The five New Zealand general inquiries into mental health have been undertaken about once a generation, or the same frequency of general stock-takes of mental health legislation. That pattern matches Simpson's findings on public inquiries in other policy domains.[71
] Two explanations might account for the infrequency of systemic stock-takes. First, mental health policy serves multifaceted social purposes of control, care and cure. Policy is complex and it can be controversial because numbers of mental disordered people are subject to involuntary detention, assessment and treatment – the most commonplace use of such powers in health legislation. Protecting fairly the civil liberties and safety of the mentally disordered individual, families and caregivers, and the public involve difficult medico-legal decisions. Ideology asserts a powerful influence upon policy solutions. Mental health lacks high status and popularity. Fickle public attitudes vary from sympathy to stigma and stereotypes. Politicians prefer not to disturb the basics of mental health policy. TF Gill, Minister of Health (1975–8), suggested that 'the broad problems of mental health' can readily become matters for rather pointless political controversy' unless skilfully handled. He saw little merit in tying such issues to specific political programmes.[72
The nature of public policy-making and government funding may also explain why advisory inquiries have been held so infrequently. RJ Polaschek, a distinguished New Zealand public servant, saw government as largely incremental, with periodic bursts of activity when marginal adjustments fell short of public expectations.[73
] Mental health policy development in New Zealand, as elsewhere, has been characterised by spasmodic bursts of reform interspersed with long periods of stagnation or neglect.[74
] Major initiatives, general reviews of legislation or services, significant organizational changes, and significant injections of new funding mark booms in the saga of New Zealand's national mental health policy [77
]. The corresponding low points include the end of either a long period of continuous government by one party, or the incumbency of long-serving top officials.
The circumstances that surrounded the formation and follow-up of every inquiry involved a mix of policy issue and politics. Each inquiry was formed when a systemic policy issue reached a level of political sensitivity and public significance. An inquiry – or the threat of one – has created a 'climate for action' as Chapman puts it.[78
] Prasser has suggested that setting up a public inquiry may serve several political purposes, including some that seem relevant to the five mental health inquiries studied here. According to Prasser, a public inquiry may elicit more specific information to guide the government. It may help to define policy problems more precisely or more acceptably at the political level. An inquiry may provide a broader range of policy options than might emerge from the public service. An independent inquiry is a way to impartially review existing arrangements, to resolve public controversy, or to promote public participation and consensus. Prasser considers that an inquiry can help a government to manage the policy agenda by the illusion of action, deflection of criticism, or co-option of critics.[79
The authority, mandate, composition, procedure and reporting style of the five inquiries reflect trends among public inquiries generally. Parliament initiated the two nineteenth century inquiries; the twentieth century inquiries were instruments of the executive, a trend consistent with the constitutional realignment in the state. The main forms of inquiry are represented in the mental health line-up, which points to the flexibility of the device. All inquiries except the Ministerial Inquiry were based in the capital city of the day.
Membership trends in the five inquiries are consistent with those in inquiries generally. Each twentieth century inquiry was chaired by a legal practitioner. AW Mackay suggests that in Canada this convention creates 'instant credibility and an aura of objectivity and independence'.[80
] The size of inquiry teams has shrunk, although New Zealand inquiries have generally been small by British standards.[81
] The odd number of members in most cases may have been intended to safeguard unanimity, as Simpson contended.[82
] Eminent citizens were chosen in different combinations of regional, gender, professional/lay and ethnic perspectives. It is interesting to note how the number of medical practitioners has dropped except for the Board of Health Committee, which was a technical body. Sir Keith Holyoake's views, which were stated earlier, reveal a 'romantic yearning for the commonsense approach to the solution of social problems and a profound distrust of professional expertise', as Borchardt suggested in his analysis of inquiries in New South Wales.[83
] The Royal Commission and Ministerial Inquiry best reflected what AR Prest termed the Noah's ark principle or the trade-off of expertise, representativeness and official acceptability.[84
Each inquiry has considered and arbitrated among different perspectives and shaped its thinking according to the weight of evidence. Inquiries before 1957 consulted only 'interested parties', or the small circle of officials, agencies, professionals, and industrial or professional associations directly involved in providing psychiatric care. Such selective involvement has been superseded by the notion that a public inquiry is an exercise in participative democracy. Any interested organisation or person who responds to a public advertisement can make a submission. Increased public awareness and the proliferation of mental health interest groups in recent years, thanks to administrative devolution, deinstitutionalisation, and state sector restructuring, is illustrated by the exponential growth in the number of submissions made to the Ministerial Inquiry from submissions received by the earlier inquiries.
