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The place of public inquiries in shaping New Zealand's national mental health policy 1858–1996

The place of public inquiries in shaping New Zealand's national mental health policy 1858–1996 Background: This paper discusses the role of public inquiries as an instrument of public policy- making in New Zealand, using mental health as a case study. The main part of the paper analyses the processes and outcomes of five general inquiries into the state of New Zealand's mental health services that were held between 1858 and 1996. Results: The membership, form, style and processes used by public inquiries have all changed over time in line with constitutional and social trends. So has the extent of public participation. The records of five inquiries provide periodic snapshots of a system bedevilled by long-standing problems such as unacceptable standards, under-resourcing, and poor co-ordination. Demands for an investigation no less than the reports and recommendations of public inquiries have been the catalyst of some important policy changes, if not immediately, then by creating a climate of opinion that supported later change. Inquiries played a significant role in establishing lunatic asylums, in shaping the structure of mental health legislation, establishing and maintaining a national mental health bureaucracy within the machinery of government, and in paving the way for deinstitutionalisation. Ministers and their departmental advisers have mediated this contribution. Conclusion: Public inquiries have helped shape New Zealand's mental health policy, both directly and indirectly, at different stages of evolution. In both its advisory and investigative forms, the public inquiry remains an important tool of public administration. The inquiry/cause and policy/effect relationship is not necessarily immediate but may facilitate changes in public opinion with corresponding policy outcomes long after any direct causal link could be determined. When considered from that long-term perspective, the five inquiries can be linked to several significant and long-term contributions to mental health policy in New Zealand. ollaries of special purpose residential institutions, medi- Background New Zealand's mental health policy and services have cal management and separate legislation. Colonial evolved along similar lines to other "old Common- administrators and politicians preferred the English sys- wealth" countries. Like other British colonies of settle- tem of institutional care over the Scottish mixed system of ment in the nineteenth century, New Zealand lunatic asylums and boarding out or community care. The endeavoured to adopt the progressive ideas of the non- concentration of specialised resources in residential care restraint system of care and treatment, along with its cor- facilities that were known at different times as lunatic asy- Page 1 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 lums, mental hospitals or psychiatric hospitals isolated require them to be produced. Some modern inquiries them professionally, socially and administratively from have undertaken or commissioned their own research. mainstream health and social services. Institutions The cost of an inquiry depends upon its duration, the remained dominant until the late twentieth century, even number of members, the size of the secretariat, the though the spectrum of mental health services widened in amount of travel for hearings or site visits, or the use of response to demands for general hospital psychiatry from overseas experts, counsel and technical advisers. A very the 1920s, community care from the 1960s and, more comprehensive manual – the latest procedural guidance recently, deinstitutionalization. The ebbs and flow of pol- to New Zealand inquiries prepared since 1925 – is mind- icy and service development in New Zealand, however, as ful of the growing body of precedent and inquiry-related in many other countries, typify a classic feature of mental jurisprudence.[4] health policy – alternating bursts of policy development and funding interspersed with long periods of quiet incre- Some scholars in the United Kingdom, Australia, Canada mental change, indifference, or even stagnation. These and New Zealand have been interested in the general pol- longstanding cycles make mental health an interesting icy-making role of inquiries. Theses by Alan Simpson policy domain in which to study the impact of public (1972) and Deborah Iversen (1992) are the best general inquiries as an instrument of reform. source of information about public inquiries in New Zea- land. Their research shows an enormous range of topics A public inquiry is a relatively independent investigation considered by inquiries. Published checklists do not that considers facts and evidence on some assigned topic, include every public inquiry held in New Zealand.[5,6] draws conclusions, and reports, usually with recommen- dations. An inquiry is publicly accountable to the New Some newsworthy incident, revelation, or a level of public Zealand Parliament or to the executive branch of govern- disquiet that makes an issue politically sensitive usually ment, most usually the Governor-General (the Queen's triggers an inquiry. Setting up an inquiry allows for an representative), government, minister, or some senior issue to be carefully considered for a time without disrupt- official, according to the status of the inquiry. ing the regular administration of government. An inquiry has prestige, legal authority to obtain information and it The public inquiry is a very versatile tool of public admin- can provide some protection to parties. Membership can istration and remains part of the apparatus of government be determined according to the nature of the issue. In in various Commonwealth jurisdictions. There has been a some cases, representatives of particular interest groups distinct shift from inquiries by parliamentary select com- might be brought together to facilitate consensus-build- mittees towards executive-appointed inquiries since mid- ing; in others, respected arbiters may be needed. Much of Victorian times as the device has evolved within the West- an inquiry's work is publicly visible. The invitational and minster constitutional system.[1-3] The executive- participative approach of a modern inquiry widens the appointed inquiry was legitimated in New Zealand in input to government policy-making. 1867 and is now the basis of most inquiries. Such inquir- ies can be initiated by the government, (royal commis- An inquiry is relatively free within certain parameters to sions and commissions of inquiry), ministers of the interpret its mandate, determine how it will gather infor- Crown (committees of inquiry), statutory agencies or offi- mation, formulate its arguments, organise its report, and cials. Royal commissions are generally held to have make recommendations as it chooses. The membership, greater prestige and standing than other forms of investi- terms of reference, and duration of an inquiry – all of gation, and they have been used traditionally to inquire which are determined by the minister or government of into topics of outstanding public importance. Royal com- the day – affect the degree of independence. missions are of medieval origin. The Governor-General of New Zealand appoints them in the Queen's name. Com- Ad hoc and temporary, an inquiry is said by Hallett to missions of inquiry are constituted by an Order in Coun- arise suddenly, like a mushroom and to vanish just as sud- cil under the Commissions of Inquiry Act 1908. The denly, once it has presented or forwarded its report to the Governor-General acts on the advice of ministers in mak- initiating public body or official.[7] An inquiry's report is ing appointments to either type of inquiry. Many Acts of then analysed by officials and ministers, who decide how Parliament vest statutory bodies with the powers of a to handle the recommendations. The report is usually commission of inquiry. published. A number have been tabled and printed in the parliamentary papers. The Commissions of Inquiry Act 1908 and amendments give a properly constituted inquiry wide powers to con- A public inquiry serves an advisory or investigative func- duct proceedings, summon witnesses, call and take evi- tion. An advisory inquiry addresses a broad issue of public dence on oath, inspect and examine documents, or to policy. An investigatory inquiry establishes the facts of Page 2 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 some incident or tragedy. The distinction between advi- Defectives and Sex Offenders (1924–25), would have sory and investigative inquiries is not always clear-cut. been included had it interpreted 'mental defective' to Investigation of an incident may lead to consideration of include mental illness as well as what is nowadays usually the policy context. The study of policy may expose abuses called intellectual handicap or intellectual disability. or mistakes.[8,9] Simpson claims that the great majority Some other advisory inquiries have touched incidentally of inquiries in New Zealand have been investigative.[10] on mental health matters, e.g., those set up to investigate That is certainly so for mental health inquiries. Significant law and order, social security, or government administra- examples of investigative inquiries in this field include tion. Such inquiries are not included in this study. inquiries into abuse and ill-treatment at the Wellington Lunatic Asylum (1881), structural defects and faulty work- Methods manship at Seacliff Lunatic Asylum (1888), suicide at The study was undertaken by reviewing the literature on Ashburn Hall licensed house (1896), a tragic fire at Sea- the evolution, functioning and achievements of public cliff Mental Hospital (1943), short-staffing in mental hos- inquiries as an instrument of government policy-making pitals (1946), the administration of Oakley Hospital, in New Zealand and comparable Commonwealth juris- Auckland (1971), the state of forensic psychiatry services dictions. The research on the five mental health inquiries (1987), and the death of a person being taken into psychi- used standard historical method based on published and atric care (1994). My analysis of mental health inquiries unpublished official records. The New Zealand Parliamen- held between 1987 and 1995 showed that these were also tary Debates provided the political context of each inquiry. investigative. Investigative inquiries provide a sort of 'rit- The reports of three inquiries were published in the Appen- ual cleansing' as a former New Zealand top mental health dices to the Journals of the House of Representatives and the official once put it.[11] On the other hand, the spate of others were published separately by the Department/Min- investigatory mental health inquiries in recent years has istry of Health. Terms of reference and membership of raised hints about the futility of 'another cycle of Inquiry some public inquiries were published among the official [sic] fatigue,' a standpoint warranted, perhaps, by mixed notices of government in the New Zealand Gazette. evidence about the outcomes of earlier investigative Records from the five inquiries have survived among the inquiries.[12] archives of the Legislative Department, the Department of Internal Affairs (which has general responsibility for the New Zealand's general mental health inquiries administration of public inquiries), and the departments Five general or policy-advisory inquiries have been con- of state responsible at different times for national mental ducted into the state of mental health services (as that health policy: the Lunatic Asylums (1876–1905)/Mental term was understood at the time) since the institution of Hospitals (1905–1947) Department, and the Department parliamentary government in New Zealand in 1854. They (1947–1992)/Ministry (since 1992) of Health. The Divi- were the sion of Mental Hygiene or Mental Health (1947–1992) provided a particular focus within the Department of  Select Committee of the House of Representatives on a Health, as has the Mental Health Section or Directorate in General Lunatic Asylum (1858), the Ministry of Health. The records and reports of each inquiry provide rich sources of material. Unpublished  Joint Parliamentary Committee on Lunatic Asylums records of an inquiry may include the warrant of appoint- (1871), ment, a transcript of proceedings, manuscript and printed reports, and administrative and financial correspondence.  Board of Health Committee on Psychiatric Services in Official records have been augmented by reference to con- Public Hospitals (1957–60), temporary press comment. Archives of the Legislative Department and Internal Affairs Departments and those  Royal Commission on Hospital and Related Services of some provincial governments were accessed to provide (1972–3), and the information on the follow-up to the inquiries of 1858 and 1871. The Department of Health Archives were used to  [Ministerial] Inquiry in respect of Certain Mental Health obtain comprehensive information about the extent of Services (1995–6). bureaucratic influence over later inquiries. Records of the Ministry of Health concerning the Ministerial Inquiry of The full titles encompass the main forms of inquiry avail- 1995–6 have not used because of the likely sensitivity and able under New Zealand law. These inquiries will be topicality of those events. referred to hereafter by their abbreviated title. The nature and number of advisory mental health inquiries can be Results confidently established from a study of published official In this section, I will outline the background of each of the records. A sixth, the Committee of Inquiry into Mental five inquiries, the membership, duration, procedures, and Page 3 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 outcome. I will then consider how each inquiry contrib- ing on whether official returns or political estimates were uted to national mental health policy. used), the idea of a central asylum for the whole colony made sense to provincial politicians on the grounds of Select Committee (1858) humanity and efficiency. The financial argument – that a Insanity was scarcely anticipated as a public policy matter colonial facility might relieve the provinces of financial when New Zealand became a British colony in 1840. The responsibility – hinted at the underlying political earliest known insane persons came to official attention dynamic. The provincial system (1852–76) created inher- because they posed a threat to public safety, could not ent tensions between the relative responsibilities, author- safely look after themselves, or because they had no fam- ity and fiscal powers of provincial governments and the ily to care for them. Care of such persons fitted the gener- central government. Provincialism was intended to ally accepted purposes of colonial government and the address demands for a measure of self-government in the civilising mission of British imperialism. The foundation isolated and scattered settlements of the colony. Finan- documents of the new colony anticipated a system of law cially struggling provinces, however, quickly learned how and order that was gradually established in the principal hard it was to discharge their responsibility to provide Pakeha (European immigrant) settlements. The colony's adequate and acceptable care for lunatics. In such circum- first mental health legislation, the Lunatics Ordinance stances, transferring responsibility to the central govern- 1846, limited disposition of a lunatic to a gaol, house of ment was attractive to the provinces. correction, or public hospital until the person was dis- charged or transferred to a 'public colonial lunatic asy- The Select Committee's membership reflected this politi- lum'. Lunatics who were not dangerous were a secondary cal dynamic. Four of the six provinces were represented on concern. This pragmatic approach was typical of other the 8-person committee. Every member had been British colonies, but it had its drawbacks. Opinion-makers involved in provincial politics and five held concurrently considered improvised care in gaols or public hospitals as parliamentary and provincial seats. EW (later Sir Edward) inhumane, inadequate and administratively irksome. A Stafford, for example, was both a provincial and national 'community care' option of boarding out or repatriation politician and took a lead as a member of the Select Com- was rarely used, except perhaps for Maori. mittee. As Premier and Colonial Secretary (the minister nominally responsible for lunacy policy and legislation), Colonial authorities took their lead from the imperium he personally followed up the Select Committee's where a burst of activity had consolidated a policy frame- report.[13] Only two committee members – one a magis- work in England during the 1840s. The state regulated trate and the other a medical practitioner – were profes- admissions and discharges through a process now known sionally acquainted with the problem of lunacy. as committal. Marketplace activities were publicly moni- tored. A chain of public lunatic asylums was under con- The Select Committee heard evidence from medical prac- struction across the country. A specialised bureaucracy titioners and from those in charge of the local gaol and was set up to inspect facilities and to set standards. This hospital at Auckland, the then capital. Politicians with framework was gradually adapted to the circumstances of some knowledge of the situation in other provinces were constituent parts of the realm and of the settler colonies. also examined. The Select Committee used a standard Given the cultural background of the British settlers, in form of questioning and it kept an unpublished verbatim essence, the choice lay between the English model of luna- record of evidence by the 14 selected witnesses.[14] The tic asylums or the Scottish mixed model of institutions Select Committee took two and one-half months to com- and grant-aided boarding out of suitable patients with pri- plete its work and submitted a two page report. vate families. In the ensuing debate, the ideals of a prop- erly designed lunatic asylum were invariably upheld, Although the Select Committee was apprised of the Scot- complete with a system of patient classification, a safe, tish model, the weight of evidence favoured an institu- healthy and orderly environment, and a regime of moral tional approach. Some of the six recommendations (see management, which included minimal physical restraint. Table 1) embodied the contemporary ideals of a lunatic asylum, purpose-built for the non-restraint system that By 1858, New Zealand politicians favoured the English was a hallmark of leading English asylums. A comprehen- system of institutional care over the Scottish mixed sive but stand-alone legal framework for lunacy was also model. The systemic policy issue to be investigated was recommended. The Stafford government adopted these the best way to provide a proper lunatic asylum. The ideal ideas although they were not immediately imple- was widely respected but of the eight provinces, only Wel- mented.