Aim well
The "doom loop" in mental health refers to a self-perpetuating cycle where a struggling system fails to deliver care, leading to sicker populations, which in turn overwhelms the system further. Because acute needs are unmet, resources are diverted to emergency or reactive services rather than proactive, long-term focused care and support.
I read an article in the UK Times recently that seemed to speak to both the predicament facing our mental health system change-makers and how to resolve it – and with the simplest of changes.
Some years ago, Schiphol Airport in the Netherlands was struggling with the constant “messiness” of the men’s lavatories – particular around the urinals. Not only was cleaning maintenance becoming more costly, but health and safety concerns were being expressed.
Be clear with your aim
Consultants were engaged; their task was to make the urinal clean and healthy places. Options such as public health campaign were considered including notices about being more careful. Programmed, regular announcements on the public address system was another option. More draconian options such as fining recidivist offenders were also proposed; but how would you separate genuine accidents from the work of “repeat offenders”? Re-design of the porcelain receptacle, with new appendages was a more radical, and more costly proposal… Building a more deluxe self-cleaning, pay (through the nose)-as-you-use facilities were an option for those who could afford it. In the meantime this project was becoming more and more expensive; a successful solution ever more evasive.
Spillage was virtually eliminated overnight.
Then a person with some novel expertise around change came up with a radically different approach. What was needed wasn’t an expensive campaign but a shift in mindset; re-frame the problem. The question he posed was: what’s the smallest possible change that will generate maximum possible results? Men like to aim. Get them to aim better. Give them something to aim at. To cut a short story even shorter, the solution was to attach a decal of a housefly onto the bowl, just above the drain, of every urinal.
I want to suggest that New Zealand mental health services’ predicament is not dissimilar to this. [Expensive] think tank/expert reports, strategies and inquiries are voluminous; political debate is endless. We seem to be going if not round in circles, then nowhere… Punctuated with new initiatives and appendages that imply reform. Mental health plans from late last Century typically remain just as relevant in 2026.
Well, to kick-off thinking… to what extent is “demand for services” something we have (in no small way) contributed to by how we have designed services? For example:
- pulling resources to acute care unless deliberated redirected…
- workforce “shortages” are an outcome of flawed system design; workforce roles are led more by scopes of practice than people’s needs
- the conclusion that “hospital demand” is inevitable / unavoidable / out of our control…
- a system that is not “user friendly” due to unnecessary complexity and fragmentation…. (the London Underground system is easier to navigate – even for first timers!)
Is funding matching outcomes or outputs? For example:Community residential bed at approx. $340 per bed night, vs. inpatient bed at approx. $1,200 - $2,000 per bed night.
UK Neighbourhood Mental Health Centres
Like many with an interest, I have been fascinated with the development of Neighbourhood Mental Health Centres currently being piloted in the UK.
A recent report[1] listed success factors – and the risks if these were not prioritised:
Open-access support – available without traditional referral barriers
Reproduce / sustaining existing inequalities
Strong non-profit/ community sector partnerships and leadership
Undermine the role of non-profit/ community sector
Lived experience leadership embedded in design and delivery
Failure to address racial/cultural disparities in coercive practices and crisis care
Relational approaches that prioritise trust, continuity and belonging
Be too heavily influenced by traditional approaches to risk management
Strong connections to wider community resources and social supports
Neglecting the wider determinants of ill-health (eg. housing, poverty, exclusion…
The simple inspiration of clean urinals
With these thoughts circulating in my head, awareness of the challenges we face in our own mental health sector, and the simple inspiration of clean urinals in Netherlands airports, here is my answer - in less than 400 words:
- Change the problem: how do we better respond to the mental health needs of communities in Aotearoa New Zealand?
- Dismantle a fragmented mental health system to build a fit-for-purpose response. This will require transitioning from an isolated, crisis-driven medical model to a holistic, community-based ecosystem. This shift demands a radical redistribution of power, funding, and resources prioritizing human rights, and lived experiences
- “Re-build”, enacting the following systemic changes:
The shift from institutional to community requires:
- Redirection of funding from large, centralized psychiatric facilities to localized, grassroots community / neighbourhood centres that provide immediate, everyday (ie. 24/7) support – and that partner with the broader community and its agencies, resources etc.
- That we expand the Peer / Lived experience workforce: Integrate individuals with lived experience into the core workforce. Peer specialists provide empathetic, highly relatable support that can complement the bio-specialist support of clinicians.
- Redefining Crisis Response: While police (and their legislated roles) may still play an important role as co-responders in supporting crisis response, emergency responses must prioritize health-led expertise before criminal justice. Core responsibility will rest with dedicated, multi-disciplinary health, ambulance, and peer-led teams.
Legislate Human Rights: Utilise the updated mental health act as a catalyst to eliminate seclusion, minimise coercive practices, eliminate indefinite treatment orders, and prioritize supported decision-making.
Adopt Holistic, less mechanistic frameworks: We need to shift away from a paradigm of predominantly seeing medical problems with social implications to understanding that mental health issues in 2026 are predominantly social problems with medical implications. We need to appreciate that responses to mental illness / health must better embrace integrated, culturally responsive approaches to care and treatment. For example, the intuitive appeal of the Te Whare Tapa Whā framework is that it values physical, mental, spiritual, and family/whānau health equally – and can contribute enormously to thinking, practice and culture and leads to more equitable reform. What responsibility does government have – beyond funding – in ensuring legislation (eg. housing, employment, education, welfare support…) actually contributes to community mental health…?
That’s 381 words... my aim was true
Final words are a quote from Dr. Paul Carling[2]; Paul was a keynote at the very first TheMHS Conference I attended; Sydney 1993.
“We need to focus on people who use our services, first and foremost as people. As citizens, with rights, responsibilities, and needs... like those of all citizens.
A transformed mental health service has its purpose, not to automatically be the primary and sole provider of treatment or interventions. Instead, it must be the force that bolsters a person’s other support networks, so that reliance on professional / clinical interventions is either minimally necessary or significantly reduced over time.”
Final thought, from Dr. Gabor Maté , Canadian physician and author:
“A society that defines success by how much you can consume, rather than how connected you are to your own humanity, is a society that manufactures its own mental health crisis.”
[1] https://amhp.org.uk/wp-content/uploads/2026/06/Neighbourhood-Mental-Health-Centre-pilot-paper-8.pdf
[2] https://www.themhs.org/wp-content/uploads/2018/06/1993brochure.pdf