The formality of proceedings has slowly been relaxed, although all inquiries have kept a verbatim record or minutes of proceedings. Since the 1960s, inquiries have followed a process of considering written submissions followed up by public hearings, cross-examination by other parties, and questioning by the inquiry team.[85
] The Ministerial Inquiry blended formal written procedures, informal discussions with selected parties, and site visits in New Zealand and Victoria.[86
] None of the five inquiries undertook an independent scientific research programme.
All reports were unanimous, although the Board of Health Committee narrowly averted a majority report. This fact bears out Weller's observation that inquiries have a choice of working entirely in the open (above stage), negotiating (behind stage) or doing secret deals (below stage).[87
] Inquiries completed their task fairly quickly, although timing was a problem in two cases. The truncation of the Royal Commission was unique in New Zealand administrative history, though apparently not in the United Kingdom.[88
An inquiry's 'sole legacy' is its report which, Hallett suggested, is said to emit 'a more or less musty aroma.'[89
] Each inquiry presented a single report at the conclusion of its proceedings, save for the Royal Commission, with three reports. As a matter of custom rather than law, each inquiry's report was published soon after it was presented. By contrast with twentieth century reports, the select and Joint Committee reports were remarkably concise. The lengthier reports of twentieth century inquiries have summarised and analysed the evidence in order to support the findings and recommendations. The Ministerial Inquiry produced the largest report of the five bodies.
Three general themes haunt the reports of the five mental health inquiries. A self-evident wish to improve standards of care and treatment points firstly to the limited importance of mental health over time in the overall priorities of government. Intermittent public interest is insufficient to resolve ongoing resource problems of adequate funding, specialist staffing, and proper facilities. The Minister of Health, Jenny Shipley, said as much when she released the report of the Ministerial Inquiry. 'Governments come and go, ministers come and go – we've had a 20-to-25 year problem where mental health has always been left last,' she said.[90
] The problem is actually far older, as New Zealand's Inspector-General of Lunatic Asylums reported in 1898:
The public are very exacting in their demands for the proper treatment of the insane, but they are roused to indignant clamour only when some painful occurrence reveals the difficulties which their officers are daily confronted with and almost despairingly struggle to overcome. In the intervals, there is no sustained resolve that their representatives shall provide the means of proper classification and treatment.[91
The role of the specialised institution in the care and treatment of mental disorder is another recurrent theme. The nineteenth century inquiries sought properly equipped lunatic asylum(s). The twentieth century inquiries faced the growing limitations of that investment in institutional psychiatry. Adopting a less institutional approach, they have recognised the need for effective co-ordination among a growing range of services. The third theme concerns the need for an effective national organisation and accountability framework to provide clear direction and leadership. This theme was most obvious in the inquiries of 1871 and 1995–96.
Prest rightly suggests that an inquiry has the difficult task of aiming its report somewhere between the rock of a politically appealing set of recommendations and the hard place of publication and damnation.[92
] Salter explains the same problem as the contradiction in a process whereby an inquiry can incorporate quite radical debate as well as quite limited, highly pragmatic and reformist goals of producing specific policy recommendations.[93
] The place of an inquiry's report on that continuum of specificity depends upon several factors. For instance, inquiries typically do not constrain their thinking within specified resource limits, so the financial cost of recommendations may be too great. The political cost of unusual or radical thinking may mean rejection, delay, or further investigation. Moreover, changes in the political environment between the inception and report of an inquiry can significantly affect the outcome. Electoral misfortune limited the effectiveness of the inquiries of 1858 and 1972–3. Cabinet reshuffles, another potentially disruptive political factor, did not disturb the other inquiries, which completed their work under the same minister.
Bureaucratic influence, however, has exerted a powerful mediating role. The nineteenth century inquiries encountered no national mental health bureaucracy, but the three twentieth century inquiries show how the department of state has acted to protect or promote its own interests. Mutualism between ministers and officials is intrinsic to Westminster constitutional systems and the Whitehall/Wellington administrative systems, which may help explain why the Department's long record in managing mental hospitals was not scrutinised by an inquiry more often. Almost certainly such scrutiny would have subjected administrators and their ministers to embarrassment. The Royal Commission's hearings on psychiatric services took place shortly after the transfer of mental hospitals, a technicality that enabled departmental officials to focus on the possibilities of the post-transfer environment rather than the deficiencies of the past.
Departmental archives demonstrate the multiple roles of the bureaucracy throughout the life of the Board of Health Committee and the Royal Commission. Officials recommended the establishment of the inquiry, drafted terms of reference and nominated expert members – all activities that fall within the normal range of advice to ministers. The department provided the committee's secretariat and that of the Royal Commission, again in line with accepted practice.[94
] The Ministerial Inquiry declined a similar offer. The department provided basic factual information, made submissions and gave evidence to each inquiry since 1957. Inquiries have also provided a chance outside the usual lines of accountability for officials to state their concerns and to make their suggestions. The late Dr DP Kennedy, Director-General of Health (1965–72), told me at the time the Royal Commission was set up, that an inquiry was one of the few occasions when a department could fly its own kites.
