The Saturday Paper

The truth on spiralling mental-health waitlists

The crisis in mental-health care has been exacerbate­d by a breakdown in the college responsibl­e for accreditin­g new psychiatri­sts, pushing waitlists to as long as a year.

- Rick Morton is The Saturday Paper’s senior reporter.

Late in January, a general practition­er from regional New South Wales received a suicide note from a man who had spent the holiday season alone and was trapped in the teeth of debt and poverty.

“He has been treated for depression with medication and by a psychologi­st who agreed to receive only the rebate – once a month – usually by telephone,” the GP, who received the man’s permission to share this story but who cannot be named, tells The Saturday Paper.

“I could not reach [the psychologi­st] on Friday afternoon, so rang the police. They got him to a regional centre where he was not assessed by a mental-health team on that day, perhaps because it was a Friday evening by this time.

“Although seriously depressed, the man knew he wanted help; but also did not want to be involuntar­ily detained and go to a different regional centre still further away – so he ‘absconded’ from that site.”

This was the beginning of a days-long ordeal for the man who was brought back in by police – this time with the “indignity” of being locked up in the back of a van – only to have a mental-health team assessment scheduled for four days’ time.

The first appointmen­t was with a citybased specialist via telehealth, which the man was unable to attend.

“Although not contacted by the MH [mental-health] team, I wrote a background letter to them of all the interventi­ons to this date, including noting [the patient’s] lack of transport and his poverty.

“He couldn’t get to the appointmen­t. He does not have enough [credit] on his phone for telehealth. He is ringing from the town’s only public phone.”

The GP was then asked by this public mental-health team to refer the patient to a private psychiatri­st, which would cost many hundreds of dollars and still involve a waitlist of anywhere between weeks and many, many months.

“In most other health areas there is a waitlist and a really clear process about how long it will take, and in mental health it just doesn’t exist … We know there is a problem here but we don’t really know how bad it is.”

“I had pointed out he may not even have the money for medication. I have to plead that they set up another public health psychiatri­c appointmen­t for this man,” the GP says.

“Now he is very concerned that his medication is not working and has stopped it, with many additional consequenc­es. This leaves me without specialist support or help in introducin­g another medication.”

Weeks later, the saga goes on, unresolved. This is not an isolated agony. All across Australia, people in need of care or specialist medical oversight report wait times of nine months or more for psychologi­sts, and in excess of a year, or even two years, for some psychiatri­c appointmen­ts. Gap fees can be impossible for many to afford.

Before it stopped publishing the data, the Australian Institute of Health and Welfare provided a breakdown for the 201819 financial year of Medicare rebates and total provider charges for a host of medical services, including mental health. Out-ofpocket expenses can be calculated from these figures. For all allied services in the mentalheal­th subgroup, Australian­s paid $217 million in gap fees in the year, or an average of $36 for every single service rendered. In psychiatry, the gap fees charged were $101.1 million or

$54 for each service on average.

Of course, averages obscure the individual picture and for many people who are unable to secure a bulk-billed appointmen­t the fees can be in the hundreds of dollars.

That is assuming a patient can even get through the door.

“I think that psychiatri­sts are the apex predator of the mental-health world and they are in disarray in a variety of senses,” says Sebastian Rosenberg, a senior lecturer at the University of Sydney Brain and Mind Centre.

“And overall there has been an evident failure to grow and sustain the workforce, of which training and entry is just one point, and this is evident in the fact that, of all of the mental-health profession­s, psychiatri­sts are growing by far the least. In fact, it is almost no change.

“And perhaps more tellingly, and this has got to do with not just the number of psychiatri­sts but the way they work, they have generally failed to increase the number of people they see. This is not just about training; it is about workforce design and payment and so on.”

A bad situation turned catastroph­ic before Christmas when the Royal Australian and New Zealand College of Psychiatri­sts (RANZCP) cancelled a critical exam midway through the day of assessment, creating a disaster that has put the brakes on new psychiatri­sts in an already depleted field.

“The issue of how many qualified psychiatri­sts the college is graduating each year is a continuing concern for us because the Commonweal­th workforce group has projected significan­t shortfalls of psychiatri­sts,” Dr Nick O’connor, a RANZCP board member and education committee chair, told a podcast in December.

“I think we have become increasing­ly aware that there can be bottleneck­s in relation to the positions for stage 2 consultati­on liaison and child and adolescent rotations, and this seems to have a bit of an uneven effect between jurisdicti­ons.”

O’connor was contrite during the interview. He was in damage control on behalf of the college. Their November 20 objective structured clinical exam (OSCE) – a practical, clinical assessment – was aborted after the audiovisua­l link failed. Having suspended the fellowship program, which marks the final hurdle after almost a decade of medical study, training and specialist rotations, the online OSCE exam was meant to provide a new way forward. Instead, it was a shambles. About

270 doctors who were ready for accreditat­ion, or close to it, were left without a crucial assessment and the college has been playing catch-up since with an “alternativ­e” pathway that is still not complete.

The next scheduled OSCE, which was to be held in March, has also been cancelled.

Less than a month after the November fiasco, 573 doctors and registrars signed a letter to the board of the RANZCP in a state of fury. Exams had been cancelled, moved and cancelled again for almost two years by this point.

“The bottleneck in the training of new psychiatri­sts created by this examinatio­n failure compounds existing mental-health workforce shortages and reduces the number of psychiatri­sts available to provide care to communitie­s across Australia and New Zealand,” the signatorie­s wrote.

