Mental Health and Wellbeing Commission Bill

The Health Committee recommended the bill unanimously with several suggested changes, which were supported by the Government.

💬 Hon Nathan Guy: Put some passion into it. Come on!

This is a happy occasion, I tell the honourable member, because the bill was supported by all parties at second reading. If the majority of Parliament votes in support of the bill, it will go through, of course, to its third reading, either immediately following or on the next sitting day and, following that, to Royal assent.

This is a bill that’s making swift progress. It is something whose time has come, and I want to thank, from the outset, the coalition partner, New Zealand First, that has supported and worked with Labour to progress the mental health commission, and also our confidence and supply partners, the Green Party. All parties are very keen to see this go through, so it’s been on the agenda for this term of Government. Of course, all of these parties also were supporting the mental health inquiry, He Ara Oranga, despite the Government of the day, the prior Government, opposing that work.

Now, this has come out as one of the recommendations out of He Ara Oranga that we re-establish the Mental Health Commission after the previous National Government disestablished it. But I’m really pleased that now the whole Parliament has united again behind that idea of having a mental health commission. So to respond to Mr Guy’s comment, it is something worth being passionate about. It is exciting that we have a whole Parliament united to have a mental health commission in place once again. The bill establishes the commission as an independent Crown entity that will hold Government and other decision makers to account for improving mental health and wellbeing, and it will contribute to better mental health and wellbeing outcomes for people across New Zealand. I’m convinced of that. It will also contribute to achieving equity for Māori and other groups that experience poor mental health and wellbeing outcomes, or poorer than the general population.

Establishing the new commission is widely supported beyond this Parliament. The majority of submissions to the select committee supported a new commission, and it was pleasing to hear the support for the bill during that second reading debate right here in the Chamber. So I want to acknowledge also before I end this contribution, the members of the Health Committee for their work—

💬 Hon Michael Woodhouse: You’re welcome.

—and the improvements that have been made to the bill. That does include you, Mr Woodhouse. Thank you for your work on this. It was great to see a unanimous recommendation from that select committee back to the House with some changes which we have been happy to adopt. So I move that this be taken as one part.

CHAIRPERSON (Hon Ruth Dyson): That’s already been agreed to, so you don’t need to do that.

Apologies, just instructed by the whips—making sure I’m doing the right thing. I look forward to the contributions across the House.

Thank you very much, Madam Chair. I thank the Minister for that introduction. He is correct: the National Party is in support of the Mental Health and Wellbeing Commission, although we do have some concerns on this side of the House. The Minister is correct: the Mental Health and Wellbeing Commission came out of the recommendations of the Government’s mental health inquiry, He Ara Oranga. But, equally, a concern of this side of the House is that the mental health commission will not have the authority to drive real change.

As the Minister has stated, this is a bit Back to the Future. The previous Mental Health Commission was disestablished in 2012, and there’d be many in the mental health sector who agreed with that decision, because it felt the Mental Health Commission of that day had lost its way. So, fast-forward to today, we have the Mental Health Foundation, who came out after Budget 2020 and were worried, after that Budget, that there seemed to be no resourcing and implementation plan for the recommendations of He Ara Oranga, and it was appearing to stall and drift. So my question to the Minister would be: how is he going to ensure this commission will have enough authority to drive those recommendations forward and, ultimately, drive mental health forward for New Zealanders, who do want to see a real change?

I thank the member Matt Doocey for his questions. He’ll be aware that there’s an interim mental health commission in place currently, with board members, that has been supported through the Ministry of Health. It is our intention to ensure that this commission is appropriately resourced, because we all in this Parliament want to see it succeed. In fact, there is one difference to the Mental Health Commission that the prior Government disestablished, in that this one will actually be a more independent Crown entity, and thus will have the ability to hold this and future Governments to account for their work in the mental health space.

I thank the Minister for that. Right, there is some independence, but independence will not necessarily bring the commission authority.

