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. 

 

The power of connection

On Thursday, the federal health minister, Ms Sussan Ley, announced a new framework to tackle what has been described the crisis in Australia’s mental health system. Key opinion leaders in this field from the AMA to top academics and researchers have had mixed responses to the announcement. For what it’s worth, this is mine.

I am a consultant psychiatrist working solely in private practice. I run a very busy clinic covering a wide range of clinical sub specialties and many of my patients have been coming for several years. Prior to this, I completed my training in a tertiary teaching hospital, and over 10 years have seen many  patients with all forms of mental illness. I have also worked in rural and indigenous areas and have first hand knowledge of what works.

Regardless of their condition, their social situation, their background, their journey, two things help patients recover. Hope and connection.

When my patients recover they tell me they were grateful I didn’t give up on them. As they became well, they could see at the very time they were most unwell they truly believed things would never get better. So my ability to hold their fears, and reinforce with consistency and kindness that things would improve, were the most therapeutic ingredients to my package of care for them. Connection with a stable consistent provider of healthcare was paramount.

As doctors, we often forget how important we are in the care of our patients. This is particularly true in psychiatry when there are so many other ‘key stakeholders’ in the delivery of care to those with mental illness. We often relinquish our roles, shy away from leadership and stifle our voices when we see care we don’t agree with. It’s almost as if the system can only work if we remain silent. But I find that very hard to do.

For what it’s worth, I have been involved in the care of patients with all forms of mental illness since the era of deinsitutionalisation, firstly as a pharmacist and then as a psychiatrist. I have seen fundamental changes to the care they receive over the past 25 years.  I liken this new round of changes to a homeopathic treatment for the mental health system.

Each time a new strategy or overhaul of care is delivered to great applause, it is as if the policy makers have diluted the pool of patients with mental illness to such a point that they focus on only the smallest fraction of those who need and deserve our care. The very small number of people who have the insight,  and know how to go and seek out some help. They talk about ‘support’ ‘engagement’ ’empowerment’ and ‘resilience’ like they are evidence based measures of successful outcomes. They talk about strengthening partnerships and improving access without any tangible way of assessing what that means. The rest are diluted out and discarded.

For the past 25 years not one single mental health policy has addressed the needs of those with severe and chronic mental illness.

Over 25 years I have seen patients with schizophrenia, bipolar disorder, borderline personality disorder, melancholic depression, anorexia nervosa and many other clinical presentations be moved from pillar to post, often quickly and at the hands of a new government. Every single time this happens the two most valuable aspects of psychiatric care, hope and connection are fundamentally destroyed. The argument that ‘well this approach ain’t working, so let’s replace it’ drives this move to destroy hope and connection.

For the past 25 years not one policy has looked at what we have and tried to improve it, rather than reinvent it.

Let’s be sure of the facts, the ones that are diluted out in the homeopathic process that is labelled mental health reform;

  • Many patients with severe and chronic mental illness require lifelong care and frequent hospitalization.
  • Being hospitalized for mental illness is not a failure of anybody but exactly the appropriate type of evidenced based care a patient needs if acutely unwell, and at risk to themselves or others. And a long hospital stay often means a patient is very unwell, not that the services are incompetent.
  • We have turned our backs on those already in long term and residential care, the very thing policy makers said they would not do when patients were turfed out of asylums. They are still here, with us, deserving of our care just as in any other severe illness, but are firmly entrenched in an overflowing ‘too hard basket’.
  • We already have a mental health system which is failing not because it is hospital based, and the idea of building primary care networks for this group of patients has no merit. Patients with severe and chronic mental illness deserve multidisciplinary care that can be flexible in a ‘step up-step down’ way and can move to provide the care and risk reduction required. The reason this doesn’t work now is not because it is based in the hospital system, but because the services are so poorly run down they can’t offer what the patient needs. Administering ‘care packages’ to these patients, already known to the professionals in the public mental health system will lead to a doubling up and waste of valuable money that could be used to create extra beds and fund more staff.
  • It is not the patient’s fault that they fall through the state government/federal government convenient ‘diffusion of responsibility’ construct.
  • Improving knowledge and awareness of mental illness by providing fact sheets and e-health approaches are good for some but this should not be applied to mentally ill patients in a broad brush way.

There is evidence for these arguments everywhere, it’s just that the whole mess that began after deinstitutionalisation is so large now that nobody wants to talk about it. Patients who left asylums in the late 1980s moved through an era of case management, mobile support teams and crisis assessment and treatment teams. But then these services became so overwhelmed they could no longer deliver assertive outreach to the level they should. With nowhere else to turn, many became ‘frequent flyers’ in our state hospital emergency departments. When they were ready to be discharged from hospital, there was no room at the chronic care units if they needed it. NGO’s that provided wonderful support and consistency such as Richmond Fellowship and St Mary’s House of Welcome suffered massive funding cuts. And rather than improving medical comorbidity in patients with mental illness, mainstreaming psychiatric services into major teaching hospitals has led to more stigma and a sense that patents with mental illness are purely bed blockers.

There is so much devil lying in the detail of this new mental health reform. It is also very disappointing that it was announced without any increase in funding for the public mental health system, and in top of that, Medicare cuts for patients with severe and chronic mental illness. I have many questions about this implementation of primary health networks (PHN’s) and it is hard to ascertain any information. In particular, I wonder who will be staffing these organisations, to what level of acuity can they provide care, and how does a patient and a health professional interface with a PHN? What will be the role of the GP, the one who should be the cornerstone of medical care for all patients? How does the private psychiatry and psychology system fit with this? How long will PHN’s be around for and what happens to the patients after the funding runs out? Allow me to be cynical because I have seen it all before. I work every day with patients with mental illness, I wear all the responsibility and I know how complicated it can be.

So what do I think we need? Well, it’s not that glamorous, and doesn’t contain a lot of rhetoric, so it probably won’t get up. But I reckon after 25 years in this area of medicine I might be onto something. My simple recipe for mental health reform (totally undiluted):

  • Allow psychiatric triage services that exist in all our major hospitals across Australia the resources and staffing to be able to pick up the phone and respond when a patient is in crisis. These clinicians often know the most unwell and vulnerable patients in their network. They have managed them for years. The know what they are doing. And they have a connection with them.
  • Boost the crisis teams and assertive outreach teams, bring back the homeless teams and all the wonderful services that could respond in a timely and safe manner.
  • Look after staff who dedicate their careers to helping some of the most disadvantaged people in our society, so they remain in the system and continue the connection.
  • Have places of haven for those who live with symptoms all the time. Be kind to them.
  • And above all, invest in acute services that know exactly how to manage mental illness and have been doing so for years.

Bring hope and connection back to the forefront of what we are trying to achieve. Not another layer of bureaucracy and more strangers that may come and go in and out of a patient’s life.

Dr Helen Schultz is a consultant psychiatrist and advocate of patients with mental illness. She is also passionate about doctor’s mental health, and attracting doctors to the wonderful profession that is psychiatry. She is the author of How Shrinks Think