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The Australian Government’s new mental health workforce strategy must be implemented urgently according to the Royal Australian and New Zealand College of Psychiatrists, with health professionals interviewed for InSight+ saying our country’s psychiatric workforce is in “crisis” and cannot meet the needs of Australians.
Two in five Australians aged 16–85 years have experienced a mental disorder in their lifetime, according to statistics released earlier this month (here).
It’s prompted the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to declare that the existing psychiatry workforce cannot support the mental health needs of Australians.
“Right now, the mental health system is fragmented, under-resourced and unable to keep up with the burgeoning demand for mental health support,” said Dr Elizabeth Moore, RANZCP President said.
“We also have a critical and chronic shortage of psychiatrists. As a result, many Australians, particularly those in regional, rural and remote areas, and First Nations people, are going without the mental health care they need.”
The College said the solution lies in the government implementing the recommendations of the Australian Government’s Mental Health Workforce Strategy.
The strategy, released on 10 October 2023, has four pillars:
- attracting and retaining Australia’s mental health work force;
- aligning the skills, availability and location of mental health professionals with the needs of consumers;
- appropriate investment to improve workplace cultures by reducing administrative burdens, addressing the causes of stress and burnout, and improvement employment stability and remuneration; and
- removing barriers to the mental health sector so different teams can access data, and improving the use of digital technology.
Multiple issues blocking supply of psychiatric services
A number of systemic issues are reducing Australians’ access to psychiatrists, said Associate Professor Jeffrey Looi, the head of the Academic Unit of Psychiatry and Addiction Medicine at the Australian National University and Federal Council representative for psychiatry for the Australian Medical Association (AMA).
“The reason that there’s a shortage of psychiatrists is there’s a shortage of health care workers internationally,” Professor Looi said.
“The shortage existed even before the [COVID-19] pandemic. This means there are fewer psychiatrists in public and private health care to train junior doctors. This in turn decreases their ability to provide timely and accessible psychiatric care, leading to increased waiting times, shorter care episodes, and shortfalls in follow-up.”
“When there is demand, our trainees will be asked to do more work, which won’t help with their training. All of this makes working in those environments less attractive.”
The funding from the Australian Government is often insufficient for the state governments to provide enough services, he said.
“This is something that Australia has struggled with for more than 30 years,” Professor Looi said.
“There’s no easy solution, other than having to look at how we do work differently.”
A system in crisis
Greater investment in the public sector may help improve the problem, Professor Ian Hickie said, who is co-director of health and policy at the Brain and Mind Centre at the University of Sydney.
“We’ve had a shortage for a long time, but now we have a crisis,” Professor Hickie said.
“We have solutions at hand. They’re multifaceted, and they’re politically difficult. The public sector part must change. [It needs] more services, but better services.
“This means working with other disciplines. We’ve got to look at investments in the public sector doing more of these assessments.
“For example, assessments for ADHD [attention-deficit/hyperactivity disorder] that you might have to pay $1000 for; if that could have been done through a public hospital for free through a training registrar, it would be much more equitable. Rather than entirely outsourced to the private sector, and therefore restricted to those who pay the most.”
Community programs take a different approach
Some community health organisations are looking at providing psychiatry services in a different way.
Flourish Australia is a community mental health organisation in Western Sydney, is working with the Western Sydney Primary Health Network (WentWest) to create a “wrap-around” approach to psychiatry.
The Primary Care Psychiatric Liaison Service (PC-PLS) model supports general practitioners (GPs) to provide psychiatric services both to assist GPs and to see patients who can bulk bill their services. The program also offers GPs access to psychosocial support through peer workers.
“Many people live with severe and complex mental health issues and don’t have good support systems in place. This program tries to do a bit of early intervention,” said Mr O’Brien, the general manager of services at Flourish Australia.
“The PC-PLS program has four objectives:
- to build the capacity of GPs to provide mental health treatment, because they see patients who have coexisting physical and mental health issues;
- to increase access to bulk-billed psychiatric assessments and consultations;
- to create a collaborative decision-making process with GPs, carers and family members; and …
- to increase service coordination within underserved communities in Western Sydney.”
