating mechanism is the mosteffective means of developing and implementing a workforce plan which will satisfy therequirements of the HFA National Mental Health Funding Plan 1998-2002, Ministry of Health’sMoving Forward and the Mental Health Commission’s Blueprint, and meeting the challenge ofworking with the major reforms to the tertiary education sector planned over the next couple ofyears. The National Mental Health Workforce Development Co-ordinating Committee willdevelop and implement a strategic framework which includes setting goals and ways to achievethem, monitor the national workforce to identify key issues which impact on service delivery, andbroker solutions between the key stakeholders, particularly the health and education sectors.

Provider leadership is considered crucial to the success of the Committee, as they best understandwhat workforce (in terms of numbers and skills) is needed to deliver the services required and thefactors which influence recruitment and retention of staff with the skills, attitudes and knowledgerequired in the mental health sector.

The Health Funding Authority has agreed to fund the Committee for an initial period of one yearonly, with further funding depending on a review demonstrating the effectiveness and value ofongoing work. It is envisaged that further revenue will be raised from other stakeholders.

Vision statement

The National Mental Health Workforce Development Co-ordinating Committee has a clearmandate from the whole mental health sector to provide a definitive framework on which to buildthe national regulation of, and national allocation of resources for mental health workforcedevelopment.34

34

Note that the Committee will advise funding bodies such as HFA and Ministry of Education. It has no delegateddecision-making authority.

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The Committee will have succeeded if in two years time there is a shared vision throughout thesector about the workforce requirements necessary to drive mental health service new directions;with all agencies exercising leadership and working together to take responsibility for theworkforce development.

The Committee’s nature and purpose

The Committee will focus on what investment will be required to develop a workforce morealigned with family and consumer service needs.

As a co-ordinating body it will ensure that effort is aligned and that the needs of the sector andinputs from relevant agencies are targeted towards consumer objectives.

The Committee will in effect act as a brokering agency which will marry the needs of thestakeholders on the one hand and the education providers on the other.

It will:

• provide a vehicle for service providers to influence agencies whose decisions impact onmental health services and consumers. This applies especially to the education sector andits allocation of resources to mental health training.

• be a catalyst for change and development in workforce competencies by makingtransparent/explicit the workforce development requirements of the national mental healthstrategy and blueprint for the next five years and setting specific objectives and ways toachieve them

• encourage the development of a national repository of workforce development informationand expertise, made readily available to assist in managing workforce issues

• assume a national leadership role for mental health workforce development.

The Committee will be analytical and advisory in nature. It will not pre-empt the roles orresponsibilities of any current agencies. It’s purpose is to ensure that effort is co-ordinated and notduplicated and that decision-making bodies have good information on which to base theirprioritising decisions.

Accountability

This Committee is supported by the Minister and all the leading agencies involved in mental healthservices. It is accountable to its funders, particularly the HFA.

The Mental Health Commission will underwrite it in accountability terms, and will be accountableto the HFA for delivering on the terms of reference through a contract.

Guiding principles

A key success factor will be the Committee’s ability to establish and maintain credibility andexcellent rapport with all the key stakeholders in mental health workforce development. It alsorequires intersectoral support.

The activities, priorities and decisions of the Committee will be guided by the followingprinciples:

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• recognising and supporting the importance of consumer involvement in optimising qualityoutcomes of training programmes and services

• recognising and being inclusive of the diverse stakeholders within the mental healthindustry with partnership arrangements which include consumers, Maori, and PacificIsland people

• optimising the quality and outcomes of training programmes by encouraging partnershipsbetween health and education providers at local, regional and national levels

• improving cost effectiveness through increasing accountability, collection anddissemination of workforce information and the evaluation of the relative costs andbenefits of different workforce development programmes

• encouraging and promulgating local innovations

• encouraging stability of the workforce through its recommendations (incremental changeswith clear guidelines for implementation)

• setting priorities in a way which balances the workforce to meet needs

• encouraging the creation and maintenance of an environment which drives and reinforcesimproved performance

• basing the work on an integrated, collegial and collaborative approach from all keystakeholders of mental health services including harnessing the specific skills and goodwillfrom throughout the sector to achieve the work programme, and using work already donewhere possible.

• ensuring the role and function is well known and understood by stakeholders and keydecisionmakers by regular consultation and communication to the sector, particularly thefunding agencies, on objectives and achievements

• functioning transparently and openly

• maximising efficiency in allocation of resources for national workforce development

• minimising operating costs, ensuring no duplication of activities.

Terms of reference

Work for the provision of an improved service for mental health consumers and their families bydetermining how providers might recruit and retain an effective workforce of mental healthworkers with the appropriate skills, values and attitudes and implement appropriate strategies toachieve this.

Assess and co-ordinate:

• workforce development requirements of all stakeholders of mental health services intorealistic national frameworks and actions

• the workforce development initiatives of all relevant parties to ensure maximum efficiencyof their efforts.

Promote:

• as a first priority, the interest of people who use mental health services

• the interests of the mental health sector by working with the education sector to ensure asmuch as possible, that training programmes properly take into account the requirements ofmental health consumers and are relevant to changing trends in mental health servicedelivery

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• local workforce initiatives, including promulgating successful initiatives to others

• information gathering to find out resource priorities of consumers for workforcedevelopment skills and qualities valued by consumers and gaps as they perceive them

• a non-discriminatory mental health culture where staff morale is maintained.

Develop:

• a vehicle which will enable collective development of systems to collaborate in the futureon national workforce development issues

• a framework for addressing workforce development requirements arising from the strategicobjectives and service priorities identified by the Ministry of Health (Moving Forward),Mental Health Commission (Blueprint), and Health Funding Authority (National MentalHealth Funding Plan 1998-2002) and others, including

– determining workforce strategies and actions to achieve them

– addressing specific workforce development issues critical to the successfulimplementation of the workforce plan as they emerge

• specific strategies for the advancement of the Maori, Pacific Islands and consumerworkforces and overseeing their implementation.

Monitor and influence as necessary:

• the impacts of policy developments in the tertiary education sector on the mental healthworkforce

• appropriateness of regulation of the workforce

• the quality of education and training in its ability to produce workers with the attitudes,values, knowledge and skills which assist consumers and families in their recovery

• expenditure on training to advise on efficient and cost-effective allocation of resources

• that the workforce is supported to reach the requisite skills in sufficient numbers toachieve the plans and take appropriate action to improve the balance of the workforce.

Note – the Committee will not be responsible for purchasing training programmes. Rather, it willprovide a framework within which funders and purchasers can target their purchasing towards thepriority areas identified.

Strategic alliances

The mental health sector, in relation to workforce development, covers a complex interface ofhealth and education sector organisations. As such, good relationships need to be fostered with thefollowing:

• mental health consumers and families, including (but not limited to) representative bodiessuch as ANOPS, GROW, Manic Depressive Society and Schizophrenia Fellowship

• Maori groups

• Pacific Island groups

• refugee groups

• mental health service providers (including NGOs, CHEs and individual providers)

• mental health workers

• students in relevant training programmes

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• all regional divisions of the Health Funding Authority

• Clinical Training Agency

• Ministry of Health

• Committee Advising on Professional Education (CAPE)

• Mental Health Commission

• Ministry of Education

• tertiary educational institutions (universities, polytechnics and private training establishments,including service providers)

• relevant Industry Training Organisations

• New Zealand Qualifications Authority

• Education and Training Support Agency

• relevant health professional agencies, including (but not limited to):

– Royal Australian and New Zealand College of Psychiatrists

– Royal New Zealand College of General Practitioners

– Medical Council of New Zealand

– New Zealand Branch of the Australian and New Zealand College of Mental HealthNurses

– College of Nursing Aotearoa New Zealand

– Nursing Council of New Zealand

– New Zealand Association of Occupational Therapists (Inc)

– Occupational Therapy Board

– New Zealand College of Clinical Psychologists

– Psychologists Board

– New Zealand Psychological Society (Inc)

– New Zealand Association of Psychotherapists

– New Zealand Association of Social Workers

– Community Support Workers Workforce Development Working Party

Managing for results

The Health Funding Authority has approved funding for an initial period of one year only. Thework of the Committee will be reviewed at this time in light of the financial environment and itseffectiveness to assess its continuation and further funding

The Committee will have a broad skill base. While the Committee should be reasonablyrepresentative of the sector, the skills, abilities and commitment of individual committee memberswill be paramount.

The combined critical competencies of the committee as a whole enabling it to achieve the termsof reference envisaged are:

• visionary/strategic thinking

• high credibility with the mental health sector

• demonstrated commitment to putting people who use mental health services first

• a high level of commitment to the work of the Committee

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• operational expertise

• mental health sector knowledge

• extensive networks

• credibility with the respective crown agencies and national allied organisations

• high credibility within their respective organisations so as to influence the use of resources

• results orientation

• negotiation skills

• positive enthusiasm about what can be achieved through workforce development

• experience/knowledge about some aspect of workforce development

• ability to work with and through others in a team

• ability to make an active contribution to the work of the Committee (commitment andtime).

The membership of the Committee

Bob Henare Mental Health Commissioner (Chairperson)Margot Mains Chief Executive, MidCentral Health Ltd (Chairperson until August 1998)Barbara Anderson Chair, HOMES NZJane Cartwright Mental Health Director, Healthlink South Ltd (from July 1998)Mason Durie Professor of Maori Studies, Massey University (until May 1998)Karleen Edwards Senior Project Manager, Mental Health, HFA (from June 1998)Kath Fox National Director of Mental Health Services, HFA (until June 1998)Cheryll Graham Administrator, Wellington Mental Health Consumers Union (from February

1999)Jacqui Graham Joint Director, Pathways IncMadeleine Heron Mental health consumer (until January 1999)Murray Johnston Mental Health Manager, Capital Coast Health (until July 1998)John Matthews Consumer representative, Tai Tokerau, Mental Health Services, Northland

Health (from February 1999)Winston McKean General Manager, Clinical Training AgencyKarl Pulotu-Endemann Mental health consultantMike Sukolski Consumer Advisor, HFA (until December 1999)Rees Tapsell Psychiatrist, Mason Clinic, Waitemata Health Ltd (from May 1998)Cindi Wallace National President, Schizophrenia Fellowship (from May 1998)Dr Janice Wilson Director of Mental Health, Ministry of Health, advisor to the Committee

The Committee will manage its contract itself and provide regular financial reports to its funders.

Risk management

The Committee is exposed to a number of risks which will need to be well managed. Theseinclude:

• the need to operate within available resources

• poor availability and quality of information

• the existence of competitive tensions between service providers and between providers andTHA

• the importance of a universal mandate to operate as a collective voice of mental healthsector in the absence of direct levers for influencing key decision-makers

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• the need to increase investment in workforce development at the same time as there areurgent short-term service priorities

• competition and changing priorities within the tertiary education sector.

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Appendix 2: Medical Practitioners in the Mental Health Workforce1998

The following analysis provides general information and comment about the whole medicalworkforce, but concentrates on the medical workforce practising psychiatry.

Information sources

• Hannah, A., Roser, B., and Linton, M. The New Zealand Health Workforce 1990.Department of Health, Wellington, 1991.

• The New Zealand Health Workforce 1994. Department of Health, Wellington.

• Miles, W. Report on the New Zealand Psychiatric Workforce. Royal Australian and NewZealand College of Psychiatrists (unpublished), August 1995.