I do want to draw the Minister’s attention to my Supplementary Order Paper, where this side of the House would like to see, under clause 11, the inclusion of the line “including recommending targets that provide clear and specific actions to be undertaken to improve people’s mental health and wellbeing”. On this side of the House, we do think the mental health commission would benefit from the ability to recommend targets, to set targets, and to report to targets, because, of course, the indicative target of the inquiry was to increase access for New Zealanders from 7 percent to 20 percent. I think it would be important that the mental health commission was able to recommend those targets, to work across various Government departments, to hold them to account, and then to report back to the public that they have been able to increase access for those specifically at the mild to moderate end, who the mental health inquiry, quite rightly, pointed out were not able to access mental health services. I would be interested to know from the Minister why there is no ability for the commission to be able to recommend targets and report on targets.

As part of its assessment of effectiveness, efficiency, and adequacy of approaches to mental health and wellbeing under clause 11(1)(c), the commission will absolutely be able to consider all recommended targets if it thinks that is what the commission should be doing. If it believes that that is helpful to the Government’s progress, or to assessing the Government’s progress, it’s free to do that. Nothing in the bill precludes the commission from recommending targets if it determines that that’s an appropriate approach. The commission will be able to make informed judgments based on evidence; changing the legislation is not necessary to give effect to what the member is suggesting.

I think we probably will agree that if that’s something that proves to be useful, we would encourage the commission to do that. But I think it’s important that the commission has the flexibility to comment on what it thinks needs to be done, that we preserve that independence, and I don’t want the commission locked into specific targets or specific assessments that it has to adhere to, set by this Parliament. I think it’s up to the commission to decide how it wants to approach this issue. It has been established as an independent entity, as we have already canvassed.

Thank you, Madam Chair. Just picking up on that last point that the Minister of Health said, there was a slightly circular argument about that, because it’s not the commission’s responsibility to adhere to the targets but the health sector’s. I heard the Minister say that it would be problematic in some way to bind the commission to either do or not do something. Well, I think that’s flawed logic. If, as he says, the commission is free to set targets, then why not build that in as part of the functions under clause 11? I very strongly support Supplementary Order Paper (SOP) 509 in Mr Doocey’s name, and, indeed, I’ve got a bill in the members’ bill ballot to do more or less the sorts of things that this proposes, right across the health sector. And, indeed, it’s modelled on the very language that the Prime Minister herself used in the bill that was passed with child poverty reduction targets.

I think we’ve seen ample evidence in the health sector in the last 2½ years about why the absence of clear expectations for service delivery leads to drift. The Minister, in his opening remarks, talked about some kind of change of heart that the National Party might have had in respect to the Mental Health Commission. I don’t think that’s what’s happened, because I will have no time and no truck with a commission that acts in most respects more like a Monday morning quarterback, sitting on the sidelines of the mental health sector, making comments about what’s going on without any real ability to influence the direction that the sector is going in. I think we’re already seeing the same sort of drift, with the lack of delivery, from the mental health report, the Paterson report, that was, I think, so important in actually setting a broad direction.

Lots of hope and money, but no actual detailed plan for the how and the who and the where and the when, is exactly the sort of thing that Mr Doocey’s SOP will actually require and encourage the commission to do. So I want the Minister to think very carefully, particularly about the changes in SOP 509 to clause 11, because we can say anything we like about what the intent of the commission is; it’s the black letter law that will guide their behaviour, and I think we have a unique opportunity right now to say this is important to us. Bringing clarity to what is expected in the sector, and setting clear targets and specific actions to deliver improvements of mental health, is going to be a fundamental ingredient in the success of this commission.