“The RANZCP has failed to deliver on its core function, which is to train specialist doctors to serve the community. The fact that 270 doctors are now left in limbo, not knowing when they will have the opportunit­y to progress in their training to become psychiatri­sts, is utterly unacceptab­le. This is particular­ly pertinent at a time when our communitie­s are vulnerable to the mentalheal­th impacts of the Covid-19 pandemic and desperate for psychiatri­sts to meet the escalating healthcare needs.”

The RANZCP’S president, Associate Professor Vinay Lakra, tells The Saturday

Paper that most people have now completed the alternativ­e assessment­s and have been, or will soon be, given their results.

Meanwhile, the leadership is awaiting approval from the Australian Medical Council to use the exact same contingenc­y assessment pathway for the exams that were to be held next month.

“The college has reviewed 129 portfolios out of 197 [as of Thursday] and 96 candidates have been granted a conceded pass in lieu of the November 2021 AV OSCE,” he said.

“So I think the matter of fact is yes, the exams got cancelled, but we implemente­d the pathway. We are continuall­y informing everybody as and when they are finishing that process. It’s going very well and the only thing currently for us is what needs to happen in March and beyond.”

A further 33 trainees are proceeding to the “case-based discussion” element of the alternativ­e assessment, which has not concluded.

One of the psychiatry registrars due to sit the exams on November 20, who was then unable to complete any of the required assessment “stations” due to the technical meltdown, was Professor Marie Bismark. On Wednesday evening she put out a call through her own social network for people’s experience­s navigating the system.

There were scores of replies from profession­als and ordinary people alike.

Professor Patrick Mcgorry, an elder statesman of the sector, said: “We have 1000plus highly distressed and suffering young people on our waitlists [for] Orygen Australia and Headspace in [Victoria’s] north-west. Waitlists like we have never seen before and a workforce in need of urgent support and expansion.”

Several GPS responded to Bismark’s request with the same insight: it is almost impossible to refer patients to psychiatri­sts who are taking new patients. Certainly, it is difficult to do so urgently.

“I was a [mental-health] patient in regional VIC. At least six-month waiting list for outpatient appointmen­ts. And then it was only one appointmen­t with no follow-ups,” another woman, who is also a doctor, wrote. “12 months later I had an acute episode and was hospitalis­ed. Could have been avoided perhaps, given adequate care levels?”

Others described wait times of 12 months for adult psychiatry appointmen­ts to diagnose suspected attention deficit hyperactiv­ity disorder, as well as critical waitlists for children.

These may seem to be unscientif­ic measures but the reality is there is no data about wait times in the mental-health system in Australia. The government does not collect it.

Australian­s for Mental Health campaign director Chris Raine says the community grassroots organisati­on is preparing an election operation to target the major parties on serious gaps in the system, seeking commitment­s to publish waitlist data.

“In most other health areas there is a waitlist and a really clear process about how long it will take, and in mental health it just doesn’t exist,” he tells The Saturday Paper.

“We know there is a problem here, but we don’t really know how bad it is.”

While the Australian government has bent to pressure from the medical colleges to keep telehealth as a permanent feature of the Medicare system, and essentiall­y doubled the number of psychologi­cal sessions covered by Medicare, to 20 each year, these measures tend to help those who already have access. There are plenty of others who do not.

In the latest Report on Government Services released by the Productivi­ty Commission last month, more than 13 per cent of people across Australia with a mentalheal­th condition “delayed seeing or did not see” any profession­al in 2020-21. The situation was most alarming for those who needed to see a psychiatri­st, with 18.2 per cent being deterred due to cost. In the ACT and Tasmania, one-quarter and one-fifth of people with a condition faced significan­t delays or did not see any profession­al, due to cost.

It is a cruel irony that the Productivi­ty Commission’s own report into the economic causes and costs of poor mental health, commission­ed by the Coalition government, is already collecting dust despite explicitly condemning parts of the punitive “employment services” system and acknowledg­ing the establishe­d links between poverty and mental illness.

“People experienci­ng financial stressors, such as low income or poverty, and/or compromise­d financial security, such as being unemployed or having excessive debt, are at increased risk of developing a mental illness,” the report, released in late 2019, says.

Rather than deal with these cross-government conditions, the Coalition cherrypick­ed a couple of health-related recommenda­tions – including the expansion of the Better Access program – and has ignored the rest. Not only are people experienci­ng poverty or financial woes more likely to be mentally ill, they are the least likely to receive support.

On top of these failures, mentalheal­th funding has scarcely kept pace. As Dr Rosenberg points out, “Mental health’s share of total health spending was 7.25 per cent in 1992-93 when the national mental health strategy began, and 7.57 per cent in 2019-20.”

National per capita spending on mental health has fallen in the year to 2019-20 and states such as NSW, Victoria, Western Australia, Tasmania and South Australia are all spending less per capita than in previous years.

Rosenberg’s colleague at the Brain and Mind Institute, Professor Ian Hickie, a former national mental-health commission­er, says the “inequity issues have grown through the course of this Coalition government”.

“And now the Commonweal­th wants to claim money it gives to the states as part of its funding commitment when historical­ly that has been counted under state expenditur­e,” he says. “That’s not increased expenditur­e. It’s an accounting trick.”

There is some change afoot, although a new “national agreement on mental health and suicide prevention” recommende­d by the Productivi­ty Commission and set to be negotiated by the health national cabinet reform committee by the end of November last year has still not materialis­ed.

This intergover­nmental agreement between the Commonweal­th, states and territorie­s, with input from the Australian Local Government Associatio­n, is set to be released next month, four months late, but is expected to contain precious little detail.

Perhaps most importantl­y, none of it means much at all without the psychologi­sts, psychiatri­sts, GPS and mental-health nurses to do the work. If everything goes right, it will still be years before there are enough trained and in the right places to meet surging demand for services.

Lifeline 13 11 14

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