Editors Note: This is the first of several essays that I will post in the coming months highlighting issues of the public mental health service at Liverpool Hospital. The views offered emanate from a time-honoured and recognised tradition of whistle-blowing advocacy. My observations and criticisms reveal difficult and true issues. They are honest, courageous, based in speaking truth-to-power and underscored in sound clinical acumen. The reasons for my outspokenness is to protect the hospital; advocate for enhanced quality and functioning of the psychiatric service; and to emphasise in particular how the Social Work profession — despite being overtly and covertly devalued can play a major and significant role in the change management in the dysfunctionally entrenched and beauracratic systems of Liverpool Hospital — as well as, make clinical contributions to the delivery of the mental health service.
By Mickey Skidmore, AMHSW, ACSW, MACSW
Despite the national decree of deinstitutionalisation in Australia; followed by institutional reforms in the 1990s involving the closure of all state run institutions for people with intellectual disabilities; South West Sydney’s public mental health service is seriously out of step and in stark contrast with these well established positions.
As recently as August 2016, of the 95-99 inpatient psychiatric beds available at Liverpool Hospital, 23 patients were literally living there as their residence — indefinitely. Even more shocking is that Medicare is paying for them to use the hospital as a glorified hotel under the guise of “treatment” at the tax payers expense. And perhaps even more alarming than either of those facts, is that the executive leadership of Liverpool Hospital seems anaemic, disinterested or powerless to address this disconnect. Only in recent years has there been some embarrassment and political pressure from the Health Ministry to coordinate an effort with LHDs in the Sydney area to begin to address this. Despite some movement in addressing this issue, a significant number of such patients remain.
Not only are these patients currently residing at Liverpool Hospital, but they have been living there for years — while the Governmental agency responsible to serve these patients offer endless delays and excuses as to why they have fallen short of their responsibility and duty of care. Even the recent PCLI (Pathways to Community Living Initiative), which is growing in FTE staff size — is little more than a concept or idea (despite previous promises of funding to literally build resources for these patients) sitting in the Ministry, floundering, awaiting funding while patients live in psychiatric wards at Liverpool hospital.
Perhaps the most egregious example was a 38 year old female readmitted to the SOUTH ward of Liverpool hospital in February 2002. This woman suffered a significant stroke in 2009, which worsened and complicated her already established mental illness and left her with serious cognitive deficits. As a result of these misfortunes, she was accepted for ADHC services. Yet at the age of 31, in a less than ideal or even clinically appropriate arrangement, she was placed in Braeside hospital (for the elderly) where she waited 5 years for ADHC to secure a recommended Group Home placement with 24hr supports. Given that ADHC was not forthcoming with a recommended placement, her public guardian reluctantly approved a return to the community with high support packages. Since July 2014 when this community plan was initiated, this patient required two subsequent psychiatric hospital re-admissions and 15 documented referrals to the on-call Community Mental Health Emergency Team (CoMHET). Moreover, there was documented evidence of her deterioration and relapse of psychotic symptoms on approximately 16 occasions, and 14 documented instances of concerns from staff regarding her impaired decision making and sexual safety concerns — yet the efforts to manage her in the community continued. It is difficult to characterise this as anything other than a disastrous and failed community experiment; and compelling evidence that this was an inappropriate placement effort that ignored the original recommendations from the health service that she be placed in a 24hr supported Group Home facility. My fierce advocacy for this patient resulted in a formal complaint being made against me, and subsequently being blacklisted within the service. I believe this grievance originated from ADHC and was orchestrated in an effort to silence me while sending a message that such actions would not go unpunished. (Despite this, I am happy to say that my advocacy ultimately prevailed, and this patient was eventually placed in a 24 hour supported group facility — but no thanks to ADHC).
In August 2016 another egregious admission was made that takes the absurd to new levels. A 36 year old man from Campbelltown was admitted to the SOUTH ward of Liverpool psychiatric hospital despite not requiring mental health treatment at all. While he does have a history of mental illness and intellectual disability, his mental illness was stable on medication at the time of admission and he required no inpatient psychiatric treatment whatsoever. This was a clearly documented and a well established fact recognised by all involved. He was however, a morbidly obese bariatric patient of 230kgs, who refused to take any responsibility for his obesity, who was waiting for ADHC to literally build a house to accommodate his size and weight. ADHC sub-contracted his initial funding package to an NGO who bought him an iPad — ostensibly to assist in advancing his education. Yet his NGO worker was frequently observed to sit with him watching movies on his iPad in the hospital corridor. Despite universal objection from every SOUTH staff member at Liverpool Hospital — citing inappropriateness on numerous fronts, and even objection from the staff at Campbelltown hospital as well, the then Director of Allied Health, wielded all of her influence and power to overlook, side-step, and disregard all these concerns and pave the way for his admission (along with assistance from an OT that now is the current PCLI coordinator/mgr), acknowledging that it would be years before he would leave the hospital for a suitable placement. The word that eventually made it to the front line staff was that this was a directive issued from the CEO of Liverpool hospital.
