Abstract
Medical Colleges have an ancient lineage which might be traced back through the universities and Academe generally to a much earlier time. While I do not doubt the importance of our ancestry, I will argue that our past does not equip us well for the challenges ahead. I issue a warning, also, that our past might drive us into irrelevancy.
This College, like all Colleges, has many features of a craft-guild of ancient time. There are exacting rights of passage on entry to the organization. Once accepted as a member, there is tacit expectation that tradition must be honoured and that the rules of the organization be accepted in their entirety. The risk for a College, or a guild, is that the organization operates in a self serving manner and comes to be out-of-touch with the realities of the bigger world.
This College, like all colleges, changes very slowly. Health care changes quickly. Health policy changes at a frenetic rate. It is my abiding concern that the College is ‘off the pace’ when it comes to the big picture of health care. Moving about over the last two years as ambassador for the College, I have been struck time and time again by others perceiving our organization as elitist, out of touch and at times just plain precious. Criticism must always be considered thoroughly. As I take in what others have said to me, criticism often turns on the belief that this College is failing to take its proper place in the economy of health care. I argue that our College has an urgent obligation to become more politically savvy and to have an increasingly powerful voice in the greater health debate.
To put matters in closer perspective, to date the core business of the College has been education and professional standards. Our energy, time and resources have gone largely into these two important areas. This has been in keeping with the tradition of other colleges. The College can be proud of its educational activities, not only the ongoing development of postgraduate training but the movement into advanced training and continuing professional development. Likewise the College can be proud of the standards it sets for the profession in a variety of domains. But it is now time to add to everyday business tasks and to adopt the broader health agenda as being of equal importance. Essential to this process will be our connection with the community. I note simply that a connection of this type is always influenced by health politics. We took the first real step with the creation several years ago of the Board of Professional and Community Relations. It is time, I suggest, to go a great deal further.
Health policy
Health care is a critical part of the life of every woman, man and child in our two countries, and worldwide. Health care competes at a political level with every other Government enterprise. Maintaining a proper standard of health care or, better still, improving the standard of health care, is only possible if there is a powerful lobby group within the community. I contend that the most effective lobby group is a combination of consumers and carers (which means you and I and every other citizen) and the medical organizations, including this College and every other College. The two groups must go forward together. The voice of consumers and carers has strengthened significantly over the past decade. The voice of this College, and every other College, is slower in coming to maturity.
New Zealand spends a paltry 6.2% of its gross domestic product on health care. Australia, at 8.5% of the GDP, spends a little more. Given political reality, our masters in both countries are unlikely to apportion more of the GDP to health care. It becomes crucial therefore to use the precious health dollar wisely. It is necessary to take a community focus when considering where the health dollar should go. In political speak, I am referring to a population health model.
Population health
Let me expand. The US spends close to 15.0% of its GDP on health care. The model which evolved in that country has been one of unfettered free enterprise (at least until recently). The individual is king, the community of individuals does not count. The rich can purchase whatever health care they wish, the poor get almost nothing. It is my contention that in our two countries we have to move our focus from the next patient we treat to a broad community focus and work hard to ensure that there is equity of health care in terms of access and quality.
You and I should remind ourselves that only a relatively small percentage of the health dollar goes currently to mental health care in our two countries. Yet World Health Organization and World Bank research makes the stark point that of the 10 diseases with greatest life-time health burden, five are of a psychiatric nature. And if that is not enough, let us also remind ourselves that the Australian Bureau of Statistics has shown that more than 50% of the Australian population with mental health needs do not have access to treatment. The situation is similar in New Zealand. Additionally, there is a marked health divide between citizens living in our inner cities and the rest who live in the outer ring of suburbia and in rural and remote areas. Inequity looms large. We cannot ignore it.
Resource distribution is another of those political speak phrases. Why beat around the bush; we are talking about rationing. Health services have to be rationed wisely. Rationing, inevitably, is part of the health debate. It is something we, as a professional group, have largely ignored. It is my view that we must enter this discussion sooner rather than later. We must take a long view and put self-serving issues aside. I have made two interlocking points relevant to my argument. First, we have to make our focus a population health model. Second, we have to address issues of access and equity.