[15-18] After a change of government in 1861, lington had actually built such an institution by 1858. planning for the central asylum ceased in favour of the With the small number of lunatics in each province and establishment of a network of provincial asylums. When with a national total of 50–100 chronic lunatics (depend- Stafford again became the Premier (1865–9), he astutely Page 4 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Table 1: Implementation of General Mental Health Inquiry Recommendations, 1858–1996 INQUIRY KEY RECOMMENDATIONS IMPLEMENTATION Select Committee (1858) Establish colonial lunatic asylum. Accepted 1858 but not implemented. Appoint commissioner to choose site. Implemented 1858. Obtain expert advice on asylum design and Implemented 1858. organisation. Adopt comprehensive and liberal treatment in Accepted and applied variably by provinces. asylum. Amend lunacy law. Implemented 1858. Revise lunacy law entirely. Implemented 1867–8. Joint Committee (1871) General government to ensure proper Limited to guidelines before 1876 and direct provision for lunatics where provision management of asylums afterwards. inadequate. Appoint specialist psychiatrist to supervise and Implemented 1876. control all asylums. Obtain more information before making Implemented 1872–4. decision about central asylum. Improve all asylums, especially Karori Left to provincial governments. (Wellington). Board of Health Committee (1957–60) Increase general hospital acute psychiatric beds Implemented progressively under hospital in four main cities immediately. capital works programme. Develop regional psychiatric units and Implemented – first unit opened 1963. outpatient clinics in 6 other cities. Divisional outpatient services expanded as staffing permitted. Establish staff in the units as per staff: patient [Implemented]. ratios. Establish child psychiatry units in four main Adopted but implemented through child health centres when staff available. clinics. Intensify specialist staff recruitment. Ongoing implementation. Second mental hospital staff to psychiatric Implemented for first units then phased out. units. Improve public attitudes towards mental illness. Accepted. Intensified public relations with World Mental Health Year 1960. Relax legal restrictions on patients' personal Implemented 1961. rights. Royal Commission (1972–3) First report Continue mental health lead by way of Adapted. allowance. Improve psychiatric hospital staffing to Accepted. eliminate need for pay differential. Set up independent study of poor working Adapted then rejected 1975. conditions that affect staff shortages. Review differential conditions of employment. Implemented. Review entry requirements to encourage Reviewed for more consideration. recruitment of male psychiatric nurses. Study extent of recruitment problem. Adapted then rejected 1975. Second report Establish national Institute of Psychiatry. Referred for consideration by key agencies. Advise those concerned without delay. Implemented. Third report Undertake national survey of service needs of Implemented 1973–4. mentally handicapped patients in psychiatric hospitals. Progressively move multiple-handicapped Deferred pending survey results. patients to general hospital care. Care for dual diagnosis or behaviourally Deferred pending survey results. disturbed mentally handicapped patients in general or psychiatric hospitals. Develop appropriate placements at home in Deferred pending survey results. foster home, community house or small special purpose institution. Discontinue practice of placing mentally Deferred pending survey results. handicapped patients in psychiatric hospitals. Page 5 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Table 1: Implementation of General Mental Health Inquiry Recommendations, 1858–1996 (Continued) Transfer responsibility for mental handicap Adapted for inter-departmental consultation. services from Health to Social Welfare Department. Place moratorium on psychopaedic hospital Implemented 1973. development. Discontinue hospital model of care for mentally Addressed through national needs survey. handicapped. Actively promote measures to prevent mental Required further investigation. handicap. Teach medical students modern views on Required further investigation. management of mental handicap. Urgently support home care, IHC facilities, Accepted in part but subject to needs survey small homes and hostels under national plan. results. Ministerial Inquiry (1995–6) Inquiry team should monitor implementation of Rejected. its recommendations. Increase mental health funding between $125– Adapted. 140 M. over 5 years. Ring-fence mental health funding. Rejected. Establish Mental Health Commission and Adapted. National Advisory Board. Request MHC to prepare national blueprint for Implemented 1998. mental health services. upheld that decentralised approach.[19] The central gov- edgeably about progressive practice from their personal ernment retained legislative responsibility, set a few visits to provincial and English asylums.[21-23] Bucha- standards, and published the reports of provincial inspec- nan could not find the same enthusiasm among members tors, but was otherwise reluctant to interfere in what had of the House of Representatives (lower house). Joint become by then a recognised provincial domain. Committee members from the Legislative Council con- tributed strongly to parliamentary debates on the topic, Joint Committee (1871) but committee members from the lower house did not By 1871, most provinces had built their own public luna- show the same zeal. The mover was the only member who tic asylum or were well on the way to doing so. Asylums participated, and even he showed little sustained inter- in the gold-rich provinces achieved very creditable stand- est.[24] Buchanan was upset by the indifference of elected ards, but slower developing and cash-strapped provinces representatives whom, he said, would let the weakest sec- lagged behind. Only the smallest provinces still relied on tions of society go to 'the wall' for the sake of retrench- makeshifts or made extra-territorial arrangements with ment.[25] He shared his opinions freely and forcibly with asylums in other provinces. From the late 1860s, asylum an eminent Scottish psychiatrist: standards were sucked into wider political moves towards nationally uniform standards and policies developed and We are willing enough to 'go in' for reproductive Public monitored by new departments of the central govern- Works. But, of course, the care of the Insane costs money, ment. Provincialism was waning although it remained a and does not 'pay.' [26] potent force in some parts of the colony, hence represen- tation of all save the two smallest provinces on the Joint Like the Select Committee, the Joint Committee had to Committee. meet and complete its work during the short parliamen- tary session that typically lasted three months. In five The Legislative Council (upper house) established this weeks, the Joint Committee heard from five invited wit- inquiry because this body took a consensual though elitist nesses, four of them local asylum doctors. The Joint Com- interest in lunatics as one group in society who carried no mittee submitted the briefest report: one sentence political weight.[20] Dr A Buchanan, MLC (Otago Prov- criticised the current situation and four more set out the ince), a key proponent of lunacy reform and chairman of recommendations. The transcript of evidence was pub- the Joint Committee, believed that less than half-a-dozen lished as an attachment.[27] parliamentarians held the cause of lunacy reform 'ear- nestly at heart'. Most of those were members of the Legis- The Joint Committee called for improvement in all asy- lative Council. Four were medically qualified, and lums, and looked to the general government to make another lay member was the Inspector of Asylums in proper provision for lunatics through the appointment of Otago. These members took a very active role in the work a specialist psychiatrist who would supervise and control of the Committee, and spoke authoritatively and knowl- all lunatic asylums. The Joint Committee also recom- Page 6 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 mended that more information be obtained before a deci- mental hospital. The villa principle was intrinsic to all sion was made about whether or not to proceed with a new institutions from 1903. Community amenities like central asylum for the colony. The recommendations were halls, libraries, canteens, and sports fields, were later addi- adopted by the Legislative Council, but not by the tions. The mental hospital was also identified with spe- House.[28,29] The government stalled. Expert advice was cialists in psychiatry, and a cadre of professionally trained sought from Dr E Paley, Victoria's Inspector of Asylums, mental nurses rather than attendants. The new model who visited New Zealand asylums in 1872.[30] Paley attempted to capture the therapeutic glamour and favour- rejected the central asylum, but supported the idea of a able public image of general hospitals, which were run by specialised national inspectorate. He went further by sug- ad hoc local authorities known as hospital boards. gesting that resident medical superintendents should be appointed to run larger asylums and that they should have Progress towards these lofty ideals was halting, patchy and a proper complement of attendants based on a staffing a reflection on the low political priority of mental health. formula.[31] Paley's report was not published until 1874, A significant credibility gap emerged between the ideals the same year that financial provision was first made for and the realities of overcrowded and short-staffed facili- the national inspectorate.[32] The inspector's job was ties. Outmoded design features and environments of advertised in Britain in 1875 and the appointee, Dr FWA those Victorian era institutions that were built in perma- Skae, took up his duties as first head of the Lunatic Asy- nent materials hampered progress towards more modern lums Department in July 1876.[33,34] approaches. A general inquiry was called for in 1903 when the overall policy of a long-serving departmental Skae's appointment reflected the government's decision head seemed outdated. [35] Although the government that lunacy administration should revert to the central successfully resisted the pressure, reforms were expedited. government in the redistribution of government activity A deputy inspector-general was appointed, and that gave when the provincial administrations were abolished in fresh impetus to reformist policies. That deputy, who was 1876. A department of state was set up to advise ministers promoted to run the Department in 1907, himself on policy, to run and inspect public asylums, and later to became stale and tired by 1925. His dogged pursuit of a regulate the country's only licensed house (private mental policy of mental hospitalisation did not match post-war hospital). Under a near century of departmental adminis- pressure for a fresh approach based on intermediate facil- tration until 1972, the country's psychiatric services ities that would avoid the stigma of mental hospitals. slowly became characterised by national uniformity, a vir- Pressure for an inquiry in 1925 was only averted by a tual bureaucratic monopoly, separatism from mainstream package of overdue reforms, including the establishment health services, and a predominantly institutional mind- of the first outpatient services and observation wards in set. These features were compounded by fickle public atti- general hospitals.[36] tudes and the low political-fiscal priority given to mental health. Multiple pressures of overcrowding, large num- The establishment and extension of outreach services, bers of long-term residents, and severe staff shortages per- however, fluctuated and was very haphazard. Progress was sisted long after a general therapeutic despair disappeared dependent upon the initiative and priority of local hospi- with the advent of electro-convulsive therapy and tran- tal boards and the availability of hard-pressed institu- quillisers in the 1940s and 1950s. tional psychiatrists, whose first priority had to be to mental hospital patients committed to their charge. Institutions were the cornerstone of psychiatric care and Under the first Labour Government's Social Security Act treatment in the New Zealand throughout this period, as 1938, the full cost of care and treatment in mental hospi- they were in western countries generally. Institutions tals (1939) and general hospitals (1941), among other expanded in size thanks to elastic social and medical def- health benefits, was met from taxation rather than patient initions of insanity. The number of institutions also grew fees. Public expectations of the public hospital system as rail and road systems opened up new regions to settle- were heightened by the ideals of that legislation, by signif- ment. After years of discussion, the name mental hospital icant progress in biomedical technology, and years by was officially adopted in 1905 to replace the outmoded post-war prosperity. The financial effects of these changes nomenclature of lunatic asylums. In its fullest sense, the foreshadowed the government's assumption of national specialised mental hospital came to incorporate 'recep- capital planning procedures and the full cost of operating tion homes' and other residential facilities for early treat- all public hospitals in 1957. ment (after 1898) which patients were encouraged to enter voluntarily following a law change in 1911. Villa- Board of Health Committee (1958–60) style accommodation for long-term patients, which By the 1950s, the patchy growth of general hospital psy- aspired to regain the rustic appeal and quasi-domestic chiatry was less tolerable to informed opinion in some scale of early asylum ideals, was another feature of the hospital boards and the press. The groundswell of criti- Page 7 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 cism was sufficient to prompt the next inquiry.[37-40] Hygiene Division. The Division could therefore accept Elected politicians were receptive to this groundswell, but general hospital units provided that the Division staffed the real political actors were the health bureaucrats. Man- them.[45] Implementation was reasonably successful aged devolution was their agenda: how to expand periph- although it took some years to fully implement some eral services without eclipsing the paramountcy of ideas. institutional services. Royal Commission (1972–3) As a technical/advisory committee, the Board of Health The threat to institutional dominance in the spectrum of Committee was the only inquiry with a very high level of psychiatric services was compounded after 1965 by moves professional input. The committee's membership was to integrate the administration of psychiatric and general stacked with senior health officials and long-standing public hospitals under local hospital boards. This culmi- hospital board politicians. This mix was probably nated in industrial action by institutionally-based psychi- designed to anticipate and manage one member, Dr W. atric nurses, who were apprehensive of the possible effects Ironside, an academic psychiatrist whose views on general of the imminent transfer upon their pay and working con- hospital psychiatric services and curbs on mental hospital ditions. Local management difficulties at Oakley Hospi- growth were well in advance of prevailing official opin- tal, Auckland, compounded the uncertainty and led to a ion. This member seems to have negotiated the right to commission of inquiry in 1971. Meanwhile, the Public record his views separately in a personal submission, Service Association, the staff union, pressed for a public which was included in the committee's report. This device inquiry into mental health services generally. made for a unanimous report, but it also provides a tanta- lising glimpse of tensions within the committee, which The Department resisted this pressure and recommended had trouble getting its members together. Internal dissent a wider and three-stage inquiry after the Medical Associa- delayed completion of the 27-page report. The Minister's tion of New Zealand (formerly the New Zealand Branch comments took 9 months to appear.[41] of the British Medical Association) lobbied the Minister. Terms of reference were cobbled together from a contem- The Board of Health Committee allowed 'certain national porary Canadian royal commission.[46] The full title of bodies and organisations interested in this matter' to the Royal Commission consciously echoed that of a major make submissions, a procedure that effectively managed departmental policy statement, A Review of Hospital and debate without exposing official institutional orthodoxy Related Services (1969), which was premised on the notion to the ideologies of pressure groups [42]. The committee of integrated health care administration. The Royal Com- was 'particularly impressed' with the opinions of the Brit- mission was one of a number set up by the weary National ish Medical Association and the medical superintendents government, which had been in power since 1960, in its of general and mental hospitals, who had been sent a final term of office (1969–72). The political timeframe questionnaire by the committee.[43] shelved a hot industrial issue well beyond the dates of the proposed transfer and the 1972 general election. Departmental officers drafted the report and completely dominated a board sub-committee that rearranged the The government caucus was consulted before Cabinet final recommendations.[44] These called for an immedi- made a final decision on the membership of the Royal ate increase in the number of acute psychiatric beds in the Commission whose composition offers an interesting four metropolitan general hospitals and the development insight into the trade-offs among experience, skills, objec- of inpatient and outpatient services in six other cities. tivity and outlook sought by the Government [47]. Sir These units were to be staffed seconded from mental hos- Keith Holyoake, the then Prime Minister (1960–72), said pitals according to appropriate staff-patient ratios. The of the Royal Commission: report recommended the establishment of specialised child psychiatry units in the four main cities when staff You look round to find some psychiatric bloke – he would were available. Other recommendations were of a more be biased in one way or the other. As far as he could see – general nature, for example, increased recruitment of spe- and this was not for the record or for quoting – he would cialist staff, improved public attitudes and a relaxation of rather have the best laymen available.