Think about this … a forced admission to an inpatient psychiatric hospital — for a patient that is stable and does not require inpatient mental health treatment; appropriated funds for service overseen initially by ADHC that provides high-end electronic equipment to watch movies and pay the salary of an NGO employee to watch movies with the patient; and an apparent willingness to literally build a house around him, despite his unwillingness to take any responsibility to make any adjustments to his diet or lifestyle; while billing Medicare for fraudulent inpatient psychiatric treatment he does not require in order to use the hospital as a hotel for years (until ADHC gets around to building his house) with the staff to be his personal attendants — all at the taxpayer expense, and potentially orchestrated by the CEO and carried out by the executive psychiatric leadership of Liverpool Hospital.
Yet another case finds a 41year old gentleman who was initially admitted in October 2015. After 30 days of acute care he was transferred to the NORTH ward of Liverpool Hospital where he remained for several months from November 2015. He had experienced multiple admissions over the years associated with his chronic and persistent mental illness which was often complicated by his illicit drug use. Frustrated by his persistent drug use triggering relapses and requiring multiple readmissions, his sister arranged to become his Enduring Power of Attorney and Legal Guardian. His most recent admission was in the context of a disagreement with the Department of Housing, where she agreed to voluntarily relinquish his unit in order to be eligible for DOH services in the future. In doing so, she created an accommodation crisis and was extremely vocal (making written complaints to the health minister) in her displeasure with the hospital wanting to discharge him in November 2015 well before the relinquishment of his unit was scheduled to occur in February 2016. She was insisting that he should be provided supported accommodation by the public mental health system despite not meeting the clinical requirements for such a service. Moreover, even when offered to him, he repeatedly refused. At the time, ADHC would typically be the agency that would provide this type of service. However, there was no indication that he ever suffered from an intellectual disability. And numerous OT Assessments over the years repeatedly revealed that this gentleman was quite capable of bathing and grooming himself; budgeting; shopping and caring for the cleaning of his unit and managing his finances. Yet despite this evidence, his sister fiercely advocated that the public service should provide this for him regardless.
In an effort to avoid further complaints to the health minister, the executive leadership of Liverpool Hospital allowed themselves to be bullied by his sister. In order to appease her, they agreed to house him (again at tax payer expense) while a referral was made to a psychiatric rehabilitation service in Orange (even though he didn’t meet the clinical criteria for such a service). She also wrote letters to the Mental Health Review Tribunal, offering a lengthy list of unrealistic expectations she hoped to impose on the public mental health service as justifications for him remaining detained against his will. As a result of these efforts she also managed to bully or persuade the Tribunal to detain him under the Mental Health Act, against his will primarily to ensure that he was institutionally contained in such a manner that he is unable to engage in further illicit drug use. Such expectations are well beyond the parameters of the inpatient psychiatric service; well outside the boundaries of “least restrictive” care; and probably an illegal action. Yet both the administration of Liverpool hospital and the Mental Health Review Tribunal looked the other way and allowed this to go on for more than 10 months before he was eventually transferred to Bloomfield Hospital in Orange.
Of the patient cohort previously mentioned, 18 do not require inpatient treatment (and haven’t for some time). They require placement. (A statement I believe would be accurate for many patients currently at Liverpool Hospital). It is unclear why there has been so little scrutiny and accountability when it comes to why the executive psychiatric leadership of Liverpool Hospital allowed ADHC to have so many patients residing at Liverpool hospital in a de facto institutional arrangement, blocking access to acute beds, and charging Medicare for inpatient treatment at the tax payers expense. In part such examples highlights the dearth of available resources to address these patients needs. It also reflects ineffective management and poor leadership from both organisations. But the list does not end with ADHC patients alone. There are several other patients who are currently in the midst of lengthy admissions that have not required psychiatric treatment for some time. Many of these patients remain due to decisions handed down from the executive management, often due to their fear that someone will complain to the health minister or threaten to go to the media.