• Demographic Trends 1998. Statistics New Zealand, Wellington, 1999.

• New Zealand Health Information Service, 1999.

• Medical Council of New Zealand, 1999.

Data collection

The data is collected annually through a workforce questionnaire included with the annualpractising certificate application form sent by the Medical Council of New Zealand to medicalpractitioners on the medical register. While completion of the survey is voluntary the responserates to the medical workforce survey are high compared with other health workforce surveys.

Workforce statistics

In 1996 the number of medical practitioners with a worktype of psychiatry was 5.1% of the totalnumber of active medical practitioners (Table 39). There has been little change in 1998 (5.2%).Similar comparisons cannot be made with the 1990 and 1994 data, because of the exclusion ofMedical Officer of Special Scale (MOSS) and house officer numbers in the data.

Table 39: Active medical practitioners working in psychiatry

Year Number of activemedical practitioners

Number of active medical practitioners35

with a work type of psychiatry

1990 6339 263*

1994 7180 303*

1996 7634 394

1998 8491 447

* Excludes MOSSs and house surgeons.

35

Specialists, Medical Officer of Special Scale (MOSSs), registrars, house officers, general practitioners (GPs), andothers.

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Table 40 sets out the makeup of the psychiatric workforce in 1990, 1994, 1996, and 1998.

Table 40: Type of medical practitioner

Type of medical practitioner 1990 1994 1996 1998

Specialist 184 205 204 244

MOSS 40 58

Registrar 79 98 114 132

House Officer 25

GP 1

Other 4 7

N/A 4

No response 6

Total 394 447

The overall increase in the number of active psychiatrists from 1990 to 1998 was 33%. Betweenthe years 1990-1994, the number of psychiatrists (specialists) increased 11.4%. A further increaseof 19% occurred between 1994 and 1998.

The number of MOSS and other medical practitioners with the worktype of psychiatry were notpublished in the Department of Health publications of 1990 and 1994.

Registrars show the greatest increase (67%) of all types of medical practitioners in psychiatrybetween 1990 and 1998.

As registrars are enrolled on specialist training programmes, the opportunity for increasing thenumber of active specialist psychiatrists in future years is promising. The challenge to the NewZealand mental health service will be to offer sufficient incentives to retain these registrars in themental health workforce.

Ethnicity

A question on the ethnicity of medical practitioners has not been routinely included in the medicalworkforce questionnaire. Prior to 1996 the only year in which an ethnicity question was includedin the workforce survey was 1992.

Table 41: Ethnicity of medical practitioners working in mental health

Ethnicity 1996 1998

European 245 375

NZ Maori 5 10

Pacific Islands – 5

Indian 11 21

Chinese 5 4

Other 50 30

No response 74 –

Total 394 447

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The European psychiatric medical practitioner workforce has risen from 62% of the totalpsychiatric workforce in 1996 to 83% in 1998 (Table 41). This figure is likely to be influenced byan increase (18%) in the numbers of overseas trained specialists (Table 44). In 1998, 12% ofrespondents with a worktype of psychiatry identified as belonging to an ethnic group other thanEuropean, Maori or Pacific Islands people.

The number of New Zealand Maori respondents increased 100% between 1996 and 1998. In 1996no respondent identified as being of Pacific Islands people’s ethnicity. Now, in 1998, there arefive medical practitioner respondents identifying as being of Pacific Islands people’s ethnicity witha worktype of psychiatry.

Gender

Table 42 provides a breakdown of the gender of all medical practitioners with a worktype ofpsychiatry from 1994 to 1998. Table 30 provides a further breakdown of the 1998 data intospecific medical groupings.

The number of female specialists across all medical specialties has varied widely within eachspeciality over the years. As a specialty, psychiatry has always attracted significant numbers ofwomen. In 1994, for example, 18% of all medical specialists were female psychiatrists.

In the worktype of psychiatry, the number of female medical practitioners had increased from 29%of the workforce in 1994 to 36% in 1998.

Table 42: Gender of medical practitioners working in mental health

Gender 1994 1996 1998

Male 145 262 284

Female 60 132 163

Total 205 394 447

It should be noted that, in 1998, in a more detailed breakdown of the data, 30% of the specialists,40% of MOSSs and 47% of the registrars are female (Table 43). This finding may indicate somefuture human resources management issues for mental health services.

Table 43: Gender by type of medical practitioner working in mental health

Gender Specialists MOSSs Registrars Total

Male 172 35 70 277

Female 72 23 62 157

Total 244 58 132 434

Country of origin

Table 44 sets out, in general terms, the country of origin of psychiatric medical practitioners. Thecontribution of overseas-trained medical practitioners is important to the mental health service. Itcan be seen in Table 6 that in both 1996 and 1998, overseas-trained medical practitioners with aworktype in psychiatry outnumbered New Zealand-trained medical practitioners. Since 1996 theyhave increased the overall psychiatric medical practitioner workforce by 16% (the New Zealandtrained workforce component increased 10%).

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Table 44: Graduation country of medical practitioners with a worktype of psychiatry by gender

Country 1996 1998

Female Male Total Female Male Total

New Zealand 72 123 195 85 130 215

Other 59 137 196 78 154 232

Not reported 1 2 3

Total 132 262 394 163 284 447

Age

The overall age to worktype ratio of specialists to MOSSs has undergone little change in the two-year period 1996-1998.

Table 45: Specialists, MOSSs and registrars with a worktype of psychiatryby age groups 1996 and 1998

Age group 1996 1998

Specialist MOSS Registrars Specialists MOSS Registrars

25-29 0 0 35 0 * 17

30-34 13 5 42 13 10 58

35-39 36 10 18 39 11 27

40-44 51 7 15 56 6 16

45-49 27 4 3 43 9 11

50-54 30 2 1 37 * *

55-59 16 5 18 6

60-64 13 2 16 *

65-69 12 2 12 4

70+ 6 3 10 5

Total 204 40 114 244 58 132

Note: * represents a number <4.

The greatest increase in overall worktype numbers for specialists and MOSSs in 1998 has occurredin the 40–55 year age group. Seventy percent of specialist psychiatrists are in the 40+ age groupsand the number of specialists and MOSS in the 70+ age group has increased 66% in the two-yearperiod 1996-1998. These figures indicate an ageing psychiatric specialist workforce.

The registrar statistics show fewer numbers in the under-30-year age group but a marked increasein numbers in the 30-40 and 45-49 year age groups.

Employment setting

The employment of the majority of medical practitioners with a worktype of psychiatry is in thepublic hospital system. Between 1996 and 1998 there has been an increase of 12% in the numberof such practitioners.

Over the same period (1996–1998) the overall increase in the number of specialists is 19%,MOSSs 37% and registrars 15%.

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Table 46: Employment setting of medical practitioners with a worktype of psychiatry 1996 and 1998

Employment setting 1996 1998

Public hospital/HHS 344 386

Solo private practice 24 28

Group private practice 8 7

University/polytechnic 11 15

Government department/agency (private hospital, IPA) 2 *

Commercial/industrial company 3 7

Other/note reported 2 *

Total 394 447


It is apparent from Table 46 that the majority of psychiatrists are employed in public hospitals.The next largest grouping is in solo private practice, followed by a number employed inuniversities/polytechnics. The breakdown of employment setting by worktype demonstrates thegrowth in the number of CHE/HHS-employed psychiatric registrars in training programmes (17%)since 1996.

The number of specialists employed in CHE/HHS in 1998 has increased since 1996 by 20%. Thenumbers of MOSSs in similar employment over the same period has increased 37%.

Data from previous years is available in limited form. It is not, however, possible to present it in aformat that allows comparison with the 1996 and 1998 data.

Table 47: Medical practitioners with a worktype of psychiatry by employment setting 1996 and 1998


Specialists MOSSs Registrars Specialists MOSSs Registrars

CHE/HHS 162 40 111 195 55 130

Commercial company/private hospital

2 5 *

Government department/agency

1 * * *

Group private practice 8 6

Solo private practice 22 26

University/polytechnic 8 3 11 *

Not reported 1

Total 204 40 114 244 58 132


Detailed work type

The breakdown of medical practitioners with a work type of mental health is further detailed inTable 48. Unfortunately the data is not comparable. It can be seen, however, from Table 48, thatthere has been a growth in several sub-specialty areas, eg. child/adolescent psychiatry by 4.5%,community psychiatry by 40%, and general psychiatry by 16%.

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With the 1996 data it is not possible to further detail the worktype of medical practitioners with aworktype of psychiatry. It is, however, clear from Table 48 that there have been significantincreases in psychiatric input for child/adolescent psychiatry (4.5%), community psychiatry (40%),and alcohol/drug dependency, forensic and general psychiatry between 1996 and 1998.

Table 48: Medical practitioners with a worktype of psychiatry by detailed worktype 1996 and 1998

Specialty 1996* 1998*

Total** Specialists Total**

Child/adolescent psychiatry 28 21 36

Community psychiatry 55 46 77

Alcoholism/drug dependency psychiatry 4 *** 16

Forensic psychiatry 19 17 22

Liaison psychiatry 15 8 12

Psychogeriatrics 25 19 29

Psychotherapy 7 5 7

General psychiatry 205 123 239

Psychological medicine/psychopaedic (or mentaldeficiency)

8 *** 9

Other/not reported 3 0 ***

Total 369 244 447

* Excludes house officers.** Specialists, MOSSs and Registrars.*** Represents a number <4.

Geographic distribution

Table 49 shows that there has been an increase in the number of specialist psychiatrists working inthe Auckland (32%), Waikato (33%), Bay of Plenty (100%), Manawatu-Wanganui (13%),Wellington (23%), and Canterbury (8%) regions, and reasonable stability in other regions. Whenthese figures are aligned with estimated resident statistics (Table 50), they present a lessencouraging picture.

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Table 49: Medical practitioners with a worktype of psychiatry by geographical region

Region 1996 1998

Specialists MOSSs Registrars Specialists MOSSs Registrars

Northland 4 1 0 5 * *

Auckland 62 12 46 82 15 55

Waikato 15 2 12 20 4 12

Bay of Plenty 6 1 1 12 * 0

Tairawhiti 2 2 0 4 * *

Hawkes Bay 1 1 1

Taranaki 4 3 0 4 4 0

Manawatu-Wanganui 15 3 4 17 * 4

Wellington 30 4 19 37 8 19

Nelson-Marlborough 6 2 0 6 5 0

Canterbury 35 8 20 38 9 24

West Coast 2 0 0

Otago 20 0 11 19 * 13

Southland 1 1 0

Locum 1

Total 204 40 114 244 58 132


Table 50: Ratio of specialists, MOSS and registrars with a worktype of psychiatryby estimated resident population at 30 June 1998*

Region Specialists MOSSs Registrars

Northland 1:28,680 ** **

Auckland 1:14,139 1:77,293 1:21,080

Waikato 1:18,260 1:91,300 1:30,4333

Bay of Plenty 1:19,858 ** 0:238,300

Tairawhiti-Hawkes Bay 1:48,225 ** **

Taranaki 1:26,675 1:26,675 0:106,700

Manawatu-Wanganui 1:13,629 ** 1:57,925

Wellington 1:11,586 1:53,588 1:20,414

Nelson-Marlborough 1:20,117 1:24,140 0:120,700

Canterbury-West Coast 1:13,692 1:57,811 1:21,678

Otago-Southland 1:14,947 ** 1:21,846

Total 1:15,541 1:65,379 1:28,727

* Figures have been rounded.** With no actual figures, the ratios could not be calculated: refer Table 11.

