As the effects of financial constraints ripple through the health sector, mental health care is particularly feeling the pinch.
Let's start with the back story.
In the 1990s, when big hospitals like Carrington and Kingseat closed, it was feared people with mental illnesses would fall through the yawning gaps in community-based services. And so it proved.
Horror stories followed.
By and large, things have improved for people needing mental health services - especially since the introduction of the Blueprint for Mental Health and a government requirement that funds allocated for mental health services could not be siphoned off by district health boards for "sexier" areas of expenditure or to reduce budget blowouts. Ringfencing, it was called.
The range of services by community providers has expanded considerably in recent years under a funding model in which district health boards issue Requests for Proposals for new services, using budget allocations linked to blueprint targets.
Though it was far from perfect, mental health expert Janet Peters says New Zealand's system, after a rocky start, has become highly regarded internationally for innovation in community mental health services.
The gaps have narrowed but the recession and government policy changes have hit community mental health agencies.
Ahead of last year's Budget and again this year, the Government has asked health boards to do all they can to trim deficits. Many agencies on one-year funding contracts fear cuts in funding from July 1 - some have already been told to expect them.
They fear more is to come. Some agencies have been told the Government is planning to lift the requirement that health boards ringfence mental health funding after the 2010/11 financial year.
They say some boards are already bending the rules by, for instance, withholding annual inflation adjustments.
There is also insecurity about how planned policy initiatives will affect the non-government (NGO) sector: the proposed national health board to plan and integrate services, the rollout of the Whanau Ora Maori community health programme and a funding shift away from secondary (hospital-based) services to the primary (GP) sector.
The community sector is already feeling the squeeze.
In Auckland, the Mind Matters house, a highly regarded recovery centre for teens and young adults, closed last month - six weeks after funding ceased from Waitemata District Health Board for three of its five beds (Auckland DHB funds the other two). Waitemata made the decision for other than funding or performance reasons.
In Christchurch, the 198 Youth Centre which provides general and mental health services, plans to close on April 30.
Wellington is one of the worst affected areas, with the Capital and Coast District Health Board warning NGOs of the need to trim $10 million from community health spending, including mental health. Neighbouring Hutt Valley DHB is also looking to trim some contracts.
But the picture varies markedly nationwide as do DHB deficits and funding approaches. The Gisborne-based Tairawhiti District Health Board says a decision to switch to an Auckland-based contractor for general mental health services will lead to better support and a focus on recovery.
The New Zealand Mental Health Survey found 4.7 per cent of New Zealanders experience severe mental health or addiction problems requiring DHB-funded services.
Mental Health Commissioner Peter McGeorge says only now is technology being introduced to count how many people are being supported in the community.
"Since deinstitutionalisation there could be thousands of people being supported in a whole variety of ways by NGOs without the people making [funding] decisions really being aware of them."
McGeorge says there's widespread uncertainty about what government policy changes and belt-tightening will mean for mental health NGOs.
"It's not that people don't support the changes but they don't know what's going to happen and what their place in the system will be.
"There's a need for more co-ordination regionally if not nationally."
Marion Blake is chief executive of Platform, an umbrella group of mental health and addiction NGOs. She understands the Capital and Coast and Hutt Valley DHBs plan to cut over $2 million in NGO funding for mental health.
"We know that money's short and there needs to be financial prudence in the health environment," says Blake. "But unless we do that in a sensible and planned way you get kneejerk responses that take away things which are quite critical to parts of the community.
"It's the insidiousness of it. The thinking is 'take a little bit off here, and a little bit off there'. A whole layer of community support services is being undermined by this piecemeal approach, which is just saving pennies really.
"There's an urgent need for an overall plan to resolve this crisis - but at present all DHBs are doing is picking off individual organisations, telling them to make considerable cuts."
Blake says the ringfence has proved "the best thing that ever happened to mental health in New Zealand". If it goes, she suspects services will soon be eroded as DHBs look to shore up hospital-based services.
"It means that money identified specifically for mental health services will just go into a big pot. Much of health board funding is demand-led - there will be hip replacements,which are much more attractive than mental health.
"I think we are seeing a major change in the way community mental health services will look after people. The fear is that DHBs will say they can absorb that work."
Rob Warriner, chief executive of the West Auckland-based Walsh Trust, says health boards are driven by their need to claw back funds where they can. "There seems to be very little discussion around where services should be heading - it's almost strategy by spreadsheet and red pen."
Warriner says Auckland services are fortunate in having moved to a three-year funding cycle whereas agencies in other districts are on one-year contracts.
He says mental health is not a "sexy" target for health funding and the ringfence led to better planning and development of services.
Warriner believes it's time to re-think the operating models used to provide mental health services.
"Twenty-five per cent of the total mental health spend goes to acute, hospital-based services, when the great majority of people who experience mental illness live in the community.
"This crisis demands significant reform of how the mental health sector is funded and provided, with less focus on DHB [secondary] services and more focus on socially inclusive services where people live."
A spokesman for Health Minister Tony Ryall says the planned shift of frontline services to the primary sector should not threaten NGO services. The new national health board planned to meet NGOs to discuss their concerns.