[48] restrictions on patients' personal rights. The appointment of a distinguished lawyer or judge, in The main recommendations accorded with departmental this case, a Queen's Counsel, to head the inquiry, fol- interests and were shaped by officials. Ironside's ideas lowed convention. In keeping with another general trend, were sidelined because the committee accepted a major previous experience as an inquiry member was sought and ongoing role for departmental institutions, which [49]. The appointment of CP Hutchinson, QC as chair of was the long-held view of the Department's Mental the Royal Commission rapidly followed the completion Page 8 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 of his commission of inquiry into Oakley Hospital. poor working conditions or the entry criteria for male Another member of the Royal Commission, J Turnbull, nursing students. had served on the Royal Commissions on State Services (1961–62) and Social Security (1969–2). Turnbull's Just before it was abolished, the Royal Commission pub- appointment may also have been intended to appease lished two more but very slender reports. The second was psychiatric nurses, because he was a retired national secre- termed 'an immediate interim report', and recommended tary of the Public Service Association. The Royal Commis- the setting up of a national post-graduate institute of psy- sion's membership was criticised for including 'a director chiatry to boost the recruitment and retention of psychia- of Watties [a major food processing business] and ... a trists.[55] The third report concerned provision for National Party City Councillor' but no nurse, as was first mentally handicapped persons. The third report con- envisaged.[50] The sole medical practitioner on the Royal cerned provision for mentally handicapped persons. The Commission was not a psychiatrist. Royal Commission's criticisms of existing model of care were shown in recommendations for a moratorium on The warrant gave the Royal Commission 28 months to the capital development of psychopaedic hospitals, for a complete its tasks, as befitted the wide mandate of such a national survey of psychopaedic hospital patients, for the prestigious body. In all probability, that time frame would development of a range of alternative general hospital and have been unmanageable because of the clumsy three- community based facilities, and for the transfer of admin- stage reporting framework. The Royal Commission was istrative responsibility for mental handicap within gov- asked first to investigate a highly specific industrial issue, ernment from health to social welfare. The very brevity of then to study psychiatric services, and finally to study the this third and 'final' report shows that it must have been wider hospital system. The possible complications of an prepared from a preliminary draft report on the same sub- approach that moved from the specific to the general than ject.[56] Neither report did justice to the 'comprehensive vice versa were foreseen but not changed.[51] The Royal report' on mental health services envisaged for stage two Commission received some 90 submissions. Nearly all of the inquiry. came from the mental health and health establishment. The Department was embarrassed by all of the Royal The Royal Commission completed a report on stage one Commission's reports. The first report cut across depart- but was only part way through stage two when it was mental arguments for salary parity. Officials therefore wound up prematurely in 1973. The warrant of dissolu- advised that the lead should be retained only as an tion cited 'certain events' which had happened after the interim measure, pending efforts to align entry standards Royal Commission was appointed, a cryptic allusion to for nurse training and conditions of employment. Inde- the change of government in late 1972, that was the real pendent investigation of conditions at selected general reason [52]. The incoming Labour Minister of Health, RJ and psychiatric hospitals was not favoured.[57] By the Tizard, took the view that governments should be proac- time the Royal Commission's other reports were consid- tive and not forestall action by setting up inquiries.[53] ered, the incoming Labour government had set up its cau- The new government wanted to implement its own ideas cus health committee. That committee was a convenient through a closed-system of considering departmental sub- mechanism to massage the official response to the Royal missions to its caucus health committee. Abolishing the Commission's thinking.[58,59] The Department con- inquiry suited top departmental officials. They were irri- temptuously dismissed the proposed institute of psychia- tated by the uncomfortable relationship with the Royal try as a 'grave risk of putting the clock back' and sought Commission, its seeming information overload, and by solutions within general post-graduate medical educa- the way the inquiry's proceedings were hogged by one tion. The proposal itself was referred to key agencies, but party with an antagonistic attitude towards the Depart- their opposition was entirely predictable [60]. Faint praise ment.[54] lavished on the report on mental handicap services as a superficially 'clear, simple and logical answer' masked The Royal Commission completed the first part of its caution about the impractical staffing implications. By the investigation on the 'mental health lead' or differential time the official response was released, the caucus com- pay scale that favoured psychiatric and psychopaedic mittee had already endorsed the department's proposals (intellectual handicap) hospital nurses over general hos- for a moratorium on capital development and for a pital nurses. The Royal Commission recommended con- national survey that effectively forestalled action on 12 of tinued payment of the lead by way of allowance but that the 20 recommendations of the third report. The Royal psychiatric hospital staffing should be improved to elimi- Commission's other ideas were to be given further consid- nate the need for the differential. The report also called for eration, particularly if they threatened current departmen- a study of various factors that affected the recruitment and tal responsibilities.[61] retention of nursing staff in psychiatric hospitals, such as Page 9 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Ministerial Committee of Inquiry (1995–6) enjoined to 'adopt procedures that encourage people to By the 1990s, the heyday of the psychiatric hospital was participate in your proceedings'. Hearings therefore took long past. Deinstitutionalisation was well underway in an place at hospitals and prisons and on marae (traditional era of cost cutting. In its wake, public anxieties about poor Maori meeting grounds).[65] co-ordination among multiple service providers were aroused by tragedies and led to some calls to bring back The Ministerial Inquiry produced the largest report of the traditional institutions. After police fatally shot an armed five inquiries. Virtually half of it consists of direct quota- man who had a history of mental illness in 1995, a Labour tions from testimony and submissions. In presenting a Opposition Member of Parliament prepared a private very human face to the problems of the mental health member's Bill to establish a full-scale inquiry. The govern- services, the Inquiry made 'no apology for not substituting ment contemplated a 'national task force' to address criti- our words for those of the submitters – that would be tan- cisms, but the Prime Minister ruled out a 'big' inquiry tamount to sanitising the objectivity of the submis- because it would only delay systemic improvements. After sions.'[66] Mindful, perhaps, of the weight of 81 another similar shooting, however, the government substantive recommendations made by Mason's 1987–88 swiftly ordered its own ministerial inquiry rather than inquiry, the Ministerial Inquiry made only five formal rec- have one imposed by the Opposition through Parlia- ommendations, though many suggestions were essen- ment.[62,63] If improved service co-ordination and pub- tially recommendations. These few formal lic safety were the systemic issues for the inquiry in 1995, recommendations were held to be 'significant in their there was also an element of political damage control. potential impact'. The inquiry refrained from making 'a raft' of detailed recommendations lest that be interpreted The Ministerial Inquiry was the first to acknowledge the as some indicator of efficiency and unless there was a real country's bicultural heritage. The Chair was Judge KH expectation that they would be implemented.'[67] Mason, who has Ngäi Tahu tribal affiliations. He was also an experienced inquiry chair, having conducted two pre- The government's response must have confirmed the Min- vious mental health inquiries. One of these, the Commit- isterial Inquiry's suspicions about the lack of bureaucratic tee of Inquiry into Procedures Used in Certain Psychiatric and political will for change. The form of the recommen- Hospitals (1987–88), drew attention to the prominence dations was retained, but not necessarily their substance. of Maori in the statistics of mental illness. The same Funding, for instance, was increased by $142.2 M. above inquiry had other Maori members, a Maori secretary, and current levels, but nearly $60 M. had to be found from a kaumatua (elder). But the composition of the 1995 within existing budgets. The government established the inquiry differed from its predecessors in other ways. It had Mental Health Commission as a 'tightly-focussed' body the smallest membership (three) – the other members with a 'watch-dog role', not as the quasi-department being a woman lawyer and a senior field worker from a envisaged by the Inquiry. The most likely explanation is major voluntary mental health service provider. It was the that the recommended body would have cut across the only inquiry without a medical member. The Ministerial prevailing management ideology of the policy-purchaser- Inquiry was unusual, too, in that its office was not based provider split. Just as important, it would have reduced in the capital city. the Ministry's own claim to national leadership. The Min- ister of Health, Jenny Shipley (1993–96), was satisfied The Ministerial Inquiry blended formal written proce- that doubling the staff within the ministry's mental health dures, informal discussions with selected parties, and site group would 'significantly boost' the ministry's perform- visits in New Zealand and Victoria. Like the other inquir- ance in providing policy advice and monitoring serv- ies, this one undertook no independent scientific ices.[68] The ministry's policy leadership role was research. Of the 720 submissions received, more than 400 enshrined in the same legislation that set up the Mental came from individuals. Three times the number of sub- Health Commission.[69] Far from the Minister's confi- missions was received than expected. Although it was dent expectation that members of the inquiry would be granted an extension of time, the Ministerial Inquiry com- satisfied by the government's response, they quickly and plained that members had less time to consider the large contemptuously condemned the bureaucratic med- volume of submissions than they would have wished.[64] dling.[70] The traditional policy community was still represented among these submissions, but a very large number came Discussion from consumer, self-help, and support groups, and the The five New Zealand general inquiries into mental health Mental Health Foundation as a general advocate for men- have been undertaken about once a generation, or the tal health. There was also a distinct Maori voice. The same frequency of general stock-takes of mental health explosion of interest can probably be attributed to legislation. That pattern matches Simpson's findings on Mason's earlier inquiry of 1987–8, which had been public inquiries in other policy domains.[71] Two expla- Page 10 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 nations might account for the infrequency of systemic the policy agenda by the illusion of action, deflection of stock-takes. First, mental health policy serves multifaceted criticism, or co-option of critics.[79] social purposes of control, care and cure. Policy is com- plex and it can be controversial because numbers of men- The authority, mandate, composition, procedure and tal disordered people are subject to involuntary detention, reporting style of the five inquiries reflect trends among assessment and treatment – the most commonplace use of public inquiries generally. Parliament initiated the two such powers in health legislation. Protecting fairly the nineteenth century inquiries; the twentieth century civil liberties and safety of the mentally disordered indi- inquiries were instruments of the executive, a trend con- vidual, families and caregivers, and the public involve dif- sistent with the constitutional realignment in the state. ficult medico-legal decisions. Ideology asserts a powerful The main forms of inquiry are represented in the mental influence upon policy solutions. Mental health lacks high health line-up, which points to the flexibility of the status and popularity. Fickle public attitudes vary from device. All inquiries except the Ministerial Inquiry were sympathy to stigma and stereotypes. Politicians prefer not based in the capital city of the day. to disturb the basics of mental health policy. TF Gill, Min- ister of Health (1975–8), suggested that 'the broad prob- Membership trends in the five inquiries are consistent lems of mental health' can readily become matters for with those in inquiries generally. Each twentieth century rather pointless political controversy' unless skilfully han- inquiry was chaired by a legal practitioner. AW Mackay dled. He saw little merit in tying such issues to specific suggests that in Canada this convention creates 'instant political programmes.[72] credibility and an aura of objectivity and independ- ence'.[80] The size of inquiry teams has shrunk, although The nature of public policy-making and government New Zealand inquiries have generally been small by Brit- funding may also explain why advisory inquiries have ish standards.[81] The odd number of members in most been held so infrequently. RJ Polaschek, a distinguished cases may have been intended to safeguard unanimity, as New Zealand public servant, saw government as largely Simpson contended.[82] Eminent citizens were chosen in incremental, with periodic bursts of activity when mar- different combinations of regional, gender, professional/ ginal adjustments fell short of public expectations.[73] lay and ethnic perspectives. It is interesting to note how Mental health policy development in New Zealand, as the number of medical practitioners has dropped except elsewhere, has been characterised by spasmodic bursts of for the Board of Health Committee, which was a technical reform interspersed with long periods of stagnation or body. Sir Keith Holyoake's views, which were stated ear- neglect.[74-76] Major initiatives, general reviews of legis- lier, reveal a 'romantic yearning for the commonsense lation or services, significant organizational changes, and approach to the solution of social problems and a pro- significant injections of new funding mark booms in the found distrust of professional expertise', as Borchardt sug- saga of New Zealand's national mental health policy [77]. gested in his analysis of inquiries in New South The corresponding low points include the end of either a Wales.[83] The Royal Commission and Ministerial long period of continuous government by one party, or Inquiry best reflected what AR Prest termed the Noah's ark the incumbency of long-serving top officials. principle or the trade-off of expertise, representativeness and official acceptability.[84] The circumstances that surrounded the formation and fol- low-up of every inquiry involved a mix of policy issue and Each inquiry has considered and arbitrated among differ- politics. Each inquiry was formed when a systemic policy ent perspectives and shaped its thinking according to the issue reached a level of political sensitivity and public sig- weight of evidence. Inquiries before 1957 consulted only nificance. An inquiry – or the threat of one – has created a 'interested parties', or the small circle of officials, agencies, 'climate for action' as Chapman puts it.[78] Prasser has professionals, and industrial or professional associations suggested that setting up a public inquiry may serve sev- directly involved in providing psychiatric care. Such selec- eral political purposes, including some that seem relevant tive involvement has been superseded by the notion that to the five mental health inquiries studied here. According a public inquiry is an exercise in participative democracy. to Prasser, a public inquiry may elicit more specific infor- Any interested organisation or person who responds to a mation to guide the government. It may help to define public advertisement can make a submission. Increased policy problems more precisely or more acceptably at the public awareness and the proliferation of mental health political level. An inquiry may provide a broader range of interest groups in recent years, thanks to administrative policy options than might emerge from the public service. devolution, deinstitutionalisation, and state sector An independent inquiry is a way to impartially review restructuring, is illustrated by the exponential growth in existing arrangements, to resolve public controversy, or to the number of submissions made to the Ministerial promote public participation and consensus. Prasser con- Inquiry from submissions received by the earlier inquir- siders that an inquiry can help a government to manage ies. Page 11 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 The formality of proceedings has slowly been relaxed, fronted with and almost despairingly struggle to over- although all inquiries have kept a verbatim record or min- come. In the intervals, there is no sustained resolve that utes of proceedings. Since the 1960s, inquiries have fol- their representatives shall provide the means of proper lowed a process of considering written submissions classification and treatment.[91] followed up by public hearings, cross-examination by other parties, and questioning by the inquiry team.[85] The role of the specialised institution in the care and treat- The Ministerial Inquiry blended formal written proce- ment of mental disorder is another recurrent theme. The dures, informal discussions with selected parties, and site nineteenth century inquiries sought properly equipped visits in New Zealand and Victoria.