Janice Wilson

Mental health services in New Zealand.

The development and reorganization of mental health services in New Zealand is underpinned by a national strategy, with increased funding from the government, and is occurring on a background of radical change in health service policy and delivery. The major challenge will be to sustain the developments to date, and increase the quality and quantity of services in a climate of ongoing change. A more integrated form of service delivery and funding would potentially enhance the development of population-based mental health services, which will allow the alignment of targeting specialty service to the 3% of the population with the highest need, with a more comprehensive approach to overall mental health service through the primary sector.

The Flight of the Wild Goose: The Psychiatrist as a Leader

about geese. When wild geese fly, as each goose flaps its wings it creates an uplift for the bird following. By following in a ‘V’ formation the whole flock adds 71% greater flying range than if the bird flew alone. When the lead goose gets tired it moves back into the flying formation and another goose flies at the point position. The geese in formation cry out from behind to encourage the goose in front to keep up their speed. It is not the cry, but the flight, the movement and air dynamics created that gives the effect of leadership. I have been interested for some time in the role of psychiatrists as leaders in the delivery and in the development of mental health services, and also as leaders in the wider context of community and society. In this Presidential Address, I will explore whether my interest has a basis in reality, or is just a fantasy. Do psychiatrists make good leaders? Are we in a position to provide leadership? And if so, how should we do this? First of all, it is important to explore what leadership actually means. It has become a very glib phrase and somewhat popular in recent years. ‘Leadership’ is the catch phrase of the 1990s, just as ‘accountability’ was the catch phrase of the ’80s. It is written and talked about greatly in the media. The idea of leadership for a new millennium is much explored: academically, politically and in communities. Indeed, we are in a phase of looking back at the old millennium, at who have been the leaders over the last 1000 years, and seeing what can be learnt from their styles and their achievements to take into the year 2000 and beyond. Unquestionably, our world, our society, our countries, our workplaces and our homes have become much more complex. There is a greater cry for leadership to be shown in organisations and in governments. We all seem to want a sense of direction, someone to guide us, someone to help us find meaning and purpose in the complex lives that we lead, and quite often, someone to tell us what is the right thing to do. Bennis and Nanus say of leadership: ‘Leadership is a word on everyone’s lips, the young attack it and the old grow wistful for it, parents have lost it and police seek it, experts claim it and artists spurn it, while scholars want it. Philosophers reconcile it (as authority) with liberty, and theologians demonstrate its compatibility with conscience. If bureaucrats pretend they have it, politicians wish they did. Everybody agrees there is less of it than there use to be’ [1]. Specific university departments have sprung up all over the western world, with titles such as ‘Department of Leadership Studies’. There is now a definitive body of literature and research developed over the last 10 years or so, which has grown out of management research and knowledge. Leadership is comprehensively studied and analysed and much written and discussed. But what does leadership actually mean in action and what does it mean for psychiatrists as we confront the challenges of changing delivery of mental health services, changing paradigms, expansion in knowledge and therapies and confined funding?

Psychiatric Disorder and Disability in New Zealand Long-Stay Psychiatric Patients

A study was undertaken of the prevalence of physical disease, psychiatric disorder and deviant behaviour in a sample of 137 long stay psychiatric patients at Porirua Hospital near Wellington, New Zealand. Patients were in the main male, single, middle-aged to elderly and of European descent. Schizophrenia was the most common diagnosis. Psychiatric symptoms were moderately severe, the most common being unusual mannerisms and posturing, anxiety, blunted affect, tension, unusual thought content and somatic concerns. Known physical disorders were present in 66 patients. Levels of neuroleptic medication were high and tardive dyskinesia was observed in almost 60% of patients. Frequency of deviant behaviour was low in absolute terms but nonetheless problematic. The frequency of deviant behaviour was similar to those reported for British patients.

Resourcing Mental Health Services in Australia and New Zealand

ere are essentially three parties in ?”” the delivery of health services. The first party is the consumer (the patient) who requires services and therefore (at least in theory) sets the demand. The second party is the service provider (health professionals, hospitals and community agencies [NGOs]). The third party is the person or organisation who pays the bill for the services (governments, health insurance companies and the patient when ‘out of pocket’ expenses are incurred). Changes are being made in both Australia and New Zealand in the ways in which funding for health services flow between these parties. This paper briefly summarises some of these changes with specific reference to mental health. The amount of funding a country allocates to mental health is determined by how economically healthy it is (e.g. the size of its gross domestic product [GDP]), the proportion of the GDP spent on health, and the proportion of the health budget spent on mental health. In Australia health gets just over 8% of the GDP compared with 7.7% in New Zealand, just over 6% in the United Kingdom, over 8% in Germany, % in France and 13% in the United States [l]. In Australia, expenditure on health is made up of allocations provided from Commonwealth and State taxes, payments made by health insurance and related funds (e.g. workers’ compensation funds) and money paid directly by consumem to health providers that is not reimbursed in any way (‘out of pocket’ expenses). In New Zealand, expenditure on health comes from tax allocations, a small contribution from ACC funds, some local funding, and direct payments from consumers to providers. ACC is a social insurance scheme which covers accident compensation, medical treatment, rehabilitation and injury prevention. Public funding made up about 77.2% of all health funding in 1994 (having decreased from 88% in 1980 and 80.6% in 1991) [2]. The international mean for public funding for health is 74.8%. In 1993/94

The New Zealand Mental Health Strategy: Is it Making Any Difference?

1.56 billion was spent on mental health in Australia (4.6% of the overall Australian health expenditure). In New Zealand in 1993194

Outcome measures in mental health services: Humpty Dumpty is alive and well

312.4 million was spent on mental health by the Regional Health Authorities (7.8% of public health expenditure excluding primary health and pharmaceuticals) [3]. The United Kingdom spends 10% of health budget on mental health services [l]. However these international comparisons are not all that meaningful because of the differences in what is included in mental health. Services such as vocational rehabilitation, social support, housing, etc. for psychiatric patients are, in some countries, counted as health expenditure while in others they are counted in different government portfolios. Of the

The President replies

1.56 billion spent on mental health services in Australia, 63% (

Presidents Letter I

981 million) was provided by States and Territories to fund public sector services, 30% (

The flight of the wild goose: the psychiatrist as a leader: PRESIDENTIAL ADDRESS

465 million) by the Commonwealth to provide rebates to private psychiatrists and general practitioners and subsidies for the Pharmaceutical Benefits Scheme (F‘BS). The remainder (

Committee of Presidents of Medical Colleges (CPMC)

113 million) is contributed by private health insurance funds to patients in private hospitals. An estimate of ‘out of pocket’ expenses incurred directly by consumers is not available.