Warning: This article is about suicide and may be distressing for some readers.
A goal of reducing New Zealand's total suicide rate by 20 per cent over 10 years was rejected over fears the Government would be held accountable if the rate didn't drop.
The target would have seen New Zealand aiming for 12 fewer people to die from suicide per year, each year until 2027. An expert panel created to advise the Ministry of Health concluded that target should be the main purpose of the ministry's new suicide prevention strategy.
But Health Minister Dr Jonathan Coleman's office pushed instead for vague phrasing, like "reduce rates of suicide", that wouldn't become an "accountability measure" for the Government.
That went against the unanimous advice of the expert panel that said using the clear, measurable target was the best way to get the whole country on board and help cut the suicide rate.
Comedian and suicide prevention campaigner Mike King stepped down from the panel in May after the Ministry of Health's eventual draft strategy was published, calling it "impenetrable", a "masterclass in butt-covering", and "deeply flawed".
Email correspondence released to the Herald under the Official Information Act shows the 20 per cent target "suggestion" was dropped after the Government's principal mental health adviser Dr John Crawshaw ran the idea past Health Minister Dr Jonathan Coleman in late February.
After meeting the minister, Crawshaw emailed the expert panel on March 3, saying: "Please be aware that we have raised the suggestion of a purpose of 20% reduction in suicide rates over 10 years.
"We have been asked how this can avoid becoming an accountability measure for Government, with insufficient levers, rather than a purpose to motivate the all-of-community approach."
The correspondence was released during work on Break The Silence, a Herald special series focusing on youth suicide. New Zealand has the second worst suicide rate among those aged 25 and under in the developed world. Our teen suicide rate - officially those aged 15-19 - is the worst.
It's not clear if Coleman or someone else in his office asked for the target to be reworded.
Crawshaw asked panel members for suggestions on how to make the strategy more palatable. At least two refused, sending back strongly-worded suggestions which said the 20 per cent target was a central plank of the strategy and should be kept.
Middlemore Hospital's clinical director of mental health and addiction, Dr Peter Watson, advised that having no target "will increase many people/groups' frustration that there appears to be limited action in a suicide prevention space".
"Setting a target is very likely to engage people in a strategy that is more meaningful in terms of a national response to suicide. This will draw focus and attention to the area but also require a 'this is everyone's problem' approach."
He dismissed the suggestion that the Government did not have the means to reduce suicide rates.
"Given that around 30 per cent of suicides occur within MH [Mental Health] service users there seems some available levers to address this."
Other effective levers would include action on alcohol reduction, reducing access to means of committing suicide, and upskilling emergency department and primary care workers, he said.
Watson told the Herald he has long pushed for a target. He had not been told why it was removed except that "the Government wasn't keen".
"At some level I understand - maybe we wouldn't reach it," he said. "My view is it's an aspirational target that helps drive activity. If we fail to meet it, we try harder and take a different approach."
In his response to Crawshaw, Emerge Aotearoa's Shaun McNeil said 20 per cent was "modest but achievable" and asked: "Why shouldn't it be an accountability measure?"
"Let's make sure there are sufficient levers! Let's use language and better articulate why it is an all-community issue which will require an all-community solution!"
The documents say the changes were ultimately made due to "political concern that Government will be held accountable for achieving this 20% reduction, when they don't have all the levers for doing so".
The strategy's purpose was originally "to reduce the suicide rate by 20 per cent . . . by 2027". But briefing notes for ministers labelled the target "contentious" and said the target had been "couched as 'to reduce rates of suicide'".
"There have been strong suggestions for a more specific reduction in suicide rates over 10 years, such as a 20% reduction over 10 years. This has not been included in the draft strategy over concern that it would be seen as a government accountability measure," it said.
The Herald asked Coleman what was meant by "accountability measure" and whether he thought the 20 per cent target was feasible.
In response he said: "The tragedy of suicide arises from many influences and factors. There are many opinions on how realistic or useful an arbitrary numerical or percentage target in relation to suicide would be. Opinions range from zero advocates, to having a goal of lowering rates."
Public consultation on the draft suicide prevention strategy ended on June 26 and officials are now preparing advice, he said.
"I have said publicly that I am open minded about further discussion on a target, including discussions with the science advisors. Any target is meaningless without the right policies, it's really important to get the settings right.
"Suicide is a whole of society problem and there needs to be an increased focus on resilience and mental wellness."
That "whole of society" response is exactly why Scotland's health ministry set a suicide reduction target.
The Scottish Government set a goal in 2004 of reducing suicides by 20 per cent over 10 years. Ten years later, suicides were down 18 per cent and have since fallen further.
Shirley Windsor, the organisational lead for Public Mental Health in Scotland, said the target had been essential in getting the entire community on board, from families and frontline workers to the highest level of Government.
So many changes were made that it's hard to know exactly what has made the difference but two factors were essential. One was creating mental health coordinator posts for each district, with funding from local and national government.
The other was training all frontline health professionals to spot the first inklings of depression or other problems, and ensuring they knew how to start conversations with people who might be at risk - even if they didn't meet the threshold to be referred for mental health treatment.
Deputy director of mental health Dr Ian Soosay said Ministry of Health officials had met with Scottish mental health experts to discuss their success.
He said it was "impossible" to be certain what made the difference, but possible factors included reducing access to means of suicide, cutting alcohol consumption and better access to mental health crisis services.
"The ministry will be looking at whether any of the actions taken in Scotland are likely to be effective here."
Several submissions on the draft strategy call for the 20 per cent target to be reintroduced, including a collective submission from bodies including Lifeline, the Northland DHB and the Mental Health Foundation.
The group said the strategy was inadequate and a missed opportunity to present "a strong, ambitious vision for reducing suicide in New Zealand".
They also pointed out that New Zealand has already committed to a 10 per cent reduction in suicide in the World Health Organisation Mental Health Action Plan 2013-2020; it's not on track to meet that goal.
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WHERE TO GET HELP:
If you are worried about your or someone else's mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call 111.
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