A Tale of Two Cities: Comparing the Mental Health Care Systems of Auckland and Ottawa
One of the coolest things about working abroad, is seeing how different places tackle similar social issues. I came to Auckland, New Zealand, eager to compare its mental health care system with the one in my hometown of Ottawa, Canada. Here are my observations so far.
Difference #1: Access to Psychiatry
Auckland has many points of access to psychiatry: 1) Primary Care Liaison: For cases of less complexity and urgency, family physicians can call and a psychiatrist or psychiatric nurse will offer eithr phone advice or a consultation with the patient and short-term follow-up. 2) The Regional Care and Recovery team: for non-urgent but more complex cases. This team has psychiatrists as well as allied health clinicians (e.g. social worker, nursing, psychology). Patients eligible for this service have a case manager to coordinate care and access to other resources. 3) A Crisis Phone Line: For urgent cases no matter the complexity. Patients or concerned loved ones can speak to a skilled mental health clinician 24/7. These clinicians triage the phone calls and offer support. A psychiatrist is available to see patients within 24-72 hours. 4) Planned Acute Care Team: A subacute team located in each mental health team is also available should a patient be determined suitable for a psychiatric appointment past 72 hours but within 3 weeks. This team offers follow-up and phone support over a period of 6-12 weeks. 5) Emergency Department: Patients can access a psychiatrist at any of the hospitals in Auckland. 6) Private psychiatry. Lastly, there is a private health care system in New Zealand for people with insurance or other means.In Ottawa, there is really only one way of accessing psychiatry reliably and that is through the emergency department. There are some family practices that have a psychiatrist, but this is very rare and there are not nearly enough to meet the mental health needs of the city. Some psychiatrists set up their own offices but it is simply chance that you come to know about them and if they are even accepting new patients. Most psychiatrists who work in the hospitals are limited to seeing only the patients that have been triaged through their own hospital emergency departments. Very few accept referrals from the community. There are no community mental health teams in Ottawa putting most of the burden of psychiatric care onto the shoulders of family physicians and emergency services.
Difference #2: Cultural and Indigenous mental health care
In Ottawa, clinical consideration for Indigenous populations rarely extends beyond a land acknowledgment at the start of a meeting. While dedicated Indigenous clinics exist, I have found it difficult to integrate their services when treating Indigenous patients. Systemically, there is a lack of recognition that specific demographics require unique mental health approaches; any specialized cultural training relies entirely on the individual clinician's motivation to seek this out. The contrast in Auckland is striking. Here, indigenous Māori culture is deeply integrated into the healthcare system. There is a dedicated Māori mental health team right next door to my clinic, and cultural advisors are available at every hospital. Māori representation among healthcare staff is substantial, and their cultural practices and values are woven into the very fabric of healthcare, allowing patients to request a Māori prayer (karakia) to open and close their medical appointments. Their language is used so routinely in daily practice—for example, referring to a patient as a Whaiora, or 'one in pursuit of health'—that in just four months, I’ve learned more Māori words than Canadian Indigenous words. This commitment to culturally responsive care even extends to dedicated mental health teams for Auckland's East Asian and Pacific Islander communities.
Difference #3: Trauma and Borderline Personality Disorder Care
In Ottawa and Auckland, the patient presentations are very similar. However, two of the hardest to treat in Ottawa due to lack of resources are patients with a history of trauma and patients with borderline personality disorder (BPD). In both these patient populations, psychiatry falls short because therapy is the mainstay of treatment and not medication. In Ottawa, there is no publicly-funded therapy available that targets Post-Traumatic Stress Disorder or BPD. It is generally acknowledged in Ottawa that these two patient populations are grossly underserved. In Auckland, there is a government organization called ACC which funds therapy for anyone who has experienced sexual trauma or accidental injuries (at home, at work, on the road, or during sport). For BPD, the gold standard therapy is called dialectical behavioral therapy. Several of Auckland’s mental health teams have psychology teams who offer the full dialectical behavioral therapy program in conjunction with offering group therapy of less intensity that focuses on building specific skills. In addition, most staff undergo some DBT-training and so can offer DBT-informed care alongside.
Difference #4: Police Resources
Another big issue when it comes to mental health care in Ottawa is when it involves police. Police are often the first responders to mental health calls and they take up huge amounts of policing resources. I see police in hospitals sitting with a patient in the emergency room as they wait for the doctor, or being asked to assess mental health patients in the community to determine if they need to be brought in for care. Auckland Police services faced similar issues and determined it was taking too much time and resources away from actual policing. This has resulted in significant changes in the past year where police have rolled back their involvement in mental health care dramatically. They are no longer first responders to mental health crises unless there is a clear danger to a person. An urgent response team responds to these calls and when a mental health team needs police support (e.g. apprehension under the mental health act), they submit an online request and coordinate when a police team is available. To avoid patients with mental health issues sitting too long in police holding cells, the urgent response team evaluates a patient within 24 hours of the police requesting an assessment. The result is that police cells and police time are freed for more appropriate use.
Difference #5: Psychiatrist compensation
In Ottawa, most psychiatrists are paid fee-for-service. This means that a psychiatrist's salary depends on how many patients she has seen. Psychiatrists are private contractors to hospitals so we have no benefits that other employees in unions have, like paid vacation and sick days. Psychiatrists have to manage our own costs of the profession like medical council membership fees and liability insurance. In Auckland, psychiatrists working in the public system are salaried and are unionized like other health clinicians. In addition, most of the professional fees are reimbursed by the health organization, including an allowance for psychiatrists to continue with our medical education, e.g. attending conferences. Under the salaried model, there is a certain workload that is expected of psychiatrists, and so far I have found it to be very reasonable. What I have come to appreciate about being salaried is that though I am paid less, the care I offer is better. This is because we see very complex patients where a lot of the care provided is actually not client-facing. There are chart reviews, ad hoc discussions with other team members and family meetings. This work is not renumerated in the Ottawa medical system. What happens is when psychiatrists are paid per clinic visit, it deprioritizes and squeezes out equally important parts of care such that we do not look after our patients properly. In Ottawa, psychiatrists feel pressured to see as many patients as possible, which is emotionally unsustainable and very lonely. In an Auckland mental health team, psychiatrists see patients with another mental health clinician and we participate in the patient's care as equals. I am not alone shouldering the burden of care and the significant risks of this care. We have time to discuss cases openly with a team full of expertise and experience that differ and compliment my own.
The last comment I would make is that the Auckland mental health system as slow as any large organization is to change and adapt, has been more flexible and responsive than I have ever experienced the Ottawa mental health care system to be. Within the 7 months I have worked here, there has been a large role out of AI medical scribes to most hospital-based psychiatrists who want a license. In addition, in the next few years, significant changes will take place to their mental health act to more closely emulate none other than the mental health acts found in Canadian legislature.
Make no mistake, there is burn-out, staff shortages and many problems that exist in the Auckland mental health care system. I suspect that the system has more built in buffers that make these stressors far more bearable on the individual. I am also very interested to see how my opinions may change the longer I am here and the rose-coloured glasses may begin to wear off.