Welcome to the summer super bumper edition of my column. I promise a sunnier read than you are used to from me, as I’d like to share some great advances we have made this year. We are finally beginning to ‘reap the harvest’ from our persistent efforts to engage in proactive and quality advocacy, networking and submissions to the NSW Mental Health Ministry.

A critical area of determined focus of the Branch over this past year has been to identify gaps undercutting quality and efficient clinical governance, leadership and workforce capacities within the mental health system. We know that there is an excessively bureaucratic culture suffocating these critical ‘tools of our trade’ to maximise mental health care outcomes.

This out-of-balance culture of bureaucratic models dominating over clinical models is increasingly creeping into the private sector too – so advocacy has also been occurring on that front, but the NSW public sector has deserved special attention!

As a result specialists and other senior medical officers have increasingly been excluded from leading the development of service design, delivery and operations. This denial of the most logically optimal workforce structure – administrators working alongside clinicians in shared responsibility and authority to serve the best interests of the community – has adversely affected mental health services more than any other medical specialty.

Decentralising the health system into autonomous Local Health District (LHD) fiefdoms has put fifteen LHD chief executives in charge of the NSW Health system and undermined forward-planning policy- making on a state-wide perspective. Where are the minimum standards of care? Where are the clinician- led models to prioritise rapid access to assessment and management by specialist and subspecialty teams (especially those subspecialties that are scarce or not available)? Where is the centralised data collection to permit transparent global and comparative outcome review and identification of system gaps? Who is holding chief executives to account for effective functioning of their kingdoms?

The most disadvantaged in our community always lose out the most in a system without centralised oversight or monitoring of the healthcare gaps, especially in a bureaucratic, penny-pinching culture top-heavy with administrative types unaware of what they are unaware of.

But the winds of change are coming! The Seclusion Review may well prove to be the ‘canary in the coalmine’ signal that the bureaucratic culture is sapping the humanity out of healthcare!

Non-clinician bureaucrats and administrators are trained to think abstractly, to model public health management of mental disorder using economic (dehumanising) concepts like supply, demand and costs (to the administration). We cannot blame them for not understanding how essential interpersonal compassion, respect, nurture, consistency and trust play in healing, recovery and relapse prevention for all health conditions and mental disorders in particular.

Good administration is an essential component of a healthcare system, of course, but it needs to serve health care – what occurs in the interaction between clinicians and consumers. It is the relationship between the consumer and the clinician that leads to good health outcomes. The work we and the multidisciplinary teams we lead (or should be leading) needs to be the central, core and sustainable healthcare activity.

So perhaps the oversimplistic model of a single consumer being in the centre of multiple concentric circles should be upgraded to a consumer with a clinician in the centre! Prioritising that relationship by putting it centre-stage would help with the cultural change necessary to help politicians and administrators aim their sights on the central healthcare process that drives good consumer experiences and outcomes: the doctor- patient relationship (or clinician-consumer or therapist-patient – whatever you want to call the party seeking healthcare and the other one providing it).

This is not mindless work – it is known to be highly emotionally taxing and associated with risks of vicarious traumatisation. It thus requires proactive measures – teamwork, supervision, peer support, education and training – to prevent individual clinicians and teams from getting burnt out with compassion fatigue and to enable sustained provision of high-quality person-centred healthcare. So-called ‘clinical support time’ therefore needs to be an essential ingredient. In a bureaucratic universe, that means it needs to be costed into the formula of providing healthcare.

It is time to drop the pretence that naming values, paying marketers to come up with feel-good slogans and running healthcare defensively (the pathognomonic marker of the bureaucratic method) by listing tick-boxes of every possible risk factor for clinicians to mark off when they assess and ‘manage’ patients is going to cut it for genuine, caring, effective healthcare – especially mental health care. So there clearly needs to be a rebalancing of the administrator-clinician relationship to enable the supporting of quality clinical relationships to be formed between patients and their clinicians effective for best outcomes.

So when I met NSW Minister of Health The Hon. Brad Hazard MP at a leadership forum hosted by AMA NSW last month I told him that the administrator-clinician relationship in NSW was so unsatisfactory, so unequal and so dysfunctional that it required marital therapy of the most assertive kind. I explained that many senior clinicians had decided to get divorced from the public system and this had left a fragmented workforce becoming so top-heavy with junior psychiatrists working part-time that the workforce profile was becoming incompatible with the provision of effective team, service, system and trainee leadership, supervision and training.