[86] None of the five lunatic asylum(s). The twentieth century inquiries faced inquiries undertook an independent scientific research the growing limitations of that investment in institutional programme. psychiatry. Adopting a less institutional approach, they have recognised the need for effective co-ordination All reports were unanimous, although the Board of Health among a growing range of services. The third theme con- Committee narrowly averted a majority report. This fact cerns the need for an effective national organisation and bears out Weller's observation that inquiries have a choice accountability framework to provide clear direction and of working entirely in the open (above stage), negotiating leadership. This theme was most obvious in the inquiries (behind stage) or doing secret deals (below stage).[87] of 1871 and 1995–96. Inquiries completed their task fairly quickly, although timing was a problem in two cases. The truncation of the Prest rightly suggests that an inquiry has the difficult task Royal Commission was unique in New Zealand adminis- of aiming its report somewhere between the rock of a trative history, though apparently not in the United King- politically appealing set of recommendations and the dom.[88] hard place of publication and damnation.[92] Salter explains the same problem as the contradiction in a proc- An inquiry's 'sole legacy' is its report which, Hallett sug- ess whereby an inquiry can incorporate quite radical gested, is said to emit 'a more or less musty aroma.'[89] debate as well as quite limited, highly pragmatic and Each inquiry presented a single report at the conclusion of reformist goals of producing specific policy recommenda- its proceedings, save for the Royal Commission, with tions.[93] The place of an inquiry's report on that contin- three reports. As a matter of custom rather than law, each uum of specificity depends upon several factors. For inquiry's report was published soon after it was presented. instance, inquiries typically do not constrain their think- By contrast with twentieth century reports, the select and ing within specified resource limits, so the financial cost Joint Committee reports were remarkably concise. The of recommendations may be too great. The political cost lengthier reports of twentieth century inquiries have sum- of unusual or radical thinking may mean rejection, delay, marised and analysed the evidence in order to support the or further investigation. Moreover, changes in the political findings and recommendations. The Ministerial Inquiry environment between the inception and report of an produced the largest report of the five bodies. inquiry can significantly affect the outcome. Electoral mis- fortune limited the effectiveness of the inquiries of 1858 Three general themes haunt the reports of the five mental and 1972–3. Cabinet reshuffles, another potentially dis- health inquiries. A self-evident wish to improve standards ruptive political factor, did not disturb the other inquiries, of care and treatment points firstly to the limited impor- which completed their work under the same minister. tance of mental health over time in the overall priorities of government. Intermittent public interest is insufficient Bureaucratic influence, however, has exerted a powerful to resolve ongoing resource problems of adequate fund- mediating role. The nineteenth century inquiries encoun- ing, specialist staffing, and proper facilities. The Minister tered no national mental health bureaucracy, but the of Health, Jenny Shipley, said as much when she released three twentieth century inquiries show how the depart- the report of the Ministerial Inquiry. 'Governments come ment of state has acted to protect or promote its own and go, ministers come and go – we've had a 20-to-25 year interests. Mutualism between ministers and officials is problem where mental health has always been left last,' intrinsic to Westminster constitutional systems and the she said.[90] The problem is actually far older, as New Whitehall/Wellington administrative systems, which may Zealand's Inspector-General of Lunatic Asylums reported help explain why the Department's long record in manag- in 1898: ing mental hospitals was not scrutinised by an inquiry more often. Almost certainly such scrutiny would have The public are very exacting in their demands for the subjected administrators and their ministers to embarrass- proper treatment of the insane, but they are roused to ment. The Royal Commission's hearings on psychiatric indignant clamour only when some painful occurrence services took place shortly after the transfer of mental hos- reveals the difficulties which their officers are daily con- pitals, a technicality that enabled departmental officials to Page 12 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 focus on the possibilities of the post-transfer environment alone its roof. Two years and a change of government rather than the deficiencies of the past. later, the practicality of building a national facility virtu- ally disappeared. Similarly, account should be taken of Departmental archives demonstrate the multiple roles of the vacillation of the governments between 1871–4 in the bureaucracy throughout the life of the Board of Health implementing the substantive recommendation of the Committee and the Royal Commission. Officials recom- Joint Committee to appoint a national inspector. The rec- mended the establishment of the inquiry, drafted terms of ommendation was ultimately but not immediately imple- reference and nominated expert members – all activities mented. The staffing arrangements proposed for regional that fall within the normal range of advice to ministers. psychiatric units by the Board of Health Committee were The department provided the committee's secretariat and initially implemented but abandoned only a few years that of the Royal Commission, again in line with accepted later. practice.[94] The Ministerial Inquiry declined a similar offer. The department provided basic factual information, Next, does implementation refer to the letter or the spirit made submissions and gave evidence to each inquiry of recommendations? The capital moratorium imposed since 1957. Inquiries have also provided a chance outside by the Department far exceeded the Royal Commission's the usual lines of accountability for officials to state their recommendation. The form of the recommended Mental concerns and to make their suggestions. The late Dr DP Health Commission was retained in the follow-up to the Kennedy, Director-General of Health (1965–72), told me Ministerial Inquiry, but not the substance. at the time the Royal Commission was set up, that an inquiry was one of the few occasions when a department The third question is whether the standard of immediate could fly its own kites. implementation should apply to all the recommenda- tions or just the key ones. Not all recommendations are Bureaucratic mediation, however, has been strongest in equal and they can not be judged equally. Some recom- advising ministers how to respond to an inquiry's report. mendations, however, were vague, sweeping, and had few As ad hoc instruments of public administration, they play handles for implementation, for example: no part in implementing their own ideas, a point that the Ministerial Inquiry (and an earlier inquiry chaired by That whilst steps should be taken to improve all Asylums Judge Mason) may not have understood. Their reports of the Colony, the state of that at Karori, near Wellington, proposed mechanisms to implement recommendations, urgently requires immediate attention and reform.[102] which indicated a lack of confidence in the depart- ment.[95,96] Inquiries lack the organisational continuity, A dissemination of knowledge of the various types of institutional memory, technical expertise, and political mental illness should lead to an early and more accurate influence of a permanent departmental administration. diagnosis of mental illness by general practitioners. Such Bureaucratic influence is considerable in determining the a general understanding, it is felt, may even prevent the fate of recommendations when an inquiry's vision con- onset of mental illness and contribute to the maintenance verges with resource realism and political endorsement. of good mental health....[103] Table 1 shows a trail of discarded or severely modified rec- ommendations that met a political and a financial cost or The specificity of some recommendations, however, like priority too high to pay. This has often been as a major many of those of the Royal Commission, may lend them- weakness of the inquiry as an instrument of public policy- selves more easily to immediate implementation. Yet any making.[97-101] list is likely to contain both key and derivative or second- ary recommendations. An assessment of the Royal Com- Assessing the overall effectiveness of the five public mission's work is also hampered by the fact that it did not inquiries by the popular criterion of immediate imple- have the opportunity to complete its mandate. mentation of a report's recommendations is problematic. Such a unidimensional standard raises three important The durable impact on mental health policy in New Zea- questions that can be answered by examples from the five land of the core ideas of each report is considerable. For inquiries. Does immediate mean a usable time when the example, the parliamentary inquiries promoted the con- report of an inquiry retains some currency among deci- cept of the ideal lunatic asylum. The ideal was never sion-makers? Literal interpretation of 'immediate imple- attained in the concept of a single national institution, but mentation' distorts the record of each inquiry. The 1858 the same ideals underpinned the establishment of a net- inquiry, for instance, would score highly as considerable work of provincial asylums. The romance and nostalgia of progress was made towards implementing the basic rec- the ideal asylum could still be found in officialdom more ommendation about a general lunatic asylum. But the than a century later.[104] The 1858 inquiry also paved the foundation stone of such an institution was never laid let way for a comprehensive and stand-alone mental health Page 13 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 statute. That principle has been followed in every general should not be judged solely by the immediate acceptabil- review of mental health legislation from the Lunatics Act ity of its report. The cause-effect relationship may take 1868 to the present Mental Health (Compulsory Assess- much longer. The report of an inquiry may be prophetic ment and Treatment) Act 1992. The third example but contribute to a climate of opinion that supports sub- involves a specialised organisation within the machinery sequent change, maybe years later, long after any direct of central government that would, inter alia, advise minis- causal link could be determined. Although implementa- ters on policy, and monitor plans and policies. The Joint tion of an inquiry's findings and recommendations is Committee mooted that idea and the Ministerial Inquiry important in assessing its effectiveness, if we consider the upheld its importance. Fourth, two inquiries made a long-term impact of the core ideas of each report, the five major contribution to the modern policy of deinstitution- inquiries can be linked to several significant and long- alisation. The Board of Health Committee report expe- term contributions to mental health policy in New Zea- dited the provision of acute psychiatric services outside of land. mental hospitals. The Royal Commission's report on mental handicap services led to the moratorium on capi- Abbreviations AJHR Appendix to the Journals of the House of Representatives. tal development in all mental hospitals and to a national survey of all patients in mental hospitals that was Wellington: New Zealand Parliament 1854-. intended to identify the need for alternative community based services. Ministerial Inquiry Inquiry under Section 47 of the Health and Disability Services Act 1993 in Respect of Certain These durable effects fit what Le Dain terms the social Mental Health Services. function of public inquiries which, he claims, is probably more important in the long term than specific recommen- NZPD New Zealand Parliamentary Debates. Wellington: dations: New Zealand Parliament 1854-. What gives an inquiry ... its social function is that it Competing interests becomes, whether it likes it or not, part of this ongoing The author(s) declare that they have no competing inter- ests. social process. There is action and interaction.... Thus this instrument ... may have a dimension which passes beyond the political process into the social sphere. The phenome- Authors' contributions non is changing even whole the inquiry is in progress. The I am the sole author of this paper. decision to institute an inquiry of this kind is a decision not only to release an investigative technique but a form References 1. Chester DN: The English administrative system 1780–1870. of social influence as well.[105] Oxford/New York, Clarendon; 1981:103-4. 2. MacDonagh O: Early Victorian government 1830–1870 Volume 6. Lon- The social role of inquiries has helped to widen the men- don, Weidenfeld and Nicholson; 1977:163. 3. Keeton GW: Trial by tribunal: a study of the development and functioning tal health policy community far beyond the original of the tribunal of inquiry London, Museum Press Ltd; 1960:21-52. 'establishment'. Participation in the proceedings of an 4. Fitzgerald R: Setting up and running commissions of inquiry Wellington: Department of Internal Affairs; 2001. inquiry may engender a sense of social contribution to the 5. Robertson E, Hughes PH: A checklist, royal commissions, commissions solution of problems. An investigatory inquiry can be and committees of inquiry, 1864–1981 Wellington: New Zealand publicly cathartic. Library Association; 1982. 6. Fitzgerald: 141-9 . 7. Hallett LA: Royal commissions and boards of inquiry: some legal and pro- Conclusion cedural aspects Sydney: Law Book Company; 1982:9. Public inquiries are an accepted tool in the process of pub- 8. Law Reform Commission of Canada: Advisory and investigative commis- sions. Ottawa 1979:5. lic policy-making. They have played a direct and indirect 9. Fitzgerald: 16 . role in shaping mental health policy throughout the his- 10. Simpson AC: New Zealand royal commissions and commis- sions of inquiry, 1909–1971. MA Thesis. Victoria University of tory of government in New Zealand and beyond that to Wellington, Political Science Department; 1973:22. the British parliamentary inquiries of the eighteenth and 11. James B: Review of psychiatric hospitals and hospitals for the early nineteenth centuries. Although their utility will no intellectually handicapped. New Zealand Hospital 1986, 38:2-4. 12. Ministerial Inquiry: Report of the Ministerial Inquiry to the Minister of doubt continue to be debated, history shows that the pub- Health Hon Jenny Shipley Wellington: Ministry of Health; 1996:5-20. lic inquiry – in both its advisory and investigative forms – 13. NZPD 20-1 April, 8 and 16 June and 9 July 1858 2:387-8. 401, 497, 531 14. Legislative Department Archives, Archives New Zealand, Wellington, File LE remains an important tool of public administration. 1/1858/4 . 15. Colonial Secretary to Superintendent, Nelson Province, 11 December 1858, The reports provide valuable snapshots of the general Nelson Provincial Government Archives, Archives New Zealand, Wellington, NP 5/2 . state of New Zealand's mental health services at different stages of evolution. The effectiveness of any inquiry Page 14 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 16. Premier to C Shoppee, 17 September 1859, Health Department File H 30/ 53. [Wellington] Evening Post, 4 September 1971, and Labour Party Confer- 21, formerly held in Department of Health head office but now destroyed ence motion (1973) cited in Simpson: 65,138 . or lost . 54. Mackie JO: Reminiscences of a retired bureaucrat 1921/2000. 17. Hood C: [Medical Superintendent, Bethlem Hospital, London] to Colonial Unpublished typescript, 2001, Section 11: 2–3, in James Ogilvie (Peter) Secretary, 30 November 1859, LE 1/1860/222 . Mackie Papers, MS Group 1007, Alexander Turnbull Library, Wellington . 18. Stafford EW, Richmond CW: The Richmond-Atkinson papers Volume I. 55. AJHR 1973, H-5:11. Edited by: Scholefield GH. Wellington: Government Printer; 56. AJHR 1973, H-6:12. 1960:467. 19 June 1859 57. Deputy Director-General of Health (Admin.) to Minister, 16 July 1973, 19. NZPD . 12 July 1866: 771 and 20 September 1867, I:1009 Draft Cabinet Paper, 9 July 1975, Cabinet Committee on the State Services 20. McLintock AH, Wood GA: The upper house in colonial New Zealand: a minute SS (75) M22 Part II of 15 July 1975, H 30/35/80 (59801) . study of the legislative council of New Zealand in the period 1854–1887 58. Deputy Director-General of Health (Admin.) to Minister, 11 May 1973 H Wellington: Government Printer; 1987:132-133. 53/52/1 (51894) . 21. Dr T Renwick [Nelson Province], 24 May 1864 and Dr D (later Sir David) 59. Deputy Director-General of Health (Admin.) to Minister, 30 May 1973, Monro [Nelson Province], 9 March 1874 (Sunnyside Asylum, Christchurch) Cabinet minute CM 73/26/17 of 18 June 1973, and Circular Letter (Hos- Visitors Book, Sunnyside Hospital Archives, Archives New Zealand, Christch- pitals) 1973/128, of 6 July 1973, ABQU [Health Department Archives, urch, CH 388/49 . Return to citation in text: [1] Archives New Zealand, Wellington] 632 W 4452, File 53/52 (no closed file 22. Dr A Buchanan (Whau Asylum, Auckland) 18 April 1873, Buchanan Dia- number) . ries, Hocken Library, Dunedin, Miscellaneous MS 773 . 60. Undated Cabinet Paper [? April-May 1973], ABQU 632 W File 53/52 (no 23. Dr JAR Menzies and Captain T Fraser [Otago Province], NZPD closed file number) . 10:299-300. 7 September 1871, and 7 August 1874, 16:471. 61. Circular Letter (Hospitals) 1973/128, 6 July 1973, ABQU 632 W 4452, 24. NZPD . 13 September 1871, and 30 October 1871, 10:343, 11:647. File 53/52 (no closed file number) . 25. NZPD 10:343. 17 October 1871, 10:343. 62. [Wellington] Dominion, 25 and 28 October and 22 November 1995 . 26. Lindsay WL: Lunacy legislation in New Zealand. Journal of Mental 63. [Wellington] Evening Post, 29–30 November 1995 . Science 1873, 18:500. 64. Ministerial Inquiry: 1–3 :180-203. 27. Appendix to the Journals of the Legislative Council, Wellington 1871, H- 65. Committee of Inquiry into Procedures used in Certain Psychiatric Hospitals 10:189-196. in Relation to Admission, Discharge or Release on Leave of Certain Classes 28. NZPD 11:. 252, 342-5, 647-9, 12, 17 and 30 October 1871 of Patients: Report of the Committee of Inquiry into Procedures used in Cer- 29. Speaker, Legislative Council to Colonial Secretary, 17 October 1871, tain Psychiatric Hospitals in Relation to Admission, Discharge or Release on Department of Internal Affairs Archives, Archives New Zealand, Wellington, Leave of Certain Classes of Patients. Wellington: Department of Health File IA 1/299, Letter No. 1871/3248 . 1988, ii:7-8. 30. NZPD . 23 July 1872, 7 August 1872, 12: 51 12: 311–312, 18 October 66. Ministerial Inquiry: 2 . 1872, 13: 773; and 30 July 1873, 14: 147. Return to citation in text: [1] 67. Ministerial Inquiry: v, 177 . 31. AJHR 1874, H-1:1-2. 68. Minister's press release, 27 June 1996 . 