Let me indulge myself in this last column I write to you as Chair. Actually, some might say I’ve already indulged during these past four years of columns! Having said that, most of the feedback has been complimentary or at least indicating appreciation of being informed by my personal perspective, interest in the content and awareness that advocacy requires strategic tactics.

If you attended the NSW Branch General Meeting in April, you would have heard the NSW committee chairs present their reports and seen reflected in my Branch Committee report a glimmer of how diligently and intensely the Branch worked this past year representing you all by the volume and quality of activity and output!

I even publically momentarily succumbed to needling pangs of guilt where I questioned myself whether I had pushed everyone too hard (I even might have used the word ‘flogged’). That was when Penny gave her report within which she stacked densely within one slide – in very small typeface – the long list submissions we had made on a multitude of salient issues, based just on this year to date. She noted they had been very comprehensive ...and, the product of a targeted consultation of NSW members – which the Branch has become more adept at conducting to ensure optimal representation.

Engagement with members was a priority goal when I took on my position due to the mounting levels of demoralisation amongst us. Over the last few years my impression has been that ‘feeling engaged’ has been steadily growing. The positive sentiments we hear expressed from members that they have felt strongly supported when they have brought issues to us has created more of a sense of community – that’s a big KPI. All our leaders and representatives must ensure we remain foremost a membership organisation.

But Penny then expressed, more conspicuously than usual (of her elegantly understated style), some highly positive sentiments about how meaningful her experience working with us has been and how much she saw us progress in becoming more influential in advancing constructive reform within the mental health sector. These were the reflections of a highly successful retiring policy/advocacy advisor.

And it dawned on me, that others have felt, like I do, that the hard work has been well worth it ...of course, if it is good work, for a good cause and especially if you get good results! Yes, yes, the latter is not necessary – but, it is a very sweet treat to taste the desert of positive progress when you are engaging in what often feels like ‘David Vs. Goliath’ contests of ideas how to approach reform! (That’s due to an increasingly polarized culture we are working within of Idealism, Political Ideologies and Populism — as opposed to the Pragmatism, Experience and Expertise that we bring.)

I am relieved to report that I feel proud and fulfilled at the completion of my term! We accomplished way more than I expected! That includes building up the NSW Branch to be a highly capable advocate both within the Binational College, the Branches and with all our NSW stakeholders. Our Branch rose to the necessity of the occasion (at a tipping point within the prevailing healthcare culture) to become an effective leader in College affairs, state healthcare system reform directions and became the go-to experts for NSW stakeholders. Whilst this requires continued efforts and there’s still a long way to go before we should be feeling too self-assured, we are in the game and running fast, with the ball.

To go where, you might ask? Well, we have some great values but you can’t achieve anything without vision. It’s great to see that we have well and truly as a College been working on that!

But now it’s my time to indulge in sharing some of my visions. (Don’t worry, not that kind you are used to assessing for... no need to try to call the NSW mental health line, hopefully). How about a vision that enables all NSW GPs to have direct access to easily accessible (i.e. using Telehealth if face-to-face is unavailable or impracticable) high-quality psychiatrist clinical support (i.e. using a consultation liaison model)?

This integrated hybrid model could include:

• advice about technical mental health issues such as medication benefits and side effects, how and when to schedule a patient or tips about accessing resources
• or guidance about triaging a patient, whether they warrant referral for a psychiatric assessment or specialty service or allied health clinician
• or brainstorming between GP and psychiatrist (and mental health nurses and allied health clinicians) following a psychiatric assessment, about what the optimal management plan might look like for that patient and how it could be actualised within their resource context
• or part of a regular case conference or supervision session to support and upskill the GP’s (or a group of GPs’) capacity to provide mental health care to his/her/their patients i.e. a true ‘liaison’ working model (paralleling how existing CL psychiatrists cater to assisting medical teams in general hospitals, including in EDs).

This could be just one service type or layer (or ‘step’) within a Stepped Care Program that could encompass a whole range of potential psychiatric services that could be matched to the needs of a particular patient/GP dyad, such as:

• Immediately accessible clinical support guidance from on-call Telehealth psychiatrists to assist with real-time urgent/crisis psychiatric assessment and triage
• Rapidly accessible Telehealth psychiatric consults for patients irrespective of where they live needing an urgent diagnostic assessment/management plan (what private psychiatrists know as a 291/293 service).
• Scheduled Telehealth therapy/allied health care for patients
• User-driven e-mental health patient education modules for GPs to use in their practices and patient e-learning psychoeducation modules that are evidence-based but pluralistic, eclectic and pragmatic i.e. based on the actual real-world psychiatric practice of experienced clinician/s, rather than some narrow CBT approach that has been ‘cut and paste’ out of some academic textbook (that’s just an example – feel free to substitute any single purist explanatory model or therapeutic modality to the exclusion of others, including pharmacotherapy).