Also I thanked the AMA NSW for helping us ‘get over the line’ on a reform of the way psychiatrists and administrators meet together in NSW, one step that could improve mental healthcare delivery in the public sector...

I am talking about the need to revise the NSW Hospital Model By-Laws in order to ensure that psychiatrists and other senior medical officers working in mental health services have formal venues across the state in which to engage with clinical leaders, management teams and Chief Executives. These regular meetings will foster collaborative governance, policy and strategy development and inclusive decision-making about deployment of resources and operations. They will facilitate improved linkages between VMOs, CMOs and Staff Specialists. They will help to improve clinical effectiveness, morale and retention of senior psychiatrists and CMOs.

Why do we need these senior medical officer mental health-specific workforce venues, when extensive and specific direction is given to the fifteen NSW LHDs in the existing By-Laws about how to ensure that the engagement process between senior medical officers and senior management teams is conducted in an inclusive, democratic and transparent manner? Section 23(3) declares: “Sufficient Medical Staff Councils should be established to ensure that all visiting practitioners, staff specialists, career medical officers and dentists of the Local Health District are members”. Though psychiatrists consider themselves in that group, the By-Laws do not make any references to Mental Health Services (MHS) and minimal consideration is given to Community Health Services.

The emphasis on Hospital Medical Staff Councils has placed MHS within LHDs at a distinct disadvantage. Whilst psychiatrists in our MHS can in principle attend the Medical Staff Council of their local hospital, these venues provide no scope for constructive discussion with the senior management teams of MHS. This especially is the case for psychiatrists working in Community MHS. The few psychiatrists who do currently attend Hospital Medical Staff Councils find it challenging to ensure specific mental health issues are given priority.

Incidentally, the By-Laws have completely ignored the so-called stand-alone mental health inpatient facilities in NSW – such as Cumberland, Morriset, Macquarie and Bloom eld – all of which primarily employ psychiatrists as senior medical officers. Remarkably, these hospitals do not have formal Hospital Medical Staff Councils operating as required under the By-Laws, with an elected chair who attends the Chairs of the Medical Staff Councils meetings auspiced by the LHD Chief Executives.

Effectively excluding the psychiatric workforce is glaringly inconsistent with these figures and facts:

• 10%: that’s the psychiatrist workforce—a sizable proportion of the total medical workforce
• 8%: that’s the MHS budget—a sizeable component of the total LHD budgets
• 50%: that’s the Community MHS budget—what most LHDs’ commit of their total MHS budgets
• MHS are operationally streamed across the LHDs—with a centralised management and budget responsible for both hospital-based, community-based and subspecialist MHS – this is a unique corporate governance structure
• MHS are subject to unique legislation (such as the MHA 2007).

This lack of a clear, robust and required structure has resulted in a reduced opportunity for psychiatrists to have representation within the operations of the LHDs’ governing structures or engagement of psychiatrists and senior medical staff to provide leadership within MHS in the same way that all other medical specialties such as medicine, surgery or obstetrics & gynaecology.

It is probably reflected to some extent in the high levels of dissatisfaction and disengagement amongst psychiatrists that two joint NSW Branch/NSW AMA/NSW ASMOF surveys conducted in 2014 and 2015, which indicated:

• poor and apparently deteriorating morale
• perceptions that available clinical resources are reduced
• perceptions that relationships between clinicians and managers are worsening,
• increasing numbers of senior clinicians leaving or planning to leave the system.

With our Senior Medical Staff not having access to Councils relevant to service in which we work, the current By-Laws present a risk to LHDs. So we have advocated for the psychiatric workforce to have available a clearly defined and formalised forum through which to assemble and participate in discussions about relevant mental health care problems and opportunities – and develop constructive solutions in collaboration with management before healthcare gaps and crises develop.

We raised this gap at multiple levels of the Ministry of Health both independently and in conjunction with the AMA NSW and ASMOF NSW, gaining support from two consecutive NSW Ministers of Mental Health as well as the Chief Psychiatrist. The Ministry has acknowledged that our proposed solution makes sense and will be adopted. Last month we sent a co-signed letter to the Chief Psychiatrist with specific suggested revisions to the By-Laws. I am grateful to the Chief Psychiatrist for inviting me to speak on this matter to all of the LHD Directors of MHS.