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Although the statistics by region collected by the Medical Council may not be congruent by regionwith those provided by Statistics New Zealand, border variations are not expected to affect theratio results significantly. It can be seen from Table 50 that there is a great range in the ratio ofpsychiatric specialists to estimated resident population at 30 June 1998. Wellington has the bestratio, at one specialist to 11,586 estimated resident population, with Tairawhiti-Hawkes Bay thelowest.

Auckland, Manawatu-Wanganui, Wellington, Canterbury-West Coast and Otago- Southland are allbelow the national average of 1:15,541 estimated population.

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Appendix 3: Nurses Working in the Mental Health Services 1998

The nursing workforce makes up the largest group of mental health workers in New Zealand. Thisreview covers registered nurses/midwives and enrolled nurses working in the mental healthservices in 1998.

Information sources

• Nursing Council of New Zealand 1999

• New Zealand Health Information Service 1999

• Hannah, A., Roser, B., and Linton, M. The New Zealand Health Workforce 1990,Department of Health, Wellington.

• The New Zealand Health Workforce 1994, Department of Health, Wellington.

• Demographic Trends 1998, Statistics New Zealand, Wellington, 1999.

Data collection

The data is collected annually through a workforce questionnaire included with the annualpractising certificate application form sent by the Nursing Council of New Zealand to all registerednurses (RNs), midwives, and enrolled nurses (ENs) on the nurses’ register. The nursing workforcesurvey response rates are the highest of all the health workforce surveys (<94%). The collection ofsuch statistics, if required by the Council, is compulsory under the Nurses Act 1977.

In this review, the description ‘active’ refers to those nurses, with a current practising certificate,who have reported in the workforce survey that they are currently working in one or more types ofnursing (on a voluntary or paid basis) in New Zealand.

Workforce statistics

Between 1990 and 1994 there was an increase in the number of active registered nurses of 13.7%(Table 51). This is in contrast to the number of active enrolled nurses, which grew only 0.3% overthe same period, followed by a decline of 33% between 1994 and 1998. The active registerednurse workforce increased a further 13.3% between 1994 and 1998.

It should be noted that in 1996 the total active nursing workforce dropped by 10% partly becauseof a reducing enrolled nurse workforce.36 The decline in the number of enrolled nurses followed agrowth of 11% between 1990 and 1994. This reduction in the active nursing workforce in 1996limited the growth in the total active nursing workforce over the four-year period between 1994and 1998, to 6%.

Table 51: Total active registered nurse and enrolled nurse workforce

Type of nurse 1990 1994 1996 1998

Registered nurses/midwives 24,724 28,122 30,553 31,869

Enrolled nurses 6,531 6,552 5,750 4,894

Total 31,255 34,674 31,303 36,763

36

There have been no enrolled nurse training programmes offered in New Zealand since 1993.

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The reduction in the enrolled nurse workforce is a result of lower demand by employers forenrolled nurses and the closure of the enrolled nurse training programmes.

Table 52 sets out the numbers of active registered nurses and enrolled nurses who responded to theannual nursing workforce survey with a worktype of mental health/psychiatry.

Table 52: Active registered nurses and enrolled nurses working in mental health 1994 to 1998

Type of nurse 1994 1996 1998

Registered nurses 2,276 2,490 2,825*

Enrolled nurses 526 464 368

Total 2,802 2,954 3,193

* At 31 March 1999, 3223 registered nurses gave their worktype as mental health.

Data from 1990 cannot be compared with later data, as the 1990 data for registered nurses andenrolled nurses was published as a combined psychiatric/psychopaedic worktype and given as apercentage of the total active registered nurse/midwife and enrolled nurse workforce groups.

In 1994 the total active registered nurse/enrolled nurse mental health/psychiatric workforce was8% of the total active nursing workforce. In 1996 this figure was 9.4% and in 1998 had reduced to8.7%, largely as a result of the reduction in the enrolled nurse mental health workforce.

The total mental health active registered nurse workforce has increased 24% since 1994. Between1994 and 1996 the increase in the active registered nurse workforce was 9%, followed by a 13%increase between 1996 and 1998.

In contrast, the enrolled nurse workforce declined 69% between 1994 and 1998.

The total registered nurse and enrolled nurse workforce reporting a worktype of mentalhealth/psychiatry increased 13% between 1994 and 1998. The largest increase of 8% occurred inthe two-year period between 1996 and 1998 (5% between 1994 and 1996).

Ethnicity

In 1994,37 a small proportion of the total active registered nurses identified themselves as Maori(2.8%) or Pacific Islands (1.1%). European/Pakeha was the largest ethnic group, at 92.1% of thetotal registered nurse workforce.

As with active registered nurses, the largest group of active enrolled nurses in 1994 recorded theirethnicity as European/Pakeha (86.3%). There were more Maori (8%) and Pacific Islands people(3.1%) amongst active enrolled nurses than amongst registered nurses.

Table 53 sets out the ethnicity data from the 1996 and 1998 annual workforce surveys. There hasbeen little change in the number of active registered nurses identifying themselves as Maori.There has, however, been an increase in the number of Pacific Islands (11%) and other ethnicgroups among the active registered nurses reporting their worktype as mental health/psychiatry.

37

The 1994 published data did not provide a breakdown of ethnicity in the worktype mental health/psychiatry for eithergroup of nurses.

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Table 53: Ethnicity of active registered nurses working in mental health in 1996 and 1998

Ethnicity 1996 1998

NZ European/Pakeha 1,902 2,098

Other European 223 304

NZ Maori 206 208

Pacific Islands 54 60

Chinese 12 19

Indian 12 10

Southeast Asian 11 16

Other Asian 8 14

Other 61 73

Not reported 1 23

The reported ethnicity of active enrolled nurses with a worktype of mental health (Table 54) doesnot show the same pattern as that described for active registered nurses. The reduction in theactive enrolled nurse workforce is expected, given that training programmes have ceased tooperate. The numbers of NZ Maori active enrolled nurses has reduced over the two-year period1996 to 1998 by 22%. The number of active enrolled nurses with a reported ethnicity of PacificIslands has reduced by 28%. (These numbers can be compared with the overall reduction of 21%in active enrolled nurses with a worktype mental health/psychiatry between 1996 and 1998.)

Table 54: Ethnicity of active enrolled nurses working in mental health in 1996 and 1998

Ethnicity 1996 1998

NZ European/Pakeha 343 270

Other European 20 15

NZ Maori 68 54

Pacific Islands 22 16

Chinese 0 1

Indian 1 0

Southeast Asian 1 1

Other Asian 0 1

Other 9 7

Not reported 0 4

Total 464 368

Gender

The national nursing workforce has consistently been largely female. In 1990, 95.1% of theregistered nurses and enrolled nurses holding annual practising certificates were female. The maleto female ratio for the registered nurse workforce was 1:16.1. For enrolled nurses the ratio was1:27.2. In 1994, 89.3% of all enrolled nurses were female. The ratio of male to female enrollednurses was 1:25 and for registered nurses was 1:16.

While the mental health service workforce has also been consistently largely female it alsocontains a significant number of males (Table 55). In 1996 and 1998 the male to female ratioamong active registered nurses was 1:2. A significant number of respondents (14% in 1996 and7% in 1998) did not report their gender.

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Table 55 demonstrates the changing mix in the male to female mental health/psychiatric nursingworkforce. An increasing percentage (30.5% in 1998) of the active registered nurse workforcenow respond as male. In contrast, the male component of active enrolled nurses in the mentalhealth sector shows a small reduction.

Table 55: Gender of active registered nurses (RN) and enrolled nurses (EN)working in mental health in 1996 and 1998

Gender 1996 1998

RN % EN % RN % EN %

Male 701 20 92 20 861 30.5 68 18

Female 1447 72 336 72 1765 62.5 271 74

Not reported 342 8 36 8 199 7 29 8

Total 2490 100 464 100 2825 100 368 100

Age

The statistics in Table 56 demonstrate some interesting trends. In 1996, 16% of active registerednurses with a worktype of mental health/psychiatry were under the age of 30. By 1998, this figurehad reduced to 14.5%. Of the active enrolled nurses there has been a reduction from 18 enrollednurses to 1 for the same age group.

Sixty-nine percent of the active registered nurses in the mental health sector in 1998 were in the30-49 age group (68% in 1996) and 16% were in the 50- plus age group (15% in 1996). Thenumber of over-60-year-olds in both the active registered nurse and enrolled nurse groups hasincreased.

The data suggest that the nursing workforce in the mental health/psychiatric sector is ageing.Although the overall number of registered and enrolled nurses has increased, the greatest increaseis in the 30-49 age group. There would appear to be a need actively to recruit younger registerednurses to the mental health service.

Table 56: Age of active registered nurses and enrolled nurses workingin mental health in 1996 and 1998

Age 1996 1998

RN EN RN EN

<20 1 0 0 0

20-24 151 0 104 0

25-29 258 18 308 1

30-34 363 70 382 36

35-39 518 96 557 69

40-44 492 126 595 97

45-49 324 70 410 89

50-54 184 37 230 33

55-59 115 30 151 22

60+ 70 13 76 15

Not reported 14 4 12 6

Total 2490 464 2825 368

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Employment setting

The workforce has increased over the two-year period. Public hospitals and their communityhealth mental health services are the largest employers of registered nurses and enrolled nurses.Significant increases in the number of both registered nurses and enrolled nurses have occurred inHHS community services (up 20%) and non-HHS clinic/trust. Information about non-HHScommunity services was not collected in 1996.

It should be noted that an increasingly significant number of registered nurses with a worktype ofmental health/psychiatry are working outside public health employment in clinics/trusts,community services, nursing agencies, self-employment, Maori health service providers, andeducational institutions. Many of these active registered nurses may, in previous surveys, havenominated the ‘other’ category as their employment setting.

Table 57: Employment setting for active registered nurses and enrolled nursesworking in mental health in 1996 and 1998


RN EN RN EN

Public hospital/HHS 1623 362 1657 263

HHS community service 643 44 774 31

Non-HHS hospital 60 17 59 11

Non-HHS clinic/Trust 10 0 52 8

Non-HHS Community Services * * 96 21

Rest home 31 9 17 3

Nursing agency 6 1 40 7

Self employed 17 2 41 3

Maori health service provider * * 24 5

Educational institution 9 0 17 0

Government dept/agency 10 4 8 1

Other 52 17 20 11

Employer not reported 16 6 20 4

Total 2490 464 2825 368

* Data not collected.

Geographical setting

As stated earlier there has been a 13% increase in the number of registered nurses employed inNew Zealand with a worktype mental health/psychiatry. Their deployment is set out in Table 58.