MENTAL HEALTH vs SUBSTANCE ABUSE
Sadly, these are not the only examples where both the leadership of Liverpool Hospital and the legal system conveniently look the other way. Both consumers and employees alike are quick to say that there is inadequate funding made available for mental health services. And while this may be an accurate view, I argue, how would we know? Conservative estimates suggest that at least 50% of the admissions to the psychiatric inpatient service at Liverpool Hospital are actually more about substance abuse than mental health. And while there is clearly some overlap where patients suffer from both disorders simultaneously, the admitting practices at Liverpool Hospital are alarming. Every day, known patients come to the ED where it is clear and unquestionable that the presenting issue that brings them to the ED is alcohol or substance abuse. Yet the doctors literally transpose the language and nomenclature of their documentation so that the patients become qualified to be admitted (and detained) as mentally ill.
There is no question in my mind that our doctors are more than capable of treating such conditions. My issue is whether the psychiatric inpatient facility of Liverpool Hospital is appropriately accredited to provide such treatment. This distinction should not be dismissed, ignored or minimised, because legally these two issues are dealt with in a distinctly different manner. The current mandate of the psychiatric hospital at Liverpool is to treat mental illness not substance abuse. The Mental Health Act does not apply to substance abuse issues in the same manner as with mental illness. Legally, patients have to agree to undergo substance abuse treatment. However, the Mental Health Act provides cover for doctors who feel obligated or compelled to admit psychotic patients regardless of whether illicit drugs induced such a condition. But the issue becomes considerably less clear and legally perilous when the issue shifts to containing patients against their will under the Mental Health Act when the primary admitting condition is a substance abuse issue or disorder. Inadequate rationalisations that a patient’s underlying mental illness somehow causes people to abuse drugs — to the point that they develop a substance abuse disorder is a shallow argument at best, that trivialises and ignores the validity of substance conditions in their own right. Finally, it could be argued that in a mental health budget that is already limited, such practice is tantamount to a misuse of allocated resources.
KPI’s CONTRIBUTION TO TOP DOWN TOXICITY
The lack of clear and decisive leadership on this issue is but one example reflecting more predominant themes of the executive leadership of Liverpool Hospital. They have created and reinforce a top-down, bullying culture whereby they have fostered a work environment that frequently does not follow or abide by their own policies, procedures, guidelines or principles. And while there are numerous reasons that underscore this dynamic, the most significant reason as is often the case — is political in nature. In many respects, it all begins with the KPI (key performance indicators) — handed down and imposed from the highest levels of Government. The most significant KPI that drives everything at Liverpool Hospital is the number of (mental health) patients in the ED and how long they wait for admission. The CEO of Liverpool Hospital compares their statistics of these indicators with other hospitals in surrounding areas and if they are too far out of line. If something raises a concern or red flag, the CEO simply orders the after hours nursing manager and/or the bed managers overseeing bed flow in the psychiatric hospital to magically make beds available so as to bring the number of patients waiting in ED to be reduced.
The main problem with this is that it creates a cascade of adverse effects that trickle down and reach the front lines that severely undermines patient care. These after hours bed managers act like gestapo agents without impunity — regardless if the manipulations they orchestrate are clinically indicated; interrupt or interferes with treatment; or even if their actions directly violate policies, procedures, guidelines or laws. If the after hours/bed mgr consults with the doctors at all, it is not uncommon for them to disregard their instructions altogether. They simply wait until after the doctors leave at 5PM and then move patients or send them on over-night leave whether the doctors have approved or not. How after hours bed managers have the authority to send a patient on leave without a doctor’s consent, or move a patient to another ward despite explicit orders to NOT be moved is astonishing. However, even more amazing is that there is no consequence or accountability for these actions — even when it was in direct violation of hospital policy and procedure; highly disruptive; interferes or worsens a patients overall care and treatment; and ultimately unnecessarily extends their length of stay.
It just goes to show how powerful the political pressures are at Liverpool Hospital. And while the after hours bed managers would no doubt state that they were simply following orders, (for fear of reprisals — or even dismissal if they did not adhere to these directives), this is clearly a cancer that is metastasising throughout the systemic culture of the psychiatric service. The cavalier, inconsistent, and chaotic manner in which the issue of leave is employed in the psychiatric hospital setting is left largely unaddressed as it is perfect cover to maintain the use of after hours bed managers who use this as the simplest and most powerful tool the executive has in order to manipulate beds in order to manage the KPI numbers.