32. NZPD . 28 July 1874, 16:270 Return to citation in text: [1] 69. Mental Health Commission 1998 Act s. 6(3). . 33. AJHR 1875, H-2B:. 1876; H-4C. 70. [Wellington] Evening Post, 7 August 1996 . 34. New Zealand Gazette 16 November 1876 :783. 71. Simpson: 26 . 35. NZPD . 7 July 1903, 123:542 72. Minister to Executive Secretary, New Zealand National Party, 14 Septem- 36. NZPD 208:. 3 and 11 September 1925 208:25-7, 267, and 12 August ber 1977, H 30 (53875) . 1943, 263:699. 73. Polaschek RJ: Government administration in New Zealand Wellington/ 37. Bourne H to Minister, 27 August 1957, Mental Health Division Archives, London: New Zealand Institute of Public Administration/Oxford Uni- Archives New Zealand, Wellington, File HMH 26/75 . Return to citation versity Press; 1958:212. in text: [1] 74. Armour PK: The cycles of social reform: mental health policy making in the 38. Director, Hospitals Division to Director, Mental Hygiene Division, n.d. [Octo- United States, England, and Sweden Washington, DC: University Press ber] 1957, Health Department Archives, Archives New Zealand, Welling- of America; 1981:8-10. ton, File H 53/97/7 ([Closed File No.] 42436) . 75. Rochefort DA: Policymaking Cycles in Mental Health: Critical 39. Director, Hospitals Division to Minister, 4 December 1957, H 29/15 Examination of a Conceptual Model. Journal of Health Politics, Pol- (32596) . icy and Law 1988, 13:129-51. 40. [Christchurch] Press, 27 January 1958 and 16 April 1958, and [Welling- 76. Brunton WA: 'A choice of difficulties': national mental health ton] New Zealand Truth, 11 February 1958, H 30/38 (30451) . policy in New Zealand 1840–1947. PhD Thesis. University of Otago, 41. Board of Health: Psychiatric services in general hospitals Wellington: Department of History 2001, 16:418-422. Department of Health; 1960:5. 77. Brunton WA: Mental health law in New Zealand: some 42. Minister to J Coogan, 2 September 1958 H 29/15/1 (27816) . sources and traditions. Community Mental Health in New Zealand 43. Board of Health: :5-7. 1985, 2:80. 44. Committee Secretary to Chairman, 16 February 1959, Secretary, Board of 78. Chapman RA: The role of commissions in policy making London: Allen Health in Circular to Members, 21 May 1959, and minutes of Board of and Unwin; 1973:86-87. Health Sub-Committee on Psychiatric Services, 29 July 1959, H 29/15/1 79. Prasser S: Royal commissions and public inquiries: scope and (27816) . uses. In Royal commissions and the making of public policy Edited by: 45. Director, Mental Hygiene Division to Minister, 11 May 1960 H 30/19/11 Weller P. Melbourne: Macmillan Education Australia; 1994:7-8. (28449) . 80. Mackay AW: Mandates, legal foundations, powers and conduct 46. Deputy Director-General of Health (Admin.) to Director-General of Health, of commissions of inquiry. In Commissions of inquiry Edited by: 16 July and reply, 20 July 1971, H 53/52 (39068) . Pross AP, Christie I, Yogis JA. Toronto: Carswell; 1990:44-45. 47. Iversen DE: New Zealand royal commissions and commissions 81. Cartwright TJ: Royal commissions and departmental committees in Brit- of inquiry, 1960–1981: a study of procedure, function and ain. London: Hodder and Stoughton; For New Zealand information, see also performance. BA Hons Thesis, University of Otago, Department of His- Iversen: 34–35 and Fitzgerald: 36 1975:78-79. tory. Curiously, Iversen omitted the Royal Commission from her study 82. Simpson: 81 . 1982:27. 83. Borchardt DH: Checklist of royal commissions, select committees of par- 48. Notes of Meeting between New Zealand Public Service Association deputa- liament and boards of inquiry. part IV: New South Wales 1855–1960 Bun- tion and the Prime Minister, 22 October H 53/52 (39068) . doora: La Trobe University Library; 1975. 49. Iversen: 28 . 84. Prest AR: Royal commission reporting. In Social research and royal 50. Director-General to Deputy Director-General (Admin.), 13 July and reply, 16 commissions Edited by: Bulmer M. London: Allen and Unwin; 1980:186. July 1971, Deputy Director-General (Admin.) to Director, Hospitals Division, 85. Haughey EJ, Fairway EJL: Royal commissions and commissions of inquiry 29 July 1971, and Cabinet minute 71/32/33 of 16 August 1971, H 53/53 Wellington: Department of Internal Affairs; 1974:31-32. (39068) . 86. Ministerial Inquiry: 1–2 . 51. Office Solicitor's memorandum included in advice to the Minister by the 87. Weller P: Royal commissions and the governmental system in Director-General of Health on 5 August H 53/52 (39068) . Australia. In Royal commissions and the making of public policy Edited 52. New Zealand Gazette, 22 February 1973. 1:309. Page 15 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 by: Weller Patrick. Melbourne: Macmillan Education Australia Pty Ltd; 1994:264. 88. Cartwright: 189 . 89. Hallett: 9 . 90. [Wellington] Dominion, 28 June 1996 . 91. AJHR 1898, H-7:3. 92. Prest: 181 . 93. Salter L: The two contradictions in public inquiries. In Commis- sions of inquiry Edited by: Pross AP, Christie I, Yogis JA. Toronto: Car- swell; 1990:177. 94. Iversen: 36–38, 40 . 95. Committee of Inquiry into Procedures used in Certain Psychiatric Hospitals in Relation to Admission, Discharge or Release on Leave of Certain Classes of Patients :181, 186-7. 96. Ministerial Inquiry: 21, 177 . 97. Simpson: 64 . 98. Prest: 184–185 . 99. Chapman: 184 . 100. Cartwright: 84–85 . 101. Salter: 174 :174. 102. Appendix to the Journals of the Legislative Council 1871:189. 103. Board of Health: 23–24 . 104. Brunton WA: Out of the shadows: some historical underpin- nings of mental health policy in New Zealand. In Past judgement Edited by: Dalley B, Tennant M. Dunedin: University of Otago Press; 2004:82-83. 105. Le Dain : The role of the public inquiry in our constitutional system (1973) cited in Ontario Law Reform Commission. Report on public inquiries. Toronto 1992:12. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 16 of 16 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

The place of public inquiries in shaping New Zealand's national mental health policy 1858–1996

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Copyright © 2005 by Brunton; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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Abstract

Background: This paper discusses the role of public inquiries as an instrument of public policy- making in New Zealand, using mental health as a case study. The main part of the paper analyses the processes and outcomes of five general inquiries into the state of New Zealand's mental health services that were held between 1858 and 1996. Results: The membership, form, style and processes used by public inquiries have all changed over time in line with constitutional and social trends. So has the extent of public participation. The records of five inquiries provide periodic snapshots of a system bedevilled by long-standing problems such as unacceptable standards, under-resourcing, and poor co-ordination. Demands for an investigation no less than the reports and recommendations of public inquiries have been the catalyst of some important policy changes, if not immediately, then by creating a climate of opinion that supported later change. Inquiries played a significant role in establishing lunatic asylums, in shaping the structure of mental health legislation, establishing and maintaining a national mental health bureaucracy within the machinery of government, and in paving the way for deinstitutionalisation. Ministers and their departmental advisers have mediated this contribution. Conclusion: Public inquiries have helped shape New Zealand's mental health policy, both directly and indirectly, at different stages of evolution. In both its advisory and investigative forms, the public inquiry remains an important tool of public administration. The inquiry/cause and policy/effect relationship is not necessarily immediate but may facilitate changes in public opinion with corresponding policy outcomes long after any direct causal link could be determined. When considered from that long-term perspective, the five inquiries can be linked to several significant and long-term contributions to mental health policy in New Zealand. ollaries of special purpose residential institutions, medi- Background New Zealand's mental health policy and services have cal management and separate legislation. Colonial evolved along similar lines to other "old Common- administrators and politicians preferred the English sys- wealth" countries. Like other British colonies of settle- tem of institutional care over the Scottish mixed system of ment in the nineteenth century, New Zealand lunatic asylums and boarding out or community care. The endeavoured to adopt the progressive ideas of the non- concentration of specialised resources in residential care restraint system of care and treatment, along with its cor- facilities that were known at different times as lunatic asy- Page 1 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 lums, mental hospitals or psychiatric hospitals isolated require them to be produced. Some modern inquiries them professionally, socially and administratively from have undertaken or commissioned their own research. mainstream health and social services. Institutions The cost of an inquiry depends upon its duration, the remained dominant until the late twentieth century, even number of members, the size of the secretariat, the though the spectrum of mental health services widened in amount of travel for hearings or site visits, or the use of response to demands for general hospital psychiatry from overseas experts, counsel and technical advisers. A very the 1920s, community care from the 1960s and, more comprehensive manual – the latest procedural guidance recently, deinstitutionalization. The ebbs and flow of pol- to New Zealand inquiries prepared since 1925 – is mind- icy and service development in New Zealand, however, as ful of the growing body of precedent and inquiry-related in many other countries, typify a classic feature of mental jurisprudence.[4] health policy – alternating bursts of policy development and funding interspersed with long periods of quiet incre- Some scholars in the United Kingdom, Australia, Canada mental change, indifference, or even stagnation. These and New Zealand have been interested in the general pol- longstanding cycles make mental health an interesting icy-making role of inquiries. Theses by Alan Simpson policy domain in which to study the impact of public (1972) and Deborah Iversen (1992) are the best general inquiries as an instrument of reform. source of information about public inquiries in New Zea- land. Their research shows an enormous range of topics A public inquiry is a relatively independent investigation considered by inquiries. Published checklists do not that considers facts and evidence on some assigned topic, include every public inquiry held in New Zealand.[5,6] draws conclusions, and reports, usually with recommen- dations. An inquiry is publicly accountable to the New Some newsworthy incident, revelation, or a level of public Zealand Parliament or to the executive branch of govern- disquiet that makes an issue politically sensitive usually ment, most usually the Governor-General (the Queen's triggers an inquiry. Setting up an inquiry allows for an representative), government, minister, or some senior issue to be carefully considered for a time without disrupt- official, according to the status of the inquiry. ing the regular administration of government. An inquiry has prestige, legal authority to obtain information and it The public inquiry is a very versatile tool of public admin- can provide some protection to parties. Membership can istration and remains part of the apparatus of government be determined according to the nature of the issue. In in various Commonwealth jurisdictions. There has been a some cases, representatives of particular interest groups distinct shift from inquiries by parliamentary select com- might be brought together to facilitate consensus-build- mittees towards executive-appointed inquiries since mid- ing; in others, respected arbiters may be needed. Much of Victorian times as the device has evolved within the West- an inquiry's work is publicly visible. The invitational and minster constitutional system.[1-3] The executive- participative approach of a modern inquiry widens the appointed inquiry was legitimated in New Zealand in input to government policy-making. 1867 and is now the basis of most inquiries. Such inquir- ies can be initiated by the government, (royal commis- An inquiry is relatively free within certain parameters to sions and commissions of inquiry), ministers of the interpret its mandate, determine how it will gather infor- Crown (committees of inquiry), statutory agencies or offi- mation, formulate its arguments, organise its report, and cials. Royal commissions are generally held to have make recommendations as it chooses. The membership, greater prestige and standing than other forms of investi- terms of reference, and duration of an inquiry – all of gation, and they have been used traditionally to inquire which are determined by the minister or government of into topics of outstanding public importance. Royal com- the day – affect the degree of independence. missions are of medieval origin. The Governor-General of New Zealand appoints them in the Queen's name. Com- Ad hoc and temporary, an inquiry is said by Hallett to missions of inquiry are constituted by an Order in Coun- arise suddenly, like a mushroom and to vanish just as sud- cil under the Commissions of Inquiry Act 1908. The denly, once it has presented or forwarded its report to the Governor-General acts on the advice of ministers in mak- initiating public body or official.[7] An inquiry's report is ing appointments to either type of inquiry. Many Acts of then analysed by officials and ministers, who decide how Parliament vest statutory bodies with the powers of a to handle the recommendations. The report is usually commission of inquiry. published. A number have been tabled and printed in the parliamentary papers. The Commissions of Inquiry Act 1908 and amendments give a properly constituted inquiry wide powers to con- A public inquiry serves an advisory or investigative func- duct proceedings, summon witnesses, call and take evi- tion. An advisory inquiry addresses a broad issue of public dence on oath, inspect and examine documents, or to policy. An investigatory inquiry establishes the facts of Page 2 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 some incident or tragedy. The distinction between advi- Defectives and Sex Offenders (1924–25), would have sory and investigative inquiries is not always clear-cut. been included had it interpreted 'mental defective' to Investigation of an incident may lead to consideration of include mental illness as well as what is nowadays usually the policy context. The study of policy may expose abuses called intellectual handicap or intellectual disability. or mistakes.[8,9] Simpson claims that the great majority Some other advisory inquiries have touched incidentally of inquiries in New Zealand have been investigative.[10] on mental health matters, e.g., those set up to investigate That is certainly so for mental health inquiries. Significant law and order, social security, or government administra- examples of investigative inquiries in this field include tion. Such inquiries are not included in this study. inquiries into abuse and ill-treatment at the Wellington Lunatic Asylum (1881), structural defects and faulty work- Methods manship at Seacliff Lunatic Asylum (1888), suicide at The study was undertaken by reviewing the literature on Ashburn Hall licensed house (1896), a tragic fire at Sea- the evolution, functioning and achievements of public cliff Mental Hospital (1943), short-staffing in mental hos- inquiries as an instrument of government policy-making pitals (1946), the administration of Oakley Hospital, in New Zealand and comparable Commonwealth juris- Auckland (1971), the state of forensic psychiatry services dictions. The research on the five mental health inquiries (1987), and the death of a person being taken into psychi- used standard historical method based on published and atric care (1994). My analysis of mental health inquiries unpublished official records. The New Zealand Parliamen- held between 1987 and 1995 showed that these were also tary Debates provided the political context of each inquiry. investigative. Investigative inquiries provide a sort of 'rit- The reports of three inquiries were published in the Appen- ual cleansing' as a former New Zealand top mental health dices to the Journals of the House of Representatives and the official once put it.[11] On the other hand, the spate of others were published separately by the Department/Min- investigatory mental health inquiries in recent years has istry of Health. Terms of reference and membership of raised hints about the futility of 'another cycle of Inquiry some public inquiries were published among the official [sic] fatigue,' a standpoint warranted, perhaps, by mixed notices of government in the New Zealand Gazette. evidence about the outcomes of earlier investigative Records from the five inquiries have survived among the inquiries.[12] archives of the Legislative Department, the Department of Internal Affairs (which has general responsibility for the New Zealand's general mental health inquiries administration of public inquiries), and the departments Five general or policy-advisory inquiries have been con- of state responsible at different times for national mental ducted into the state of mental health services (as that health policy: the Lunatic Asylums (1876–1905)/Mental term was understood at the time) since the institution of Hospitals (1905–1947) Department, and the Department parliamentary government in New Zealand in 1854. They (1947–1992)/Ministry (since 1992) of Health. The Divi- were the sion of Mental Hygiene or Mental Health (1947–1992) provided a particular focus within the Department of  Select Committee of the House of Representatives on a Health, as has the Mental Health Section or Directorate in General Lunatic Asylum (1858), the Ministry of Health. The records and reports of each inquiry provide rich sources of material. Unpublished  Joint Parliamentary Committee on Lunatic Asylums records of an inquiry may include the warrant of appoint- (1871), ment, a transcript of proceedings, manuscript and printed reports, and administrative and financial correspondence.  