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Table 58: Active registered nurses and enrolled nurses working in mental healthby geographical region in 1996 and 1998

Region 1996 1998

RN EN RN EN

Northland 68 7 93 6

Auckland 610 94 704 81

Waikato 215 31 232 24

Bay of Plenty 100 9 134 10

Tairawhiti 24 17 23 10

Hawkes Bay 56 12 73 9

Taranaki 48 13 51 11

Manawatu-Wanganui 197 38 230 41

Wellington 348 51 353 28

Nelson-Marlborough 84 38 99 23

Canterbury 437 46 523 38

Otago 190 64 180 54

Southland 39 14 60 6

West Coast 74 30 70 27


Total 2490 464 2825 368

Table 58 shows that the largest percentage increase in registered nurses with a worktype of mentalhealth/psychiatry occurred in Southland (53%). Other increases occurred in Bay of Plenty (34%),Hawkes Bay (30%) and Northland (36%). Two regions show reductions in the number ofregistered nurses – 6 % each in both Otago and the West Coast. Wellington shows an increase ofonly 1% associated with a significant reduction in its enrolled nurse workforce of 46%. Tairawhitishows a reduction of one registered nurse and of 42% in its enrolled nurse numbers.

In Table 59 an attempt has been made to provide a picture of the number of active registerednurses to the estimated resident population in mid 1998. It records numbers (not full timeequivalents) of registered nurses with a worktype of mental health/psychiatry. A table setting outthe number of full time equivalent registered nurses to the estimated resident population in 1998would provide a different picture.

A similar table of the numbers of active enrolled nurses and the total estimated population at30 June 1998 is not provided because of the nationally declining enrolled nurse workforce.

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Table 59: Active registered nurses working in mental health per estimatedresident population at 30 June 1998

Region 1998

Northland 1:1542

Auckland 1:1647

Waikato 1:1574

Bay of Plenty 1:1778

Tairawhiti 1:2030

Hawkes Bay 1:2003

Taranaki 1:2092

Manawatu-Wanganui 1:1007

Wellington 1:1214

Nelson-Marlborough 1:815

West Coast 1:470

Canterbury 1:932

Otago 1:1046

Southland 1:1595

Total estimated population ratio 1:1342

From the figures in Table 59 it can be seen that Northland, Auckland, Waikato, Bay of Plenty,Tairawhiti, Hawkes Bay, Taranaki and Southland have fewer registered nurses with a worktype ofmental health/psychiatry than the national average. Tairawhiti, Hawkes Bay and Taranaki havingthe most significantly poor ratios per estimated population.

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Appendix 4: Occupational Therapists Working in the Mental HealthServices 1998

This profile of the occupational therapy workforce in the mental health services begins with a briefcoverage of the occupational therapy profession as a whole.

Information sources

• Hannah, A., Roser, B., and Linton, M. New Zealand Health Workforce 1990, Departmentof Health, 1991.

• The New Zealand Health Workforce 1994. Department of Health.

• Annual reports to practising occupational therapists in 1997, 1998 and 1999 by the NewZealand Health Information Service, Ministry of Health.


• Occupational Therapy Board annual practising certificate statistics.

• New Zealand Association of Occupational Therapists Inc.

• Schools of Occupational Therapy at the Auckland Institute of Technology and OtagoPolytechnic.

Data collection

The data is collected annually through a workforce survey questionnaire included with the annualpractising certificate invoice sent by the Occupational Therapy Board to holders of current annualpractising certificates in February/March of each year. Completion of the survey is voluntary.

Size and character of the profession

The 1998 statistics are based on 752 active (working) occupational therapists who responded to thehealth workforce survey. This represented 59.5% of the 1264 occupational therapists whopurchased 1998/99 annual practising certificates between March and November 1998. It is notknown if the annual practising certificate holders who do not respond to the surveys are working asoccupational therapists, generic health professionals, or something else.

Care needs to be taken when interpreting the occupational therapist health workforce survey data.Survey forms are not sent out to new registrants or new applicants for annual practisingcertificates, after the main February/March annual practising certificate invoice mailing. Thetiming of Occupational Therapy Board meetings and the number of applicants approved forregistration in any one year will affect annual practising certificate purchases for that year.

For example, the Occupational Therapy Board registered 191 occupational therapists at threeboard meetings after the Occupational Therapists Health Workforce Survey was sent out in 1998.These new registrants did not receive workforce surveys but have been counted in the total of paid(issued) annual practising certificates for the 1998 survey period. A total of 1231 annualpractising certificate invoices and workforce survey forms were sent out in March 1998. ByNovember 1998, 1264 annual practising certificates (including the new registrants) had been paid.

The rate of attrition has reduced (approximately 50%) since 1991 when the single School ofOccupational Therapy was sited at the Central Institute of Technology. Attrition rates haveaveraged 20% at Otago Polytechnic (with a low in 1997 of 13%) and at the Auckland Institute of

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Technology (AIT) they reduced from 18% in 1993 to 14% in 1995. AIT’s attrition rate of 26% in1998 for the 1995 cohort is lower than its average. (Student intakes at each school for each yearfrom 1991 to 1998 inclusive range from 61–67. Graduate outputs from both training schoolsaverage around 100 per annum.)

Occupational therapists working in the mental health services practise, not only in acute psychiatryand continuing care (psychiatric) but also in rehabilitation and community/domiciliary services.The survey returns do not allow for a further breakdown into psychiatric or non-psychiatricworktypes for the rehabilitation and community/domiciliary data. The rehabilitation andcommunity/domiciliary data are included for general information.

Age and gender of active occupational therapists

The 1998 active occupational therapy workforce is consistently predominantly female (97%). Themajority of the males are less than 40 years of age, and all males who responded to the 1998survey are less than 50 years of age. The overall number of males has risen from 11 in 1991 and13 in 1994 to 19 in 1998. (Respondents who did not identify their sex have been excluded fromthe analysis.)

In 1990, 40.8% of the workforce were under 30 years of age. In 1996 and 1998 this figure hadreduced to 22.4 and 19.7% respectively. Thirty-six percent of the 1998 workforce are aged under35.

Table 60: Age and gender of active occupational therapists for the years 1994, 1996 and 1998

Gender Age groups Total

<25 25-29 30-34 35-39 40-44 45-49 50-55 55-59 60+

Notreported

1994

Male 0 4 4 2 2 1 0 0 0 0 13

Female 15 116 133 136 94 68 43 45 14 15 679

NR* 0 1 0 0 0 0 0 0 0 2 3

Total 15 121 137 138 96 69 43 45 14 17 695

1996

Male 1 3 4 6 4 1 19

Female 37 136 146 133 122 67 48 44 21 13 767

NR* 1 1 1 3

Total 38 139 151 139 126 69 48 44 21 14 789

1998

Male 1 1 3 7 4 3 0 0 0 0 19

Female 49 97 127 123 141 71 51 34 24 12 729

NR* 0 0 0 1 0 0 0 0 0 3 4

Total 50 98 130 131 145 74 51 34 24 15 752

* Not reported

Given the total number of new graduates as well as overseas graduates registering with theOccupational Therapy Board each year, there is a need to undertake a comprehensive survey tofind out where recent graduates are working. It is not known how many of these graduates arepractising in New Zealand or overseas, and how many are working in occupational therapy orrelated jobs.

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Ethnicity

The majority of occupational therapists identify themselves as belonging to the New ZealandEuropean/Pakeha ethnic group. This is a consistent feature of the occupational therapistsworkforce.

The data is not strictly comparable between years because of the different ways ethnicity has beenreported. In 1994 and 1996 sole ethnicity was reported. In 1996 there were 14 New ZealandEuropean/Pakeha males and 1 Chinese male. The 1998 figures record priority ethnicity for thefirst time.38

Table 61: Ethnicity by number and as a percentage of the total active workforce

Ethnicity 1994 1996 1998

Number Percentage Number Percentage Number Percentage

NZ European/Pakeha 585 84.2 639 81 613 81.5

Other European 70 10.1 98 12.4 86 11.4

NZ Maori 0 0 5 0.6 13 1.7

Pacific Islands 0 0 4 0.5 3 0.4

Chinese 6 0.9 6 0.8 6 0.8

Other 13 1.9 8 1 26 3.5

Not reported 21 3.0 29 3.7 5 0.7

Total 695 100 789 100 752 100

While the profession overall has minimal representation from Maori and Pacific Islands people,five of the 13 responding Maori occupational therapists in 1998 gave their worktype as acutepsychiatry and continuing care (psychiatric) (Table 61). No Pacific Islands occupational therapistsresponded under these two worktypes.

Table 62 shows that 104 occupational therapist respondents to the 1998 health workforce surveygave their worktypes as acute psychiatry and continuing care (psychiatric). An unknown numberresponding with the worktypes of rehabilitation and continuing care/domiciliary will also beworking in mental health services.

38

Prior to 1995, ethnicity for statistical purposes was defined basically in racial terms and was measured according to aperson’s degree of Maori and Pacific Islands blood. The new modified ethnic questions are consistent with theconcept of ethnic self-identification. They are aimed at providing more detailed statistics, incorporating a broaderrange of ethnic options as well as providing an opportunity for multiple response. The priority from multiple ethnicgroup reporting is taken from the Statistics New Zealand Ethnic Group code table. As a result of the changes, ethnicbreakdowns from 1996 are not comparable with earlier years (New Zealand Information Service 1999).

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Table 62: Worktype by prioritised ethnicity for active occupational therapistsin mental health services 1998

Ethnicity Rehabilitation Acutepsychiatry

Continuing care(psychiatric)

Community/domiciliary

Total

NZEuropean/Pakeha

152 33 51 140 376

Other European 29 6 7 14 56

NZ Maori 2 3 1 6

Samoan 1 1

Cook IslandsMaori

1 1

Chinese 4 1 5

Other 4 1 6 11

Not reported 1 2 3

Total 192 41 63 163 459

Employment setting

Table 63 provides a breakdown by main employment setting of occupational therapists in 1998who stated that they are working in mental health services (acute psychiatry and continuing care(psychiatric)). As noted above, an unknown number of occupational therapists responding withthe worktypes of rehabilitation and continuing care/domiciliary will also be working in mentalhealth services.

Table 63: Worktype by main employment setting for active occupational therapistsin mental health services in 1998

Employer Rehabilitation Acutepsychiatry

Continuing care(psychiatric)


Total

CHE/HHS 102 39 49 119 309

Private practice (selfemployed)

46 1 2 24 73

Private practice(employed)

19 6 25

Private hospital or resthome

3 1 3 7

Schools (education) 2 2 4

Government department/Crown agency

4 1 5

Community/voluntaryorganisation

4 2 1 7

Other 5 2 2 9

Employer not reported 7 1 6 6 20

Total 192 41 63 163 459

NB: Occupational therapists can report >1 worktype in their employment setting.

While Table 63 shows the number of active occupational therapists working in 1998 acrossworktypes impacting on mental health services, the following tables show the changes that haveoccurred over the four years from 1994 to 1998 for each worktype.

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Table 64: Numbers of occupational therapists reporting that they work in acute psychiatryby employment setting 1994-1998

Employment setting 1994 1996 1998

CHE/HHS 38 50 39

Private practice (self employed and employed) 0 0 1

Private hospital or rest home 0 2 0

Community/voluntary organisation 0 0 0

Other 0 1 0

Employer not reported 0 1

Total 38 53 41

Overall there has been minimal growth in the numbers of occupational therapists reporting thatthey practise in acute psychiatry over the years 1994-1998 (Table 64). It is not known why thenumbers have fallen back so markedly between 1996 and 1998. On the other hand, there has beena 29% increase in the number of occupational therapists who gave their worktype as continuingcare (psychiatric) over the same period (Table 65).