We will also continue to advocate for all other reforms that we believe will help to turnaround the significant psychiatric workforce problems in LHDs. For example, we have already successfully ensured that the Binational Education and Training Department will require state health facilities to provide adequate Clinical Support Time for supervision of trainees as part of College accreditation requirements. There are a number of other measures we intended to take to the Chief Psychiatrist’s Leadership Forum, such as developing after hours shifts in emergency departments for staff specialists and providing for cover for trainees and specialists on leave. In the wake of cancellation of that forum we will continue to liaise directly with the Ministry and with other stakeholders like ASMOF and AMA.

Our engagement with the Mental Health Branch has risen to a whole new level these past few months. We had a particularly productive meeting with the Chief Psychiatrist in which we agreed to work together towards state-wide subspecialty system reform. I will be presenting some conceptual modelling regarding improving subspecialty service provision using clinical network redesign at an upcoming meeting of the NSW Mental Health Program Council. The number of executive meetings and invitations to formal Ministry committee meetings have risen this past year to better reflect the cooperative approach necessary to develop good quality policy and strategy.

We are very appreciative of the funding grant from the RANZCP Office of the CEO to conduct a fully independent pilot study review of subspecialty services within NSW, to assist us in this critical reform area (which all states are struggling with as well as all other specialist craft groups). This structural and funding issue is intimately associated with the model of care we psychiatrists provide.

Our interest is not in separating general and subspecialty services but in integrating them. So this isn’t about credentialing – it is about developing a system that ensures that the community get their needs met from the leading-edge clinical care of serious mental disorders in a manner that is timely, equitable and facilitates access to quality specialist and subspecialist care. We have the opportunity to work together with the Chief Psychiatrist to leave a structural reform legacy with huge positive repercussions.

We will be prioritising those subspecialties that need most attention and can inform our review most effectively. We will be assuming that a ‘hub, spoke and rim’ model will be the basic blueprint structure that will accommodate all the subspecialty groups – those that have been formalised by the development of advanced training programs, those that are informal but essential to the state and those that are grossly underdeveloped but so important that they need advocacy to cultivate their key requirements to create a cohesive state-wide network. The subspecialties that the Branch Committee have approved at the time of writing are Child & Adolescent and Psychotherapy from the formal group, Intellectual Disability and Perinatal & Infant Psychiatry from the informal group, and Psychiatric Rehabilitation and Addiction Psychiatry in the underdeveloped group.

The Executive Director of the Mental Health Branch has indicated that she is establishing a subspecialty working group and is undertaking an impressive mental health workforce review with some exciting end-points in sight including a psychiatric workforce review and the development of a workforce ‘dashboard’ that will enable real-time monitoring of the specialist mental health workforce composition throughout NSW. This will hopefully reveal gaps, provide ‘red warning lights’ and opportunities for improvement across all sectors. We have highlighted the problem of fractionation of the psychiatric workforce, training blockages and loss of experienced senior psychiatrists from the system.

To its credit the Ministry has produced some aspirational models of care for some subspecialties which we have consulted upon and encouraged funding for in our pre-budget submissions. And I am impressed by the work of the state-wide eating disorders strategic plan and implementation, which we can learn from whilst assisting with some of the gaps they have been identified such as the need for leadership capacity reform.

Also of great timing is the completion and application of the National Mental Health Services Performance Planning Framework (Tool), which had been years in development by the Commonwealth Department of Health after taking it over from NSW – congratulations for having the courage to develop ‘ideal’ workforce figures to aim for based on population demographics.

Currently, the tool is not open for public viewing and will require an authorised user to attend a three day training workshop. The Branch Committee appreciated an overview of the tool by a senior Ministry policy officer. The potential of this tool to support demographically based service planning and to keep the LHD bureaucrats honest is huge!

Speaking of transparency, Nick O’Connor, John Allan (who was Chief Psychiatrist when the NSW Mental Health Commission was born) and I enjoyed the opportunity to discuss the future of the Commission with Prof David Chaplow as part of the Ministry’s review of the Commission and its Act. We strongly advocated for a set of reforms to clarify and mandate the role of the Commission. Moreover, we clearly emphasised that it needs the teeth to make it effective (at improving NSW MHS) by revising its Act to give it unfettered access to all relevant health information so it can provide transparent report cards to the LHDs and subspecialties.

