Abstract: Accountability within mental health services has been thrust to the forefront as an issue for the
mental health sector over recent years, largely within the context of the move from institutional
to community based care for people with serious mental illness. Very little information has
been available regarding the range of issues seen as needing attention within the sector. This
review of clinical accountability within mental health services has occurred as part of a wider
process of information gathering undertaken by the Mental Health Commission to facilitate
accurate strategic planning for the national development of mental health services.
A project team representative of the major stakeholder groups within mainstream mental health
services was commissioned and given the brief to undertake a “snapshot” review of practice
regarding clinical accountability, identify key issues which are highlighted during the review
and make recommendations regarding developments which might be necessary to improve
accountability of mental health services. In approaching it’s task, the project team soon
realised that clinical accountability is an elusive concept, and that there is a lack of shared
definition and of a framework for understanding both clinical accountability and the wider
accountabilities within the health sector. A review of the literature regarding accountability in
health services was thus undertaken. To canvas opinion within the range of stakeholder
groups, two complementary questionnaires were developed – one for providers of services, and
one for people receiving services (consumers and family members). These questionnaires were
designed to be used in a semi-structured interview format, and sought respondents’ views
regarding a range of issues and aspects of clinical accountability. Visits were then made to one
urban and one rural health area in each region of New Zealand, and interviews conducted with
the range of stakeholder groups of mental health services.
The literature review revealed that the lack of shared definitions and frameworks for
understanding accountability in the health sector is a universal phenomenon, and a number of
suggested frameworks and models were found in the literature. An excellent review of
accountability in health care (1) outlined three components of accountability (Who – the locus
of accountability, What – the domains of accountability, and How – the procedures of
accountability), which interact to create a matrix of accountability. The three dominant models
of accountability which prevail are then outlined – the professional model (which equates to
clinical accountability), the economic model (the accountability of the market place), and the
political model (the accountability of the political sphere). The fact that these models cannot
readily be integrated and in fact may be in conflict with one another is highlighted. The three
components of accountability suggested helped to frame the analysis of data, and have been
used in reporting the findings and outlining the conclusions of the project.
The findings of the project affirmed the elusiveness of the concept of accountability, and the
need for development of shared definitions and frameworks for understanding and debate within
the sector. While there was a notable diversity of viewpoints and opinions expressed, a number
of important trends were evident. It was apparent that while all services visited had some
structures and processes to support accountable practice, there was significant variation in the
extent to which these were developed, and how helpful and effective they were found to be by
those working in and those using services. Overall it was clear that whilst all of the services
visited had some systems in place to address issues of clinical accountability, there is a great
need for development in this area, and for resolution of a number of important areas of
differing opinion which are likely to compromise accountability of practice.

Abstract: Journeys Towards Equality describes and analyses all the major work in New Zealand to counter discrimination against people with experience of mental illness. As the size of this report suggests, there is a lot of it going on in many agencies and sectors. Yet most of this work has only started in the last decade.
An initial major development was the amendment of the Human Rights Act in 1994 to include protections for people with disabilities. In the same year the Office of the Health and Disability Commissioner opened. The Mental Health Commission, with its mandate to reduce discrimination, started operating in 1996 and published the Blueprint in 1998. In the same year the Like Minds, Like Mine project began. The Ministry of Health’s 1997 mental health strategy, Moving Forward, included an anti-discrimination objective, although no targets were set. Also in 1997 the national Mental Health Sector Standards created a standard for promoting community acceptance of people with mental illness. And in 2001 the government published the New Zealand Disability Strategy, before setting up the Office for Disability Issues in 2002.