Why I quit as a psychiatrist in the dysfunctional behemoth that is the HSE

IN THE past two weeks, we have read about the resignations of two well known, highly respected consultant psychiatrists from the HSE. Both had similar reasons for doing so – the low priority given to mental illness that made working conditions unbearable.

Neither of these men is a “snowflake” who needs smelling salts at the sight of a distressed child. On the contrary, both are very experienced and have worked hard to deliver a service as best they can in primitive conditions.

In March 2016, I too handed in my resignation to the HSE after more than a year of reflection and discussion with my family.

My contract had three elements to it: the HSE and the Mater Hospital, both as a consultant psychiatrist, and University College Dublin as the Professor of Psychiatry. I resigned from my positions and then returned exclusively to the Mater Hospital, on a different contract.

Like my colleagues, I could no longer deal with the frustration of dealing with a system that was run by the dysfunctional, visionless, rigid behemoth that is the HSE. I was very fortunate I could return to the Mater and serve the public in my current position as a consultant.

The structure of the mental health services differs from that of other specialties. Access to a consultant and the multidisciplinary team is based on the address at which the person resides. So a patient being seen in the Mater Hospital as an emergency will only receive their treatment from the HSE services based in the Mater if they reside within the designated area for that hospital and funded by the HSE. Otherwise they will be transferred, immediately after assessment, to their designated service.

A snapshot of some of the problems that arose with the HSE will illuminate why I resigned.

All psychiatric units provided out-of-hours cover by a junior doctor and a consultant. Consultant psychiatrists in the Mater/HSE service work a one-in-four duty roster, which is high. A psychiatric unit about 4km away has a consultant rota of one in eight.

Consultants wished to merge the rosters so we would then be on call one night in 12 covering both hospitals. We were due to begin in January 2013 and the week before an order was issued by email from a senior line manager that it was not to go ahead. No reason was given.

This would have resulted in significant savings. A similar plan to merge the night rosters for the junior doctors was considered impossible by management.

Contracts for members of the multi-disciplinary team were drawn up by the HSE with little regard to the clinical needs of patients.

For example, an occupational therapist was appointed, the only one for the service operating out of the Mater. Upon her arrival, I asked if she could carry out an assessment on one in-patient to establish if she would look after herself on discharge. I was advised this person would only see outpatients. No reason was given by management.

This mind-boggling rule had not been discussed with any of the consultants working the HSE/ Mater psychiatric service.

AFURTHER decision, made in or around 2014 by the HSE without consultation, was that henceforth all acutely mentally ill people who present to the Mater emergency department and require admission would have an overnight stay in the psychiatric ward there and then be transferred to their local services the following day. This proposal was unique, as nobody had ever heard of such an arrangement in any other psychiatric service.

It was also dangerous because acutely ill patients need understimulation rather than the over-stimulation that contact with multiple doctors and nurses in a short period entails.

Neither could the safety of patients and of staff be guaranteed due to the small size of the unit. The ill-conceived arrangement was abandoned when we voiced our grave concerns.

On several occasions between 2013 and 2015, the psychiatric unit in the Mater Hospital had to close to acute admissions because of nursing shortages. Alternative arrangements were put in place.

There were similar recruitment problems for junior doctors and at times the service was staffed by locums, some of whom had little or no psychiatric experience.

When patients change address, their care has to transfer to the service designated for that address even though they may only have moved across the road.

A doctor-patient relationship that has lasted for many years will be shattered by diktat as social workers, psychologists and day hospitals are forbidden from offering services to people outside their designated area. There is no flexibility in this.

There is no provision for an alternative when the doctorpatient relationship breaks down as there is invariably only one per area although the latter may change in the near future.

The absence of specialism in relation to certain conditions such as eating disorders, personality disorders and dual diagnosis is a huge deficiency. It is HSE policy that all psychiatrists must provide services across the range of disorders.

Just as the rules about a patient’s address are applied rigidly, so too are the regulations about specialism.

Recruitment and retention in child psychiatry is abysmal and in-patient treatment is gravely under-resourced so children are still being placed in adult units if they are acutely mentally ill.

Some of the problems are financial but others stem from a lack of accountability and from rigidity. ‘A Vision for Change’ is the Government blueprint for the delivery of psychiatric services. It has become ‘A Vision for Torpor’.