12 Dec 2023

‘Robbing Peter to pay Paul’: How a $664m mental health scheme gave with one hand and took with another

Stylised illustration of crying face with cloud over head
From In Depth Special Projects, 5:00 am on 12 December 2023

The single biggest mental health initiative in the last five years appears to have merit. But it has come at a cost.

In the $2 billion package of measures for mental health rolled out over the last five years, there is one programme that towers above all others.

The ‘Access and Choice’ programme, funded with $664m, established 1100 ‘health improvement practitioners’ (HIPs) and ‘health coaches’ into GP clinics and other primary health settings.

The idea was for people to be able to get help with low to moderate mental health problems at their GP office.

“When a GP identifies a mental health or addiction issue they can physically walk with their patient to a trained mental health worker to talk,” said the Health Minister at the time of its announcement in 2019, David Clark.

The scheme would eventually reach 325,000 people, Clark said, helping more New Zealanders to stay well, which would reduce demand on expensive acute services.

Has this scheme worked? An RNZ investigation into the outcomes of an historic investment in mental health found:

* The scheme has not reached the number of people it said it would.
* It has been staffed by a large number of health workers taken from other parts of the mental health system.
* There is anecdotal evidence of value but no formal evaluation of outcomes has been done.

Stylised illustration of two people in chairs during a therapy session

Photo: RNZ

What was delivered

The scheme ran into issues in its first year. Take up was initially low and there were problems getting the workforce in place. Still, the government insisted it would meet the 325,000 target Clark set in 2019.

Today, health officials warn that target may be difficult to reach unless more staff can be found to run the programme.

While more than one million free sessions have been delivered to date, it was hoped to reach 255,000 people by June this year, but reached only 207,800. The 325,000 target has often been described as having a deadline of June 2024. But officials now say it’s actually to have enough capacity for “up to” 325,000 from that date.

The responsibility for meeting whatever the goal actually is now falls to one of the biggest critics of the programme, National MP Matt Doocey, who is the country’s first ever Minister for Mental Health.

Doocey says the lower than expected uptake of the service is a concern.

“I'm also concerned about the barrier that having to go to your GP poses for people as well. There might be thinking on how we can utilise the community and NGO sector, who could probably provide more accessible access and choice programs,” he says.

A 2022 review of the programme’s first three years by the Mental Health and Wellbeing Commission found a chronic worker shortage was still hampering the delivery of services - particularly for Māori and Pacific - and $99m set aside for workforce development had been underspent.

Read more from RNZ’s investigation into spending on mental healthcare:

* What ever happened to the $2 billion that was poured into mental healthcare?
* Tomorrow: More patients, nowhere near enough doctors
* Thursday: The rolling crisis in youth mental health

Andrew Little speaks to media

Former Health Minister Andrew Little, who was in charge for the rollout of most of the Access and Choice scheme. Photo: RNZ / Angus Dreaver

‘Cannibalising’ the system

Many of the staff that have been recruited to the scheme have created a new problem.

According to the commission’s review, almost 60 percent of HIPs and 40 percent of health coaches have previously worked in the mental health and addiction sector. Many of them leave gaps in the roles they used to cover and acute care has not improved, the review found.

It’s a situation where “Peter is being robbed to pay Paul,” says clinical psychologist Dougal Sutherland, who was part of the Ministry of Health’s Psychology Workforce Taskforce until it was disbanded.

“Anecdotally, I know lots of examples of people that have said: ‘I don't want to work in a DHB anymore. It's bloomin hard and we don't get paid very much and I could go and do the same job, or, you know, a similar job in a primary setting … but there was no plugging of the gaps behind that because there had been no major investment in the workforce.”

Andrew Little took over as Health Minister in December 2020 and oversaw the programme’s rollout until he gave up the portfolio in February. He left Parliament in November following Labour’s election defeat.

Little admits there was some “cannibalising” of the mental health workforce as a result of the scheme.

“The reality about the Access and Choice programme is that a lot of the Health Improvement Practitioners were actually former mental health nurses or trained mental health nurses so there was a bit of cannibalising the system … but we needed those extra frontline roles in primary care.”

He points out that as a result of the programme, there are 1100 full time equivalent roles in the community addressing mental health that did not exist four years ago.

“They are there now and tens of thousands of people a month are getting help. … We unashamedly made that a priority focus.”

In some areas, like Auckland, only around 30 percent of HIPs and HCs have come from secondary care.

Has it actually worked?

Anecdotal evidence suggests the programme is helping to boost and maintain wellbeing, but there’s been no large scale study of its effectiveness.

The Department of Prime Minister and Cabinet reviewed parts of the overall $1.9bn package in 2021 and 2022, but only assessed progress towards “delivering outputs” and wellbeing outcomes were not assessed.

It also wasn’t part of the Mental Health and Wellbeing Commission’s remit to evaluate the quality of service being delivered by Access and Choice when it looked at the programme’s first and third years of operation. 

However, a 2022 Te Whatu Ora-funded independent review of Access and Choice services attached to GP clinics assessed the wellbeing of 448 under 25-year-olds between their first and last session, and comparisons “mostly demonstrated positive changes” in wellbeing.

More generally, it had also resulted in GPs prescribing fewer medications for depression, anxiety and sleeping disorders.

Another study, commissioned by Tū Whakaruruhau - The Auckland Wellbeing Collaborative measured wellbeing outcomes of 35,605 patients who took part in 44,101 sessions across 72 GP practices over a year.

Published in July, it found 91 percent of sessions were rated as “very helpful” and 60 percent of consumers said their wellbeing improved between their first and last sessions. Referrals for talk therapy and to secondary services also declined.

It notes the need for a “comprehensive evaluation” of the scheme at local and national levels to further explore these findings.

Tauranga GP Luke Bradford agrees. His clinic has had HIPs and HCs attached to it for the last year.

“It’s made a big difference,” Bradford says.

“It has enabled us to help those sort of low to middle acuity patients with mental health issues, stresses, anxieties, and some of those speed bumps that occur in life.”

Royal New Zealand College of General Practitioners medical director Dr Luke Bradford.

Dr Luke Bradford Photo: Supplied

Bradford, who is also the medical director at the Royal New Zealand College of General Practitioners, says it was “absolutely right” for the former Labour government to put such a massive amount into primary health, but he would like to see a wider study of the programme’s efficacy in boosting wellbeing and its impact on prescriptions.

“I think it would be a really useful piece of information to research and probably necessary as we look to really analyse whether the program is a success.”

New Zealand Association of Counsellors has a similar view. President Sarah Maindonald applauds the programme’s intent but worries about the quality of advice being given to people.

“I feel really torn because on one side of things they are trying to increase the volume of people that can get assistance. But as a qualified and specialist counsellor I'd be really concerned about some of the issues that they're having to deal with,” Maindonald says.

“It's a much more holistic approach to health, which could be really good, but a lot of people present with quite complex traumas and challenges and they need to have someone that has some understanding of depths and those areas.”

Te Whatu Ora says as well as the external evaluations of the programme carried out so far, all providers are required to give monthly monitoring reports.

“Service development is also informed by feedback from service users about their personal progress and satisfaction with the support they are receiving,” Te Whatu Ora mental health director Jo Chiplin says in a statement.

Little says he’s confident the programme is a success.

“We've rolled out a significant whole new channel for people to get help and support. It has been, and I'm confident it will continue to, make a significant difference.”