Kintsugi: Comprehensive repair of Australia’s fractured psychiatric care system

Abstract

Objective

We provide an update of the current challenges facing public and private psychiatric care sector in Australia, contextualised by international and national information on factors affecting health system performance.

Conclusions

There are practical and sustainable repairs that may bridge the gaps between primary care, private psychiatrists, and the public psychiatric system. These are based upon foundations of better linkages, adequate infrastructure, improved social support, and reforming public and private sector workplaces to retain healthcare workers despite pandemic-related attrition. Professional organisations need to redouble their efforts as advocates to governments, in the media matrix, and the general public.

“The acknowledgement of our weakness is the first step towards repairing our loss.” Thomas à Kempis

Clinical research and policy analysis highlight the extraordinary convergence of challenges that threaten the sustainability of public psychiatric hospital and community care in Australia, and worsen access to psychiatric care for people with the most severe and disabling psychiatric illnesses. Public psychiatry is part of a healthcare sector that was already struggling before the pandemic. ¹ Yet unaddressed challenges to sustainability relate to both the structure and function of public psychiatric care. These failings require repair analogous to the Japanese craft of pottery repair, kintsugi, wherein the golden seams that bridge the fractures, that is, infrastructure and workforce, make public psychiatry whole again.

Kintsugi of private and public sector care

An associated challenge is the capacity of general practice to provide and coordinate psychiatric treatment in primary care due to Medicare underfunding and related factors. ² This reduced primary care capacity necessarily leads to increased acute hospital and community patient presentations. Modernising Medicare to support GPs and private psychiatrists to provide sustainable primary and specialist psychiatric care is essential. ² Expanded capacity for primary psychiatric care based in general practice will require nursing and allied health access for GP practices, and better linkages to Aged Care and disability services. Modernised general practice changes will improve access and exit block to public psychiatric care.

Structurally, the underfunding of the acute hospital and community service sector has led to insufficient capacity, which in turn, results in access block for patients who need acute psychiatric care. There has been a stasis in public psychiatric bed numbers compared to a 3.8% increase in private psychiatric beds from 2014–15 to 2018–19. ³ As a result, Australia’s provision of 40.9 psychiatric beds per 100,000 is below the optimal level as defined by international Delphi consensus. ³ This reduced bed capacity leads to shorter average lengths of stay and risks of inadequate treatment, as bed-days are significantly truncated to facilitate flow-through.

There is also the issue of ‘exit block’, ⁴ where patients cannot be discharged due to the lack of community support services and/or specialist accommodation. This especially applies to older people and those with significant disabilities. The Aged Care and Disability Service sector is inter-related structurally with public psychiatric services through older persons psychiatric care, and disability support services, all of which require adequate funding and support to avoid the community support care challenges faced by high-income countries such as the UK ⁵ and Australia. ⁴ Shortfalls in the funding and provision of non-clinical social supports compromise the ability of patients to remain in the community and indirectly lead to increased presentations to public psychiatric care and hospital stays.

Psychiatrists must collectively call for sustainable repair of the national public and private system that address these structural and functional challenges, in order to provide effective public and private psychiatric patient care. For instance, consistent with other areas of medicine, the funding of public hospitals and community services should be equally shared by the federal and state governments, ⁶ and funding should increase with population growth and need. These agreements between levels of government require approaches that are appropriate for each location and guided by health needs assessments and clinical research that can then inform the required hospital bed and community capacity, as well as appropriate workforce requirements.

Kintsugi of the public sector workforce

Functionally, it remains essential to have an adequate and sustainable workforce in order to successfully utilise acute hospital and community care infrastructure. However, the pandemic has led to workforce shortfalls from clinicians leaving the healthcare sector, heightened by psychological stress, adverse working conditions, lack of organisational support, and individual risk factors. ⁷ Public psychiatric services in Australia were already depleted of clinicians prior to the pandemic, but the exodus has continued, due to moral injury, burnout, and declining workplace health and safety. ⁸ Ecologically, the sustained effectiveness of private psychiatric services before and during the pandemic ⁹ may be leading to psychiatrists, nurses, and allied health workers moving to the private hospital and outpatient sector.

