New director of mental health should bring sigh of relief

By Carroll du Chateau

By CARROLL DU CHATEAU

In a profession where doctors and managers alike tend to pussyfoot around the blindingly obvious, forensic psychiatrist Dr David Chaplow is as refreshing as a cool, effervescent glass of Perrier.

For 23 years Chaplow, one of the least politically correct - and most effective - people in the business, has worked at the sharp, tough end of mental health care.

As director of Auckland's Mason Clinic for the criminally insane, his clients included people such as the nurse who, after hearing voices, killed her elderly patients by beating them and kicking them down the steps of their Paratai Drive home.

As the director of Regional Psychiatric Services responsible for the development of regional forensic services for Auckland, Chaplow has also put together one of the best forensic mental health services in the world.

Six weeks ago Chaplow, now 56, was promoted to the two top mental health jobs in the country. As Director of Mental Health he is responsible for the way the Mental Health Act is used, both in the community and by the country's 22 directors of mental health.

As he describes it, "People who care for people are accountable to me."

But it is his second role as Chief Adviser, mental health, to the ministry, which is possibly more important, signalling a long-awaited stiffening of attitude towards mental health policy at government level.

You can pick Chaplow's straight-shooter style throughout the past decade. After the release of an 188-page report into the treatment of diagnosed schizophrenic Johnny Manu in July last year, Chaplow did not take the politically acceptable line expected from a psychiatrist of his standing. "The Mason Clinic is far too small for the demand. Our 60 beds have replaced 400," he said bluntly.

Again, after the Lachlan Jones report - a schizophrenic who axed Malcolm Beggs to death in Universal Drive in 1999 and then killed himself - Chaplow insisted, "Yes, we do need more institutional care for people. If our crisis units are operating at 80 per cent, that's too tight."

Why? "These are not hotels but crisis units. People crack in prison and in the community, they need care and they need it now."

Chaplow's quiet determination to wring more facilities for mental health out of the system is well known. Throughout the dismal decade following the closing of New Zealand's mental hospitals without adequate community facilities in place to care for patients, he has had the courage to speak out and to criticise.

Where Chaplow goes, facilities follow. His area of forensic medicine is not strangled by politically correct attitudes. All of which means that today, while most parts of our mental health service have dangerous gaps, New Zealand's forensic service is world-class.

And still Chaplow argues for - and gets - more beds, more staff, more resources. The newly-released report into Forensic Services, signed off by Janice Wilson, deputy director-general of the Mental Health Directorate, recommends introduction of 31 new forensic and forensic step-down beds (that is highly-supervised community beds) throughout the country, new prison forensic teams, court liaison teams plus what are called community assertive treatment teams.

Against this background, it is no surprise that Chaplow has been elected to move to the Ministry of Health in Molesworth St, Wellington, to head the mental health sector on an open-ended contract - a decision which, like most things under this Labour Government, shows the hand of Prime Minister Helen Clark.

It was Helen Clark who was Minister of Health in 1989 when Chaplow arrived back in the country after 10 years in Queensland, training and working as a specialist forensic psychiatrist.

At the time Auckland mental health was in chaos.

"I was just appalled," says Chaplow. "Oakley Hospital had just closed, Carrington was a shell of its former self with 350 people. Titewhai [Harawira] was in prison [for assaulting a patient at Carrington's Maori mental health unit, the Whare Paia]. We almost didn't come, but in the end we decided there was something we could contribute.

"Then, the day I arrived in March 1989, Ms Clark sacked the Auckland Hospital Board. We didn't buy a house for three years because the situation was so unstable. There were major changes in deinstitutionalisation - basically they were emptying the hospitals in the face of few facilities in the community."

Today, Chaplow sits in the back garden of his detective son's One Tree Hill home, drinking the mug of tea brought by his daughter-in-law Joanne while friends and babies come and go - thinking back to the years when patients routinely set fire to the chapel at Carrington and treatment for the criminally insane meant straitjackets - and his two-month-old grandson gurgles in the background. "I can remember sitting bolt upright at midnight and saying to my wife, 'My God, what have I done?"'

In 1968, when he met his wife Rebecca during "a very short stint" working as a GP at Whakatane, life was much simpler. "It was a seminal event, meeting Rebecca," he says. "She came from Matapihi in Tauranga, from the Ngai Te Rangi tribe. It was one of those classic nurse meets doctor across the table things. Seeing those wide, unblinking eyes ... "

Together the couple moved to Kopeopeo, a small 50 per cent Maori suburb in Whakatane where Chaplow, whose mother spoke Bengali and whose grandfather had been a missionary to India and wrote five books on Islam, was the traditional family doctor delivering about 130 babies a year, dealing with psychological problems, the lot.

But it was his fluency in Maori, plus his affinity with Maori mental health that was most hard to come by, and highly prized, in 1970s New Zealand. "I was asked to join the Whakatane Psychiatric Unit one day a week," he says "and it soon became clear that I needed to train in psychiatry if I was going to continue. So Becky and I and [by then] four kiddies upstumped and went to Brisbane.

"That was a very dark chapter of my life," he continues. "It was tragic to see how the mentally ill were dealt with in prison - very typical of the way things were happening around the world. And this despite the advances made in Britain after the Butler Report said that mentally sick people in prison should be brought into secure hospital care."

Ten years later, with a Fellowship of the Royal Australia and New Zealand College of Psychiatry (FRANZCP) plus seven years working in Brisbane's 1800-patient psychiatric asylum and in the prison forensic service, Chaplow was back.