Ken, Penny and I met last month with the new NSW Mental Health Commissioner, Catherine Lourey, and an entourage of her staff, at Maddison House. It was a very upbeat meeting that left us feeling positive and optimistic about working together towards positive real outcomes. This Commissioner has wide experience working as a health bureaucrat within the LHD system. I believe we are both on the same page about the necessity of having open access to information and plugging the leaking holes which can tempt health administrators to raid mental budgets.

I recently attended two full days of College meetings in Canberra – the Branch Chairs’ Forum and the Medical Advisory Committee – with representatives of all the Branches, Faculties and Sections sharing information and brainstorming with the Board, executives and departmental managers of the Binational Office. It provides a good forum for the Board to gauge what is happening in all jurisdictions and professional interest areas to assist them in developing positions, policy and to inform on advocacy.

There has also been some sadness to share with you. We recently lost an outstanding consumer advocate, Jackie Crowe – a National Mental Health Commissioner. Our Chief Psychiatrist had commissioned Jackie to assist with the Review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities this year. I met Jackie at an Open Forum that we, the AMA NSW and ASMOF NSW requested be part of the Seclusion review, to give our members the opportunity to have direct input. The event was hosted at the NSW Branch under the auspices of the CASP/SLAM leadership program. Nick O’Connor did an exceptional job as Chair to bring Jackie on board along with John Allan, Peggy Brown and Murray Wright, to join me (NSW Branch) with Tony Sara (ASMOF NSW) and Choong-Siew Yong (AMA NSW) on a panel.

I spent many hours engaged with Jackie in candid discussion about mental health reform advocacy in NSW. Jackie, as a consumer and carer, was very impressed and appreciative to the NSW Branch for our proactive advocacy work, willingness to express opinions that did not necessarily match those of presiding populist ideologies, and open debate amongst members about the role of Mental Health Commissions. She said this was a breath of fresh air for discerning consumer advocates (like her) who were looking for more leadership from psychiatrists in the system reform space. She also strongly believed that consumer representation badly needed sophisticated and contemporary representatives to work collaboratively with psychiatrists to create meaningful constructive change.

Jackie said she laid awake at night worrying about the dangers of developing a vulnerable peer workforce to be distributed throughout the mental health system including on the front-line in acute services. She believed that was a fraught direction for public policy to go. We agreed there are some arenas such as drug and alcohol, which has an evidence-base (e.g. Alcoholics Anonymous), and perhaps rehabilitation where there is some promising research taking place. It’s time for the college to develop a policy on the peer workforce policies being espoused and pushed onto health departments.

The Branch dinner was an outstanding success. I was delighted that President Elect John Allan could attend on behalf of the Board. Angelo Virgona was a very entertaining guest speaker and had some powerful messages about our profession and its future. The 2017 Meritorious Services Award recipient Ed Freed attended with his wife and was most honoured and delighted. There was a good proportion of early career psychiatrists in attendance and welcoming new NSW Fellows was therefore a raucous affair! Enjoy the photos Ken has assembled for your viewing pleasure. I think you will pick up the great atmosphere at a spectacular venue.

I acknowledge the outstanding efforts of the highly motivated and talented Branch team – Ken, Linda, Susan, Penny and Roisin. It is going to be a challenging year ahead with the Maddison House renovations in full swing.

I thank most appreciatively the eager and dedicated efforts of the Branch Committee – Angelo, Michael, Saretta, Victor, Andrew, Choong-Siew, Judith, Ralf, Judy, Nick and Melissa – who have liaised between meetings, attended monthly meetings going well into the night after a hard day’s work, sat on subcommittees and supported me, tolerated me and even had faith in my contributions!

Also thank you to all those members who made extra contributions along the way with our submissions and advocacy – you know who you are. Don’t forget to check out the NSW Branch webpage on the College website, which has access to all our salient correspondence and shows off the high-calibre of our collective work.

There will be elections for the NSW Branch Committee in February and if you wish to be part of paving the way for cutting-edge state-wide mental health reform whilst representing your colleagues, profession, patients and community, consider nominating yourself!

I wish you and your families and your patients a wonderful summer holiday period, festive season, New Year and hope you take time to have some well-earned recreation breaks with your loved ones. It has been an honour to represent you this past year.

Best wishes

Gary Galambos

Chair, NSW Branch Committee

Dec/Jan 2017 NSW Branch Newsletter

18 March 2018