To respond to the points raised by the Hon Michael Woodhouse, the challenge, of course, with having targets is that, in this particular context, He Ara Oranga was much more focused on prevention and promotion of wellbeing. It may be that a commission would consider an approach around access targets or other targets too focused on a treatment or illness approach rather than a wellbeing or prevention approach. I think it should be free, as an organisation, as an independent entity, to choose how it sets up its measures of success across the system. So that’s what permitted. As I’ve mentioned before, there’s nothing to stop it setting up targets if it thinks that’s the right thing to do to hold a Government of the day to account. Indeed, I think it would be anticipated that if the Government of the day set itself targets, the commission would be there to judge the success of the Government of the day in achieving those particular targets it had set itself. That would be a reasonable role to assume the commission might fulfil as an independent monitor.

Well, that would be absolutely fine, except the Minister of Health has done an 180 degree turn-around in respect of the setting of targets, particularly in mental health. As shadow Minister in 2017, he called on the Government and the Minister of Health to set a suicide reduction target and proposed a 20 percent reduction in suicidality in New Zealand. Indeed, he forced Dr Coleman, basically, to match him. It was like a mental health telethon on the campaign trail. The moment the Minister gets to office: oh no, that’s a bit hard. The narrative was one death is one too many, and that I agree with; I’m not doubting that. But we need to set off on a journey of reduction in self-harm and suicidality in this country, that will not be achieved if we aren’t very clear about that as the goal.

Now, broadly, we all agree that that’s the case, but, in order to be able to say, “Well, let’s take the first steps in that.”, we set the target, we understand the plan, and we understand where the risk is. Whether it’s in rural communities—we just had a sharp spike in poor mental health outcomes and suicidality—whether it’s our youth, whether it’s Māori and Pasifika, who all have higher rates of suicidality than the general population, then that highlights those things for the commission to be able to say, “OK, sector. This is where you should be looking. Good looks like a reduction in these areas and specific actions being taken to improve the mental wellbeing of the people in those most vulnerable groups.”

The Minister can, sure, say, “Well, that can happen at any time.” The fact is he leads. He leads the discourse and the thinking around this, and he pivoted on that. The moment he had the opportunity to set a target, he equivocated. He stepped back from that. Actually, I think that strengthens the case for the commission to be able to be more of a watchdog than a poodle and say, “You know what: this Government and its agencies should be heading in this direction.” That’s why putting it into the law is going to be so important.

At the risk of getting into the debate about what targets should be and so on, as the member has, I would say that the interim mental health commission is precisely tasked with ensuring that the Government is doing the things it said it would do in terms of rolling out a programme of increased access.

But the Government has chosen to put a record amount into mental health, $1.9 billion. Included in that $1.9 billion is half a billion dollars that is focused on widening accessibility to mental health. It is the very job of the interim mental health commission, and in a similar way I’d imagine a permanent mental health commission to hold the Government of the day to account for the tasks it set itself for delivery of those particular goals.

What those goals might be is, indeed, a matter for debate. I don’t agree with the way the member has characterised my previous views or positions. I don’t want to get too far in to that. But I fundamentally think the important thing here is that the commission has the independence to, if it chooses, set some goals or things it’s going to hold the Government to account on, or to hold the Government to account on, in an independent way, the tasks it set itself. It’s up to the commission, and the bill is entirely permissive, in that regard. We seem to be having the same conversation backwards and forwards, so I’ll leave it there.

Well, just to carry on where the Minister left off, I think the Opposition and the Minister going back and forth, in fact, experientially highlights the argument we’re making, because if there is no clarity on who sets the targets, then can the commission and the Government just have that circular discussion that gets nowhere? Then we end up with the problem we had with the last commission where people felt it had lost its way because it had no authority to make a difference. So if the Minister is saying, “Well, we don’t need targets in this legislation because the Government can set targets.”, what happens then, when the Government chooses not to set targets? Then how can the commission hold the Government to account? The whole point here is, by setting a target, you become accountable, and then the Mental Health and Wellbeing Commission will have authority.