Table 65: Numbers of occupational therapists reporting that they work in continuing care (psychiatric)by employment setting


CHE/HHS 40 47 49

Private practice (self-employed and employed) 0 2 2

Private hospital/rest home 8 3 1

Community/voluntary organisation 2 2

Other 4 2

Employer not reported 0 6

Total 48 58 62

There has been no change in the number of occupational therapists who give their worktype asrehabilitation but there has been a marked change in employment settings. CHE/HHS and privatehospital/rest home employment setting numbers have declined significantly. The 124% growth inprivate practice employment is unlikely to be occurring in mental health services.

Table 66: Numbers of occupational therapists reporting that they work in rehabilitation byemployment setting


CHE/HHS 143 119 102




Other 0 6 5

Employer not reported 0 0 7

Total 186 202 186

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There has been a marked reduction of 17% in the number of occupational therapists who give theirworktype as community/domiciliary in a CHE/HHS, and a 100% increase in private practice(Table 67). A number of these occupational therapists are expected to be working in the mentalhealth services.

Table 67: Numbers of occupational therapists reporting that they work in community/domiciliaryby employment setting


CHE/HHS 142 147 119




Other 1 3 2

Employer not reported

Total 167 180 155

From Tables 64-67 it can be seen that there are peaks by employment setting in 1996 for totalworktype numbers in acute psychiatry, rehabilitation and continuing care/domiciliary. Thesepeaks are unexplainable. What is of concern is the significant decline in employment in theseworktypes as demonstrated in the 1998 data.

Although the above figures show the main employment types of the occupational therapists whoresponded to the surveys, each occupational therapist can specify more than one work type. Manyoccupational therapists work in more than one field even within their main employment setting.

Geographic distribution

Table 68 gives additional information on where active occupational therapists were working in theworktypes of acute psychiatry, continuing care (psychiatric), rehabilitation and community/domiciliary by geographical region in 1998.

There is a very uneven distribution of occupational therapists working in mental health services(psychiatry) across the country. Although the geographical regions described in the workforcesurvey may not be completely congruent with those used by Statistics New Zealand, differencesare unlikely to affect the ratios to any significant effect. The lowest ratio of occupationaltherapists to estimated resident population occurs in the Taranaki region (1:106,700), followed byWaikato (1:91,300). The Auckland region has the highest ratio at 1:3998. Full-time equivalent(FTE) ratios provide a different picture (Table 68).

Although there are schools of occupational therapy in the Otago and Auckland regions, they do notaffect the above statistics. No responding occupational therapist working in the educationalservices reported working in acute psychiatry or continuing care (psychiatric).

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Table 68: Main worktype by geographic region for active occupational therapists 1998

Geographicregion

Rehabilitation Acutepsychiatry

Continuingcare

(psychiatric)


Total Ratio of OTs inpsychiatry to

residentpopulation39

Northland 4 1 2 10 17 1:47,800

Auckland 53 10 19 23 105 1:3998

Waikato 17 1 3 16 37 1:91,300

Bay of Plenty 15 3 2 13 33 1:47,660

Tairawhiti 2 5 7 1:46,700

Hawkes Bay 8 4 3 9 24 1:20,885

Taranaki 5 1 6 12 1:106,700

Manawatu-Wanganui

11 5 2 13 31 1:33,100

Wellington 25 5 8 24 62 1:32,976

NelsonMarlborough

4 1 3 2 10 1:30,175

West Coast 2 1 1 1 5 1:16,450

Canterbury 34 5 11 22 72 1:30,462

Otago 9 4 5 13 31 1:20,922

Southland 2 1 3 3 9 1:23,925

N/A 1

Not reported

Total 192 41 63 163 459 1:36,968

NB: Total occupational therapists are the total working in this area in their main employment setting.

39

Resident population estimate at 30 June 1998 based on the number of New Zealand residents in New Zealand oncensus night, 5 March 1996, adjusted for the net undercount at the 1996 census (1.2%) and for the estimated numberof New Zealand residents temporarily overseas on 5 March 1996 (40,000). Includes the population of KermadecIslands, people on oil rigs, the population of the Chatham Islands District and Campbell Island (from Table 6.2,p.123, Demographic Trends 1998).

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Table 69: FTEs worked in main employment setting in each region for occupational therapists

Geographicregion

Rehabilitation Acute psychiatry Continuing care(psychiatric)


Northland 0.8 0.4 0.5 6.1

Auckland 30 6.2 10.8 11.7

Waikato 8 1 2.4 7.75

Bay of Plenty 6.9 1.5 0.5 4.8

Tairawhiti 0.5 0 0 2.4

Hawkes Bay 3.9 2.6 1.4 4.6

Taranaki 2.2 0 1 4.1

Manawatu-Wanganui

4.3 2.7 0.7 3.2

Wellington 14.5 2.7 3.3 8.54

Nelson-Marlborough

1.25 0.8 3 0.78

Canterbury 22.6 3.8 5.8 8.9

West Coast 1.75 0 0 0.5

Otago 3.8 2 2.9 6.5

Southland 1.2 0.1 1 1.4

Overseas 0.45

Not specified 0.25 2.4

Total FTEs 102.4 23.8 33.3 73.67

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Appendix 5: Registered Clinical Psychologists Working in MentalHealth Services 1998

This profile of the registered clinical psychologist workforce provides some general informationand comment about the registered psychologist workforce but concentrates on those registeredclinical psychologists who may be practising in the mental health service.

Information sources

Information has been sourced from:

• Hannah, A., Roser, B, Linton, M. The New Zealand Health Workforce 1990. Departmentof Health 1991.

• The New Zealand Health Workforce 1994. Department of Health.


• Psychologists Board.

• Demographic Trends 1998, Statistics New Zealand. Wellington, 1999.

Data collection

The data is collected annually through a workforce questionnaire included with the annualpractising certificate invoice sent out each year to currently registered psychologists by thePsychologists Board. Completion of the survey is voluntary.

Size and character of the registered psychologist profession

Psychologists are registered under the Psychologists Act 1981. Only psychologists practising in,or contracted to work for, the state sector are required to be registered by the Psychologists Board.Once registered, a psychologist, even if not working in the state sector, must hold an annualpractising certificate legally to practise as a psychologist.

Table 70: Number of annual practising certificate purchased

Year Number of annualpractising certificates

purchased

Completed surveysfrom respondents who

were active

Active response rate(percentage)

1994-95 856 558 65

1995-96 ? 659 62

1996-97 940 696 74

1997-98 998 659 66

1998-99 1025 611 59.6

Survey data forms are sent out to all registered psychologists holding annual practising certificatesin February/March of each year. The 1998 results and response rate cover the period betweenMarch and November 1998. Forty-five additional psychologists who were registered at threeboard meetings held during the survey period did not receive health workforce survey data forms.The number of annual practising certificates paid for by the end of November was 1025.

The 1998 statistics are based on the 611 active working registered psychologists who responded tothe health workforce survey. This represents 59.6% of the 1998 annual practising certificate

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holders. A further 2.6% responded to the 1998 survey but did not report that they were activelyworking. It is not known if the annual practising certificate holders who did not respond to thesurvey (37.8%) are working as registered psychologists.

Workforce statistics – registered clinical psychologists

Interpretation of the statistics for a picture of the registered psychologist workforce in the mentalhealth sector is difficult. Although the use of ‘main worktype’ to capture essential data is useful,the interpretation of the workforce data for this group of health workers is confusing.

All registered psychologists in HHSs must hold a qualification in clinical psychology or clinicalneuropsychology to be employable. Therefore all HHS-employed psychologists practise clinicalpsychology. All will at some time use counselling as a therapeutic technique. More sophisticatedcounselling is psychotherapy.

It is estimated that approximately two thirds of those registered psychologists who state that theywork in clinical psychology, psychotherapy and counselling, and are employed in an HHS, arepractising in the mental health service.40 This estimate may not, however, be accurate for areasoutside the main centres except Dunedin. The number of consumers treated in the private sectorwho have a psychotic disorder is estimated to be less than 1%.41

The number of non-registered psychologists practising clinical psychology is not known. But, asthey would need to be practising in the private sector, it is not a factor that needs to be consideredin this analysis for the mental health service.

Age and gender distribution

Females make up the greatest proportion of registered psychologists who responded that they had aworktype of clinical psychology, psychotherapy and counselling in 1994, 1996 and 1998(Table 71). This figure increased from 239 in 1994 to 343 in 1998 (43%) with gains evident ineach of the three worktypes. (Statistics on psychotherapy as a worktype were not collected in1994.). Apart from the worktype clinical psychology, the number of males practising in the othertwo main worktypes of psychotherapy and counselling has decreased.

The majority (71%) of active registered psychologists in 1998 who gave their main worktype asclinical psychology, psychotherapy or counselling, were in the 40 years plus age group (Table 72).Twenty-eight percent were under the age of 40 years and 9% were over the age of 60 years. Thisgives the impression that active registered psychologists responding to the survey for the threeworktypes are predominantly middle aged. The data also gives an impression that registeredpsychologists practise psychotherapy and counselling at a later stage in their practice or,alternatively, that it is not an area of practice that is particularly appealing to younger registeredpsychologists.

40

This estimate is based on personal communication with the President of the NZ College of Clinical Psychologists.

41Personal communication.

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Table 71: Sex by main worktype in clinical psychology, psychotherapy and counsellingin 1994, 1996 and 1998

Work type* 1994 1996 1998

Male Female NR** Total Male Female NR Total Male Female NR Total

Clinicalpsychology

136 173 0 309 139 214 5 358 153 218 5 376

Psychotherapy – – – – 44 46 1 91 32 55 2 89

Counselling 66 66 0 132 55 60 1 116 40 70 0 110

Total 202 239 0 441 238 320 7 565 225 343 7 575

* Respondents were able to classify more than one work type in their principle employment setting.** Not reported.

Table 72: Worktype by age group of active registered psychologists 1998

Age group Clinical psychology Psychotherapy Counselling Total

<20 1 1

25-29 22 1 5 28

30-34 40 2 6 48

35-39 55 9 10 74

40-44 63 15 13 91

45-49 64 24 20 108

50-54 45 10 19 74

55-59 23 11 21 55

60+ 21 16 13 50


Total 336 89 110 535

Ethnicity

Because of the different ways ethnicity has been reported over the years, it is not possible to usethe data for reliable comparisons.42

In 1998, 25 registered psychologists identified as NZ Maori in their response to the survey. Thiswas 4.7% of total respondents by prioritised ethnicity. Thirteen gave their main worktype asclinical psychology, three gave their main worktype as psychotherapy, and three stated that theirmain worktype was counselling (Table 73).

No Pacific Islands people identified as registered psychologists in 1998. This is a disturbingfeature of the workforce, given the high proportion of Pacific Islands people using mental healthservices.

42

Prior to 1995, ethnicity, was for statistical purposes defined basically in racial terms, and was measured according toa person’s degree of Maori and Pacific Islands blood. The new modified ethnic questions are consistent with theconcept of ethnic self-identification. They are aimed at providing more detailed statistics, incorporating a broaderrange of ethnic options, as well as providing an opportunity for multiple response. The priority from multiple ethnicgroup reporting is taken from Statistics New Zealand Ethnic Group code table. As a result of the changes, ethnicbreakdowns from 1996 are not comparable with earlier years (New Zealand Information Service, 1999).

