9 February Shane Rattenbury MLA Minister for Mental Health GPO Box 1020 Canberra ACT By to:

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1 9 February 2018 Shane Rattenbury MLA Minister for Mental Health GPO Box 1020 Canberra ACT 2601 By to: Dear Minister Re: Ongoing psychiatry workforce shortage in the ACT The ACT Branch of the Royal Australian and New Zealand College of Psychiatrists (RANZCP ACT Branch) has prepared this submission to highlight ongoing concerns regarding the psychiatry workforce shortage and offer recommendations for the Government s consideration. To provide effective mental health services requires a specialised workforce with psychiatry being a critical element of this workforce. As well as delivering clinical services, psychiatrists provide clinical leadership and governance and teach and supervise psychiatry trainees, medical students and other staff. The RANZCP ACT Branch is concerned that the ongoing workforce shortage is adversely affecting patient care. Workforce shortages increase the clinical load of the remaining psychiatry workforce and, in both acute and community settings, the shortage of psychiatrists has limited the opportunities for psychiatrists to provide treatment and follow-up for patients. The prolonged effects of excessive workload also have negative impacts on the health and wellbeing of psychiatrists and trainees. There is an urgent need to recognise this impact and recruit staff to facilitate leave cover. Please see the attached submission which contains specific recommendations which could be used to alleviate the psychiatry workforce shortage in the ACT and assist with attraction, recruitment and retention of the medical workforce. We encourage you to discuss the submission with the Minister for Health and the Treasurer to enable these issues to be addressed as a matter of priority. I look forward to discussing this issue with you further in March 2018 at the ACT Branch s Annual Scientific Meeting. In the meantime, if you would like to get in contact please do not hesitate to contact me via Bronwen Evans, Manager, Policy Branches, via bronwen.evans@ranzcp.org or by phone on (03) Yours sincerely A/Prof Jeff Looi Chair, RANZCP ACT Branch PO Box 152, Deakin West ACT 2600 Australia T F ranzcp.act@ranzcp.org ABN

2 to Minister for Mental Health February 2018 advocate for mental health resources commensurate with the burden of disease 309 La Trobe Street, Melbourne VIC 3000 Australia T F ranzcp@ranzcp.org ABN

3 About the Royal Australian and New Zealand College of Psychiatrists The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises governments on mental health care. The RANZCP is the peak body representing psychiatrists in Australia and New Zealand and as a bi-national college has strong ties with associations in the Asia-Pacific region. The RANZCP has approximately 6000 members bi-nationally including more than 4000 qualified psychiatrists and over 1500 members who are training to qualify as psychiatrists. The RANZCP ACT Branch represents almost 100 members including over 60 qualified psychiatrists and 36 members who are training to qualify as psychiatrists. Introduction As outlined in the ACT Chief Health Officer s Report 2016, mental health has a significant impact in the community; 17% of adults surveyed reported being diagnosed with a mental illness in the preceding 12 months (ACT Health, 2016). To provide effective mental health services requires a specialised workforce, with psychiatry being a critical element of this workforce. As well as delivering clinical services, psychiatrists provide clinical leadership and governance and teach and supervise psychiatry trainees and medical students and other staff. The RANZCP ACT Branch has prepared this submission to document the effects of the ongoing psychiatry workforce shortage, offer recommendations and highlight other areas for attention. Workforce Australian Institute of Health and Welfare (AIHW) data shows that in , there were 12.8 FTE psychiatrists per 100,000 population in the ACT (AIHW, 2017a). While this figure was on par with the Australian average (12.7 FTE psychiatrists), the RANZCP ACT Branch estimates that as at January 2018, there were approximately 8.75 FTE psychiatrists per 100,000 population in the ACT across all sectors (public and private) 1. For the ACT population of 400,000, there should be 50.8 FTE psychiatrists based on the Australian average; on our estimates there are approximately 35 FTE, representing a shortfall of 15 psychiatrists across public and private sectors. This represents a critical workforce shortage across the ACT. There are inadequate psychiatrist staff levels in multiple areas including the Adult Mental Health Unit and the Short Stay Unit at Canberra Hospital, the Older Persons Mental Health Inpatient Unit at Calvary Hospital, the Dhulwa Mental Health Unit, Child and Adolescent Mental Health Services and community mental health services territory wide. 1 Mental Health, Justice and Addiction Services have 41 FTE specialist positions. 5 are filled by (non-psychiatrist) physicians, 5 positions are vacant, leaving 27 FTE psychiatrists working in the public sector. Using the 2016 census population of 397,397, this equates to 6.75 FTE psychiatrists per 100,000 in the public sector. (These services have expanded and it has been estimated that up to 45 FTE psychiatrists are needed to staff the expanded Forensic, Child and Adolescent mental health services as well as fill shortages. Note that a workforce of 45 FTE psychiatrists would represent 11 FTE psychiatrists per 100,000 population.) It is estimated that there are 6 8 private psychiatrists in the ACT but this is difficult to estimate due to uncertainty about fractions of employment. This represents FTE per 100,000 in the private sector. Total = 8.75 FTE per 100,000. RANZCP ACT Branch submission Page 2 of 6

