Nurses must take their rightful place in mental health; nurses must assume a more powerful role in mental health and health care generally, to ensure a broader perspective is brought to bear on all health issues.

THE VIEWPOINT articles in the December/January 2002/2003 issue of Kai Tiaki Nursing New Zealand by Tony O'Brien (1) and Chris Parsons (2) both mentioned issues in relation to nurses working in mental health settings, and the adverse impacts of multidisciplinary care in a number of cases.

The truism that nurses are with inpatients 24 hours a day highlights a very important issue in relation to the effective coordination of multidisciplinary mental health care, ie care of a person with mental health problems should not be dictated by medical considerations alone.

In mental health there seems to be a theory of inverse proportions operating, ie the people who have less direct care of a patient have greater weight in directing the focus of service provision or clinical treatment. These people can be broadly grouped into four categories: allied health professionals; medical practitioners; support service administrators; and management. Each of these groups of non-nurses, all of whom spend less time with patients than nurses, seem to regard their perception of the patients needs (or service needs) to be superior to those of nurses, and assume their point of view should be paramount. This weird science has resulted in the catastrophes highlighted in the viewpoints. (1,2)

The thwarting of nurses professional opinion and rightful dominance in relation to directing multidisciplinary care occurs in inpatient and community settings. It can seen in the tendency of medical practitioners to be the gatekeepers of admission to inpatient units; in managers who under staff services to unsafe levels; in medical staff deciding a person should be discharged to clear a bed for another patient who must be admitted. These practices appear endemic throughout mental health.

While lack of resources may have forced these ill-advised actions in some cases, lack of money seems to be used as an excuse for inactivity and lack of planning to try and circumvent problems before they arise. The tough questions in relation to making the mental health sector work need to be asked and properly answered by those who are able to effect positive change.

Since 1987, the health sector in general has been rationalised, made more efficient, cost-effective and productive in management terms. However, the patient and their significant others may have felt the converse has actually occurred! Waiting times are burgeoning, people are dying, people are in more pain, and people who do eventually get into hospital are sent home before they feel able to cope. Community-based services are overwhelmed and cannot meet all the needs of post-discharge patients.

Increasing resources is not a panacea but it needs to be understood that all the productivity gains possible within the mental health sector have already been made. It is now time for the Government (as the tool of the wider public) to invest in health, and to do this quickly--a dedicated health tax of two percent would provide an adequate injection of capital into this now skeletal sector. It is time to stop the spin doctoring and call things as they really are. District health board (DHB) debt carried over from a failed quasi-business model needs to be wiped out, and not taken into account when considering "new" spending in the sector.

The duplication of functions and devolvement of health away from direct government accountability and control will only serve to siphon precious funds away from direct health care. New Zealand is such a small country that for every region to have its own health administration is ridiculous administrative functions should be centralised, as should the provision of some key programmes and services. Mental health needs to be provided under a consistent service delivery model. Industrial integrity and egalitarian employment will allow for better distribution of staffing and essential expertise--something that seems to be sadly lacking within the sector at the moment.

Given that staff are the greatest asset of any service, more care and attention needs to be given to establishing good recruitment and retention strategies; to encouraging the development of local expertise; to paying rates equal to those in the rest of Western world; to encouraging staff and providing incentives to maintain relevance of knowledge and skills; and to supporting innovation and creativity, especially in consumer-directed and provided support services. Consumer services need to have a pool of people available to provide business expertise not available within their numbers, and this expertise needs to be adequately remunerated.

It is sad but true that the only way to forge ahead is to combat the political hegemony of non-nurses in the health sector. More nurses need to be providing policy advice to government, key appointments within the Ministry of Health such as the Director General of Health and the Director of Mental Health need to be opened up to nurses who have the ability to provide analysis based on a multifaceted frame of reference--not just a biochemical medical model. Being a medical practitioner gives no better grounding for such key positions than being a nurse and this needs to be reflected in the actual appointments made. There are suitably qualified nurses who can undertake such roles and they should be able to do so without the medical fraternity instigating patch protection strategies.

It is essential to develop nurse-led health care in New Zealand--from top policy level through to the day-to-day care and treatment of individuals. By refocusing the health system away from a single perspective medical model to a bio-psycho-social holistic nursing perspective, the opportunity for creativity and renewed development of the public health system can be achieved.

REFERENCES

(1) O'Brien, A.J. (2002) Judging care against standards in mental health. Kai Tiaki Nursing New Zealand; 8:11,22-23.

(2) Parsons, C. (2002) Advocating for mental health patients in a system under stress. Kai Tiaki Nursing New Zealand; 8: 11, 24-25.

--Brent Doncliff, RCpN, BN, Dip HealthSci (Nsng), is a health service and management consultant in private practice based in Wairoa, Hawke's Bay.