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Table 73: Worktype by prioritised ethnicity for active registered psychologists 1998

Ethnicity Clinical Psychology Psychotherapy Counselling Total

NZ European/Pakeha 258 62 85 405

Other European 45 14 16 75

NZ Maori 13 3 3 19

Chinese 4 4

Indian 2 1 1 4

Other Asian 2 1 1 4

Other 10 6 3 19


Total 336 89 110 535

Work type

The total numbers of active registered psychologists working in clinical psychology,psychotherapy and counselling in CHEs/HHSs increased 30% between 1994 and 1998. Thefigures for psychotherapy and counselling are static.

Table 74: Worktype43 by main employment setting for active registered psychologists

Employment setting Clinical psychology Psychotherapy Counselling

1994 1996 1998 1994* 1996 1998 1994 1996 1998

CHE/HHS 118 148 154 – 21 19 14 11 16

Private practice (self employed) 92 97 97 – 44 55 50 45 58

Private practice (employed) 11 15 13 – 4 2 6 8 4

University/polytechnic 31 31 18 – 9 4 12 9 8

Special Education Service 8 6 5 – 3 2 24 17 6

Children & Young PersonsService**

15 14 10 – 0 1 5 3 1

Dept of Corrections*** 22 29 15 – 1 0 1 3 0

Other government departments 2 2 1 – 0 0 4 2 2

Voluntary agency 2 9 9 – 5 0 4 7 4

Commercial/industrial organisation 0 – 0 - 1 5 –

Consultant to private sectoremployer

0 - – - - 0 - –

Consultant to public sectoremployer

- 0 1 – 0 0 - 0 1

Other 7 8 4 – 2 3 9 4 7

Not reported 1 0 9 – 0 3 2 0 3

Total 309 357 336 – 89 89 132 114 110

* Not recorded.** Previously recorded as Department of Social Welfare.*** Previously recorded as Justice Department.

43

Psychologists can report >1 worktype in their employment setting.

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Overall (clinical psychology, psychotherapy and counselling) CHE/HHS figures for 1996 and 1998demonstrate that the number of registered psychologists employed increased from 180 to 189(Table 74). If, as it is estimated, approximately two-thirds of clinical psychologists working inCHEs/HHSs work in mental health services, there would appear to have been little increase in thenumbers of clinical psychologists employed in the service over the two-year period.

When the descriptor worktype of psychotherapy is included within either clinical psychology orcounselling and the period of time is extended to include the 1994 statistical year, the increase inthe number of registered psychologists practising in CHEs/HHSs rises from 132 to 189 (43%). Itcan be assumed that this means that the number of registered psychologists employed in mentalhealth services also increased. Nevertheless, an increasing number of registered clinicalpsychologists are employed in CHEs/HHSs to work in such areas as pain management clinics andcardiology services.

Table 75 shows the number of active registered psychologists giving their main worktype asclinical psychology in a CHE/HHS by regional employment type per estimated resident populationat 30 June 1998, out of the 611 who responded to the survey.

Table 75: Employment type by region of active registered psychologists workingin clinical psychology in a CHE/HHS in 1998

Region Number Registered psychologists working in clinicalpsychology in a CHE/HHS per estimated resident

population at 30 June 1998

Individual FTEs Individual FTEs

Northland 2 1 1:71,700 1:143,400

Auckland 39 29.6 1:29,728 1:39,169

Waikato 10 5.8 1:36,520 1:62,965

Bay of Plenty 8 5.0 1:29,787 1:47,660

Tairawhiti 0 0 0:46,700 0:46,700

Hawkes Bay 5 2.7 1:29,240 1:54,148

Taranaki 6 4.8 1:17,783 1:22,229

Manawatu-Wanganui 11 8.2 1:21,064 1:28,256

Wellington 16 12.4 1:26,794 1:34,573

Nelson-Marlborough 10 1 1:12,070 1:120,700

West Coast 1 1 1:32,900 1:32,900

Canterbury 35 26.1 1:32,900 1:18,674

Otago 8 6.9 1:13,926 1:27,289

Southland 2 1.6 1:23,538 1:59,813

Total 153 112.2 1:24,784 1:33,797

* Percentage of total (376) psychologists working in clinical psychology by region.

Nelson-Marlborough and Northland regions have the lowest ratios of FTE-registered psychologistsper estimated population working in clinical psychology. Taranaki, Manawatu-Wanganui,Canterbury, West Coast and Canterbury are the only regions with better ratios than the nationalaverage.

Tables 76 and 77 set out information about the numbers of all active psychologists in the fields ofclinical psychology, psychotherapy and counselling by geographical region.

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Table 76: Main worktypes by region for active registered psychologists 1998

Region Clinical psychology Psychotherapy Counselling Total

Northland 7 1 6 14

Auckland 75 32 29 136

Waikato 29 6 8 43

Bay of Plenty 14 2 3 19

Tairawhiti 3 1 4

Hawkes Bay 8 3 1 12

Taranaki 9 1 2 12

Manawatu-Wanganui 22 5 9 36


Nelson-Marlborough 9 6 4 19

West Coast 2 1 3

Canterbury 62 14 22 98

Otago 36 5 12 53

Southland 5 1 6

N/A 4 3 2 9

Total 336 89 110 535

NB: Total psychologists is the total working in this area in their main employment setting.

Of the total number of active registered psychologists in a region, Table 77 sets out those whogave their employment type as a CHE/HHS. From comments made earlier in this review, it is theCHE/HHS-registered psychologists who are most likely to be working in mental health services.

It should be noted that the borders of the regions used by the New Zealand Health InformationServices for the statistical workforce data and the regions described by Statistics New Zealand maynot be strictly congruent. The differences are, however, not deemed to be sufficiently significantto affect the workforce picture set out in Table 77.

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Table 77: Active registered psychologists in CHE/HHS main employment setting by worktypein each geographical region in 1998 and per estimated resident population at 30 June 1998

Geographical region Clinicalpsychology

Psychotherapy Counselling Total* Total*

No. FTEs No. FTEs No. FTEs No. FTEs

Northland 4 3.1 2 0.6 1:23,900 1:38,757

Auckland 38 24.1 5 1.7 5 0.9 1:24,154 1:43,423

Waikato 9 6.0 3 0.9 1 0.3 1:28,092 1:50,7222

Bay of Plenty 10 4.4 1 0.3 1 0.3 1:19,858 1:47,660

Tairawhiti 1 1.0 1:46,700 1:46,700

Hawkes Bay 4 1.4 1 1:29,240 1:104,429

Taranaki 4 2.8 1 0.8 1:21,340 1:29,639

Manawatu-Wanganui 10 7.2 1 0.1 1:21,064 1:31,740

Wellington 24 16.6 1 0.1 2 0.4 1:15,878 1:25,070

Nelson-Marlborough 6 2.7 3 1.0 1 0.1 1:12,070 1:31,763

Canterbury 30 20.4 2 0.4 1 0.3 1:14,770 1:23,099

West Coast 1 1.0 1:32,900 1:32,900

Otago 12 7.8 1 0.1 2 0.4 1:12,553 1:22,687

Southland 0:95,700 0:95,700

Not reported 1 1

Total 154 98.5 19 4.5 16 3.9 1:20,063 1:35,472

* These figures have been rounded.

Table 77 shows a scattered CHE/HHS workforce with Northland, Auckland, Waikato, Tairawhiti,Hawkes Bay, West Coast and Southland being significantly worse off than the national average innumbers of active registered psychologists working in CHEs compared with the estimatedpopulation in their regions at 30 June 1998. Taranaki and Manawatu-Wanganui are close to thenational average.

With FTEs, the picture in Table 77 changes. Some of the regions remain the same, but fromHawkes Bay and northwards the ratio of active registered psychologists per estimated populationat 30 June 1998 falls short of the national average. With no apparent active registeredpsychologist employed in a CHE/HHS in Southland, that region also lies well outside the nationalaverage.

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Appendix 6: Maori Working in Mental Health Services 1999

In March 1999 a telephone survey of mental health providers was undertaken to establish theapproximate number of Maori working in mental health services in New Zealand. The followingreport provides a snapshot of the Maori mental health workforce over the three-month period ofthe survey. It is by no means complete as not all providers were able to provide the data, or wereable to be contacted. However, it provides the sector with a picture of the current Maori mentalhealth workforce and a benchmark against which future Maori mental health workforce can bemeasured.

Method

Mental health services were surveyed to ascertain:

• staffing numbers by job type; health professional (or other) background; type ofemployment; numbers of non-Maori staff working for a Maori provider; funded vacancies

• contracted services provided

• training requirements relating to – tikanga Maori, clinical/professional, management.

Mental health providers surveyed were all those who contract with the Mental Health Group of theHFA. Provider contact details were obtained from each divisional office of the HFA. Data hasbeen analysed by HFA region.

Five hundred and seventy organisations were contacted by telephone. Of these 235 were excludedfrom the sample because they did not provide mental health services. This leaves a response rateof 88.65%. While this seems a good response rate some major mental health providers whoresponded were unable to provide complete data on their staff. However, the positive response isindicative of the importance of Maori mental health workforce development to providers.

A small number of providers (30) were unable to be contacted because of incorrect contact details,no response to messages, or closure of the service.

Accuracy of data

The information reported needs to be read with some caution – it is a snapshot only. Whilst everyeffort was made to ensure the accuracy, reliability and completeness of the data there were twoknown factors impacting on it. Some significant HHSs were not able to provide comprehensivedata about Maori staff working in their mainstream services. The survey highlighted that a numberof respondents do not record ethnicity data on staff, therefore information provided on Maori staffwas subjective.

The lack of recorded data on ethnicity demonstrates one impact of human rights legislation onemployment and brings into question the feasibility of collecting such data in the future.

Profile of the Maori mental health workforce

The survey identified 1434 Maori in paid employment in the mental health services. Of thesample, 74.7% were employed full-time and 25.3% part-time. Table 78 sets out the number ofstaff by worktype of the various categories of workers.

The greatest proportion by worktype are support workers including Maori mental health workers at45.9%, followed by registered nurses at 16.5%. The health professional workforce comprises

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31.4% of the sample. This category includes social workers, therapists and counsellors along withnurses, psychologists and medical practitioners. Many of those identified in the sample asmanagers/team leaders may also be health professionals but were recorded in only one category.

Figure 1: The Maori mental health workforce by worktype and employment

0 100 200 300 400 500 600 700

Kaumatua

Kuia

Tohunga

Support worker/Maori mental health worker

Tangata whaiora worker

Psychiatrist or MOSS

Psychiatric registrar

Registered nurses

Enrolled nurses

Social workers

Clinical psychologist

Occupational therapist

Manager/team leader

Therapist

Counsellor

Other

Wor

ktyp

e

Number

Full time

Part time

The Midland region recorded the greatest proportion of the surveyed Maori mental healthworkforce. This may be due to sample bias or reflect the relatively high percentage of Maori in thepopulation compared to the other three HFA regions.

It is difficult to estimate the distribution of the workforce between Maori and mainstream mentalhealth services because raw numbers do not take into account factors such as the size of theservice. However, there appears to be a balance between mainstream and Maori services.

The major service types where the Maori workforce are employed are residential, adultcommunity, acute/sub-acute in-patient and alcohol and drug services.

Kaumatua/kuia

The distribution of kaumatua/kuia between HHSs and NGOs is reasonably even. The surveyidentified 23 kaumatua/kuia work for HHS services and 25 for NGOs. Most providers indicatedthey had access to a kaumatua. They were offered either a koha or payment for their work.