4 Workforce shortages increase the clinical load of the remaining psychiatry workforce which can adversely affect patient care. Due to understaffing, community teams have been unable to provide timely follow-up appointments for patients following discharge from the ward. This exposes patients to risk of relapse and increased likelihood of need for re-admission to inpatient care. The prolonged effects of excessive workload also have negative impacts on psychiatrist and trainee health and wellbeing. However, both psychiatrists and trainees have been less able to take personal leave or study leave due to the increased workload and lack of adequate leave cover. The RANZCP ACT Branch considers that if immediate arrangements are not made to facilitate leave cover, the result will be a chronically stressed workforce at risk of burnout and an ongoing negative impact on patients and mental health services. Given the critical shortage of psychiatrists at present, the RANZCP ACT Branch supports the use of locums in the short term to ease workload pressures and allow local consultants and trainees to take leave. However, in order to appropriately address the complexities of mental health-care provision and the medium- to long-term challenges of attraction, recruitment and retention of psychiatrists, the RANZCP ACT Branch considers that a specific psychiatry workforce plan is needed. The Victorian Branch of the RANZCP was commissioned by the Victorian Government to produce a report on the Victorian psychiatry workforce to contribute to workforce planning and development for the public mental health sector. The Victorian Branch would be pleased to present an overview of the report and offer views on a way forward to the ACT Government. Factors identified in the Victorian psychiatry workforce review as challenges to recruitment and retention of psychiatrists that apply equally to the ACT are: overwork and stress due to workforce shortages including excessive workload when on-call feeling undervalued relative to the commitment and amount of service provided increased red tape, bureaucracy, and paperwork lack of support for maintaining clinical records insufficient administrative support which reduces time for clinical work increased risk of experiencing serious adverse events through violence and abuse lack of financial rewards (disparity in income between private and public sector approaches that quoted for Victoria metropolitan private practice versus rural, twice the remuneration per day in private). Another challenge to recruitment identified in Victoria that also applies to the ACT is the recruitment of specialist international medical graduates can present hidden costs and unexpected delays due to approvals required from multiple authorities and therefore causes temporary workforce shortages. Urgent recruitment of locum staff to fill vacancies to levels that facilitate cover for personal, annual and study leave. Development of a psychiatry workforce plan, based on the model used in Victoria. - Undertake an analysis of mental health workforce requirements per population served in order to establish benchmarks for each section of the mental health service. - Factor in leave, supervisory requirements and time for professional development into workforce planning. RANZCP ACT Branch submission Page 3 of 6

5 - Ensure that existing staff are able to access leave, professional development leave and provide supervision with at least 20% pro rata non-clinical time, as per the current medical Enterprise Bargaining Agreement. - Review, design and implement a rostering model that meets clinical demand 7 days per week. - Identify and introduce financial and other incentives (including, but not limited to, market competitive remuneration) to attract, recruit and retain psychiatrists in the public mental health sector. - Introduce penalty loading payments for onerous or hazardous duties (e.g. acute mental health unit and emergency psychiatry). - Establish academic psychiatry appointments to assist with recruitment and retention as they add: prestige, learning and development opportunities, attract academically interested psychiatrists, enhance meaningfulness of jobs due to involvement in teaching and research, assist with translation of research into practice. Mental health beds Australian acute hospitals are facing excessive demand for mental health beds (Allison and Bastiampillai, 2015) yet as shown by the Organisation for Economic Community Development (OECD) research, Australian hospitals contrast poorly to other OECD countries for hospital psychiatric care beds per 100,000 population. Australia has 29 beds per 100,000 people compared to the bed average of all OECD countries (71 beds per 100,000 people) or 46 beds per 100,000 people in the United Kingdom (OECD, 2015). Data from the AIHW (2017b) reveals that in , there were 18 mental health hospital beds per 100,000 people in the ACT well below the levels in other Australian states South Australia (29 hospital beds per 100,000 population), Queensland (30 hospital beds per 100,000 population) and New South Wales (36 beds per 100,000 population). Adult Mental Health Unit, Canberra Hospital A 2017 media report has highlighted continuing pressure on the Adult Mental Health Unit (AMHU). The Unit is regularly over safe numbers of patients and while it should be staffed by four consultant psychiatrists, in addition to the AMHU and Acute Services Medical Director (a psychiatrist), as of January 2018 it was only staffed by four full-time locum consultants. Apart from the Director, there are no permanent staff psychiatrists working within the AMHU. On occasion, it has been staffed by only one psychiatrist (The Canberra Times, 2017). Due to the demand for acute mental health beds, there is a very high turnover of patients in the Unit and patients sometimes have to be discharged earlier than is ideal. The general shortage of psychiatrists in AMHU and community mental health centres results in less than optimal opportunities for treatment and follow-up due to limited consultation time versus workload. The RANZCP ACT Branch urges the Government to consider adequate public sector psychiatrist staffing to ensure safe and sustainable acute mental health care, based upon the above recommendations for workforce. RANZCP ACT Branch submission Page 4 of 6