Board of Health Committee on Psychiatric Services in Official records have been augmented by reference to con- Public Hospitals (1957–60), temporary press comment. Archives of the Legislative Department and Internal Affairs Departments and those  Royal Commission on Hospital and Related Services of some provincial governments were accessed to provide (1972–3), and the information on the follow-up to the inquiries of 1858 and 1871. The Department of Health Archives were used to  [Ministerial] Inquiry in respect of Certain Mental Health obtain comprehensive information about the extent of Services (1995–6). bureaucratic influence over later inquiries. Records of the Ministry of Health concerning the Ministerial Inquiry of The full titles encompass the main forms of inquiry avail- 1995–6 have not used because of the likely sensitivity and able under New Zealand law. These inquiries will be topicality of those events. referred to hereafter by their abbreviated title. The nature and number of advisory mental health inquiries can be Results confidently established from a study of published official In this section, I will outline the background of each of the records. A sixth, the Committee of Inquiry into Mental five inquiries, the membership, duration, procedures, and Page 3 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 outcome. I will then consider how each inquiry contrib- ing on whether official returns or political estimates were uted to national mental health policy. used), the idea of a central asylum for the whole colony made sense to provincial politicians on the grounds of Select Committee (1858) humanity and efficiency. The financial argument – that a Insanity was scarcely anticipated as a public policy matter colonial facility might relieve the provinces of financial when New Zealand became a British colony in 1840. The responsibility – hinted at the underlying political earliest known insane persons came to official attention dynamic. The provincial system (1852–76) created inher- because they posed a threat to public safety, could not ent tensions between the relative responsibilities, author- safely look after themselves, or because they had no fam- ity and fiscal powers of provincial governments and the ily to care for them. Care of such persons fitted the gener- central government. Provincialism was intended to ally accepted purposes of colonial government and the address demands for a measure of self-government in the civilising mission of British imperialism. The foundation isolated and scattered settlements of the colony. Finan- documents of the new colony anticipated a system of law cially struggling provinces, however, quickly learned how and order that was gradually established in the principal hard it was to discharge their responsibility to provide Pakeha (European immigrant) settlements. The colony's adequate and acceptable care for lunatics. In such circum- first mental health legislation, the Lunatics Ordinance stances, transferring responsibility to the central govern- 1846, limited disposition of a lunatic to a gaol, house of ment was attractive to the provinces. correction, or public hospital until the person was dis- charged or transferred to a 'public colonial lunatic asy- The Select Committee's membership reflected this politi- lum'. Lunatics who were not dangerous were a secondary cal dynamic. Four of the six provinces were represented on concern. This pragmatic approach was typical of other the 8-person committee. Every member had been British colonies, but it had its drawbacks. Opinion-makers involved in provincial politics and five held concurrently considered improvised care in gaols or public hospitals as parliamentary and provincial seats. EW (later Sir Edward) inhumane, inadequate and administratively irksome. A Stafford, for example, was both a provincial and national 'community care' option of boarding out or repatriation politician and took a lead as a member of the Select Com- was rarely used, except perhaps for Maori. mittee. As Premier and Colonial Secretary (the minister nominally responsible for lunacy policy and legislation), Colonial authorities took their lead from the imperium he personally followed up the Select Committee's where a burst of activity had consolidated a policy frame- report.[13] Only two committee members – one a magis- work in England during the 1840s. The state regulated trate and the other a medical practitioner – were profes- admissions and discharges through a process now known sionally acquainted with the problem of lunacy. as committal. Marketplace activities were publicly moni- tored. A chain of public lunatic asylums was under con- The Select Committee heard evidence from medical prac- struction across the country. A specialised bureaucracy titioners and from those in charge of the local gaol and was set up to inspect facilities and to set standards. This hospital at Auckland, the then capital. Politicians with framework was gradually adapted to the circumstances of some knowledge of the situation in other provinces were constituent parts of the realm and of the settler colonies. also examined. The Select Committee used a standard Given the cultural background of the British settlers, in form of questioning and it kept an unpublished verbatim essence, the choice lay between the English model of luna- record of evidence by the 14 selected witnesses.[14] The tic asylums or the Scottish mixed model of institutions Select Committee took two and one-half months to com- and grant-aided boarding out of suitable patients with pri- plete its work and submitted a two page report. vate families. In the ensuing debate, the ideals of a prop- erly designed lunatic asylum were invariably upheld, Although the Select Committee was apprised of the Scot- complete with a system of patient classification, a safe, tish model, the weight of evidence favoured an institu- healthy and orderly environment, and a regime of moral tional approach. Some of the six recommendations (see management, which included minimal physical restraint. Table 1) embodied the contemporary ideals of a lunatic asylum, purpose-built for the non-restraint system that By 1858, New Zealand politicians favoured the English was a hallmark of leading English asylums. A comprehen- system of institutional care over the Scottish mixed sive but stand-alone legal framework for lunacy was also model. The systemic policy issue to be investigated was recommended. The Stafford government adopted these the best way to provide a proper lunatic asylum. The ideal ideas although they were not immediately imple- was widely respected but of the eight provinces, only Wel- mented.[15-18] After a change of government in 1861, lington had actually built such an institution by 1858. planning for the central asylum ceased in favour of the With the small number of lunatics in each province and establishment of a network of provincial asylums. When with a national total of 50–100 chronic lunatics (depend- Stafford again became the Premier (1865–9), he astutely Page 4 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Table 1: Implementation of General Mental Health Inquiry Recommendations, 1858–1996 INQUIRY KEY RECOMMENDATIONS IMPLEMENTATION Select Committee (1858) Establish colonial lunatic asylum. Accepted 1858 but not implemented. Appoint commissioner to choose site. Implemented 1858. Obtain expert advice on asylum design and Implemented 1858. organisation. Adopt comprehensive and liberal treatment in Accepted and applied variably by provinces. asylum. Amend lunacy law. Implemented 1858. Revise lunacy law entirely. Implemented 1867–8. Joint Committee (1871) General government to ensure proper Limited to guidelines before 1876 and direct provision for lunatics where provision management of asylums afterwards. inadequate. Appoint specialist psychiatrist to supervise and Implemented 1876. control all asylums. Obtain more information before making Implemented 1872–4. decision about central asylum. Improve all asylums, especially Karori Left to provincial governments. (Wellington). Board of Health Committee (1957–60) Increase general hospital acute psychiatric beds Implemented progressively under hospital in four main cities immediately. capital works programme. Develop regional psychiatric units and Implemented – first unit opened 1963. outpatient clinics in 6 other cities. Divisional outpatient services expanded as staffing permitted. Establish staff in the units as per staff: patient [Implemented]. ratios. Establish child psychiatry units in four main Adopted but implemented through child health centres when staff available. clinics. Intensify specialist staff recruitment. Ongoing implementation. Second mental hospital staff to psychiatric Implemented for first units then phased out. units. Improve public attitudes towards mental illness. Accepted. Intensified public relations with World Mental Health Year 1960. Relax legal restrictions on patients' personal Implemented 1961. rights. Royal Commission (1972–3) First report Continue mental health lead by way of Adapted. allowance. Improve psychiatric hospital staffing to Accepted. eliminate need for pay differential. Set up independent study of poor working Adapted then rejected 1975. conditions that affect staff shortages. Review differential conditions of employment. Implemented. Review entry requirements to encourage Reviewed for more consideration. recruitment of male psychiatric nurses. Study extent of recruitment problem. Adapted then rejected 1975. Second report Establish national Institute of Psychiatry. Referred for consideration by key agencies. Advise those concerned without delay. Implemented. Third report Undertake national survey of service needs of Implemented 1973–4. mentally handicapped patients in psychiatric hospitals. Progressively move multiple-handicapped Deferred pending survey results. patients to general hospital care. Care for dual diagnosis or behaviourally Deferred pending survey results. disturbed mentally handicapped patients in general or psychiatric hospitals. Develop appropriate placements at home in Deferred pending survey results. foster home, community house or small special purpose institution. Discontinue practice of placing mentally Deferred pending survey results. handicapped patients in psychiatric hospitals. Page 5 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Table 1: Implementation of General Mental Health Inquiry Recommendations, 1858–1996 (Continued) Transfer responsibility for mental handicap Adapted for inter-departmental consultation. services from Health to Social Welfare Department. Place moratorium on psychopaedic hospital Implemented 1973. development. Discontinue hospital model of care for mentally Addressed through national needs survey. handicapped. Actively promote measures to prevent mental Required further investigation. handicap. Teach medical students modern views on Required further investigation. management of mental handicap. Urgently support home care, IHC facilities, Accepted in part but subject to needs survey small homes and hostels under national plan. results. Ministerial Inquiry (1995–6) Inquiry team should monitor implementation of Rejected. its recommendations. Increase mental health funding between $125– Adapted. 140 M. over 5 years. Ring-fence mental health funding. Rejected. Establish Mental Health Commission and Adapted. National Advisory Board. Request MHC to prepare national blueprint for Implemented 1998. mental health services. upheld that decentralised approach.[19] The central gov- edgeably about progressive practice from their personal ernment retained legislative responsibility, set a few visits to provincial and English asylums.[21-23] Bucha- standards, and published the reports of provincial inspec- nan could not find the same enthusiasm among members tors, but was otherwise reluctant to interfere in what had of the House of Representatives (lower house). Joint become by then a recognised provincial domain. Committee members from the Legislative Council con- tributed strongly to parliamentary debates on the topic, Joint Committee (1871) but committee members from the lower house did not By 1871, most provinces had built their own public luna- show the same zeal. The mover was the only member who tic asylum or were well on the way to doing so. Asylums participated, and even he showed little sustained inter- in the gold-rich provinces achieved very creditable stand- est.[24] Buchanan was upset by the indifference of elected ards, but slower developing and cash-strapped provinces representatives whom, he said, would let the weakest sec- lagged behind. Only the smallest provinces still relied on tions of society go to 'the wall' for the sake of retrench- makeshifts or made extra-territorial arrangements with ment.[25] He shared his opinions freely and forcibly with asylums in other provinces. From the late 1860s, asylum an eminent Scottish psychiatrist: standards were sucked into wider political moves towards nationally uniform standards and policies developed and We are willing enough to 'go in' for reproductive Public monitored by new departments of the central govern- Works. But, of course, the care of the Insane costs money, ment. Provincialism was waning although it remained a and does not 'pay.' [26] potent force in some parts of the colony, hence represen- tation of all save the two smallest provinces on the Joint Like the Select Committee, the Joint Committee had to Committee. meet and complete its work during the short parliamen- tary session that typically lasted three months. In five The Legislative Council (upper house) established this weeks, the Joint Committee heard from five invited wit- inquiry because this body took a consensual though elitist nesses, four of them local asylum doctors. The Joint Com- interest in lunatics as one group in society who carried no mittee submitted the briefest report: one sentence political weight.[20] Dr A Buchanan, MLC (Otago Prov- criticised the current situation and four more set out the ince), a key proponent of lunacy reform and chairman of recommendations. The transcript of evidence was pub- the Joint Committee, believed that less than half-a-dozen lished as an attachment.[27] parliamentarians held the cause of lunacy reform 'ear- nestly at heart'. Most of those were members of the Legis- The Joint Committee called for improvement in all asy- lative Council. Four were medically qualified, and lums, and looked to the general government to make another lay member was the Inspector of Asylums in proper provision for lunatics through the appointment of Otago. These members took a very active role in the work a specialist psychiatrist who would supervise and control of the Committee, and spoke authoritatively and knowl- all lunatic asylums. The Joint Committee also recom- Page 6 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 mended that more information be obtained before a deci- mental hospital. The villa principle was intrinsic to all sion was made about whether or not to proceed with a new institutions from 1903. Community amenities like central asylum for the colony. The recommendations were halls, libraries, canteens, and sports fields, were later addi- adopted by the Legislative Council, but not by the tions. The mental hospital was also identified with spe- House.[28,29] The government stalled. Expert advice was cialists in psychiatry, and a cadre of professionally trained sought from Dr E Paley, Victoria's Inspector of Asylums, mental nurses rather than attendants. The new model who visited New Zealand asylums in 1872.[30] Paley attempted to capture the therapeutic glamour and favour- rejected the central asylum, but supported the idea of a able public image of general hospitals, which were run by specialised national inspectorate. He went further by sug- ad hoc local authorities known as hospital boards. gesting that resident medical superintendents should be appointed to run larger asylums and that they should have Progress towards these lofty ideals was halting, patchy and a proper complement of attendants based on a staffing a reflection on the low political priority of mental health. formula.[31] Paley's report was not published until 1874, A significant credibility gap emerged between the ideals the same year that financial provision was first made for and the realities of overcrowded and short-staffed facili- the national inspectorate.[32] The inspector's job was ties. Outmoded design features and environments of advertised in Britain in 1875 and the appointee, Dr FWA those Victorian era institutions that were built in perma- Skae, took up his duties as first head of the Lunatic Asy- nent materials hampered progress towards more modern lums Department in July 1876.[33,34] approaches. A general inquiry was called for in 1903 when the overall policy of a long-serving departmental Skae's appointment reflected the government's decision head seemed outdated. [35] Although the government that lunacy administration should revert to the central successfully resisted the pressure, reforms were expedited. government in the redistribution of government activity A deputy inspector-general was appointed, and that gave when the provincial administrations were abolished in fresh impetus to reformist policies. That deputy, who was 1876. A department of state was set up to advise ministers promoted to run the Department in 1907, himself on policy, to run and inspect public asylums, and later to became stale and tired by 1925. His dogged pursuit of a regulate the country's only licensed house (private mental policy of mental hospitalisation did not match post-war hospital). Under a near century of departmental adminis- pressure for a fresh approach based on intermediate facil- tration until 1972, the country's psychiatric services ities that would avoid the stigma of mental hospitals. slowly became characterised by national uniformity, a vir- Pressure for an inquiry in 1925 was only averted by a tual bureaucratic monopoly, separatism from mainstream package of overdue reforms, including the establishment health services, and a predominantly institutional mind- of the first outpatient services and observation wards in set. These features were compounded by fickle public atti- general hospitals.[36] tudes and the low political-fiscal priority given to mental health. Multiple pressures of overcrowding, large num- The establishment and extension of outreach services, bers of long-term residents, and severe staff shortages per- however, fluctuated and was very haphazard. Progress was sisted long after a general therapeutic despair disappeared dependent upon the initiative and priority of local hospi- with the advent of electro-convulsive therapy and tran- tal boards and the availability of hard-pressed institu- quillisers in the 1940s and 1950s. tional psychiatrists, whose first priority had to be to mental hospital patients committed to their charge. Institutions were the cornerstone of psychiatric care and Under the first Labour Government's Social Security Act treatment in the New Zealand throughout this period, as 1938, the full cost of care and treatment in mental hospi- they were in western countries generally. Institutions tals (1939) and general hospitals (1941), among other expanded in size thanks to elastic social and medical def- health benefits, was met from taxation rather than patient initions of insanity. The number of institutions also grew fees. Public expectations of the public hospital system as rail and road systems opened up new regions to settle- were heightened by the ideals of that legislation, by signif- ment. After years of discussion, the name mental hospital icant progress in biomedical technology, and years by was officially adopted in 1905 to replace the outmoded post-war prosperity. The financial effects of these changes nomenclature of lunatic asylums. In its fullest sense, the foreshadowed the government's assumption of national specialised mental hospital came to incorporate 'recep- capital planning procedures and the full cost of operating tion homes' and other residential facilities for early treat- all public hospitals in 1957. ment (after 1898) which patients were encouraged to enter voluntarily following a law change in 1911. Villa- Board of Health Committee (1958–60) style accommodation for long-term patients, which By the 1950s, the patchy growth of general hospital psy- aspired to regain the rustic appeal and quasi-domestic chiatry was less tolerable to informed opinion in some scale of early asylum ideals, was another feature of the hospital boards and the press. The groundswell of criti- Page 7 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 cism was sufficient to prompt the next inquiry.