Support workers/Maori mental health workers

The greatest proportion of the Maori mental health workforce by work type are support workersincluding Maori mental health workers who together comprise 45.9% of the number of paid Maoriworking in mental health services. Of these support workers 71.1% are full time and 28.9% arepart time. The range of roles undertaken by support workers varies between services. Initially thesurvey defined them as people working in residential supported accommodation and respiteservices, however they also work in areas such as day programmes. Some Maori mental health

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workers primarily provide cultural care. However, it was difficult to distinguish this group in thesurvey.

There are a number of Maori professionals working in mental health services from non-healthdisciplines eg. lawyers and teachers.

Registered nurses

The second largest category identified in the sample is registered nurses who constituted 17.3%. Anumber of registered nurses are employed as managers/team leaders. The survey has recordedthem as managers/team leaders. The NHIS data (Appendix 3) only identifies nurses who identifythemselves as active in nursing. This excludes, therefore, nurses who are in management or non-nursing positions.

Tangata whaiora workers

There are 58 tangata whaiora workers, constituting 4% of the sample. A large majority (87.9%)work part-time. Fifty-seven percent of tangata whaiora work in the Central region.

Medical staff

There are two Maori consultant psychiatrists and one child psychiatrist working in mental healthservices in New Zealand. This is one less than in 1996. The survey identified one Maoripsychiatric registrar, although anecdotally it is understood that there are others.

Other professional staff

Of the seven Maori psychologists identified in the survey, all but one is employed in an HHS. Allof the psychologists working for HHSs are working in clinical psychology, and at least three areregistered clinical psychologists.

The survey identified three full-time Maori occupational therapists working in mental healthservices.

Manager/team leaders

There is a wide variation in the types of roles held by the 89 or 6.2% of those Maori working inmental health services who were identified as team leaders and managers. Their roles ranged fromchief executive officer to a clinician with a part time role as a manager.

Counsellors

Ninety-eight (6.8%) Maori were categorised as counsellors. They work mainly in alcohol and drugservices. A number in this category do not hold any formal qualifications. HHSs and largeralcohol and drug services are the services employing qualified counsellors.

Others

There were 130 (9.1%) Maori whose worktype did not fall into any of the above categories. Theseincluded 42 Maori staff whose worktype was not known by the respondent. This category alsoincluded Maori working in a number of other positions that did not fit the service worktype, eg.project workers, clinical co-ordinators, psychotherapist, co-ordinators.

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Maori mental health workforce by HFA region

The Midland region has the largest proportion of the Maori mental health workforce in the sample,despite having a smaller total population than the Central and Northern areas. However, Midlandregion has a larger percentage (24.25%)44 of Maori in its population than the other three areas.

Figure 2: Graph of identified Maori mental health workforce by HFA region

0

100

200

300

400

500

600

Northern Midland Central Southern

Health Funding Authority Region

Sta

ff nu

mbe

rs

Part-time

Full-time

Table 78 gives the total Maori mental health workforce by HFA region and worktype.

Maori registered nurses identified in the Midland region make-up 42.3% of registered nurses in thesample. This suggests the Midland area employs proportionately more nurses than the other threeregions or that significant under-reporting occurred in other areas with consequent under-estimation of total Maori workers.

44

Based on population data from the Blueprint p.30.

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Table 78: Maori workforce identified in the survey by Health Funding Authority region and work type

Work type Southern Central Midland Northern TOTAL

F/T P/T F/T P/T F/T P/T F/T P/T F/T P/T Total

Kaumatua 1 5 2 4 1 6 12 10 21 31

Kuia 1 2 1 5 1 3 3 5 11 16

Tohunga 1 1 1

Support worker/Maorimental health worker

49 23 104 34 121 87 194 46 468 190 658

Tangata whaiora worker 2 33 6 11 1 5 7 51 58

Psychiatrist or MOSS 1 2* 1 2 1 3

Registrar 1 1 1

Registered nurse 36 4 38 10 98 7 49 6 221 27 248

Enrolled nurse 2 10 2 12 1 6 30 3 33

Social worker 7 1 6 2 16 2 14 43 5 48

Clinical psychologist 1 3 1 1 1 6 1 7

Occupational therapist 1 1 1 3 3

Manager/team leader 11 1 15 5 24 2 29 2 79 10 89

Therapist 1 1 2 2 2 1 1 6 4 10

Counsellor 12 1 18 7 40 3 16 1 86 12 98

Others 1 2 9 7 32 9 62 8 104 26 130

Total 124 42 209 104 354 124 384 85 1071 363 1434

* One psychiatrist who works part time work for two services was initially recorded as 2.

Numbers of Maori mental health providers

The survey identified the following numbers of providers:

• approximately 73 NGO Maori providers and 21 HHSs with Maori mental health teamsalthough some comprise only two people

• 165 mainstream providers, including HHSs.

Forty percent of Maori in the sample work in Maori mental health services with the remaining59.7% in mainstream services. In particular, the majority of support workers, registered nursesand social workers are employed in mainstream services.

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Table 79: Maori mental health workforce by provider category and work type

Work type Maori mental health services Mainstream services

F/T P/T Total F/T P/T Total

Kaumatua 7 14 21 3 7 10

Kuia 5 9 14 2 2

Tohunga 1 1

Support worker/Maori mental health worker 186 65 251 282 125 407

Tangata whaiora worker 2 11 13 5 40 73

Psychiatrist or MOSS* 1 1 2 2

Registrar 1 1

Registered nurse 92 16 108 129 11 140

Enrolled nurse 5 1 6 25 2 27

Social workers 16 2 18 27 3 30

Clinical psychologist 4 4 2 1 3

Occupational therapist 3 3

Manager/team leader 49 7 56 30 3 33

Therapist 5 2 7 1 2 3

Counsellor 45 6 51 41 6 47

Others 18 8 41 86 18 104

Total 434 143 577 637 220 857

* One psychiatrist who works part-time work for two services was recorded as 2.

Maori mental health workforce by service type

Table 80: Maori mental health workforce by service type

Type of service Number ofservices

Full time Part time Total

Residential 94 352 185 537

Day programmes 35 39 53 92

Child, youth and family 35 49 21 70

Forensic 7 67 2 69

Adult community 39 192 29 221

Alcohol and drug 57 114 25 139

Dual diagnosis 10 9 2 11

Early intervention 7 7 2 9

Mobile crisis 13 19 1 20

Acute / sub-acute inpatient 20 166 14 180

Rehabilitation inpatient 8 41 1 42

Tangata whaiora 7 1 22 23

Liaison consultation 4 10 10

Other 12 5 6 11

Total 348 1071 363 1434

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Residential and day programmes

Residential services include home-based support and supported accommodation from level 1-4.45

Most supported accommodation and home-based support services have been developed in the lastsix years, it can be assumed that a large proportion of their workforce has been employed duringthis time.

Residential and day programme service areas have by far the largest proportion of the Maoriworkforce (43.9%). Health professionals comprise 8.6 % of this workforce (excludingmanagers/team leaders and others) with support workers comprising the largest proportion (75%)of the workforce in these services.

Child, youth and family services

These services employ 4.9% of the Maori workforce identified in the survey. There is generalconcern in the sector that there are too few qualified and experienced child and youth Maoriworkers to provide specialist services. Twenty nine percent of the Maori workforce in theseservices are non-health professionals.

Forensic services

There are five regional forensic services in New Zealand, employing 4.8% of the Maori mentalhealth workforce. The number of Maori workers employed in this area appears to be reasonable,although 53.6% are not health professionals.

Adult community

The adult community mental health services are the second largest employer of the Maori mentalhealth workforce. One respondent in this service group were unable to provide a breakdown ofstaff qualifications, hence they have been coded in the ‘other’ category.

Thirty six percent of this workforce are registered nurses and 11% support workers/Maori mentalhealth workers.

Alcohol and drug services

Alcohol and drug services are the fourth largest employer of the Maori mental health workforce.The survey identified 57 alcohol and drug services throughout New Zealand. The number ofservices and workforce numbers may be understated, as not all known providers were included inthe survey.

Counsellors constitute 61.2% of the workforce in these services with Maori mental health workersa further 10%.

Dual diagnosis and early intervention services

Both services have very small Maori workforce numbers, together comprising 1.4% of therecorded workforce. Dual diagnosis services are often provided by an alcohol and drug serviceprovider. Providers expressed concern about the lack of training available in this area.

45

Refers to HFA contracting levels.

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Mobile crisis and acute/sub-acute inpatient services

Mobile crisis services are generally provided by HHSs and employ 1.4% of the Maori workforce inthe survey. This figure appears low given that mobile crisis services are frontline services andoften provide the route for Maori to gain entry into mental health services. The low numbers ofMaori employed in these services may also indicate that Maori consumers are assessed by non-Maori staff when crises arise.

Acute and sub acute inpatient services employ the third largest number of the Maori mental healthworkforce identified in the survey. Fifty percent of these are registered and enrolled nurses and24.4% support workers/Maori mental health workers.

Rehabilitation inpatient services

Most of the eight rehabilitation inpatient services are provided by HHSs. Maori mental healthworkers comprise 52% of this workforce, with registered nurses (31%) the next largest group.

Tangata whaiora services

There are a total of seven recorded tangata whaiora services. All but one tangata whaiora workeremployed in these services are employed on a part-time basis. The reasons for this are not clearbut may be due to the impact of earnings on social welfare benefits or the availability of resourcesin the services. Two providers in the Central region employ the majority of this workforce.

Liaison consultation services and other services

There were four services identified as liaison consultation services. Services in the category ‘otherservices’ (12) captured services such as administration services, project work and health promotionwork, with the major category of worker described as administrator. Both service groups havesmall workforce numbers.

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Appendix 7: Workforce Development and Training to PromoteRecovery – Draft (Mental Health Commission)

Introduction

The Mental Health Commission is keen to see that training courses for people who will work inmental health incorporate the concept of recovery and the strategies that promote it. Consumers ofmental health services frequently confirm that it is discriminatory attitudes and the failure ofservices to adequately promote hope that restrict opportunities for recovery. While there is no onestrategy for all that will promote recovery, approaches that are comprehensive and which combinehigh quality clinical care within a context that acknowledges and responds to social, psychological,emotional, housing, income and personal health needs is most likely to promote recovery. Thispaper discusses the need for training courses to ensure that such material is included within theircontent.

The National Mental Health Strategy, the Blueprint and Recovery

The National Mental Health Strategy does not use the term ‘recovery’ but its underlying principlesand its objectives are consistent with a recovery approach. The Mental Health Commission’sBlueprint sets out the changes needed for mental health services to implement the strategy. Themajor qualitative change it promotes is the need for a recovery approach in all mental healthservices. The principles of the strategy are set out in the Blueprint. (Attachment 1).

Mental health related training courses need to ensure that discrimination, recovery approaches andconsumer participation within all aspects of service planning and delivery are incorporated intotheir curricula. The role of each of these elements in promoting environments conducive to goodpractice are set out in the Blueprint.

What courses should include recovery education?

The Commission would like to see that all generic training programmes that produce any healthprofessionals likely to work within mental health and related services have recovery education.This includes psychiatrists, clinical psychologists, nurses, occupational therapists, Maori healthworkers, cultural workers/advisors/translators, drug and alcohol workers, social workers,community support workers, employment and training specialists, general practitioners and family/carers. Recovery education components should be incorporated into the generic trainingprogrammes as well as in post-graduate and speciality training programmes. Each professionaland occupational group will need some generic skills and attitudes to foster recovery in peoplethey work with. Each will also need quite different skills depending on the different professionalrole they take.