In New Zealand the system had taken to the reform process with gusto. Between 1988 and 1991 the health sector, and particularly mental health, was rocked by shockwave after shockwave. Deinstitutionalisation, said mental health experts and the cash-strapped Auckland Hospital Board, was the long word for compassion.

Hundreds of people released from Carrington Hospital went into boarding house arrangements not equipped to look after them. Only the most difficult and dangerous inmates, about 25 in all from Kingseat and Carrington, formed the core who ended up in the Mason Clinic.

"Things had been torn apart with nothing in place to replace them. Can you imagine trying to develop anything against this scenario?" says Chaplow, grey eyebrows raised above twinkling blue eyes. But, as New Zealand's newly-appointed first Director of Regional Forensic Psychiatry for Waitemata Health and member of the National Forensic Advisory Committee, he had little choice.

While Rebecca worked as a pioneer in psychiatric court liaison, then gained her diploma in mental health (she is now completing an MBA from Massey University), Chaplow set about putting together the country's first true forensic mental health service. It was a tough environment.

"Frankly, a lot of people had to be sacked, others had to be brought into line," he says. "The alignment between management, clinicians, Maori and the unions was very bad. The guidance given by Ken Mason [author of the Mason report into mental care] provided a template for us to drive through cohesion out of the shambles."

Although he was primarily concerned with forensic and Maori mental health, Chaplow, with his unassuming manner and lack of obvious neuroses, brought clarity to the general confusion.

"I can remember someone saying to me, 'My God, David, you're the most normal person I've ever met."'

Between 1989 and 1993 six forensic regions - Otago, Christchurch, Wellington, Wanganui, Hamilton and Auckland - were established and forensic care teams and secure units built. The Mason Clinic, just behind Carrington Hospital (now Unitec), opened in February 1992, and became the country's main forensic mental health unit. As Chaplow, who had purpose-designed it from the beginning, says, "At last I had a hospital, and a service, to become director of."

Today Chaplow is justifiably pleased with the Mason Clinic which took the place of the feared, old-fashioned and scandal-ridden Oakley.

"New Zealand should be proud ... I'm proud. My team took the vision of Ken Mason and his inquiry team and made it happen. We've compared our recidivism figures with Canada who are considered the best in the world, and we're better than them. Even our homicide rate is on a par with the British and Canadians."

Now, hopefully, Chaplow is about to work the same magic for the rest of our mental health services. How? He takes a pen and scribbles his master plan on the back of the newly-released Framework for Forensic Mental Health Services.

"This is the problem area," he says, putting a thick black border round one section, "the DAMHS, the District Adult Mental Health Service." What Chaplow is talking about is the community care section of psychiatric services - the part of the service that brought us Lachlan Jones, Johnny Manu and the rest.

Why do these avoidable cases keep coming up? "The weakest link is the community," he says. "We haven't got enough horsepower. Teams are very thinly stretched."

His plan has two prongs. Strengthening statutory leadership via the act - basically to encourage directors to take closer oversight of their clinicians. Health Minister Annette King's edict seeking a standardisation of privacy policies to allow parents, caregivers and flatmates into the information loop following the Malcolm Beggs murder is a good start. But Chaplow wants more.

"We work with about 12 different acts. People come to me and say, 'David, what are we going to do here?' I say, first establish what's common sense and what's good clinical practice. Obviously it's not sensible to leave out caregivers when talking about medication. People who use the Privacy Act to avoid giving out information don't get much sympathy from me."

Prong two is to "haul the various interest groups out of their silos and make them work together." This includes tying together the Mental Health Commission with its focus on benchmarking and anti-discrimination programmes and the ministry, prioritising child and adolescent services, strengthening community forensic services "so providing a clinical pathway that takes people through from sickness, risk and maybe crime, and to rehab" plus keeping the impetus going in Maori and Pacific Island mental health.

"My dream really is to have clinical systems which match the enthusiasm of individual staff and meet the needs of patients," says Chaplow. "Community care is going to be a career option [for clinicians, nurses and psychiatric social workers]. People will be safe in their jobs and rewarded by them. We need a workforce that's up to scratch, with high retention, high morale, well led. Right now staff turnaround in some areas is 20-30 per cent a year. We achieved a workforce turnover of about 6 per cent when I was director of the Mason Clinic which was terrific."

There is progress. Legislation due within the next year will bring intellectually disabled people under compulsory care legislation.

"The Mental Health Act actually excluded committal of the mentally disabled who didn't have a mental illness, so we didn't have any purchase on them," explains Chaplow, who is part of the advisory group to the bill. "The new legislation, which applies only to those charged with an offence, will allow courts to send mentally disabled people to compulsory care instead of prison. Then, if danger still exists after their sentence, people will be able to be brought before the court again to apply for an extension of the compulsory care order."

As he says, "It's better than what we've got. You can at least keep intellectually disabled people, who can't control their sexual urges, under compulsory care."

But what about the old, old problem of people who look as though they might offend (such as Lachlan Jones who didn't come under the forensic ambit but was obviously highly dangerous and in the high-risk category)? What power does the system have over them? Again, with disarming honesty, Chaplow admits he doesn't have all the answers - yet.

As he collects our coffee cups, he ponders. "What does it take? In that case I don't know ... Again we're looking for statutory leadership via the act. Remember, I've been in the job only six weeks. We've got a lot of work to do, but I'm excited. I believe we can do it."

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