After we were approached by some regional PHNs beseeching for assistance to find ways to access more private psychiatric care, I was inspired to work on developing a hybrid Stepped Care-Consultation Liaison-Telehealth model of care. In my role as chair I made efforts to engage with all NSW stakeholders: PHNs, Agency for Clinical Innovation, Mental Health Unit, Chief Psychiatrist, as well as the MAC, Branch Chairs’ Forum, MBS Review Working Group, Section of Private Practice, the AMA Psychiatrists Group and the NSW AMA.

Of course, all of this should be provided on top of the existing highly valued, effective and efficient services provided to the community by private practice psychiatry as we now have it, both face-to-face consults in consulting rooms or hospitals, and those visionaries utilising Telehealth as a core modality for their practices. I am not suggesting that they could be substituted for by a cheaper model. Stepped care should equate to increasing the range of treatment modalities and methodologies available, not restricting them. Traditional face-to-face psychiatric practice and Telepsychiatry can be enhanced – to be bigger, better, more integrated – and more appreciated ...by being made more accessible and effectual, utilising modern methodologies and technologies.

Specialist access gaps are caused by a lack of psychiatrists, big distances that characterise our state/country, socioeconomic factors and system issues (I have rattled on about that a-plenty, so not in this final column). Many non-urban mental health consumers and their families in particular forgo specialist care due to these barriers. This scenario is increasingly being replicated, to a lesser extent, even in urban areas – in particular due to access barriers to most psychiatric subspecialties. The NSW subspecialty review is underway as I write, which promises to be a game-changer – stay tuned to discover how Managed Clinical Networks might prove to be the solution to preventing decimation of subspecialty services.

Telehealth is a cost-effective healthcare delivery method that can provide essential healthcare services to all Australians irrespective of geography. There have been many years of pioneering work in the public sector, including by our Chief Psychiatrist, and the last seven years of private practice experience in providing psychiatric care to patients across Australia directly from our consulting rooms since new Medicare items (and transient MBS incentives) were introduced in July 2011. Whilst local and fly-in services (despite many having been disbanded by many LHDs) remain important, Telehealth is “changing the landscape” of provision of psychiatric care to the Bush. It has indeed been shown to increase access to health services and up-skill health professionals1.

1 Moffatt, Jennifer J. and Eley, Diann S. (2010)The reported benefits of telehealth for rural Australians.Australian Health Review, 34 3: 276-281.

According to a number of colleagues with large Telehealth practices, it often takes place at the General Practice office and these sessions generally include direct conversations between the psychiatrist and GPs and other mental health stakeholders, such as support workers and mental health nurses. It would be a straightforward extension of these practices to provide clinical support directly to GPs utilising the same communications modality.

Another approach that GPs and psychiatrists (in both public and private practice) have been very positive about is the utilisation of a consultation-liaison model2.

Over the last year, the RANZCP NSW Branch has been a member of an Advisory Group for a Western Sydney PHN project to improve access to psychiatrists through a consultation-liaison model with ten local GP practices. Dr Andy Ang and a peer support worker presented at our Branch General Meeting on their experiences delivering this pilot program over the past year. The response from all present was very upbeat, as had been the case when I raised pursuing advocacy for this model at the previous year’s General Meeting.

The Mental Health Nurse (MHN) Incentive Program has been shifted to be under the funding and governance umbrella of PHNs, which creates an improved opportunity for a new integrated model where PHNs could facilitate and encourage MHNs to work with all Telehealth psychiatrists in order to use multidisciplinary care and support to enhance those services. In fact, I suggest that it would be the hallmark of a world-leading healthcare system if PHNs prioritised that every psychiatric practice in the state be enriched by the massive benefits to patient care that a MHN can add, in addition to facilitating general nurses for every GP practice.

Easily-accessible online psychoeducation could also assist us and GPs to help patients during clinical consultations if it were cleverly designed to be concise, engaging and facilitate patients pursuing further course content in their own time – this is most likely if the program were designed by our practicing clinicians rather than well-meaning clinicians or academics of lesser breadth of knowledge, training, skills and experience than we have. Wouldn’t it be great if GPs could be assisted to provide psychoeducation to their patients that was just a wee bit more sophisticated than: “You have a chemical imbalance; take this pill, and that will fix you”?

It would also be positive progress to expand a GP’s options beyond that of referring their patient to the psychologist who sub-lets a room from them in their practice. Not that co-locating is necessarily a bad thing, but if it’s the only other step in their ‘stepped care’ model, then that’s not really giving patients the diverse ingredients of a successful management package that could turnaround their clinical course and outcomes, is it?