The Commission would like to see professional groups and people responsible for training coursesbegin to discuss how the training they are providing could better increase the skills, attitudes andknowledge of those who participate in them to promote recovery. It is only by such constructivedialogue taking place that the different professional groups and trainers will become clearer aboutthe particular skill packages that are required to foster environments where individuals who usemental health services and their families are treated with real dignity and respect, where they areencouraged to be partners in the journey to health. Skills alone will not produce these changes, asthey will need to be accompanied by the appropriate attitudes. The Mental Health Commissionhas published the “Map of the Journey: Toward equality respect and rights for people whoexperience mental illness”. Mary O’Hagan has also presented an earlier paper to the National

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Workforce Coordinating Committee on workforce training to reduce discrimination. That paperneeds to be considered in conjunction with the information on recovery training.

What is recovery?

“Recovery is a journey as much as a destination. It is different for everyone. Forsome people with mental illness, recovery is a road they travel on only once or twice,to a destination that is relatively easy to find. For others, recovery is a maze with anelusive destination that takes a lifetime to navigate.” Mary O’Hagan, MHCcommunication, 1998.

Recovery is happening when people can live well in the presence or absence of their mental illness– and the many losses that may come in its wake, such as isolation, poverty, unemployment anddiscrimination. Recovery does not always mean that people will return to full health or retrieve alltheir losses, but it does mean that people can live well in spite of them.

The concept of recovery can be applied to most beliefs about the origins and nature of mentalillness – biological, psychological, social or spiritual. Some people believe the origins, or at leastthe prolonging of mental illness, does not just lie in the person with the illness but in the worldaround them. It may be impacted on by their family, social injustice, unresponsive services or atraumatic event. In these cases recovery does not just need to happen in the individual – thepeople and systems that contribute to the person's illness also need to change to enable thatindividual to live a better life.

The role of the mental health sector in recovery

People working in mental health services must use a recovery approach in their work. Therecovery approach is consistent with the guiding principles of the strategy, especially those thatstate that services must empower consumers, assure their rights, use evidenced based approaches,get the best possible outcomes for them, increase their control over their mental health and well-being and enable them to fully participate in society. Families where they are involved insupporting a person with mental illness and where that person wishes them to be involved needalso to be included and to have their own needs considered. The approach is also consistent withthe National Mental Health Standards which build on the guiding principles and translate theminto measurable criteria for service performance.

The Blueprint elaborates on what recovery means to mental health services. Attachment 2contains an interpretation of what the various components may mean for people deliveringservices.

What resources will be available to assist to promote recovery into all trainingprogrammes?

The Commission is keen to see that all training programmes, generic and specialist, undergraduateand post-graduate, provide all participants with opportunities to create an environment where theywill work in a ways that promote recovery. Mary O’Hagan has been contracted by theCommission to undertake a programme of work that will further develop recovery concepts. Thiswork will result in papers on recovery from the four perspectives of Maori, Pacific peoples,families, and people who use forensic services and their families. In addition, Mary is currentlycompleting a piece of work that defines the competencies required for people to promote recoveryapproaches. This will be an important piece of work for people involved in future workforceplanning as it will make explicit the competencies that all training courses should meet.

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Dr Julie Leibrich is currently producing a book of twenty-four people’s individual journeys torecovery. This will be a valuable resource for all training and educational programmes that arepreparing people to work in the mental health area. The book will enhance understanding of whatrecovery means, the sort of things that assisted people to recover, and provide insight into whatpeople who have recovered believe contributed to their recovery.

As these resources are completed they will be made available to the appropriate national workforcecoordinating organisation and training organisations.

To have training programmes across all professional groups and mental health workforce sectorsthat produces people with the skills, knowledge and attitudes to promote recovery is one of the keychallenges that confronts those who have responsibility for the future development of theworkforce.

Conclusion

The Mental Health Commission believes that real progress in improving service delivery to peoplewho use mental health services will only occur when those who work in services use evidencedbased, effective practices and apply these in a way that promotes recovery. A sound understandingof the principles that guide delivery of services in a way that promotes equality, dignity and respectfor service users and their families is also a requirement. Future workforce planning and thedevelopment of training programmes and courses must include the opportunity for participants toacquire the skills to apply evidence based effective practices along with the ways of practice thatallow them to create healing environments. We recommend that the National WorkforceCo-ordinating Committee take whatever action is required to ensure that future courses and allworkforce planning cover development of the competencies required to promote recovery.

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Attachment 1: Adapted from the Blueprint

Guiding principles

Moving Forward sets out the following 17 principles for guiding service delivery anddevelopment:

• encouraging services that empower individual consumers and their families/whanau andcaregivers

• encouraging services that enable people of any age, culture, gender or individual interest tofully participate in society

• encouraging the development of better specifications for services purchased and providedto meet the needs of different groups of consumers and their families/whanau andcaregivers

• ensuring Maori involvement in the planning of mental health services for Maori and indesigning services appropriate to Maori needs

• ensuring consistent safety standards to protect the health of consumers and the public

• improving the cultural safety of services and ensuring that services accommodate culturaldifferences, especially Maori

• improving people’s access to appropriate services of acceptable quality

• encouraging services to contribute to the best possible outcomes for consumers and theirfamilies

• respecting personal dignity and privacy

• encouraging services to be delivered in a way that minimises disruption to the lives ofpeople with mental health problems and disabilities

• increasing the sensitivity of services and support systems to the changing needs andpreferences of people

• giving priority to cost-effective services that provide the best value in terms of healthgains

• encouraging services to be integrated at all levels and to be focused on achievingmaximum wellness and independence for all consumers

• assuring the rights of people with mental disorders and disabilities within the context ofoverall community needs and rights

• encouraging programmes and services that enable individuals, families and communities toincrease control over and improve their mental health and well-being

• improving community understanding and acceptance of mental illness and helping tocreate supportive social environments for those who have a mental illness

• working intersectorally to encourage the development and implementation of policiesand programmes that will help maintain and improve the mental health and well-being ofcommunities.

The Commission supports these principles and their implementation throughout the sector.

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Attachment 2: Adapted from the Blueprint

What makes recovery happen?

Recovery happens when mental health services reflect the principles of the Treaty ofWaitangi: partnership between the Crown and Iwi, positive Maori participation, and activeprotection by the Crown of Maori interests.Training programmes should therefore include education on the Treaty and concepts of Maorimental health, and the implications of these two things on mental health service delivery.

Recovery happens when mental health services enable people to find the right help at theright time, for as long as they need it.Training programmes need to include education on the structure and function of the mental healthsystem. They must also provide people with the skills to find out what is happening with othercommunity services and to link people with these other services. It is about providing people witha broader view of the way the whole system works. It is also about making sure that everyone whoworks in mental health services has the ability to undertake comprehensive assessment andreferrals or at a minimum, the ability to refer people to those who can.

Recovery happens when mental health services give people the best help available whoeverthey are and wherever they are.This means that training programmes must make sure that people are provided with the skills toconstantly keep up to date with best practices and to have the opportunity to acquire skills (andattitudes) that enable them to evaluate outcomes from interventions. Promoting attitudes thatfoster continuous learning and constant evaluation and self assessment of practices is important.

Recovery happens when mental health services provide for people in the context of theirwhole lives, not just their illnesses.Training programmes must provide workers with the skills to detect and treat or refer people fortreatment if the have unwanted symptoms of mental illness. Workers must, however, also haveskills to detect when other wider social, interpersonal, and welfare concerns are causing continuedstress and anxiety. Workers need to have the opportunity to learn about the impact of these factorson mental health, and the skills to assist people to counter their isolation, poverty, unemployment,discrimination and anything else they have lost in the wake of their mental illness.

Recovery happens when mental health services protect service users' rights and treat themwith respect and equality.All professional and training programmes need to explore the ways in which they can make surethat they offer opportunities for people who are going to work in the mental health sector to havethe attitudes and skills that will enable them to work with people to offer them the most autonomyand choice possible. Those who work in mental health service must have the attitude and skills toinvolve service users in all decisions made within the service that affect their lives. They mustalso have training in rights protection and the opportunity to learn about health user rights and themechanisms for making sure that these are protected.

Recovery happens when mental health services are staffed by people who are compassionateand competent to assist people in their recovery.This means the workforce must have the opportunity to acquire knowledge and skills in facilitatingwellness, and have the interpersonal and motivational skills to help people fully participate in theirown recovery. This requires workers to have the opportunity to learn about differing views onmental health, and differing cultural contexts and practices for promoting recovery, and the abilityto work with people in ways that promote and enhance their self esteem and sense of themselves.

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Recovery happens when mental health services enable people with mental illness to take oncompetent roles.Training programmes need to be able to provide workers with the skills and attitudes to work intrue partnership with people who will use services. Such partnerships will need to exist at alllevels within services, so workers will need to be able to work individually in partnership andpromote active participation in the people they are working with to take part in their assessmentsand in decisions about their treatment and support.. They will also need to be able to workcollectively with people who use services in planning and evaluation contexts.

Recovery happens when mental health services can prevent people from using themunnecessarily or from staying in them for too long.To do this effectively, training programmes for mental health workers for all professional groupswill need to provide people with the skills to identify and improve the personal risk factors and thesocial conditions that contribute to the development of mental illness. Workers will need skills inearly intervention practices so that they can effectively work with those with initial contact withthe mental health system. Workers will also need the opportunity to acquire skills in recoveryeducation so that they can more effectively work with people who are currently using services andassist them to recovery. Such education will include the knowledge of the differing mentalillnesses, symptoms, effective treatments, crisis planning and prevention, maintaining a healthylifestyle, rights and self-advocacy, countering discrimination, communication, problems solvingskills, using support networks and using community resources to find such things as work andhousing, social and recreational activities.

Recovery happens when mental health services can look outward and assist people to findand use other community services, supports and resources.To effectively promote recovery mental health workers will need to have the skills to link withother services and agencies and to be able to work with service users to link them to communityservices when this is appropriate. This will sometimes mean that mental health workers will needto be competent to address discrimination and, where necessary, to effectively advocate on behalfof mental health service users.

Recovery happens when everything that people who work in mental health services writes,says and does:46

About everything

• demonstrate commitment to the Treaty of Waitangi

• show that they have incorporated the views of people with mental illness.

About people with mental illness

• reflect the way they themselves would like to be treated or referred to

• show hope for people with mental illness

• demonstrate respect for them

• validate their experiences

• acknowledge their competence

• appreciate their diversity

• show their lives are bigger than just their illness or the services they use.

46

This material was adapted from a checklist produced for the Mental Health Commission by Mary O’Hagan.

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About mental health services

• advocate partnerships with people with mental illness at all levels

• show that they need to be easy to get into and out of

• show that they need to ensure physical, psychological and cultural safety

• promote choice for service users and the use of compulsion as a last resort

• show how they can improve services users’ capacity to lead fulfilling lives

• show how they can improve the capacity of other sectors and the wider community to givesupport and equal opportunities to people with mental illness.

About other sectors and the wider community

• show how they need to fulfil their responsibilities to give support and equal opportunitiesto people with mental illness.

About central government

• show how it can create the conditions for people with mental illness to have equalopportunities and their rights protected

• show how it can best use its resources to maximise the potential of people with mentalillness to lead fulfilling lives.

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