[37-40] Hygiene Division. The Division could therefore accept Elected politicians were receptive to this groundswell, but general hospital units provided that the Division staffed the real political actors were the health bureaucrats. Man- them.[45] Implementation was reasonably successful aged devolution was their agenda: how to expand periph- although it took some years to fully implement some eral services without eclipsing the paramountcy of ideas. institutional services. Royal Commission (1972–3) As a technical/advisory committee, the Board of Health The threat to institutional dominance in the spectrum of Committee was the only inquiry with a very high level of psychiatric services was compounded after 1965 by moves professional input. The committee's membership was to integrate the administration of psychiatric and general stacked with senior health officials and long-standing public hospitals under local hospital boards. This culmi- hospital board politicians. This mix was probably nated in industrial action by institutionally-based psychi- designed to anticipate and manage one member, Dr W. atric nurses, who were apprehensive of the possible effects Ironside, an academic psychiatrist whose views on general of the imminent transfer upon their pay and working con- hospital psychiatric services and curbs on mental hospital ditions. Local management difficulties at Oakley Hospi- growth were well in advance of prevailing official opin- tal, Auckland, compounded the uncertainty and led to a ion. This member seems to have negotiated the right to commission of inquiry in 1971. Meanwhile, the Public record his views separately in a personal submission, Service Association, the staff union, pressed for a public which was included in the committee's report. This device inquiry into mental health services generally. made for a unanimous report, but it also provides a tanta- lising glimpse of tensions within the committee, which The Department resisted this pressure and recommended had trouble getting its members together. Internal dissent a wider and three-stage inquiry after the Medical Associa- delayed completion of the 27-page report. The Minister's tion of New Zealand (formerly the New Zealand Branch comments took 9 months to appear.[41] of the British Medical Association) lobbied the Minister. Terms of reference were cobbled together from a contem- The Board of Health Committee allowed 'certain national porary Canadian royal commission.[46] The full title of bodies and organisations interested in this matter' to the Royal Commission consciously echoed that of a major make submissions, a procedure that effectively managed departmental policy statement, A Review of Hospital and debate without exposing official institutional orthodoxy Related Services (1969), which was premised on the notion to the ideologies of pressure groups [42]. The committee of integrated health care administration. The Royal Com- was 'particularly impressed' with the opinions of the Brit- mission was one of a number set up by the weary National ish Medical Association and the medical superintendents government, which had been in power since 1960, in its of general and mental hospitals, who had been sent a final term of office (1969–72). The political timeframe questionnaire by the committee.[43] shelved a hot industrial issue well beyond the dates of the proposed transfer and the 1972 general election. Departmental officers drafted the report and completely dominated a board sub-committee that rearranged the The government caucus was consulted before Cabinet final recommendations.[44] These called for an immedi- made a final decision on the membership of the Royal ate increase in the number of acute psychiatric beds in the Commission whose composition offers an interesting four metropolitan general hospitals and the development insight into the trade-offs among experience, skills, objec- of inpatient and outpatient services in six other cities. tivity and outlook sought by the Government [47]. Sir These units were to be staffed seconded from mental hos- Keith Holyoake, the then Prime Minister (1960–72), said pitals according to appropriate staff-patient ratios. The of the Royal Commission: report recommended the establishment of specialised child psychiatry units in the four main cities when staff You look round to find some psychiatric bloke – he would were available. Other recommendations were of a more be biased in one way or the other. As far as he could see – general nature, for example, increased recruitment of spe- and this was not for the record or for quoting – he would cialist staff, improved public attitudes and a relaxation of rather have the best laymen available.[48] restrictions on patients' personal rights. The appointment of a distinguished lawyer or judge, in The main recommendations accorded with departmental this case, a Queen's Counsel, to head the inquiry, fol- interests and were shaped by officials. Ironside's ideas lowed convention. In keeping with another general trend, were sidelined because the committee accepted a major previous experience as an inquiry member was sought and ongoing role for departmental institutions, which [49]. The appointment of CP Hutchinson, QC as chair of was the long-held view of the Department's Mental the Royal Commission rapidly followed the completion Page 8 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 of his commission of inquiry into Oakley Hospital. poor working conditions or the entry criteria for male Another member of the Royal Commission, J Turnbull, nursing students. had served on the Royal Commissions on State Services (1961–62) and Social Security (1969–2). Turnbull's Just before it was abolished, the Royal Commission pub- appointment may also have been intended to appease lished two more but very slender reports. The second was psychiatric nurses, because he was a retired national secre- termed 'an immediate interim report', and recommended tary of the Public Service Association. The Royal Commis- the setting up of a national post-graduate institute of psy- sion's membership was criticised for including 'a director chiatry to boost the recruitment and retention of psychia- of Watties [a major food processing business] and ... a trists.[55] The third report concerned provision for National Party City Councillor' but no nurse, as was first mentally handicapped persons. The third report con- envisaged.[50] The sole medical practitioner on the Royal cerned provision for mentally handicapped persons. The Commission was not a psychiatrist. Royal Commission's criticisms of existing model of care were shown in recommendations for a moratorium on The warrant gave the Royal Commission 28 months to the capital development of psychopaedic hospitals, for a complete its tasks, as befitted the wide mandate of such a national survey of psychopaedic hospital patients, for the prestigious body. In all probability, that time frame would development of a range of alternative general hospital and have been unmanageable because of the clumsy three- community based facilities, and for the transfer of admin- stage reporting framework. The Royal Commission was istrative responsibility for mental handicap within gov- asked first to investigate a highly specific industrial issue, ernment from health to social welfare. The very brevity of then to study psychiatric services, and finally to study the this third and 'final' report shows that it must have been wider hospital system. The possible complications of an prepared from a preliminary draft report on the same sub- approach that moved from the specific to the general than ject.[56] Neither report did justice to the 'comprehensive vice versa were foreseen but not changed.[51] The Royal report' on mental health services envisaged for stage two Commission received some 90 submissions. Nearly all of the inquiry. came from the mental health and health establishment. The Department was embarrassed by all of the Royal The Royal Commission completed a report on stage one Commission's reports. The first report cut across depart- but was only part way through stage two when it was mental arguments for salary parity. Officials therefore wound up prematurely in 1973. The warrant of dissolu- advised that the lead should be retained only as an tion cited 'certain events' which had happened after the interim measure, pending efforts to align entry standards Royal Commission was appointed, a cryptic allusion to for nurse training and conditions of employment. Inde- the change of government in late 1972, that was the real pendent investigation of conditions at selected general reason [52]. The incoming Labour Minister of Health, RJ and psychiatric hospitals was not favoured.[57] By the Tizard, took the view that governments should be proac- time the Royal Commission's other reports were consid- tive and not forestall action by setting up inquiries.[53] ered, the incoming Labour government had set up its cau- The new government wanted to implement its own ideas cus health committee. That committee was a convenient through a closed-system of considering departmental sub- mechanism to massage the official response to the Royal missions to its caucus health committee. Abolishing the Commission's thinking.[58,59] The Department con- inquiry suited top departmental officials. They were irri- temptuously dismissed the proposed institute of psychia- tated by the uncomfortable relationship with the Royal try as a 'grave risk of putting the clock back' and sought Commission, its seeming information overload, and by solutions within general post-graduate medical educa- the way the inquiry's proceedings were hogged by one tion. The proposal itself was referred to key agencies, but party with an antagonistic attitude towards the Depart- their opposition was entirely predictable [60]. Faint praise ment.[54] lavished on the report on mental handicap services as a superficially 'clear, simple and logical answer' masked The Royal Commission completed the first part of its caution about the impractical staffing implications. By the investigation on the 'mental health lead' or differential time the official response was released, the caucus com- pay scale that favoured psychiatric and psychopaedic mittee had already endorsed the department's proposals (intellectual handicap) hospital nurses over general hos- for a moratorium on capital development and for a pital nurses. The Royal Commission recommended con- national survey that effectively forestalled action on 12 of tinued payment of the lead by way of allowance but that the 20 recommendations of the third report. The Royal psychiatric hospital staffing should be improved to elimi- Commission's other ideas were to be given further consid- nate the need for the differential. The report also called for eration, particularly if they threatened current departmen- a study of various factors that affected the recruitment and tal responsibilities.[61] retention of nursing staff in psychiatric hospitals, such as Page 9 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 Ministerial Committee of Inquiry (1995–6) enjoined to 'adopt procedures that encourage people to By the 1990s, the heyday of the psychiatric hospital was participate in your proceedings'. Hearings therefore took long past. Deinstitutionalisation was well underway in an place at hospitals and prisons and on marae (traditional era of cost cutting. In its wake, public anxieties about poor Maori meeting grounds).[65] co-ordination among multiple service providers were aroused by tragedies and led to some calls to bring back The Ministerial Inquiry produced the largest report of the traditional institutions. After police fatally shot an armed five inquiries. Virtually half of it consists of direct quota- man who had a history of mental illness in 1995, a Labour tions from testimony and submissions. In presenting a Opposition Member of Parliament prepared a private very human face to the problems of the mental health member's Bill to establish a full-scale inquiry. The govern- services, the Inquiry made 'no apology for not substituting ment contemplated a 'national task force' to address criti- our words for those of the submitters – that would be tan- cisms, but the Prime Minister ruled out a 'big' inquiry tamount to sanitising the objectivity of the submis- because it would only delay systemic improvements. After sions.'[66] Mindful, perhaps, of the weight of 81 another similar shooting, however, the government substantive recommendations made by Mason's 1987–88 swiftly ordered its own ministerial inquiry rather than inquiry, the Ministerial Inquiry made only five formal rec- have one imposed by the Opposition through Parlia- ommendations, though many suggestions were essen- ment.[62,63] If improved service co-ordination and pub- tially recommendations. These few formal lic safety were the systemic issues for the inquiry in 1995, recommendations were held to be 'significant in their there was also an element of political damage control. potential impact'. The inquiry refrained from making 'a raft' of detailed recommendations lest that be interpreted The Ministerial Inquiry was the first to acknowledge the as some indicator of efficiency and unless there was a real country's bicultural heritage. The Chair was Judge KH expectation that they would be implemented.'[67] Mason, who has Ngäi Tahu tribal affiliations. He was also an experienced inquiry chair, having conducted two pre- The government's response must have confirmed the Min- vious mental health inquiries. One of these, the Commit- isterial Inquiry's suspicions about the lack of bureaucratic tee of Inquiry into Procedures Used in Certain Psychiatric and political will for change. The form of the recommen- Hospitals (1987–88), drew attention to the prominence dations was retained, but not necessarily their substance. of Maori in the statistics of mental illness. The same Funding, for instance, was increased by $142.2 M. above inquiry had other Maori members, a Maori secretary, and current levels, but nearly $60 M. had to be found from a kaumatua (elder). But the composition of the 1995 within existing budgets. The government established the inquiry differed from its predecessors in other ways. It had Mental Health Commission as a 'tightly-focussed' body the smallest membership (three) – the other members with a 'watch-dog role', not as the quasi-department being a woman lawyer and a senior field worker from a envisaged by the Inquiry. The most likely explanation is major voluntary mental health service provider. It was the that the recommended body would have cut across the only inquiry without a medical member. The Ministerial prevailing management ideology of the policy-purchaser- Inquiry was unusual, too, in that its office was not based provider split. Just as important, it would have reduced in the capital city. the Ministry's own claim to national leadership. The Min- ister of Health, Jenny Shipley (1993–96), was satisfied The Ministerial Inquiry blended formal written proce- that doubling the staff within the ministry's mental health dures, informal discussions with selected parties, and site group would 'significantly boost' the ministry's perform- visits in New Zealand and Victoria. Like the other inquir- ance in providing policy advice and monitoring serv- ies, this one undertook no independent scientific ices.[68] The ministry's policy leadership role was research. Of the 720 submissions received, more than 400 enshrined in the same legislation that set up the Mental came from individuals. Three times the number of sub- Health Commission.[69] Far from the Minister's confi- missions was received than expected. Although it was dent expectation that members of the inquiry would be granted an extension of time, the Ministerial Inquiry com- satisfied by the government's response, they quickly and plained that members had less time to consider the large contemptuously condemned the bureaucratic med- volume of submissions than they would have wished.[64] dling.[70] The traditional policy community was still represented among these submissions, but a very large number came Discussion from consumer, self-help, and support groups, and the The five New Zealand general inquiries into mental health Mental Health Foundation as a general advocate for men- have been undertaken about once a generation, or the tal health. There was also a distinct Maori voice. The same frequency of general stock-takes of mental health explosion of interest can probably be attributed to legislation. That pattern matches Simpson's findings on Mason's earlier inquiry of 1987–8, which had been public inquiries in other policy domains.[71] Two expla- Page 10 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 nations might account for the infrequency of systemic the policy agenda by the illusion of action, deflection of stock-takes. First, mental health policy serves multifaceted criticism, or co-option of critics.