The NSW Chief Psychiatrist is convening a second NSW Mental Health Medical Workforce and Leadership Forum (Forum) in late September. I wasn’t able to attend the first one, held late last year, and this upcoming Forum is occurring during school holidays when I am away again.

The genesis of the Forum was in part a response by the Chief Psychiatrist to the findings of the 2014 and 2015 AMA (NSW), ASMOF (NSW) and NSW Branch joint surveys of public sector psychiatrists, which identified significant concerns about resourcing, workforce gaps and clinician-manager relations causing low job satisfaction and morale leading to a disturbingly high proportion of the NSW psychiatry workforce expressing an intention to leave the public sector.

It will be important to ensure appropriate representation and contribution from the RANZCP NSW Branch at the Forum to advocate for the broad range of reforms that we have developed that have the potential to meaningfully enhance workforce morale, productivity and the capacity of the NSW mental health system to produce quality health outcomes.

I was unable to comment on the outcomes of the first Forum held in September 2016 as meeting notes or action points were not provided. We will be carrying the workforce reform ideas to this Forum that we have canvassed with the current and previous Mental Health Ministers:

1. Amendment of Model LHD By-laws to establish dedicated Mental Health Medical Staff Councils in every LHD
2. Improving the triage of acute mental health presentations and in particular the management of patients with mental disorders and illnesses in NSW Emergency Departments
3. Adjusting staff specialist job descriptions for LHD psychiatrists to reflect the appropriate balance necessary between clinical duties and clinical support duties, in particular taking into account the need to ensure adequate clinical support time for the supervision of trainees.

Last year, we followed up the August NSW Branch Committee meeting, attended by the then Mental Health Minister with correspondence stating “the NSW Branch is advocating for a change to the LHD By-Laws to ensure that there is a more structured, formal and consistent approach to enable psychiatrists to communicate with Local Health District management, Executives and Boards. We believe that this could be achieved by Local Health Districts being directed to establish Mental Health Medical Staff Councils. We were encouraged by the expressed interest of the NSW Chief Psychiatrist to progress this initiative.” The following month, in September last year, the formation of these Medical Staff Councils was agreed to be a positive step forward at the NSW Chief Psychiatrist’s Mental Health Medical Workforce and Leadership Forum.

However, we were disappointed to discover late in July this year, from the feedback of our AMA and ASMOF NSW colleagues who attended the most recent Medical Services Committee (a high-level meeting between those parties and key Health Ministry personnel), that the Mental Health Branch had not yet asked the Legal Branch to begin tackling this proposal, despite our discussions with them. We understand that the Legal Branch had in fact been specifically conducting a review of the Model LHD By-laws for more than a year – during which time our Pathologist colleagues raised issues affecting their craft group leading to amendments being made for the next iteration of the By-Laws.

It is disappointing that the clearly enunciated concerns of our profession and proposed By-Laws revision, a solution supported by the AMA (NSW) and ASMOF (NSW), has not yet been followed up. We will of course continue to ensure this issue stays on the agenda, using the positive response to the Pathologists as a strong precedent.

In fact, whilst waiting patiently for a consultation request to be made to us on this issue – to meet with the relevant parties or provide more detailed rationale and recommendations to those conducting the By-Laws review, we had been working on a thorough explanatory document. After meetings and discussion with ASMOF (NSW) and AMA (NSW), we provided this document to them to take to the most recent Medical Services Committee for their information.

The proposal had apparently been well received at the first Medical Services Committee in December last year. Whilst that body doesn’t actually have any role in driving reform (only reviewing and discussing any proposed reform brought to it), we wanted to bring to its attention that we had informed the Ministry that the existing By-Laws have failed to ensure that Psychiatrists and CMOs have access to Medical Staff Councils (MSCs) that relate directly to the management structure of mental health services, thereby contributing to the demonstrated low morale and leadership engagement of psychiatrists within the NSW public mental health system.

I understand that there has been an opinion expressed as to why there may be case not to pursue this reform – being that there is nothing in the existing By-Laws that prevents LHDs from enacting the establishment of mental health MSCs right now. (Other than, of course, that most have been able to evade doing so, to date, disabling the specialist psychiatric workforce from having access to what other specialists have.)

