Te Ara Tika The Right Way - The Delivery of Mental Health Services
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Executive Summary
This review describes the complex and often dynamic challenges of delivering mental health services within the New Zealand Prison system. Challenges which are typically unique to this setting - and which significantly impact on how care is provided, how services are accessed, treatments managed, relationships sustained, and ultimately what outcomes are possible.
Prioritising the need for security (over health service delivery) will mean that many of these challenges cannot easily be managed or amended. And in this regard, the tenants of operating a prison will inevitably frame the parameters upon which health services are delivered. However, the point of this review is not to simply itemise or elucidate these concerns – rather, to identify what enhancements are possible, where new opportunities for development exist, and how mental health outcomes for those in our care can be improved.
A particular feature of this approach has been to locate a comprehensive suite of pragmatic and sustainable recommendations. Recommendations which are aspirational and future focused, but which can be accommodated within existing structures, policies or processes. Likewise, recommendations that align with and support other strategic documents or departmental focus areas. The point being, that any developments must be cognisant of both the opportunities and immense challenges of providing mental health care to our prison population.
Many of these challenges will centre on these types of structural or logistical tensions. However, these are further exacerbated by a range of other socio-demographic and clinical confounders. Key to which is the assertion that the prison population does not mirror the community population. And in terms of mental health, these differences are often quite profound.
The most significant of which is the fact that the prevalence of mental ill-health will be measurably higher amongst the prison population. These issues are also likely to be far more acute, more complex, comorbid, more difficult to treat, result in poorer outcomes, and are more likely to have been catalysed by significant traumatic events. To this end, and while the challenges of delivering mental health care with a prison setting are immense, these issues will be significantly amplified when contextualised according to the type of people likely to require care.
In response, Ara Poutama Aotearoa: The Department of Corrections has over a number of years introduced a range of initiatives designed to better meet the mental health needs of prisoners. These have (on the whole) been well-received and based on good intent. However - the impacts and outcomes of these programmes have not always been as efficacious or enduring as anticipated. Oftentimes lacking the resource, infrastructure, coordination or integration required to support success. Or simply not being afforded with the time and space to truly determine effectiveness.
Over the past five years or so years, greater emphasis has therefore been placed on consolidating the Departments approach to the delivery of mental health services. To increase both the number and range of mental health supports available as well as the amount of resource provided. While these have led to enhanced levels of access, as well as improvements in the range and scope of care delivered - issues of coordination and consistency (across sites and within services) have remained. Likewise, a broad range of related concerns - structural, clinical, cultural, and organisational - have further impacted the type and quality of care provided.
In order to better understand these issues, and to ensure that the recommendations described within this review were fit-for-purpose and derived from good evidence, a comprehensive (mixed-methods) methodology was developed. This included reviews of the literature, interviews with experts, surveys, focus groups, hui, wananga, conference attendance, presentations, formal meetings with policy, strategy, and cultural experts, tohunga and rongoā practitioners, managers, clinicians, prisoners, whānau members, and special interest groups – including women, gender-diverse, and young people. As well – a number of site-visits (typically occurring over two/three days) were also organised and to ensure that more specific delivery issues and perspectives were captured. More detail about the methodology used for this review is outlined in the body of this report.
Given the broad scope of information and data collected - the analysis, organisation, and presentation of findings initially proved difficult. Notwithstanding, and as the process of review and data synthesis took shape, a number of seminal themes began to emerge. These emergent themes, however, were not always able to be clustered together or into a single inventory of ideas or concepts.
Eventually however, five broad categories or Pou were identified.
- Pou Arataki: Six Mental Health Principles
- Pou Hinengaro: Four Mental Health Platforms
- Pou Rautaki: Ten Mental Health Investments
- Pou Kokiri: Five Mental Health Catalysts; and,
- Pou Hua: Outcomes and Recommendations
Each of the five Pou contain a summary collection of ideas, concepts, issues and opportunities which have been garnered from the research and review process. The first Pou - Pou Arataki, outlines the principles used to guide the review and especially the recommendations. The Pou Hinengaro focus on the various factors (often peripheral to service delivery) and which are required to support or sustain mental health and wellbeing within a prison setting. The Pou Rautaki are more specific and explore service and delivery related challenges and opportunities. Pou Kokiri describe investments which are required to maintaining quality and future growth. Finally, the Pou Hua is a summary of the key recommendations generated from the review and how these should be prioritised or actioned.