Of course it’s not their fault! How much training do GPs get in psychiatry? (I still tell new registrars – such as at the recent NSW trainee orientation day – that it took me three years of training just to feel that I was beginning to get to know what I was doing in this specialty!) And how vulnerable are GPs to inheriting the same stigma and negative stereotypes about us, our practices and our/their patients without positive training experiences? How hard is it, also, to access us (e.g. ‘Sorry, my books are full for the next three months’)? Even if they can, how hard is it for them to match the right psychiatrist to the needs of their particular distressed patient/family/practice staff? And how good are we at corresponding with them (am I evoking some pangs of guilt)?

Are we making the most of the emerging, dominant 21st century digital culture that enables online technology to maximise capacity for two parties to collaborate most efficiently to optimise service provision? Look at how online models and processes have taken over catching taxis, renting holiday apartments, buying or selling houses, paying bills, even dating – let’s face it, all industries are being transformed by internet-based IT!

There is a lot of interest by our patients in IT. They routinely research their symptoms, diagnoses, treatments, clinicians and hospitals, which influences their decisions and behaviours. They increasingly come to us with Actigraphy data on their mobile phones and watches about their sleep-wake cycles and graphs of their mood and other symptoms. There is an explosion of studies examining how Actigraphy can assist in diagnosis and management of mental disorders. It is inevitable that cutting edge technologies such as Actigraphy, Virtual Reality and Artificial Intelligence are going to contribute substantially to our assessments, treatments and multidisciplinary care in the future!

2 Williams, Dodding,Wilson, Fuller,Wade, Consultation-Liaison to General Practitioners Coming of Age:The South Australian Psychiatrists’ Experience, Australasian Psychiatry, vol. 14, 2: pp. 206-211 (2006)

But if we ‘back up’ a bit to what’s achievable right now: GPs and consumers would benefit from at least an integrated package of initial GP clinical support where a patient is discussed in preparation for a Telepsychiatry consult (sometimes for particular objectives to be met), which is followed-up by another GP clinical support session where brainstorming can assist in the development of a ‘management package’ that the GP can oversee utilising local workforce and system resources.

This change in practice would foster increased confidence for GPs and psychiatrists to work together collaboratively – something GPs have been complaining has been very much missing from primary mental health care. And it would upskill GPs, improving their management of mental health presentations. It would also help them to feel supported, less isolated, maybe even reduce burnout and adverse events.

There are some associated salient issues that I have been involved in developing, driving or contributing towards (both in this role and within the Section of Private Practice Psychiatry) such as:

• The RANZCP Professional Guideline for Best Practice Referral, Communication and Shared Care Arrangements between Psychiatrists, General Practitioners and Psychologists, not only because of the huge benefits of multidisciplinary care that many (not all) of our patients can gain from collaboration, but also because online IT can facilitate these processes;
• Preserving patient confidentiality is particularly important with the ever-increasing place of online IT in our practices and risk of privacy being undermined; the rising tide of subpoenas led the RANZCP to form a Working Party after consistent internal lobbying by the SPPP and Faculty of Psychotherapy and others, which produced a Position Paper and reform strategy including advocacy for law reform;
• The MBS Review Working Group is making recommendations about how psychiatric care can be improved upon in the private sector and could be a great opportunity to reform private practice in the ways I’ve suggested;
• Private Health Insurers and the NDIS should be prevented from going down US-style managed care pathways;
• the whole insurance industry, and perhaps many other industries, could benefit from more access to informed psychiatric understanding, advice and guidance, including enhancing utilisation of online ITs to access independent psychiatric care for people with mental disorders who are otherwise being suboptimally managed.

I feel very fortunate in having had the wonderful experience of serving in these roles, which enabled me to work with some amazing colleagues and to have learnt a lot more about the practice of psychiatry. I have gained a deeper respect for what we do, the people who share my calling and the variety of ways in which we contribute to this professional area. I have developed new and closer friendships, networks and meaningful connections amongst colleagues and staff. Thank you to those who have supported me and the work that we do.

Thanks to the College staff who I have been privileged to meet and work closely with – both at the binational and home turf. All the Branch managers we have had have been fine, outstanding, wholesome people, but Ken is the best of the finest! I wish Penny well for her retirement and future exploits in northern NSW – you have been a godsend to us and we will certainly treasure your invaluable contributions! Thank you Susan, we are so lucky to have your bright gleaming countenance and comportment at our shopfront! Linda is simply a legend. Roisin, you elevate the room with your spirit! It’s been real fun sharing Maddison House with you all! Thanks for making it feel like a second home. I look forward to seeing its transformation from its well-earned renovation.

Thank you Branch Committee – friends and countrymen, who have given generously of your time, passion and energy (and risked your reputations working alongside my pushing the envelope at times). I look forward to meeting with the new team, the new chair and contributing in whatever way you see fit. (Bearing in mind I do plan to have a bit more of a restful life and pursue some distinct private ventures, some of which have been inspired by my work here...)

Best wishes

Gary Galambos

Chair, NSW Branch Committee