The model is based on similar models trialled in New Zealand, such as the Kia Haha: Manage Better, Feel Stronger program, Mr O’Brien said.
“GPs are time poor and they’re supporting people who experience severe and complex mental health issues, such as schizoaffective disorder and bipolar disorder,” Mr O’Brien said.
“GPs have training. But we also had feedback saying, ‘We want to help this person, but it’s beyond our skill set.’ So having psychiatrists available helps.”
Flourish employs one psychiatrist who works part time with 11 general practice clinics. The psychiatrist also runs a private practice.
“We were originally funded to have a full-time psychiatrist, and we had two employed part time,” Mr O’Brien said.
“But the other psychiatrist chose other work. As you know, psychiatrists are ‘as rare as hen’s teeth’.”
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I am surpised that junior doctors think the reason for not going into pyschiatry due to income is valid. Firstly if you are smart enough to get into medicine, you should be smart enough to get into other fields that get you far higher income at an early age with little work than being a medical specialist. Secondly for immediate satiety for money, the surgical resident get paid more as they do more on call and surgical departments are more likely (but not always) to pay overtime than other specialities. Worse, very few surgical residents get into formal training program. And not everyone are born a proceduralist. So frankly the idea that psychiatrist has lower income may be misguided; they need to see beyond public hospital setting (currently they are comparable to most physicians)
Another comment about not having psychiatrist in the centre of mental health care: as much as this sounds like a solution, it is the same kind of idea as having a rural nurse to provide healthcare when you can’t attract a doctor. Some can scream as much as they want that they serve the purpose but no one would admit that this only came about when you can’t keep a doctor in those places for long. And whatever model of care (MOC) people propose, whenever a doctor is involved, despite the other healthcare workers also being AHPRA regulated, the doctor’s own craftgroup is more likely to be harsher on their own, even if the MOC doesnt involve the doctor as the dorminant role, and worse, the doctor’s indemnity cover is a far bigger target for those seeking compensation than any other healthcare worker (even if they also have indemnity cover). And whatever MOC people propose, you still need a willing and available doctor to participate in it. So whatever less number of psychiatrist you need in a modified MOC as a compromise (let’s face it, if there is sufficient doctors, we wouldn’t be talking about it) you still need a basic number which it is very clear to some of us (or at least to myself) we don’t have the numbers
In NSW there is still about 35 unfilled psychiatric training positions. The number of new psychiatrists being trained is still far too low. When asking residents about what options they are considering almost none consider psychiatry. The reasons they usually give are often financial (the same reasons they are not considering General Practice). Compared to other options in medicine eg surgery the wages are significantly lower and the training (seeing acutely unwell and sometimes dangerous patients) is very difficult. It is unfortunate but until there is more pay equity, psychiatry will forever stay understaffed.
I think we need to ask critical questions about whether a mental health system should operate with psychiatry as the assumed head. This is not what happens in other areas like AOD, where psychiatrists have an important, but not dominant role. The question is less in my view whether we have enough psychiatrists, and more whether the current approach is an effective and sustainable one.
More pluralistic models of care that are less medicalised assist this. That isn’t to deny the importance of medical treatments at times, but rather to question whether that discipline needs to dominate – financially and conceptually – how we approach distress and crisis.
Over the last 30 years, there is a huge spike in medication prescription as mainstay of treatment with CBT not taken up by many GP as they are actually losing money than doing multiple Consult B within the same time slot. Few people started on antidepressants ever been taken off these drugs since they have not resolve or learn to cope with the stressors in their life, or make changes to improve their circumstances.