Functional workforce reforms are needed to recruit and retain clinicians in primary care, acute hospitals, and the community sector. This includes addressing issues of worker turnover, psychological stress, adverse working conditions, lack of organisational support, ⁷ as well as considering individual factors, such as burnout and moral injury. ¹⁰ Structural-organisational approaches to reducing burnout include duty-hour limitations, safer working conditions, increased autonomy and sense of control, and a validating and supportive work environment. ¹⁰

However, there is also a need to actively recruit clinicians into public psychiatric care. Some of this can be fostered by improved industrial conditions that enshrine better working conditions, such as work-life balance, career development, education, adequate leave, and psychosocial support. ¹¹ Similarly, a commitment to health and wellbeing of staff, as well as prevention of bullying and harassment, by inclusion of staff wellbeing as a key performance indicator, as recently enacted in South Australia. ¹²

Kintsugi through the private sector

Comprehensive solutions must include the private psychiatric sector, which in Australia is complementary to the public sector. Enhancements need to be underpinned by the goodwill of both public and private sectors, through the structural complementarity of acute public sector hospital and community services and private outpatient and hospital services – as it stands – neither sector has the capacity alone to serve the Australian community. The interdependence of both mandates exploration of innovative models of care that bridge the two sectors to improve capacity. ¹³ These might include the following: improved data linkage and information sharing arrangements; liaison services to link patients across services; shared-care case-conferencing; clinical supervision; and staff education. ¹³ These innovative models need to be implemented alongside the bolstering of public sector services by recruiting private psychiatrists and trainees/JMOs as visiting medical officers or locum staff to address existing staffing shortages worsened by the pandemic.

Vigilance is also warranted with the potential bracket creep of private health insurance (PHI) providers to provide parallel outpatient and private psychiatric services in the form of US-style managed care. ¹⁴ The formation of a buying group to purchase medical services by a PHI consortium, the consequent challenge in the Australian Competition Tribunal, and the Deed of Settlement has demonstrated the potential perils of managed care through selective contracting, limiting choice of treatment, and gatekeeping to limit healthcare use. ¹⁴ Limitation of private psychiatric services could lead to increased public sector demand.

Recommendations

These repairs require coordinated action by state and federal governments. Yet, to date, there have not been substantive responses in Australia that holistically address the challenges, despite many inquiries and national mental health strategies. ¹⁵ Failures in mental healthcare governance ¹⁶ and political spin to obscure inaction, ¹⁷ militate against effective repairs.

Structural and functional flaws compromise the provision of psychiatric care for those most in need, and increase the strains on stretched general hospital and community services. ¹ Comprehensive and urgent repair is needed:

1. Supporting the ongoing viability of general practice in providing primary mental healthcare. This requires serious reform of the financial sustainability of general practice, based on modernising Medicare such that patient reimbursements adequately reflect real-world costs. Recent incentives to support bulk-billing for families with young children, concession card-holders, and pensioners are a welcome first step.

2. Shared State and Federal funding of public hospitals and community services, that is, 50:50 split as during the first three years of the pandemic. There is especial need for adequate numbers of acute and non-acute public hospital beds, as well as funding of public community mental health services to prevent hospital access block.

3. Federal government funding for community support, aged care, and disability services must be commensurate with need, to provide timely and effective transition to community care, and to avoid hospital exit block.

4. None of the structural changes proposed above will be effective unless there is a fit-for-purpose national healthcare workforce strategy that includes all workers, and especially the medical workforce in general practice, psychiatry, and aged care.

5. Improving workplace health and wellbeing and organisational reform, will enhance medical workforce capacity in public and private psychiatric healthcare services. Responsibility for healthcare worker morale, health, and wellbeing needs to be a key performance indicator for public and private sector health administrators.

6. Repairing psychiatric care for Australians must be predicated on the complementarity of public and private services. In addition to seeking private psychiatric support for staffing shortfalls in the public sector, there needs to be implementation of proven innovative models of shared care. US-style managed care must be avoided.