On this side of the House, we’re concerned that we will have a commission set up, and then no one will listen to it. So how is this commission, if it’s not having targets, going to have teeth to make a difference, because there wouldn’t be one member in this House who hasn’t been moved by the stories they’ve heard of their constituents impacted by mental health themselves, their family, and their work colleagues. We’ve all heard the call in the 52nd Parliament that we need to get on and work together to make a difference. Now, the Opposition agrees with that, but if the Minister could just clarify, then: whose role is it to make targets: the Government or the commission? How do we end up not getting in this circular discussion that we are tonight where both the Government and the commission can’t hold each other to account?

Well, I mean, the member asks good questions here. The point I would make is that the commission’s job will be to hold Governments to account for their delivery of mental health services, for the improvement in mental wellbeing across society, and so on, whatever that looks like. So, if the Government, as some Governments have chosen to do, sets narrow—I would argue, pointless and/or misleading—targets for themselves that they think they can achieve politically but actually make no meaningful difference to people’s wellbeing, the commission can choose to observe them or ignore them, or it can set out real measures of progress, consult experts, consult the consumers in the sector who use the service, and make its own judgment about whether a Government is making progress or not. So I don’t see that the authority should sit with the Government about what the right targets to measure are or aren’t. I think that should sit with an independent commission that can choose to consult with those who are actually using the services, consult with experts, look at the international evidence, and form a view on whether Governments are doing the right thing by their people in terms of mental health or not, regardless of whether the Government of the day chooses some convenient political targets that it might meet.

I thank the Minister for that answer. Then, if he agrees that the Mental Health and Wellbeing Commission should be able to set targets, where in the legislation does it give the authority to set targets?

I have covered this point previously, but I’ll cover it again. As part of its assessment of effectiveness, efficiency, and adequacy of approaches to mental health and wellbeing, under clause 11(1)(c), the commission will absolutely be able to consider or recommend targets if that is what the commission thinks the Government should be doing.

The question is that Matt Doocey’s amendments to clauses 8 and 11, set out on Supplementary Order Paper—

💬 Matt Doocey: Madam Chair?

CHAIRPERSON (Hon Ruth Dyson): —509, be agreed to.

💬 Matt Doocey: I’m sorry, I’m a bit confused. Are we carrying on with our calls?

CHAIRPERSON (Hon Ruth Dyson): Well, I didn’t hear anyone take a call, so I started putting the vote. [Interruption] Sorry, you didn’t seek a call, so I didn’t—

💬 Matt Doocey: Yeah, I was a bit perplexed. I didn’t realise that we were—

CHAIRPERSON (Hon Ruth Dyson): I don’t call people who don’t seek a call, as a general rule.

💬 Matt Doocey: I didn’t realise we were near the end of the debate. I thought we would be at the start of it, and I thought there’d be some leniency for the Minister sitting down and the Opposition members collecting their thoughts.

CHAIRPERSON (Hon Ruth Dyson): Mr Doocey, do you have a point of order?

💬 Matt Doocey: No. I’m seeking a call, Madam Chair.

CHAIRPERSON (Hon Ruth Dyson): I had already started taking the vote. You could urge for my reconsideration.

💬 Matt Doocey: I raise a point of order, Madam Chairperson. Speaker’s ruling 63/3 says the member may seek a call before the Chair takes the vote.

CHAIRPERSON (Hon Ruth Dyson): I’d already started it—I’d already started taking the vote.

💬 Matt Doocey: That’s right. But Speaker’s ruling 63/3 says that the Chair would need to finish the vote, and the member can seek a call before it’s finished.

CHAIRPERSON (Hon Ruth Dyson): Could I just ask the member to resume his seat. Mr Doocey, if you want to be called, you have to stand and seek a call. So if Mr Doocey wants to try that now—Mr Doocey.

