https://doi.org/10.1177/0004867419848840 Australian & New Zealand Journal of Psychiatry 1–3 DOI: 10.1177/0004867419848840 © The Royal Australian and New Zealand College of Psychiatrists 2019 Article reuse guidelines: sagepub.com/journals-permissions journals.sagepub.com/home/anp Australian & New Zealand Journal of Psychiatry, 00(0) The portrayal of psychiatry in the recent He Ara Oranga (HAO) Report into New Zealand’s mental health and addic- tion services raises significant concerns for the profession as a whole. This once-in-a-generation report recom- mends a decisive shift away from what is termed ‘Big Psychiatry’ towards a new sector called ‘Big Community’ (New Zealand Government, 2018: 97). Big Psychiatry is characterised as a medi- cally led system where ‘most resources are used for psychiatric treatments, clinics and hospitals’ (p. 36). Big Psychiatry is criticised as having a colonising world- view, together with a legacy of paternal- ism and human rights breaches. In response to this depiction of psychiatry, the HAO Report recommends creating Big Community where ‘resources are used for a broad menu of comprehensive community-based responses’ (p. 36) that embrace multiple worldviews, and respond to people at risk with compas- sion and support. Big Community is praised as having a strong commitment to partnership, recovery, spirituality and human rights. The rhetoric of the HAO Report follows from the mid-20th century reform movement that campaigned for the closure of psychiatric hospitals. This reform has dominated mental health policymaking in English-speaking countries for the last 60 years. As a result, New Zealand, Australia, Canada, Ireland, the United Kingdom and the United States have far lower numbers of hospital-based psychiatric beds than most other high-income countries. Tyrer et al. (2017) have suggested that bed numbers have fallen below a criti- cal threshold in English-speaking coun- tries and that ‘More experiments in community care will never be effective if the bed base is too low’ (p. 363). This prediction brings into question the HAO Report’s overall strategy. Moving from Big Psychiatry to Big Community would have been appro- priate national policy during the early phases of deinstitutionalisation in New Zealand, when significant num- bers of patients lived in mental hospi- tals. It is inappropriate in contemporary New Zealand, which already has a largely deinstitutionalised mental health system. After the early 2000s, community services became the larg- est part of New Zealand’s mental health system, and by 2016, most patients (91%) were treated exclu- sively by community mental health services with only 9% receiving inpa- tient care, according to the Office of the Director of Mental Health. The HAO Report also proposes changes to the Mental Health Act (MHA) that could have the unintended conse- quence of further reducing access to inpatient psychiatric care, due to rais- ing the threshold for compulsory treatment. If the proportion of patients receiving inpatient care is fur- ther reduced, the potential for adverse outcomes needs to be closely monitored, as there is a risk of under- treating severe mental illness, as cur- rently happens in many parts of the United States, which led the way on psychiatric bed reductions in the English-speaking countries. It is important for policymakers to note that New Zealand already has ‘Small Psychiatry’ by international standards. In 2016, New Zealand was ranked 32nd out of 36 member coun- tries in the Organisation for Economic Cooperation and Development (OECD) for numbers of hospital- based psychiatric beds; New Zealand reported 31 beds per 100,000 popula- tion (in general hospitals and stan- dalone psychiatric hospitals), which was far below the OECD average (69 beds per 100,000 population). New Zealand also reported far fewer men- tal health beds than comparable high- income countries in data collected by the World Health Organization (WHO). New Zealand reported hav- ing 38 mental health beds per 100,000 population (in general hospitals, psy- chiatric hospitals and residential care), compared with a median of 71 beds per 100,000 population for all high- income countries and 93 beds per The He Ara Oranga Report: What’s wrong with ‘Big Psychiatry’ in New Zealand? Stephen Allison 1 , Tarun Bastiampillai 1,2 , David Castle 3 , Roger Mulder 4 and Ben Beaglehole 4 1 College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia 2 Mind and Brain Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia 3 The University of Melbourne and St Vincent’s Health Australia, Melbourne, VIC, Australia 4 Department of Psychological Medicine, University of Otago, Christchurch, New Zealand Corresponding author: Stephen Allison, College of Medicine and Public Health, Flinders University, Bedford Park, Adelaide SA 5042, Australia. Email: stephen.allison@flinders.edu.au 848840ANP ANZJP EditorialAllison et al. Editorial