Then the hospital system relied heavily on “mental health nurses” to address the throughput workload at this interface, so there is no apparent need to train more psychiatrists while the nurses managed those inpatients not admitted under psychiatric team, often with very little direct input from these specialists (often you struggle to find who underwrites the nurses decision or treatment plan… which is almost always follow up with their GPS and their private psychiatrist… except they haven’t seen one for ages, because they can’t pay or the specialists has a long waiting list even for old patients). So there is insufficient workforce coming up to support or replace those incumbent and burnout.
Lastly there are a big demand for psychiatrists (public and private) for perverse reasons, largely related to them becoming effectively the gatekeepers to medical and social support linked to certain diagnoses, for example ADHD, autism (adult and children), getting these diagnoses for some in the community is used as a reason for their behaviour or actions past and future.
Prof Hickie suggests that “assessments for ADHD [attention-deficit/hyperactivity disorder] that you might have to pay $1000 for; if that could have been done through a public hospital for free through a training REGISTRAR (my emphasis)”. Why would those accessing public services have to be seen by a trainee? What is keeping psychiatrists out of the public system?
As a paediatrician we know a lot of these people have been flagged in childhood. They rarely have access to psychiatry assistance so we partner with GPs to help these complex children often with complex families. We are not psychiatrists but are trained in challenging behaviours. As thanks the majority of us in the private sector received a caution 2 years ago (post added trauma of COVID) that we saw too many 132 Item Numbers which is for 45minute consultation with 2 or more significant comorbidities. Hence these children often now have same care but are financially disadvantaged as to charge a lesser Item means a much larger gap payment only way an hour consult with many reports can be viable or some paeds are refusing to see them hence implications for GPs are obvious.
As I psychiatrist of 20+ years and currently in the public sector, I concur the profession is in crisis. The system is too fragmented with too many services doing the same thing, resulting in significant gaps for others. Community Mental Health services are so stretched there are no therapeutic interventions occurring other than depot medication and patients get doctors appointments once every six months if they are lucky. Having essentially psychosis only services mean the trainees and medical students are missing out on the full breadth of training required to be a specialist psychiatrist.
Nursing practice is also in crisis with decreasing numbers of skilled nurses due to attrition and decreasing interest. I am seeing increasing use of security staff leading me to think we’re going back to the days of wardens providing the majority of the “care” in the institution.
Increased resourcing is part of the solution, but integration of the fragmented services is essential, increased access to public mental health services by those with high prevalence disorders is also required with increased access to publicly funded psychology and social work.
We need space in the public sector to take on more patients rather than constantly sending patients with high levels of need back to GPs who are already stretched.
I agree with my colleague who highlights the failure of the medical model as the sole way of treating our patients but with decreased resourcing there’s little time for the bio-psycho-social model.
I had hoped to stay working for another 15 – 20 years but I’m now looking at ways out and have even heard trainees saying they are looking at ways of leaving clinical medicine altogether.
Nothing is more detrimental to a patient or a system than a bad psychiatrist. They abound in their own glory, making up diagnoses as is their want and dismissing patients if the problem becomes too complex.
But it is the good psychiatrists who are “as rare as hen’s teeth”.
And always in demand!
The psychiatric workforce crisis has multiple origins, not the least of which have been shortsighted politically-based decisions over many years. For instance, Michael Wooldridge as Health Minister cut GP training in ’96, burdening that particular workforce into the future. Similarly, the RANZCP decided that psychiatrists should mostly function as “consultants” and advise GPs (whose numbers were now reduced) rather than treat patients. Biologism then took over so everyone was increasingly medicated because the workforce took substantial hits. Now we’re in crisis. It seems it’s a crisis of policy-making that didn’t have the community at front-of-mind.
1. When psychiatrists have no availability, GPs have no choice but to pick up the pieces.
2. A number of years ago, I was involved in a programme where we saw seriously ill psych patients, with a psychiatrist coming to the practice for a few hours per week for support, seeing about 2 patients per week. The psychiatrist was paid by the Qld government, and we covered the practice overheads out of our pockets. The GPs had to rely on Medicare. No level E items in those days. Nevertheless, the number of “no shows” was considerable. We had to pull out of the programme, as we were losing so much money.