Access and equity
Getting services to those with mental health needs is an enormous challenge. The Australian Medical Workforce Advisory Committee (AMWAC) is the body which in recent years has been estimating the projected medical workforce needs in this country. AMWAC uses a medical template rather than considering the medical and allied workforce. The AMWAC survey of our discipline tells us that we do not graduate a sufficient number of psychiatrists in Australia to meet the projected needs of the population. I cannot share this finding. I suggest that AMWAC, tethered by its medical template, misses the point. There is a massive unmet need for mental health services in our two countries. We will never meet it simply by increasing the number of psychiatrists. The only way to meet the need will be to consider all disciplines who work in the mental health arena and to use the high level comprehensive skills of psychiatrists in a manner optimal to the community.
Currently, mental health services are delivered predominantly by general practitioners in both our countries. This is as it should be. There is no person better placed than the family doctor to know the needs of an individual and to provide care in a timely and efficient manner close to home. The other medical group is ourselves. Interestingly, we are registered in this country as consultant physicians in psychiatry. Yes, there is strong evidence that we practise less consultant medicine than we should, with current emphasis–at least in the private arena–on providing specialist treatment services.
Going beyond the medical fraternity, we meet up with clinical psychologists and clinical nurse specialists. Neither group has been given proper credit in the equation of mental health care. Clinical psychologists are highly trained in the talking therapies and have a strong claim in the domain of counselling. The quest for financial reimbursement for their patients cannot be ignored. Additionally, clinical nurse specialists have high expertise in the delivery of mental health care, particularly in a community setting. Visit one of our remote regions and you will agree.
It is a time, I suggest, to reposition ourselves as one of a coordinated group of professions who take responsibility for the mental health care of citizens in both countries, rather than perpetuate a ‘them and us’ situation. There has been precious little dialogue between the organizations. Often confrontation between the groups has been feudal, each group behind fortified walls distrustful of all others. The time has come to do things differently.
Workforce
As we address the workforce issue, it will become obvious that psychiatrists (at least in the private arena) will need to re-think their work practices. It is my view that we should use our comprehensive training in the best interests of the whole population and provide services to empower others working alongside. But as I have said on numerous occasions, a psychiatrist can only be a good consultant if she/he is a good clinician. We might set targets for ourselves, perhaps aiming for a treating specialist/consultant ratio of 75: 25 by 2005.
Our patients have been fortunate (at least in Australia) in receiving rebates under the Medical Benefits Scheme. However, rebates within the mental health domain only exist currently when the service is supplied by a psychiatrist. While it may be uncomfortable, it is time to consider Government support for clinical psychologists performing similar work to ourselves. But two matters need to be emphasized: new rather than old money is needed for this purpose and the Medical Benefits Schedule should not be the conduit for rebates to people treated by clinical psychologists.
Similarly, we must support every effort to increase the skills of general practitioners in the mental health domain. In Australia, beyondblue is developing an impressive five-year programme to enhance identification and treatment of people with mental health problems. We must be part of the project. Similar projects in New Zealand will require support. Let me assure anyone who is now becoming nervous that the needs of the population are enormous and there is ample work for everyone.
Psychiatric practice
Treatments adopted in the mental health domain must be acceptable to the consumer, they must be based on evidence and be cost efficient. The word ‘treatment’ might be used broadly to include self-treatment (education, hands-on treatment tools using appropriate IT), treatment by the population for the population (reduction of mental health risks within a community) and the more conventional treatments practised by most of us.
Closely linked with treatment in all its forms is medical communication. Citizens in both our countries require psychiatrists and other mental health professionals to communicate effectively and accurately. The paper record will inevitably give way to the electronic record, this allowing enhanced and rapid communication between two or more health providers. A record of this type is going to be important in various settings, not the least in the emergency department at your local hospital. The technology required to establish electronic medical records will inevitably be complex, but the major issue will be confidentiality. This vexed matter will need to be worked through thoroughly.
There are many health policy matters which are hot at any given time. Off the top of my head come: the development of privacy guidelines in keeping with changing legislation, the critical issue of indemnity insurance, forging a proper path into professional life for colleagues trained overseas, enhancing the workforce in areas of need, dealing with stigma particularly at a higher political level and the expansion of Medicare Items to allow consultant activities. Try as we might to deal with these matters, we are managing less well than we should. Yet these are the very matters which are critical to the community. These matters are not essentially about education or standards, but they are equally important. Clearly, we have to increase our skill in the health policy arena. But doctors are not trained in the politics of medicine. Nor are we experts in the business of developing the medico-political case, or putting the case to Government.