Associate Health Minister Dr Jonathan Coleman District Health Board said mental health funding went up $85 million to $1.181 billion last year, but would be reviewed to deliver the best services.
Funding would remain ring-fenced, he said, but board's needed spending flexibility.
AN ESCAPE FROM THE DHB BUBBLE
Student Liz Morton was referred to the Mind Matters Trust house in Titirangi as a 17-year-old in late 2003, after a previous admission to the Starship child and adolescent unit.
She has since spent occasional further periods at the house when acutely unwell.
Each visit has greatly assisted her recovery.
"Part of it was just removing me from my situation, but there was also a rehabilitation emphasis you would not get elsewhere," says the poised and confident 24-year-old, who is now studying part-time at Auckland University.
"We would actively work on recovery, looking at how to deal with symptoms and initiate routines to get back to basics. It was focused on getting you back into the community rather than staying in the bubble that is [District Health Board] mental health services."
"It was quite intensive in terms of working towards recovery," Morton says.
"A lot of places offer time-out but they don't necessarily bring you back to the community and teach you the skills to resume your normal life.
"The one-to-one relationship with specialist staff was amazing.
"The environment was beautiful. It was very therapeutic, with views out to the Manukau Harbour and the bush, and the fact it was just for young people. It certainly saved me going into hospital a couple of times. In a lot of units you are surrounded by older, more chonically ill people, and that can be frightening.
"It's bizarre to be shutting it now - it's as if District Health Boards had a more intuitive view of mental health care in 2003 than they do in 2009.
"It's so important we have these places and supported accommodation - otherwise there's nowhere else to go.
"There's nothing else around that's focused on young people."
Morton is taking arts and sciences papers at university, with the long-term goal of a medical career.
FUNDING A MIXED BAG
Capital and Coast District Health Board has signalled $10 million cuts in community health spending, including mental health.
Wellink is a charitable trust with about 130 staff who work with Wellingtonians experiencing severe mental illness. Chief executive Virginia MacEwan says the DHB has signalled a significant funding cut for the 2010/11 financial year, blaming its large deficit. "At least 80 per cent of our funding goes on staff so there will be staff losses and service cuts.
Platform, an umbrella group of mental health providers, claims $2 million will be trimmed from mental health spending in Wellington and the neighbouring Hutt Valley DHB. Chief executive Marion Blake says the agencies help about 1500 people daily in the two districts.
"What we are facing is considerable numbers of people ... who will no longer have access to quality support services. They will suffer, their families will suffer and communities will suffer."
She says Wellington NGOs had been moved off three-year contracts and on to one-year arrangements.
"They are providing services to probably 1500 people on a daily basis and we haven't got a guarantee they will be running in three months time."
The Clubhouse, a Newtown drop-in centre with up to 1700 visitors a month, says it faces a 10 per cent cut in funding which will affect staffing levels.
"I don't see how we can operate safely with a third less staffing," says general manager Karin Keith. "The cut is effectively our annual rent. We can't provide the service from the street."
Capital and Coast spokeswoman Raylene Bateman says a figure for mental health savings has not been specified and no decisions have been made. She says agencies have been asked to consider a range of potential savings.
The Lower Hutt Women's Centre, which receives funding for mental and general health services from the Hutt Valley DHB, says it was verbally advised that funding would cease from July 1, removing half its annual budget.
But Hutt Valley acting chief executive Michael Hundleby says the women's centre is one of a small number of contracts under scrutiny and no decisions have been made.
The closure of the 198 Youth Centre at the end of next month has sparked protests and marches. The service with about 1000 clients has provided free sexual health, mental health and GP services for 15 years.
It needs about $700,000 to keep running but Canterbury District Health Board funding for 2009/10 fell from $550,000 to $460,000, The Press reported. This year, the board signalled a move to a new youth one-stop shop.
The looming closure of Christchurch's Refugee and Migrant Centre is a further blow to the city's needy groups.
The Tairawhiti District Health Board's decision to award mental health support contracts to the Auckland-based Challenge Trust means a $400,000 budget cut for existing provider Turanga Health and the loss of 15 jobs. Respite and rehabilitation services leading to jobs or training will be cut back, says Turanga chief executive Reweti Ropiha.
But Tairawhiti CEO Jim Green says the decision is not cost-driven but aims to provide a wider range of services for the same money. He says the move will mean people get better support with more emphasis on recovery. He says Turanga will continue as a Maori provider.
ADHB funding and planning manager Robert Ford says about a third of the board's mental health budget goes to community based agencies and funding has grown by about 7 per cent a year between 2006 and 2009. He says line-by-line reviews are not unusual and it's sensible that boards are prudent with public money and seek to get the best from services.
Ford says the Auckland, Waitemata and Counties Manukau DHBs try to be consistent and have moved contracts from one-year to three-year terms. He expects funding for 2010/11 to be similar to this year's and the board is not looking to make any cuts based on financial constraints.
Louise Carr is CEO of Pact Group, which provides mental health services in Otago, Southland and the West Coast. Carr is also an Otago DHB member. She says there's no pressure to limit or rationalise contracts in her area.
She says the Government has asked DHBs to try to move some secondary (hospital) services to community providers where it's cheaper.