A new way of thinking about Psychiatry. Moving from tertiary to primary models of care within Primary Health Networks (PHN’s).

It’s been a long time between blog posts and upon reflection, I feel it has come about as I have wavered about a sense of direction. Working as a psychiatrist in clinical practice is extremely rewarding, but I find that I need time away from the intensity of the work in order to write.

The last 6 months have been filled with some tremendous opportunities. Opportunities that I could never have imagined, but in some way have been working hard towards, and have come about from one single tweet.

The tweet was on the back of a blog I wrote about regarding the establishment and funding of Primary Health Networks (PHN’s) by the Australian Federal Government. When I heard about the development of a new layer of ‘care’, ‘service delivery’, ‘approach’ or ‘solution to the mental health crisis’ I was angered. Upon reflection, the anger stemmed from this deeply held belief of mine that as psychiatrists we were being overlooked and undervalued for what we did. That if only a new layer of bureaucracy was introduced the ‘mental health crisis’ would go away.

That federal politicians knew more about caring for patients with mental illness than I did.

So I decided to take this one to Twitter and made a request of the Hon Minister for Health, Ms Sussan Ley.  I invited her to come to my private practice in Melbourne and see what psychiatrists do. I wanted her to understand that myself and my colleagues probably weren’t that excited about precious dollars going to a new service model. We wanted funding to do more of what we did well.

She said yes.

After our meeting in January 2016, as promised, Ms Sussan Ley introduced me to the Executive Director of the North Western Melbourne Primary Health Network. My ‘PHN’. So, rather than continue to criticise, I was able to learn more about what this PHN in particular wanted to achieve.

All of this has been quite revealing to me, because it is a really powerful example of what happens when you presume others know what you do, or what you can offer. When you presume you command a certain level of respect and you find out, you don’t. See, in my world that is private practice, the best I can hope to achieve is to make a difference on an individual level. I become consumed with the needs of the patient, and become blinkered to what else is happening around me in the mental health arena. I lose sight of the fact that I cannot presume to have a role in the delivery of services to those with a mental illness at a systemic level purely because I am a psychiatrist.

Because, as I have found out over the past few months, most people within and without the mental health space see psychiatrists as largely irrelevant.

Very few psychiatrists have been consulted about what they feel patients with mental illness need since the era of de-institutionalisation. Some revolutionary ones have set up services they believe in and are proud of. Most psychiatrists I know feel completely defeated by the amount of work and the lack of funding that defines mental health care in Australia.

And the lack of funding and sheer amount of work that psychiatrists must encounter has led to a very dangerous mis-perception in society. That mental health services can function without our input.

We are described as inaccessible, scarce, and unavailable to meet the needs of many Australians with mental illness. We are seen as a ‘last resort’.

Hence, why I believe most of the mental health reform that has occurred within Australia has involved all the other mental health professionals out there. And yes, we desperately need multidisciplinary approaches to patient care, but there is a level of ignorance that during this time we have maintained our relevance and authority.

We are in fear of losing our most highly valuable place within the psychiatric multidisciplinary team.

And the proof is there. In the PHN that I work within, the population groups are as diverse as the field of medicine. There are areas of some affluence, but also marked poverty. The network covers five correctional centres, accommodation for refugees, homeless people, significant amounts of Aboriginal and Torres Strait Islander people, as well as people with gender and identity issues. Substance use disorders are prevalent across all of these groups. There are layers and layers of trauma. There are also plenty of skilled clinicians working as best as they can for these very diverse and vulnerable patient groups.

Very few services, away from major metropolitan hospitals, would have any access to a psychiatrist.

So, I now have this opportunity to take an in depth look at the services within my network and evaluate to role and value that psychiatrists bring to it. I want to think about caring for patients in a different way to the tertiary care model. I want to know what services and their patients think about us. I want to know if psychiatry trainees feel they can manage these complex areas of mental health care, or if they feel their training and exposure to such areas is missing or substandard. I am excited by the challenge and have embraced a new way of thinking, that is, bringing services and care to the patients, rather than the other way around. I could continue to resist, but at the end of the day I don’t see that the way we are currently meeting the needs of those with mental illness is working anyway.

Dr Helen Schultz is a consultant psychiatrist and author of “How Shrinks Think”. She begins her new role as Independent Expert Advisor, Mental Health, NWMPHN this month.