A College response
We are at a watershed. Either we continue to do well with our core business (education, standards) and muddle along in the health policy arena, or we take the major step of accepting health policy tasks as being just as important as the other two. For myself, I don't think we have a choice. Should we decide, in the near future to get serious in the health policy arena, then we must accept that real expertise is required and we have to learn to respond far more quickly than is usual for an organization such as ours. The political process does not wait!
How able is this College right now in the health policy arena? I doubt that we even get to first base. I have pondered the matter a great deal. There are two issues which make health policy tasks very difficult. The first is our current College structure, the second is our lack of expertise. I will deal with them sequentially.
This College has the most complex structure of any organization known to me. It is quite Byzantine. What is more, it gets worse year by year, decade by decade. What organization elsewhere would have a Board of Directors (General Council) of 26 people and 6 observers? What organization elsewhere would have a Board of Directors meeting but twice a year? and what organization elsewhere would have eight geographical groups, several Faculties, a number of Boards, many Committees and a series of Special Interest Groups? If that is not enough, then remember that Council is supported by an Executive group which meets four times a year. The only simple thing in our current structure is the weekly telephone conference linking the three senior College Officers and the Executive Director.
Where in this structure do we have the capacity to work up projects in a thorough and timely manner? Where do we gain and master the language of Government and the health bureaucrat? Where do we learn the expertise to ‘talk turkey’ with the decision makers? The first step, I am sure, is to have a major stock-take of College structure and to simplify our structure in a way which facilitates decision making and communication. Twice now Council has debated the matter of structural change, on the first occasion voting against change in any significant way and on the second occasion putting forward a cautious message which led me to leave the matter on the table rather than risk a second negative vote.
As I leave the Presidency, I am more certain than ever that if we want to survive as a College and consolidate our place in the larger medical world, we have little choice other than to restructure this organization to improve the decision-making process and to become more nimble and able. There are numerous ways of achieving this. One would be a smaller Board of Directors constituted by a number of elected representatives from our two countries and the Chairs of four or five restructured Boards. The Council could then meet four times a year, or even more often by telephone conference. Think for a moment about how this might speed up decision making. There are, of course, half a dozen other ways in which we might proceed. The task is getting urgent, particularly if we are to broaden the things we do and if we wish to do them well. Other colleges have faced identical problems of aged and creaking structures. Some of them have moved to reorganize and are beginning to reap the benefits.
The second matter is one of expertise. The time is coming where we need a small health policy unit within the College. The advantage of having someone to organize and support Fellows in the health policy domain hardly needs to be emphasized. We will be left floundering if health policy matters are not considered in a timely and thorough manner. We need expertise also in that complicated matter of lobbying. Walking the corridors of the parliament is not for the innocent. Take a look at the Royal Australasian College of Physicians and you will see how valuable a health policy unit can be. We should learn from this. We may even be able to have links with it.
You will appreciate by now that I believe this profession has done well in its time-honoured core business of education and standards, but there is a pressing need for us to expand our activities. We are stumbling at the moment when it comes to our proper place in the medical economy. We have a voice which is barely heard at the present time. The community expects us to speak up about the many issues which make up modern medicine. Not to do so is to abrogate our responsibility.
And so to come back to where I started, we cannot be trapped by our past. While not forgetting the history of the College and organized medicine before it, to continue the tasks thought appropriate by our founding colleagues is hardly enough. We must stay vital and relevant and have a clear and powerful voice as we take our proper place in the health arena. I am talking about a new paradigm. It links the College much more closely with the community. It is about responsibility to the community, accountability, creativity and alliances with others. The College no longer positions itself above the hurly-burly of health politics. It accepts realpolitik and positions itself as a leader in the never ending process of change.
I have worn this gown with pride and have carried the badges of office these last two years. I am keenly aware of our past and the fine tradition of the College. I am equally aware that we can never stand still and that we should be eager to shape the future. We have a large responsibility as the senior mental health profession. We must reposition ourselves to be a more powerful force, always remembering that the good of the broader community is paramount.
Psychiatry in this still very new century is going to be different. It will place new challenges before every one of us. We can stay as we are and risk becoming irrelevant or we can move to become a highly respected and broad-based professional group, closely linked with others who work towards better services for the peoples of our two countries. The choice is yours.