Whilst the Model By-Laws require that all senior medical staff must have access to a Hospital MSC, this is a loose requirement without any specific stipulation that an LHD establish a MSC for its mental health services. Most LHDs do not in fact have mental health-dedicated MSCs and for those very few that do, the current By-Laws do not provide clear guidance around how they should operate. That’s because, in contrast to other specialist health services, mental health services are streamed services across each LHD with distinct budgets, management structures and governance frameworks. Therefore, having access to a General Hospital MSC is irrelevant to many of our staff specialist members.

Establishing Mental Health MSCs will be critical to improving clinician-manager relationships through a structural underpinning to encourage a culture shift towards closer communication and collaboration between clinicians, clinician leaders and non-clinician administrators. Naturally, we will continue to advocate for this straightforward, sensible, workable workforce reform.

We have also recommended that the staff specialist job descriptions of LHD psychiatrists be seriously considered during the Forum. In particular, we have suggested that:

• There be an appropriate balance between hours rostered for clinical duties and hours rostered for clinical support duties, in particular ensuring adequate clinical support time be reserved for the supervision of trainees.
• After-hours psychiatrist shifts at busy hospital psychiatric units and emergency departments be introduced to enable better and more timely clinical decision-making, assist with bed ow and management, provide registrars and CMOs more support on the frontline and improve patient safety, in the context of increasing numbers of after-hours hospital presentations.
• There needs to be a clear and consistent policy and practice to replace junior and senior medical officers’ leave, as it is an unacceptably high burden for colleagues to cover registrars’ and consultants’ annual leave and study leave in addition to their own roles – we believe this is a matter of doctor welfare that is a tangible step the Ministry can take if it is serious about suicide reduction in the medical workforce.
• Consideration be given to the development of a manual for clinical directors to make the transition to these roles less challenging.
• Leadership skills be built and developed through the Ministry sponsoring a number of leadership development rotations for advanced trainees.

Following this year’s Forum, I hope to be able to report back to you on the outcomes based on meeting notes and action points provided from the NSW Chief Psychiatrist. Hopefully there will be some movement since last year.

What about subspecialty reform? I have written in this column before and advocated at meetings with various levels of government over the last year that we need to develop more state-wide subspecialist workforce networks, such as perinatal, psychogeriatric, rehabilitation, gender dysphoria and others. And those that do exist need to be reformed in the context of the post-mainstreaming era where LHDs have been given so much autonomy.

We have submitted a Business Case to the Office of the CEO (RANZCP Binational Office) for funding approval for a state-wide service review of subspecialty networks in NSW. If we get the go-ahead, we will prioritise examining our child and adolescent specialist mental health system as we have been receiving feedback for years now about the low morale, loss of highly trained clinical staff, decimation of quality inpatient programs, failure to reform and improve provision of community care, sidelining of senior psychiatrists and difficulty in accessing child and adolescent psychiatrists and beds by CL teams. There is an overlapping concern about reducing access of general and advanced trainees to subspecialty terms and Fellowships.

Our submission co-signed with the RACP to fund the stage one development of a gender dysphoria specialty service for NSW is not going away. Letters to the Health Minister are apparently pouring in from distressed and desperate consumer families who can no longer access multidisciplinary assessment at Westmead Children’s Hospital with the closure of the informal service at Westmead due to an ongoing lack of resources. Ken, Penny and I met with some of these families who are not only seeking guidance and information, but starting to actively lobby for a funded, sustainable service for their young loved ones. We discussed our submission along with our other efforts, including the pre-budget submission this year, in which we advocated for funding the relatively tiny cost entailed compared with other health services.

I recently gave the Minister for Mental Health, Tanya Davies, a tour of a private mental health unit that has been developed specifically to cater to the care of young adults. This unit has been established with the goal to become a centre of excellence where public, private, NGO and academic sectors can intersect for this subpopulation that in particular bene ts hugely from a subspecialty expert team approach. I explained to the Minister how the unit had been proposed, designed and operated by clinicians and how the administrators appear to see their role as being to support the clinicians rather than presuming to lead, control or tell the clinicians how to do their job! The unit has a long waiting list but has dramatically assisted our CL colleagues running PEC units and servicing EDs around NSW to have available to them a tailor-made high-quality subspecialty program where they may refer young adults who have been bouncing in and out of crisis services or who would bene t from a subspecialist team’s assessment, management and triage over a 2-3 week admission.

The Minister was awed not by the high morale of the clinicians (which was probably not what she’s used to seeing), not by the incredibly high-grade purpose-built design of the unit ensuring a maximally therapeutic environment (she acknowledged the opposite appears to be more the status quo), but by what three young people told her – how differently their experiences were compared to what they’d had in the public system. In fact, what these consumers had to say was downright appalling.