6 Training The RANZCP is responsible for accrediting training programs in psychiatry to ensure they provide quality training experiences that facilitate the training of safe and competent psychiatrists. The RANZCP ACT Branch has significant concerns about the effect on trainee psychiatrists of the ongoing workforce shortages. Trainees are at risk of burnout from prolonged, increased workloads. The greater workload also impacts on trainees ability to receive adequate supervision and support. The RANZCP training program requires at least 6 months FTE in an adult acute setting, with accompanying on-call work. However, workforce shortages, pressure to discharge patients to meet National Emergency Access Targets (NEAT), safety concerns and other factors, place an unacceptable level of stress on many trainees during this important period of training. The RANZCP ACT Branch is concerned not only for the trainees physical and mental health but also for the future of psychiatry training in the ACT for it is likely that if working conditions do not improve, the retention rate for trainees will decline. The RANZCP ACT Branch urges the Government to consider adequate public sector psychiatrist staffing to ensure safe and sustainable training supervision and support, based upon the above recommendations for workforce. Perinatal and infant mental health services Women are at greater risk of developing a mental illness following childbirth than at any other time (Kowalenko, 2000). While most postnatal psychiatric illness can be managed with outpatient treatment, in some cases the illness and associated risk can be severe enough to warrant admission to hospital (Salmon et al., 2003). It is widely accepted that women requiring inpatient treatment have improved outcomes if accompanied by their babies. However, there is no perinatal mental health unit in the ACT nor are there dedicated mother baby inpatient beds. The RANZCP ACT Branch urges the Government to consider including a perinatal mental health unit in the program to update the Centenary Hospital for Women and Children. Private sector There are not enough psychiatrists working in private practice in the ACT to ease pressure on the public system. It is estimated that there are 6 8 FTE private psychiatrists in the ACT but this is difficult to estimate due to uncertainty about fractions of employment. This represents FTE per 100,000 in the private sector (total psychiatry workforce = 8.75 FTE per 100,000 population). The private psychiatrists (at best 2 FTE per 100,000) have a limited capacity to assess and care for new referrals, due to existing patient care load. As a consequence of the shortage of private psychiatrists, there are limited numbers of psychiatrists admitting to the sole private psychiatric hospital in the jurisdiction. In addition, many of the private psychiatrists work in the public sector as well, which can lead to increased workload with on-call responsibilities across both sectors. Given the overlap between private and public sector psychiatry, the RANZCP ACT Branch suggests that the capacity of the private sector must be considered when developing a psychiatry workforce plan. RANZCP ACT Branch submission Page 5 of 6

7 References ACT Health (2016) Healthy Canberra: Australian Capital Territory Chief Health Officer s Report Canberra, Australia: ACT Government. Allison S, Bastiampillai T, Licinio J, Fuller DA, Bidargaddi N, Sharfstein SS (2017) Molecular Psychiatry; advance online publication 11 July Australian Institute of Health and Welfare (2017a) Psychiatrist workforce. Available at: mhsa.aihw.gov.au/resources/workforce/psychiatric-workforce/ (accessed 24 July 2017). Australian Institute of Health and Welfare (2017b) Specialised mental health beds and patient days. Available at: mhsa.aihw.gov.au/resources/facilities/beds/ (accessed 24 July 2017). Kowalenko N, Barnett B, Fowler C, Matthey S (2000) The Perinatal Period: Early Intervention for Mental Health. Clinical Approaches to Early Intervention in Child and Adolescent Mental Health. Vol 4 Australian Early Intervention Network for Mental Health in Young People, c/o CAMHS Southern, Flinders Medical Centre, South Australia, Australia. Salmon M, Abel K, Cordingley L, Friedman T, Appleby L (2003) Clinical and parenting skills outcomes following joint mother-baby psychiatric admission. Australian and New Zealand Journal of Psychiatry 37(5): The Canberra Times (2017) ACT mental health system in grip of 'crippling' shortage of psychiatrists. Available at: (accessed 10 October 2017). RANZCP ACT Branch submission Page 6 of 6

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