I’m on the home stretch of my second (and last) term in this role. That leaves one more newsletter to go after this column! This is my time to begin some reflection about the most salient experience of my professional life: representing you, my NSW colleagues, to lead positive change these past four years.

There have been some difficult moments – because, to have any chance of actually seeing change occur in the current political climate (rather than engage in lots and lots of talking in meetings that go somewhere in the vague direction of their title but don’t somehow seem to reach any concrete place...), there has been a need at times to play a disruptor role, which has caused some noses to be bent out of shape. There’s no pleasure in that for a psychiatrist. We are used to shaping minds into healthy states. But we know, from our clinical work, the critical value of open communication, assertiveness, limit setting, reality orientation and above all, humour (including the satirical kind). In a populist thin-skinned humourless culture, noses don’t just bend, they break.

There have been bonuses. The highest returns in satisfaction have proven to come from investing time, energy and hope into longer-term aspirations ... and then to experience some of them begin to actually ‘take off’... Who would have thought it possible in a system where administrators are too busy playing ‘doctors and nurses’ to allow the doctors and nurses to treat patients! Is there actually some prospect that the controllers will stomach us being close enough to the heart of the system to resuscitate it into a functional conscious state?

The election for a new NSW Branch Committee is upon us (amongst other representative groups and leadership roles – such as the Board – see Angelo’s opinion in Guest Article). It has been such a joy to be part of what has been an ‘A-team’ of colleagues because the fellowship, camaraderie and mutual respect I have witnessed has been awe-inspiring! And invigorating! My message to you is that you might be surprised to discover just how rewarding contributing to your profession by representing your colleagues can be.

For those of you lone wolf activists out there – try some real advocacy! ...collaborating with those who trained, supervised, mentored and did triple shifts alongside you in your formative years! Reform the whole system – not just the parts you happen to be interested in (which then takes resources away from other areas) or that you don’t realise you don’t know as much about as you think you do, yet have stiff opinions about! (Did I mention that playing health politics also increases your ‘second order’ mentalisation cognitive capacities? ... participating has its health benefits).

I’ve been thinking about the root causes of the underlying dysfunction that makes our public system so much less effective, efficient and appealing than it could be, holding us back from being a first class health system leading the world in quality, access and clinician-led innovation.

At the top of the list is its bureaucratic culture. We need a culture shift to return the health system to having a single purpose: treating patients! To do that, a lot more of its funding needs to be spent on direct patient care compared with administration – was suggested by an astute colleague. A health system spending 80% vs 20% would be able to treat more patients per funding dollar – that is, be more efficient – than a system that spends 50% on direct patient care and 50% on administration, for example. (Also, more funds would be available for more humane, interpersonally responsive, values-based care.)

It doesn’t make sense for the public and private health systems to have such different administrative systems whilst performing largely overlapping functions. In fact, ironically, despite its increased proportion of cost, the public health system administration is perceived as distant, hierarchical, inflexible and ever-growing, whilst the private system is flatter and more flexible.

A 70-bed Private psychiatric hospital usually has a half a dozen admin staff and its By-Laws require that a Medical Advisory Committee consisting of a representative group of psychiatrists regularly meet with the executive team (e.g. chief executive, deputy, director of nursing, medical director or superintendent) every month to sort out problems and initiate any desired changes soon afterwards, as the typical governance model. Compare that to the public system, where we lobbied for over a year (and needed to recruit the assistance of the NSW AMA) to pave the way for a regular forum to be established where NSW’s public psychiatric workforce could meet regularly with LHD chief executives (after a decade of careless inattention to the intent and spirit of the LHD By-Laws).

Patients in the public system are generally more ill, so providing them with increased care ought to require more clinician involvement, not more administrators. You don’t hear: “Nurse, this patient is very ill – call in the Acute Admin Team – stat!” hollered throughout emergency departments, do you? The public system should in theory actually have a higher ratio of clinicians-to-administrators than the private system due to the acuity and severity of the presentations there.

So I am suggesting that it’s a ‘numbers game’ as much as about having good governance structures. If clinicians don’t substantially outnumber bureaucrats, that’s much more likely to lead to a system led by self-serving bureaucrats – which in reality means funded, designed and operated on economic principles much more than those specific principles we (and society) know are essential for good healthcare – medical ethics and values-based, evidence-based person-centred practices. I just don’t believe you can legislate humanitarian care. In fact, non-clinical bureaucrats telling clinicians how to do their work by ‘proselytising from their pulpits’ about value-added models, is only likely to be counterproductive because it demonstrates the incongruity and perversity of a topsy-turvy system in which the ‘tail wags the dog’.

The tone is set from the top. We are a social hierarchical animal at heart. (We create society’s culture, it is not the other way around as many left-wing ideologues mistakenly believe; and extreme right-wingers underestimate the power of culture to balance out our more animalistic ‘survival and control’ instincts.) So there is nothing more powerful than our chief psychiatrist having the courage to state in his Review of Seclusion, Restraint and Observation in NSW Health Facilities that cultural factors appear to be the most substantial contributors to adverse outcomes resulting from poor decision-making in clinical patient management, and the solution must include leadership reform. Whilst we considered the inquiry to have some deficiencies, overall we were impressed with that key message.