Madam Chair, thank you very much. So it’s fair to say the Minister has been very clear tonight that he does not want the word “targets” explicitly mentioned in the Mental Health and Wellbeing Commission Bill, and one can only, well, assume why that might be. That might be also to do with when the Opposition does ask how the Government is tracking on increasing the access target from 7 percent to 20 percent and doesn’t get an answer.

The next part I want to move on to on my Supplementary Order Paper is looking at the focus of the Mental Health and Wellbeing Commission on research. This side of the House, under functions of commissions, believes that the commission should have the authority to direct research into mental health. What is interesting is after Budget 2020, the organisation New Zealanders for Health Research put out a press release, and they did some analysis: under Budget 2019, there was only $131 million put into health research. That is 0.81 percent of the healthcare spend. In Budget 2020, that had fallen by $13.7 million to $117.5 million—down to 0.71 percent. They are advocating that on an international benchmark, New Zealand should be investing into health research at 2.4 percent of our health spend. You could even go further and, potentially, look at some ring-fencing and say that, out of that total health research spend, a percentage of that should be for mental health. One of the reasons I think this is important is because, as we know in mental health, we still don’t know a lot. In fact, I’ve heard academics say we are 50 years behind where physical health is, in the sense of research, and, if you look at the amount of research and development in the last 50 years for physical health, it shows how much we have to make up.

So my question to the Minister is: why is there no mention of research, and what importance does he put for the Mental Health and Wellbeing Commission on focusing on the need for research in mental health?

The commission is required to have sight of evidence. It is a broad term; that includes research and also includes other components such as data and evaluation. The commission’s regard to consider the available evidence clearly encompasses research. So my assessment of it is that changing the legislation is not necessary to give effect to the point being raised by the member.

While we’re on the subject of what the bill does and does not say, I want to draw attention to the amendment to clause 11(3) in Mr Doocey’s Supplementary Order Paper 509, which talks about promoting a social investment approach in carrying out the functions of the Act. I recall from the report—and I can just about give the member the page number; it’s 201—in its summary of the core functions of the mental health commission, that it is specifically identified in the recommendations that the commission “Develop an investment and quality assurance strategy for mental health promotion and prevention”. Yet the functions and powers of the commission as listed in clause 11 do not include that. I think that’s a really, really important additional function that the commission should have in law, because what an investment approach does is it takes the question of where the investment in our mental health resources is best put, and, at the moment, frankly, I think the DHB system is one that works against where the best investment should be going, which is into that low to moderate mental health need, which the report specifically identified. Whereas I think there are plenty of examples, including in the Minister’s own home city, where the DHB has probably diverted—well, not probably: it has diverted resources into that secondary care sector at the expense of the very much needed primary and community NGO-type mental health for low to moderate conditions, where that was the better investment.

Actually, I think the amendment to clause 11(3) by the addition of (3A) is absolutely vital in making it clear, not only to the commission but to the DHBs themselves that that is where—rather, I wouldn’t jump to the conclusion—the research that Mr Doocey talks about, but also a specific focus on where the best investments should be put absolutely should be in the black-letter law so that there be no doubt that the commission can direct, can require, rather than being the Monday morning quarterback that I talk about. For that reason, I think that clause in particular is very much needed in the bill.

My view is that there’s no particular need to specify the commission have a particular approach, or promote a particular approach, such as the social investment approach. In fact, the commission itself, through assessment of the evidence, which is the point we’ve just covered—the available research currently—may decide that a different approach is better for advancing the wellbeing.

So this is somewhat contradictory in terms of what the member’s put forward: at the one point suggesting that you’ve got to have an eye for the available evidence and research, and then suggesting a particular approach that might come from that research. I would say that the commission, ultimately, would be best placed to consider whether a social investment approach or another approach is the appropriate way to perform its functions.

