A mental health workforce in crisis

There is overwhelming agreement that New Zealand faces a health workforce crisis,[[1,2]] although one might argue that, like our workforce, the word “crisis” is getting worn out from overuse.

A recent editorial in the New Zealand Medical Journal lamented the government’s response to the problems in New Zealand’s health sector, with a transparent approach to rationing healthcare seen as the most viable short-term solution.[[3]] Rationing is already happening across the health system, including in mental health. However, mental healthcare rationing is being done in an ad hoc way, mostly by individual clinicians and strained services. A lack of transparency about rationing of mental healthcare risks worsening inequities, disproportionally affecting Māori because of existing systemic biases.[[4]] Rationing will inflict moral injury on clinicians[[5]] and it might also breach human rights. For example, workforce pressures are lowering the quality of mental healthcare provided to people in prisons, leading to breaches of the United Nations Optional Protocol to the Convention Against Torture.[[6]]

In response to concerns about New Zealand’s mental health and addiction services, the New Zealand Government conducted a national inquiry in 2018. He Ara Oranga, the inquiry report, recommended publicly funded mental health and addiction services expand to improve care across the whole spectrum of illness severity.[[7]] Expanding services before first ensuring the needs of people with the most severe problems can be met seems absurd. Furthermore, while He Ara Oranga noted the burnout and trauma being experienced by mental health staff,[[7]] its recommendations gave no specific plans to address workforce issues beyond brief mention of workforce modelling (recommendation 6) and setting “workforce development and […] wellbeing priorities” (recommendation 10).

The current situation reflects the slow demise in secondary mental health services over the past 60 years[[8]] since de-institutionalisation began. Allison et al. noted that the He Ara Oranga report continued a tradition of rhetoric promoting community care, but it overlooked the fact that psychiatric inpatient bed numbers in New Zealand were already low by high-income country standards.[[8]] This lack of inpatient beds is a major source of stress for clinicians in both inpatient and outpatient settings.[[9]] Inpatient staff wellbeing is affected by high acuity, pace of work and exposure to violence. Those working in outpatient settings have caseloads of people who are more unwell than in the past. In many cases these patients cannot access good quality housing due to stigma and cost. Healthy food is also out of reach for many. The lack of ability to alter these social determinants makes it harder for clinicians to address patients’ mental illness, and this is likely to produce a sense of powerlessness that fuels burnout.[[10]] Options for management of outpatients who pose serious risks to themselves or other people are more and more limited, leaving clinicians to carry a heavy burden.

The strain in the mental health workforce is evident in recent reports published by Te Pou (New Zealand’s centre for mental health workforce development)[[11]] and the Health Workforce Advisory Board.[[2]] Promisingly, Te Pou report that the funded mental health workforce grew by over 10% between 2018 and 2022 against a background of a 7% increase in the New Zealand population.[[12]] However, closer scrutiny of the data from Te Pou is more alarming. First, more than 10% of funded positions are vacant, implying those in the workforce are doing at least 10% more work than they should be. Second, the lowest rate of growth was among nurses—the largest and arguably the most vital part of the mental health workforce. In contrast the highest growth was in advisors, managers and administrators. Third, the mental health workforce is aging rapidly, with around half aged over 50 and one fifth over 60. This suggests the workforce shortages will get worse as that cohort retires. Fourth, progress has been made with increasing workforce participation by Māori, but the proportion of Māori in the workforce—around 14%—still needs to double to match the ethnic profile of those accessing care.

Like He Ara Oranga, the Mental Health and Addiction Workforce Action Plan 2017–2021[[13]] was flush with aspirational goals but short on concrete solutions. For example, the Action Plan noted that the number of nurses in New Zealand per 100,000 population was already falling and was expected to fall further. However, the plan provided virtually no practical plans to attract, train or retain more nurses. In contrast, recent work by the Health Workforce Advisory Board has at least produced tangible outputs such as lowering the barriers to people with specialist skills entering the country.[[2]]

Solutions

We do not have all the solutions to New Zealand’s mental health workforce problems, but we can point to some directions where the answers may lie.

First, clinicians with a tertiary degree in the health sciences still make up most of Te Whatu Ora’s mental health and addiction workforce.[[11]] This is no longer a sustainable option. There is an increasing need to recruit people without a tertiary degree-level health qualification but with other desirable attributes, including lived experience of mental illness and a deep understanding of tikanga Māori and Pasifika culture. This workforce would initially function at the level of healthcare assistants or support workers but with a defined pathway for career progression via an apprenticeship model. Universities and polytechnics should remain involved in training this workforce, but they will need to adapt and be more responsive to its needs. For example, training would be delivered flexibly online during paid work hours rather than via traditional classroom-based models.

Second, there is a need to recruit people with existing tertiary health science qualifications who are not currently in the workforce. Funded refresher training is already in place to help bring nurses back into the workforce, and this is a worthwhile initiative.[[2]] As the mental health workforce is two thirds female, recruitment and retention efforts should be focussed on women. Recent changes to employment conditions for nurses have begun to address gender pay equity. However, despite years of industrial negotiations there is still some way to go, with nursing pay still the subject of litigation in the Employment Court.[[14]]

Third, strategies to retain existing staff are urgently needed. Much has been written on this issue, but seemingly little has been done about it. Burnout is a major barrier to retention. It has been described as a global crisis for doctors[[15]] and is highly prevalent among psychiatrists in New Zealand.[[9]] For nurses, factors reported to improve retention include more autonomy, participation in governance activities, good leadership, adequate resources and good interdisciplinary communication.[[16]] Well-designed financial incentives would also help staff retention and morale.

Conclusions

A strong and healthy secondary care workforce is the foundation of New Zealand’s mental health system. Currently, this system and the people working in it are on the brink of collapse. The workforce is not going to be rebuilt via more inquiries, blueprints or strategy documents. It is now time for action, not words.

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