The NSW Branch Committee and its Governance, Leadership and Workforce Subcommittee will be ‘knuckling down’ to work out how we can lead change in the wake of that Review. The solutions will require consideration of the essential resources, gaps and practical realities that affect the capacity to practice in clinical, leadership and management roles.

When it comes to assessing the efficiency of health system administration, I would like to propose that a most important (but currently non-existent) Key Performance Indicator should be the proportion of health funding spent on clinical care vs administration i.e. a Clinical-to-Administrative funding ratio. Regularly comparing the administrative efficiency of the public vs private health systems would assist to stem the temptation of bureaucrats and administrators from replicating, adding layers, taking over control or wasting taxpayer dollars on excessive risk-management. If it can be demonstrated that the public system turns out to spend more of each funding dollar on administration than does the private sector, that would represent an opportunity for micro- economic reform.

With the administrative approach within the private sector being an existing working model, there is no need to re-invent the wheel! We could just transition from a public health administration model to a private health administration model. This is not about privatising mental health. It’s about refining the public health system’s administration system based on the lessons learnt from the private health system.

And we have the perfect NSW statutory body to monitor and report on this ratio and other KPIs for mental health services provided by LHDs and other state-funded entities (such as statewide subspecialty networks and any NGOs receiving mental health dollars). Who, you may ask? Well, wouldn’t that be the perfect job for the NSW Mental Health Commission (MHC) – if its role, job description and powers are revised in the wake of the Review of its Act, for which we have robustly advocated?

The culture shift also isn’t about out-sourcing public administration to the private sector. In fact, quite the reverse – it’s about learning from the private system’s administrative structure and approach to improve the administrative efficiency and effectiveness of the public health system. It’s also not about starving the existing public health administration of funds, as that would make a more problematic system. No, it’s about transforming an inefficient, wasteful structure into a well-organised, productive system.

It is analogous to learning lessons from how other countries administer their health systems. The public mental health system would continue to remain entirely the government’s responsibility, where it belongs. But it is worthy of note that overseas experience indicates that neither those heavy-laden with administrators nor those run by non-clinician administrators are the elite bastions of healthcare excellence. The best healthcare facilities are those run by experts in the core business – the practice of Medicine to treat patients – the medical doctors. Actually there is a Medical College in Australia dedicated to graduating medical leaders in healthcare. Another system KPI for the MHC Mark 2 could be to monitor whether the chief executives our health services are graduates of the RACMA, who are more likely to understand how to support mental health services equally to that of other specialist health services.

Without effective top-level leadership, with the authority for high-level decision-making, there is no-one capable at the top of taking responsibility for developing a workable statewide-nationwide blueprint for the mental health system. Is it really a surprise that the landscape becomes a fragmented, loosely stitched-together plethora of principles, funding promises, band-aid appeasements and autonomous ‘businesses’ competing for healthcare dollars (LHDs, services outsourced to the NDIS – an insurance scheme, NGOs), without a lightship at the top of the hill to provide coordination and guidance? The autonomous LHD/subspecialty network model is proving to be a catastrophic failure – there are critical services within the current system that are on the edge of collapse.

The lowest hanging fruit are the subspecialties. Even a formalised funded subspecialty network like the Sydney Children’s Hospital Network has not been immune from the ‘reality’ of a non-integrated statewide system ‘catching up’ with it. The Branch Committee was dismayed to receive a request for this service to be categorised an Area of Need. Think about that – the twin centres of excellence for this subspecialty dedicated to providing psychiatric care for those mentally disordered youth in NSW requiring the highest level of expertise, located in the metropolitan hearts of Sydney, surrounded by the highest density of child & adolescent psychiatrists in the country (and following a decade of investment to increase training numbers of this craft group) – needing to look for overseas doctors rather than attract the nest from our ranks.

The workforce itself is begging to be reformed. The highest priority needs to be given to ensuring that there are adequate numbers of psychiatrists and trainees to meet the community demand, that they are able to function effectively in their roles. Staff specialist Psychiatrists need to have non-clinical time available to provide system governance, lead the multidisciplinary teams, supervise and mentor trainees and contribute to critical committees. VMOs need to be brought back to fill the clinical gaps.

Neither psychiatrists nor trainees should be spending much time covering for colleagues on any type of leave. And registrars should be able to access all the essential training rotations they require, have a positive experience and be tempted back into a system where there are psychiatrists available of all levels of seniority and experience.

