The role of government policy in service development in a New Zealand statutory mental health service: implications for policy planning and development

The research

This study involved an organisational case study. It utilised multiple research techniques to capture different perspectives and depth of evidence.^8,9 The research involved 27 qualitative interviews with nine staff including: the General Manager; the Rehabilitation Service’s Manager; Unit Managers from the Adult Community and the Community Rehabilitation Services; a Clinical Coordinator from a Community Mental Health Team; an Acute Inpatient nurse; a psychiatrist; a consumer advisor; and a cultural representative. Participants were invited to volunteer via information circulated throughout Living Well. Volunteers were approved by the senior management team. Alongside the interviews, 28 formal service development reviews, projects, businesses cases and strategic plans produced by Living Well over a 4-year period were analysed. These documents captured a written record of service development activity at Living Well. Thirteen operational and strategic meetings, held over a period of 4 weeks, were also observed and recorded, and the preceding 6 months’ worth of minutes analysed. The study also included an analysis of literature, research, policy and external inquiries related to mental health care and treatment in New Zealand. The main government policy documents which had relevance to this study were: Te Tāhuhu – Improving Mental Health 2005–2015: The Second New Zealand Mental Health and Addiction Plan; ² and Te Kōkiri: The Mental Health and Addiction Action Plan 2006-2015. ³

A single case was chosen as this facilitated an in-depth, multifaceted understanding of the service development processes and the relationship between government policy and service development.^9–12 There are limitations to using a single case, in particular the ability to generalise the study’s findings.^9–12 However, there is limited research on service development within New Zealand statutory MHS and this study provides a valuable contribution from the perspective of Living Well. It also provides for the opportunity for verification of Living Well’s experience through future studies.

The challenges of interpreting government policy for use in service development

At Living Well, staff narratives reflected tensions regarding how to include government policies in the service development process. Clinicians and managers articulated two opposing views on this; on the one hand they expressed a desire for the policy documents to include more detail about implementation, while on the other hand a concern at a local service delivery level to being directed by policy makers. A senior manager discussed the challenges of interpreting government policy: ‘the trouble is the [policy] direction is very broad and when you want any specifics around it that is where the difficulty comes from’. The lack of specificity meant that while priority was given to the ideas contained within government policy, in reality these were not embedded within the administrative or service development processes of the organisation. Consequently, managers and clinicians struggled to understand and evaluate how to implement policies within the service delivery setting.

Clinicians and managers expressed uncertainty about the effectiveness and applicability of government policy to service development and delivery. They felt that government policy should provide mechanisms to ensure consistency not just in terms of the broader vision of the sector, but also in terms of service configuration, programme delivery and practice standards. Clinicians and managers articulated a lack of congruence between the high-level strategic goals stated in policy documents and the direct service delivery environment. One senior manager summed this up: ‘There is a mismatch between what the ideal is and the theory is and what you can practically do with the money’. Participants felt that the goals of government policies often reflected broader political agendas or were responding to need in a particular area. Service providers were then required to act on these policies even when they did not respond to or fit with local need. For example, Living Well had been required to develop and implement strategies for a particular cultural group, which was not a high user group in that region. This required shifting resources from one area to another. This lack of congruence created unease and resulted in a degree of mistrust in their relationship with the Ministry of Health.

Motivating factors for service development

At Living Well, service development was both planned and unplanned. There were a myriad of motivating factors for service development including government directives, issues related to patient need, the local context and service demands.

The key concepts and principles from government policy were repeated in local strategic aims and project goals at Living Well. The inclusion of these key concepts and principles reflected the importance attached to government policy in the consideration of planned service development. However, the inclusion of these concepts and principles did not translate to the service development process; rather, service development was motivated by the immediacy of operational and clinical concerns related to patient need and service demands. Operational responses included the management and administrative actions required to deliver MHS on a daily basis, including staff cover and rosters; bed availability; maintenance requirements; risk minimisation and audit; information technology; human resource concerns; and budgetary requirements. Clinical concerns related to the acuity or level of ‘unwellness’ of patients and the clinical responses required to meet the needs of these people. The priority given to responding to clinical and operational concerns at Living Well mirrors the pattern observed in the USA by Aarons et al., ¹³ who noted that programmes within MHS are selected based primarily on fit with the organisation’s structure, roles and priorities as opposed to following high-level policies.

The lack of direct connection between national policies and the practice environment at Living Well concurs with Ellard’s ¹⁴ and Butler’s ¹⁵ analysis of the mental health systems of the United Kingdom and Australia. These researchers noted that changes in practice did not result from the detail of policy documents, but instead from clinicians working pragmatically to find solutions to the challenges they faced locally in their work.^14,15 Management at Living Well placed importance on being seen to implement government policy, for example, by implementing required restraint training packages to minimise risk and fulfil compliance obligations, but staff struggled to translate the role of policy in service development alongside the day-to-day demands of delivering services. Rather, operational and clinical concerns took precedence over a planned approach to implementing government policy.

The establishment of an aftercare service and a clinic for clozapine patients were examples of service development motivated by local operational and clinical concerns rather than policy obligations. Once these services were established, staff then made links with the values and the vision detailed in government policy to rationalise the service development and secure funding for these programmes. The development of the aftercare service and clozapine clinic were successful service development initiatives motivated by local concerns, that then secured ongoing funding as they aligned with the values contained within government policy including Te Tāhuhu and the Primary Health Care strategy.^2,6

Conclusion

At Living Well, staff struggled to understand how to prioritise government policy as part of service development, as other imperatives such as patient need, local context and service demands took priority. This case study adds to the knowledge of service development within statutory MHS in New Zealand and has a number of important implications for future planning, development and implementation of policy including giving consideration to how clinicians interpret and implement policy when faced with a myriad of competing operational and clinical concerns. In New Zealand, the service delivery environment is complex and involves many contradictions embedded in trying to develop and implement government policy alongside local service delivery. This study demonstrated that despite compliance obligations attached to government policy, staff and managers lacked clarity on how to interpret and implement policy, meaning that more often local pressures drove service development.