Just following up on that, I think the Minister misunderstood his own legislation, because it says very much, under clause 8(2), “the Minister must have regard to the need for members to collectively (a) have knowledge, understanding, and experience of—”, and then it goes on to have a range of approaches: public health, population health, improving health outcomes. All that this side of the House is saying is that, out of the range of those health approaches, why would you not have “social investment approach”, because, as we know with social investment, it is taking the longer-term view—and the Minister himself talked about the challenge between treating mental illness and also taking a preventative approach. We all know the social investment approach is grounded in looking at long-term welfare liability, committing resource upfront—that might be doubly expensive—but to be actually intervening early and making a difference.

I think you could apply the same with mental health, especially when we know that, for people with lifelong mental health illness, 50 percent of them first present before the age of 14; 75 percent of them first present before the age of 24. Yet the average age of their first presentation is late-20s, early-30s. So we know there’s about a 10-year gap where we don’t capture people, and actually taking an approach that would actually be also data driven would be ensuring that all our services are feeding in the data at an anonymous level so that we can build that evidence base. And where we would disagree with the Minister around the term “evidence” is that evidence only points to where the evidence is at the moment, and that comes back to my original point—that we should actually be growing the evidence base. That’s why, in my Supplementary Order Paper, it talks about the mental health commission, in clause 11(1)(d), “to promote alignment and collaboration in research undertaken in respect of the effectiveness of approaches to mental health and wellbeing, including identifying gaps in the evidence base and promoting research to address those gaps”.

So I would like to hear from the Minister: yes, he does have evidence mentioned in this legislation but where does it refer to the responsibilities of the Mental Health and Wellbeing Commission to actually focus on research and direct research to inform that evidence base? Or this mental health commission, in fact, will have no oversight or interest in research.

Promoting collaboration across entities that are involved in or contribute to mental health and wellbeing may involve encouraging good practice, sharing information, and working with stakeholders to identify unmet needs and gaps. It will also include sharing evidence and ensuring that the evidence base is strong. I think that’s likely to be a clear part of the commission’s role. Again, I don’t think that that needs explicit stating, and, in particular, I don’t think that a particular approach needs to be recommended. The commission should have regard to the evidence. They should seek to learn the evidence as it’s emerging, and involve themselves in that.

I think also the other point to make, in response to the member’s wider point, is that the Health Committee’s recommendation—accepted by the Government—that the bill is clear that when it’s carrying out its functions, the commission must consider the available evidence, is specified in clause 11(3)(a) of the bill—so, you know, to take it right back to the point of where this is already cited. So I think the bill as drafted addresses the issue adequately, without getting us into a position where it’s recommending one particular approach that is fashionable right now be adopted.

To conclude, in my final call for tonight on this committee of the whole House for the Mental Health and Wellbeing Commission Bill, National will be supporting this bill. But, for the reasons we have outlined in this debate, we do want to put it on Hansard that we do have concerns that the Mental Health and Wellbeing Commission may not have the authority to deal with the demands that New Zealanders and mental health services are facing today, especially in the context of COVID-19, where the Epidemic Response Committee has heard of forecasting by Sir Peter Gluckman of potentially tens of thousands of New Zealanders who will lose their job and lose their incomes and develop real, serious mental distress. No one in this House wants to see the Mental Health and Wellbeing Commission go back to the future. We have been here before. Many in the mental health sector felt the previous commission had lost its way, and we do implore the Government that giving this commission the ability to focus on some of those key points mentioned in my Supplementary Order Paper today will give the commission more authority and ability to work across many Government departments—Corrections, Education, Justice, Health, and others—to actually develop a mental health strategy which is whole-of-Government and will make a real difference in New Zealanders’ lives. Thank you, Madam Chair.

Just to close, I do want to thank that side of the committee for its support of this commission, that has been worked on by New Zealand First, Labour, and the Greens. We believe that this is a huge step forward in having an independent commission able to hold this Government and future Governments to account, in a thoroughly independent way. I commend this bill to the House.

The question was put that the amendments set out on Supplementary Order Paper 509 in the name of Matt Doocey be agreed to.