One young person had reached out repeatedly for help whilst growing more and more psychotically depressed, then after a near-fatal suicide attempt, she was traumatised by admission to an adult unit (despite being under 18) where she felt vulnerable to exploitation by the inpatients and aversive non-therapeutic interactions. A second patient told about how she had been hospitalised for months in an adult unit (whilst aged well under 18) where she had been repeatedly secluded, restrained and sedated, which had not been necessary in the voluntary young adult unit – it appeared that a major likely contributor was the skillset of the clinicians being unmatched to her developmental needs, leading to overly defensive interventions.

Together with the AMA (NSW) and ASMOF (NSW), we co-signed a letter to the Minister for Mental Health in early June in which we provided in-principle support for the NSW Chief Psychiatrist’s review into seclusion, restraint and observations, but raised two serious concerns: the composition of the review panel and the limited scope of the Terms of Reference (TOR). The response from the Minister in late June indicated that no changes were made to the panel membership nor to the scope of the TOR.

Whilst it remains regrettable that there is no independent psychiatric expert representation on the panel and the scope continues not to consider wider system issues, the NSW Branch has proposed two consultations: firstly, an executive meeting with the Review Panel, and secondly, a workshop style open membership meeting with the Chief Psychiatrist in his role as Chair of the review. Even though these meetings do not equate to representation on the panel they will give NSW psychiatrists a voice in the review. The Branch Committee outsourced facilitation of the second meeting to SLAM, which negotiated the inclusion of Peggy Brown and John Allan, with Tony Sara from ASMOF (NSW) and Choong Siew Yong representing AMA (NSW).

Each of our organisations maintains our previous position that the TOR should be broadened to ensure a consistent state-wide standard of care is provided to manage acute behavioural disturbance using not only evidence-based seclusion, restraint and observation guidelines but also:

• Sedation guidelines
• Supporting models of care for psychiatric units and emergency departments
• An adequate, well-trained mental health service workforce
• Training and education for all NSW health staff in effective de-escalation and debriefing techniques.

We have also noted that the TOR do not distinguish between children and adults and suggested that the review should consider the following broader system measures to minimise seclusion and restraint rates in child and adolescent inpatient units:

• An adequate child and adolescent psychiatry subspecialty workforce thriving within a well-designed state- wide subspecialty system, with inpatient beds and Assertive outreach Child and Adolescent Mental Health teams commissioned in all LHDs determined by demographic service planning projections
• A review and optimisation of the architecture of inpatient units
• Training of clinical staff in emergency departments in best practice care of children and adolescents presenting with emotional distress
• A redesign of emergency departments to support the best practice care of children and adolescents presenting with emotional distress
• Adequate aftercare and follow-up services in the community for young people to ensure that acute crisis admissions do not become the default option.

Kym Jenkins (RANZCP President), Andrew Peters (RANZCP CEO) and John Allan (RANZCP President-Elect) recently visited our Branch, first meeting with me and then attending the beginning of our last Branch Committee meeting. An important governance issue I discussed with them was how the Binational Office (BNO) and our Branch can optimally communicate and collaborate to produce NSW submissions and respond to invitations from NSW stakeholders more effectively and efficiently. This is proving to be more complex and demanding than when we worked more independently.

It is critical to find the right balance between efficiency, effectiveness and independence. Our Branches most understand the systems, structures, contexts and histories within our jurisdictions. We are in the optimal position to most closely develop relationships and collaborations with the local stakeholders and develop and advocate for reforms when identifying opportunities for improvement. However, our contributions must be consistent with Binational Policies, we must utilise the resources of the BNO including its large Policy department/other College staff/committees, and work closely with the elected Board in proportion to their interest in contributing to our affairs.

A Branch Chairs Forum also met recently where we discussed trainee access to subspecialty rotations, ketamine, medical marijuana and the Voluntary Assisted Dying Bills sweeping through our states. The Branch Chairs and the BNO are amazed at the volume of submissions, meetings and communication occurring between the NSW Branch and key stakeholders. All salient correspondence can be found on the NSW Branch webpage.

We don’t need to worry about Ken, Penny, Linda, Roisin and Susan getting bored working for us! And for more excitement, as Ken will outline in his column we are in the process of planning a major renovation of our beloved Maddison House.

Best wishes

Gary Galambos

NSW Branch Chair

Aug/Sep 2017 NSW Branch Newsletter

18 March 2018