Ironically, despite the perceived decline in aspects of our healthcare system, by those of us who experienced what it was like when it was less bureaucratic and more clinically oriented and, more importantly perhaps, saw the potential of how much even better it could become – things have not got so bad that there is rioting. However, the politicians are aware of a swelling discontent and resentment in the community, especially regarding access to quality mental health care in the public sector. And we are aware of the rising demoralisation in our ranks and the steady haemorrhaging of senior colleagues from the public sector to the extent that junior doctors, multidisciplinary teams, patients and administrators are losing invaluable expertise and leadership. Trainees and medical students are losing the experience of mentors modelling humanitarian medical values and the highest levels of knowledge, skills and practices within an apprenticeship training model that has served previous generations well.

We don’t really know whether the lion’s share of the public budget spending on mental healthcare is increasingly being consumed by sprawling bureaucracies, because there is an absence of information about this and most other aspects about NSW mental health system. The basic data reflecting ‘the lay of the land’ has become unavailable in the wake of outsourcing the running of NSW mental health services to LHDs, subspecialty networks and NGOs without recognising that close oversight would still be necessary. I know because I asked the NSW Health Department’s Mental Health Branch for the most basic data possible upon being elected to my role four years ago – our State’s mental health specialist workforce breakdown, numbers and types of hospital beds, etc. I was told to ask the MHC – a MHC that had been openly complaining that it has no access to this essential data and no power to demand access for the entire five years of its existence!

To the credit of the Mental Health Branch, it appears to be taking this issue seriously and developing a methodology for accessing real-time workforce data and developing workforce plans including a psychiatric workforce plan. It has invited me to participate on a working group developing a NSW Strategic Framework for Mental Health 2018-2022 and the Branch Committee considered its progress recently. Highlights of our feedback included:

• Reforming inpatient care needs to be included as a key reform strategy to align with the critical recommendations of the Seclusion Review, to ensure a high quality, efficient, accessible system responsive to patients’/families’ clinical needs. The current inadequacies in inpatient models of care, workforce, culture, governance structures and inpatient and emergency department designs need to be explored alongside much-needed reform of community mental health services.
• Development of leadership and cultural shift among the mental health workforce requires greater emphasis, including KPIs for workforce vacancies.
• Access to psychiatrists: we hear repeatedly from patients, families and private Fellows concerned by the difficulties in accessing timely psychiatric assessment and evidence-based interventions in the public sector, especially in subspecialty areas.
• Expansion of the peer workforce: people with lived experience can contribute essential knowledge and support to the planning, management and delivery of services, but the literature does not support extending a peer workforce according to a number of meta-analyses including an Australian Cochrane review. There are some subpopulations for which there is some or early evidence of benefit of peer workforce support, such as drug and alcohol/addiction services and psychiatric/comorbid rehabilitation services.
• Aboriginal mental health service development: improving Aboriginal mental health services should be a priority reform area. We suggested diverting the majority of funds currently marked for a generalised expansion of the peer workforce (focusing on the ‘acute care’ frontline services) to targeting specific peer worker initiatives (based on evidence and identified need such as Aboriginal mental health) and prioritising the development of a high-quality Aboriginal mental health workforce consisting of psychiatrists, psychiatry trainees, nurses, allied health clinicians, CMOs administrators, including peer workers and volunteers, should be an immediate reform focus. There is an unacceptable imbalance between the funding for 28 new peer workers and 116 scholarships to support an emerging peer workforce compared with the funding of 7 Aboriginal mental health positions.

Investment of scarce mental health dollars should be aligned to interventions for which there is a clear and prioritised need as well as sufficient evidence of effectiveness, which points to structured interventions followed by fidelity targeting to well de ned therapeutic goals in specific types of patients. The future NSW MHC may help to weed out how much funding is being used to support non-evidence based ideologies, fantasies and experiments devised by committees, commissions and political cycles – fueled by economic rationalists, activists and so called reformers increasingly operating outside of professional medical colleges. Many of these experiments are themselves being conducted, at tax-payers expense, outside the mainstream healthcare system when it comes to mental health. Is it any surprise that the senior psychiatric workforce has been bailing from this mess?

We, as has always been the case for those dealing with the intangible, obscure and multifarious healthcare problems, remain the most vulnerable specialists to being underestimated, unheeded and sidelined. Until society is mature enough to give our expertise equal standing to that of our colleagues who deal with tangible healthcare problems, the community will continue to be underserviced – with less sophisticated models, a disenchanted underperforming workforce, unhealthy culture, negative experiences by healthcare providers and consumers, and poorer quality health outcomes.

2018 will be a year for new faces, advocacy and exciting activity on multiple fronts. It will be a year for hard work and for embracing the NSW Branch membership and building positive relationships with the many other key stakeholders concerned with mental health in the community. I am hopeful the Branch will continue to advocate proactively, consistently and opportunistically – using deficits, gaps and negative publicity as an opportunity to push for constructive, positive, specialist-led system reform. To that end we must continue to prioritise nurturing a positive, sustainable and productive NSW Branch community.

I look forward to seeing or speaking with you in 2018, either at one of our NSW Branch educational, social or organisational events. Please feel free to reach out to us if you wish to contribute in any way beyond the outstanding work that you already do!

Best wishes

Gary Galambos

Chair, NSW Branch Committee