Bureaucratic mediation, however, has been strongest in advising ministers how to respond to an inquiry's report. As ad hoc instruments of public administration, they play no part in implementing their own ideas, a point that the Ministerial Inquiry (and an earlier inquiry chaired by Judge Mason) may not have understood. Their reports proposed mechanisms to implement recommendations, which indicated a lack of confidence in the department.[95
] Inquiries lack the organisational continuity, institutional memory, technical expertise, and political influence of a permanent departmental administration. Bureaucratic influence is considerable in determining the fate of recommendations when an inquiry's vision converges with resource realism and political endorsement. Table shows a trail of discarded or severely modified recommendations that met a political and a financial cost or priority too high to pay. This has often been as a major weakness of the inquiry as an instrument of public policymaking.[97
Assessing the overall effectiveness of the five public inquiries by the popular criterion of immediate implementation of a report's recommendations is problematic. Such a unidimensional standard raises three important questions that can be answered by examples from the five inquiries. Does immediate mean a usable time when the report of an inquiry retains some currency among decision-makers? Literal interpretation of 'immediate implementation' distorts the record of each inquiry. The 1858 inquiry, for instance, would score highly as considerable progress was made towards implementing the basic recommendation about a general lunatic asylum. But the foundation stone of such an institution was never laid let alone its roof. Two years and a change of government later, the practicality of building a national facility virtually disappeared. Similarly, account should be taken of the vacillation of the governments between 1871–4 in implementing the substantive recommendation of the Joint Committee to appoint a national inspector. The recommendation was ultimately but not immediately implemented. The staffing arrangements proposed for regional psychiatric units by the Board of Health Committee were initially implemented but abandoned only a few years later.
Next, does implementation refer to the letter or the spirit of recommendations? The capital moratorium imposed by the Department far exceeded the Royal Commission's recommendation. The form of the recommended Mental Health Commission was retained in the follow-up to the Ministerial Inquiry, but not the substance.
The third question is whether the standard of immediate implementation should apply to all the recommendations or just the key ones. Not all recommendations are equal and they can not be judged equally. Some recommendations, however, were vague, sweeping, and had few handles for implementation, for example:
That whilst steps should be taken to improve all Asylums of the Colony, the state of that at Karori, near Wellington, urgently requires immediate attention and reform.[102
A dissemination of knowledge of the various types of mental illness should lead to an early and more accurate diagnosis of mental illness by general practitioners. Such a general understanding, it is felt, may even prevent the onset of mental illness and contribute to the maintenance of good mental health....[103
The specificity of some recommendations, however, like many of those of the Royal Commission, may lend themselves more easily to immediate implementation. Yet any list is likely to contain both key and derivative or secondary recommendations. An assessment of the Royal Commission's work is also hampered by the fact that it did not have the opportunity to complete its mandate.
The durable impact on mental health policy in New Zealand of the core ideas of each report is considerable. For example, the parliamentary inquiries promoted the concept of the ideal lunatic asylum. The ideal was never attained in the concept of a single national institution, but the same ideals underpinned the establishment of a network of provincial asylums. The romance and nostalgia of the ideal asylum could still be found in officialdom more than a century later.[104
] The 1858 inquiry also paved the way for a comprehensive and stand-alone mental health statute. That principle has been followed in every general review of mental health legislation from the Lunatics Act 1868 to the present Mental Health (Compulsory Assessment and Treatment) Act 1992. The third example involves a specialised organisation within the machinery of central government that would, inter alia
, advise ministers on policy, and monitor plans and policies. The Joint Committee mooted that idea and the Ministerial Inquiry upheld its importance. Fourth, two inquiries made a major contribution to the modern policy of deinstitutionalisation. The Board of Health Committee report expedited the provision of acute psychiatric services outside of mental hospitals. The Royal Commission's report on mental handicap services led to the moratorium on capital development in all mental hospitals and to a national survey of all patients in mental hospitals that was intended to identify the need for alternative community based services.
These durable effects fit what Le Dain terms the social function of public inquiries which, he claims, is probably more important in the long term than specific recommendations:
What gives an inquiry ... its social function is that it becomes, whether it likes it or not, part of this ongoing 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 phenomenon is changing even whole the inquiry is in progress. The decision to institute an inquiry of this kind is a decision not only to release an investigative technique but a form of social influence as well.[105
The social role of inquiries has helped to widen the mental health policy community far beyond the original 'establishment'. Participation in the proceedings of an inquiry may engender a sense of social contribution to the solution of problems. An investigatory inquiry can be publicly cathartic.