[79] social purposes of control, care and cure. Policy is com- plex and it can be controversial because numbers of men- The authority, mandate, composition, procedure and tal disordered people are subject to involuntary detention, reporting style of the five inquiries reflect trends among assessment and treatment – the most commonplace use of public inquiries generally. Parliament initiated the two such powers in health legislation. Protecting fairly the nineteenth century inquiries; the twentieth century civil liberties and safety of the mentally disordered indi- inquiries were instruments of the executive, a trend con- vidual, families and caregivers, and the public involve dif- sistent with the constitutional realignment in the state. ficult medico-legal decisions. Ideology asserts a powerful The main forms of inquiry are represented in the mental influence upon policy solutions. Mental health lacks high health line-up, which points to the flexibility of the status and popularity. Fickle public attitudes vary from device. All inquiries except the Ministerial Inquiry were sympathy to stigma and stereotypes. Politicians prefer not based in the capital city of the day. to disturb the basics of mental health policy. TF Gill, Min- ister of Health (1975–8), suggested that 'the broad prob- Membership trends in the five inquiries are consistent lems of mental health' can readily become matters for with those in inquiries generally. Each twentieth century rather pointless political controversy' unless skilfully han- inquiry was chaired by a legal practitioner. AW Mackay dled. He saw little merit in tying such issues to specific suggests that in Canada this convention creates 'instant political programmes.[72] credibility and an aura of objectivity and independ- ence'.[80] The size of inquiry teams has shrunk, although The nature of public policy-making and government New Zealand inquiries have generally been small by Brit- funding may also explain why advisory inquiries have ish standards.[81] The odd number of members in most been held so infrequently. RJ Polaschek, a distinguished cases may have been intended to safeguard unanimity, as New Zealand public servant, saw government as largely Simpson contended.[82] Eminent citizens were chosen in incremental, with periodic bursts of activity when mar- different combinations of regional, gender, professional/ ginal adjustments fell short of public expectations.[73] lay and ethnic perspectives. It is interesting to note how Mental health policy development in New Zealand, as the number of medical practitioners has dropped except elsewhere, has been characterised by spasmodic bursts of for the Board of Health Committee, which was a technical reform interspersed with long periods of stagnation or body. Sir Keith Holyoake's views, which were stated ear- neglect.[74-76] Major initiatives, general reviews of legis- lier, reveal a 'romantic yearning for the commonsense lation or services, significant organizational changes, and approach to the solution of social problems and a pro- significant injections of new funding mark booms in the found distrust of professional expertise', as Borchardt sug- saga of New Zealand's national mental health policy [77]. gested in his analysis of inquiries in New South The corresponding low points include the end of either a Wales.[83] The Royal Commission and Ministerial long period of continuous government by one party, or Inquiry best reflected what AR Prest termed the Noah's ark the incumbency of long-serving top officials. principle or the trade-off of expertise, representativeness and official acceptability.[84] The circumstances that surrounded the formation and fol- low-up of every inquiry involved a mix of policy issue and Each inquiry has considered and arbitrated among differ- politics. Each inquiry was formed when a systemic policy ent perspectives and shaped its thinking according to the issue reached a level of political sensitivity and public sig- weight of evidence. Inquiries before 1957 consulted only nificance. An inquiry – or the threat of one – has created a 'interested parties', or the small circle of officials, agencies, 'climate for action' as Chapman puts it.[78] Prasser has professionals, and industrial or professional associations suggested that setting up a public inquiry may serve sev- directly involved in providing psychiatric care. Such selec- eral political purposes, including some that seem relevant tive involvement has been superseded by the notion that to the five mental health inquiries studied here. According a public inquiry is an exercise in participative democracy. to Prasser, a public inquiry may elicit more specific infor- Any interested organisation or person who responds to a mation to guide the government. It may help to define public advertisement can make a submission. Increased policy problems more precisely or more acceptably at the public awareness and the proliferation of mental health political level. An inquiry may provide a broader range of interest groups in recent years, thanks to administrative policy options than might emerge from the public service. devolution, deinstitutionalisation, and state sector An independent inquiry is a way to impartially review restructuring, is illustrated by the exponential growth in existing arrangements, to resolve public controversy, or to the number of submissions made to the Ministerial promote public participation and consensus. Prasser con- Inquiry from submissions received by the earlier inquir- siders that an inquiry can help a government to manage ies. Page 11 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 The formality of proceedings has slowly been relaxed, fronted with and almost despairingly struggle to over- although all inquiries have kept a verbatim record or min- come. In the intervals, there is no sustained resolve that utes of proceedings. Since the 1960s, inquiries have fol- their representatives shall provide the means of proper lowed a process of considering written submissions classification and treatment.[91] followed up by public hearings, cross-examination by other parties, and questioning by the inquiry team.[85] The role of the specialised institution in the care and treat- The Ministerial Inquiry blended formal written proce- ment of mental disorder is another recurrent theme. The dures, informal discussions with selected parties, and site nineteenth century inquiries sought properly equipped visits in New Zealand and Victoria.[86] None of the five lunatic asylum(s). The twentieth century inquiries faced inquiries undertook an independent scientific research the growing limitations of that investment in institutional programme. psychiatry. Adopting a less institutional approach, they have recognised the need for effective co-ordination All reports were unanimous, although the Board of Health among a growing range of services. The third theme con- Committee narrowly averted a majority report. This fact cerns the need for an effective national organisation and bears out Weller's observation that inquiries have a choice accountability framework to provide clear direction and of working entirely in the open (above stage), negotiating leadership. This theme was most obvious in the inquiries (behind stage) or doing secret deals (below stage).[87] of 1871 and 1995–96. Inquiries completed their task fairly quickly, although timing was a problem in two cases. The truncation of the Prest rightly suggests that an inquiry has the difficult task Royal Commission was unique in New Zealand adminis- of aiming its report somewhere between the rock of a trative history, though apparently not in the United King- politically appealing set of recommendations and the dom.[88] hard place of publication and damnation.[92] Salter explains the same problem as the contradiction in a proc- An inquiry's 'sole legacy' is its report which, Hallett sug- ess whereby an inquiry can incorporate quite radical gested, is said to emit 'a more or less musty aroma.'[89] debate as well as quite limited, highly pragmatic and Each inquiry presented a single report at the conclusion of reformist goals of producing specific policy recommenda- its proceedings, save for the Royal Commission, with tions.[93] The place of an inquiry's report on that contin- three reports. As a matter of custom rather than law, each uum of specificity depends upon several factors. For inquiry's report was published soon after it was presented. instance, inquiries typically do not constrain their think- By contrast with twentieth century reports, the select and ing within specified resource limits, so the financial cost Joint Committee reports were remarkably concise. The of recommendations may be too great. The political cost lengthier reports of twentieth century inquiries have sum- of unusual or radical thinking may mean rejection, delay, marised and analysed the evidence in order to support the or further investigation. Moreover, changes in the political findings and recommendations. The Ministerial Inquiry environment between the inception and report of an produced the largest report of the five bodies. inquiry can significantly affect the outcome. Electoral mis- fortune limited the effectiveness of the inquiries of 1858 Three general themes haunt the reports of the five mental and 1972–3. Cabinet reshuffles, another potentially dis- health inquiries. A self-evident wish to improve standards ruptive political factor, did not disturb the other inquiries, of care and treatment points firstly to the limited impor- which completed their work under the same minister. tance of mental health over time in the overall priorities of government. Intermittent public interest is insufficient Bureaucratic influence, however, has exerted a powerful to resolve ongoing resource problems of adequate fund- mediating role. The nineteenth century inquiries encoun- ing, specialist staffing, and proper facilities. The Minister tered no national mental health bureaucracy, but the of Health, Jenny Shipley, said as much when she released three twentieth century inquiries show how the depart- the report of the Ministerial Inquiry. 'Governments come ment of state has acted to protect or promote its own and go, ministers come and go – we've had a 20-to-25 year interests. Mutualism between ministers and officials is problem where mental health has always been left last,' intrinsic to Westminster constitutional systems and the she said.[90] The problem is actually far older, as New Whitehall/Wellington administrative systems, which may Zealand's Inspector-General of Lunatic Asylums reported help explain why the Department's long record in manag- in 1898: ing mental hospitals was not scrutinised by an inquiry more often. Almost certainly such scrutiny would have The public are very exacting in their demands for the subjected administrators and their ministers to embarrass- proper treatment of the insane, but they are roused to ment. The Royal Commission's hearings on psychiatric indignant clamour only when some painful occurrence services took place shortly after the transfer of mental hos- reveals the difficulties which their officers are daily con- pitals, a technicality that enabled departmental officials to Page 12 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 focus on the possibilities of the post-transfer environment alone its roof. Two years and a change of government rather than the deficiencies of the past. later, the practicality of building a national facility virtu- ally disappeared. Similarly, account should be taken of Departmental archives demonstrate the multiple roles of the vacillation of the governments between 1871–4 in the bureaucracy throughout the life of the Board of Health implementing the substantive recommendation of the Committee and the Royal Commission. Officials recom- Joint Committee to appoint a national inspector. The rec- mended the establishment of the inquiry, drafted terms of ommendation was ultimately but not immediately imple- reference and nominated expert members – all activities mented. The staffing arrangements proposed for regional that fall within the normal range of advice to ministers. psychiatric units by the Board of Health Committee were The department provided the committee's secretariat and initially implemented but abandoned only a few years that of the Royal Commission, again in line with accepted later. practice.[94] The Ministerial Inquiry declined a similar offer. The department provided basic factual information, Next, does implementation refer to the letter or the spirit made submissions and gave evidence to each inquiry of recommendations? The capital moratorium imposed since 1957. Inquiries have also provided a chance outside by the Department far exceeded the Royal Commission's the usual lines of accountability for officials to state their recommendation. The form of the recommended Mental concerns and to make their suggestions. The late Dr DP Health Commission was retained in the follow-up to the Kennedy, Director-General of Health (1965–72), told me Ministerial Inquiry, but not the substance. at the time the Royal Commission was set up, that an inquiry was one of the few occasions when a department The third question is whether the standard of immediate could fly its own kites. implementation should apply to all the recommenda- tions or just the key ones. Not all recommendations are Bureaucratic mediation, however, has been strongest in equal and they can not be judged equally. Some recom- advising ministers how to respond to an inquiry's report. mendations, however, were vague, sweeping, and had few As ad hoc instruments of public administration, they play handles for implementation, for example: no part in implementing their own ideas, a point that the Ministerial Inquiry (and an earlier inquiry chaired by That whilst steps should be taken to improve all Asylums Judge Mason) may not have understood. Their reports of the Colony, the state of that at Karori, near Wellington, proposed mechanisms to implement recommendations, urgently requires immediate attention and reform.[102] which indicated a lack of confidence in the depart- ment.[95,96] Inquiries lack the organisational continuity, A dissemination of knowledge of the various types of institutional memory, technical expertise, and political mental illness should lead to an early and more accurate influence of a permanent departmental administration. diagnosis of mental illness by general practitioners. Such Bureaucratic influence is considerable in determining the a general understanding, it is felt, may even prevent the fate of recommendations when an inquiry's vision con- onset of mental illness and contribute to the maintenance verges with resource realism and political endorsement. of good mental health....[103] Table 1 shows a trail of discarded or severely modified rec- ommendations that met a political and a financial cost or The specificity of some recommendations, however, like priority too high to pay. This has often been as a major many of those of the Royal Commission, may lend them- weakness of the inquiry as an instrument of public policy- selves more easily to immediate implementation. Yet any making.[97-101] list is likely to contain both key and derivative or second- ary recommendations. An assessment of the Royal Com- Assessing the overall effectiveness of the five public mission's work is also hampered by the fact that it did not inquiries by the popular criterion of immediate imple- have the opportunity to complete its mandate. mentation of a report's recommendations is problematic. Such a unidimensional standard raises three important The durable impact on mental health policy in New Zea- questions that can be answered by examples from the five land of the core ideas of each report is considerable. For inquiries. Does immediate mean a usable time when the example, the parliamentary inquiries promoted the con- report of an inquiry retains some currency among deci- cept of the ideal lunatic asylum. The ideal was never sion-makers? Literal interpretation of 'immediate imple- attained in the concept of a single national institution, but mentation' distorts the record of each inquiry. The 1858 the same ideals underpinned the establishment of a net- inquiry, for instance, would score highly as considerable work of provincial asylums. The romance and nostalgia of progress was made towards implementing the basic rec- the ideal asylum could still be found in officialdom more ommendation about a general lunatic asylum. But the than a century later.[104] The 1858 inquiry also paved the foundation stone of such an institution was never laid let way for a comprehensive and stand-alone mental health Page 13 of 16 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:24 http://www.anzhealthpolicy.com/content/2/1/24 statute. That principle has been followed in every general should not be judged solely by the immediate acceptabil- review of mental health legislation from the Lunatics Act ity of its report. The cause-effect relationship may take 1868 to the present Mental Health (Compulsory Assess- much longer. The report of an inquiry may be prophetic ment and Treatment) Act 1992. The third example but contribute to a climate of opinion that supports sub- involves a specialised organisation within the machinery sequent change, maybe years later, long after any direct of central government that would, inter alia, advise minis- causal link could be determined. Although implementa- ters on policy, and monitor plans and policies. The Joint tion of an inquiry's findings and recommendations is Committee mooted that idea and the Ministerial Inquiry important in assessing its effectiveness, if we consider the upheld its importance. Fourth, two inquiries made a long-term impact of the core ideas of each report, the five major contribution to the modern policy of deinstitution- inquiries can be linked to several significant and long- alisation. The Board of Health Committee report expe- term contributions to mental health policy in New Zea- dited the provision of acute psychiatric services outside of land. mental hospitals. The Royal Commission's report on mental handicap services led to the moratorium on capi- Abbreviations AJHR Appendix to the Journals of the House of Representatives. tal development in all mental hospitals and to a national survey of all patients in mental hospitals that was Wellington: New Zealand Parliament 1854-. intended to identify the need for alternative community based services. Ministerial Inquiry Inquiry under Section 47 of the Health and Disability Services Act 1993 in Respect of Certain These durable effects fit what Le Dain terms the social Mental Health Services. function of public inquiries which, he claims, is probably more important in the long term than specific recommen- NZPD New Zealand Parliamentary Debates. Wellington: dations: New Zealand Parliament 1854-. What gives an inquiry ... its social function is that it Competing interests becomes, whether it likes it or not, part of this ongoing The author(s) declare that they have no competing inter- ests. social process. There is action and interaction.... Thus this instrument ... may have a dimension which passes beyond the political process into the social sphere. The phenome- Authors' contributions non is changing even whole the inquiry is in progress. The I am the sole author of this paper. decision to institute an inquiry of this kind is a decision not only to release an investigative technique but a form References 1. Chester DN: The English administrative system 1780–1870. of social influence as well.[105] Oxford/New York, Clarendon; 1981:103-4. 2. MacDonagh O: Early Victorian government 1830–1870 Volume 6. Lon- The social role of inquiries has helped to widen the men- don, Weidenfeld and Nicholson; 1977:163. 3. 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