DISMAL ORGANISATIONAL LEADERSHIP
For years the executive leadership have been unsuccessful in getting representative levels of feedback from its staff. Time after time they consider it quasi-successful if they approach a 50% response to their survey efforts. Despite cajoling and an endless array of enticements (raffles, food, coffee, etc) a significant majority of the staff decline to participate. It is common knowledge among the front line staff that the executive leadership has demonstrated convincingly — time and again that they are not really interested in any ideas or suggestions that run counter to whatever they have already decided. And despite their efforts to assure anonymity, by hiring outside firms to collect the responses, they still ask for and on some occasion require identifying information that leaves many of the staff feeling unsafe and thus unwilling to provide genuine feedback — for fear of reprisals from the executive in one way or another.
ENABLING PROFESSIONAL INCOMPETENCY
Beyond the previous examples, the executive leadership’s ineptness is also evident in their oversight of staff as well. There was one particular Allied Health professional in the inpatient mental health service at Liverpool Hospital that was widely recognises as inept and problematic. For years the near unanimous consensus of the staff was that this person was ill-equiped and unable to perform the basic requirements of their professional duties. Several years ago this staff member was assigned to PECC, but this was too far removed from the main psychiatric wards and no one really had a handle on how to supervise them. Thus, they were reassigned to an acute ward where theoretically they would be closer to their immediate supervisor and better oversight could occur. This too proved to be unsuccessful. When it became clear they could not manage the duties of an acute ward they were reassigned to a long-stay (sub acute) ward. After a year in which there was little to no interventions or action provided by this person for any of the patients on that ward, they were reassigned again to yet another acute ward — despite the fact that they had already demonstrated they were unsuccessful and unable to manage an acute ward.
After multiple years of problematic performance issues it was widely viewed that this person may require performance management interventions. Despite the confidential nature of such an intervention, the Director of Allied Health at that time (the same individual that made it her mission to admit the morbidly obese man) assured me (in conversations that were probably inappropriate and beyond the parameters of policy) that this person would be performance managed at the very least, or their work-related short-comings otherwise addressed. It is because of the confidential nature of this HR policy that we may never truly know if any of that ever took place. However, this person remained employed in the mental health service for many years before they eventually resigned. It is baffling that the executive leadership of Liverpool Hospital would elect to deal with this very significant concern in much the same manner as the Catholic church did with its problematic priests — simply reassign them and move them around repeatedly without properly or adequately addressing the underlying problems — and pretend that people do not notice.
This type of profound, systemic chaos and dysfunction underscores the basic ability to address a host of problematic expectations that the public holds for the mental health service at Liverpool hospital as well. Increasingly, the public looks to Liverpool Hospital to meet many of their unmet needs, in the midst of limited or even reduced social services. The month prior to the NDIS roll out in Southwest Sydney I heard several NUMs recounting stories of how high ranking ADHC staff were suggesting to families that if they wanted to relinquish guardianship responsibilities of their intellectually disabled, grown children that they should drop them off at the ED of Liverpool hospital and leave. Increasingly as indicated previously, families expect and sometimes demand that their family members be contained indefinitely (against their will if necessary) so as to prevent them from using illicit drugs. Despite having a dedicated governmental agency to address accommodation and housing issues (DOH), an increasing number of people show up at the ED at Liverpool hospital and threaten to kill themselves as a strategy for the psychiatric hospital to provide accommodation for them. Another example is when minors are inappropriately admitted to an adult psychiatric service, and then the parents refuse to take them back following discharge. Mandatory reports to FACS rarely aid in the facilitation of discharge in these scenarios, and vacancies in refuges for minors is extremely limited, not to mention problematic and less than ideal in many other ways.
While the benevolent approach to avoid discharging people to the streets is perhaps one of the kindest things that can be said about Liverpool hospital, the inconsistent and chaotic leadership prohibits any realistic discussions or explorations on any limits to be set for the increasing social problems that are well beyond the scope of psychiatric service and the hospital’s capabilities. Ironically, the response to these issues is short-sighted, inadequate and poor, and has resulted in nearly 35-40% of the available psychiatric beds being blocked at any given time — and growing, thereby making it even more difficult to meet the KPI guidelines.
Additionally, the executive leadership is quite averse to anyone making complaints to the health minister or worse, going to the media. Employees of the service are contractually prohibited from making any public statements that would highlight any of these concerns. Such manoeuvres however, contribute to a significant lack of transparency. However, if they followed their own policies, procedures, and guidelines with any sense of consistency, the service could confidently rely on the fact that while not perfect, they were on solid ethical and professional footing. They may have to amend their policies occasionally to improve or make things better, but this is how it’s suppose to be. Unfortunately, this is rarely the case at Liverpool hospital. They make executive exceptions all too frequently that fly in the face of their established rules and guidelines, often at the expense of patient care.
These are but a few examples from the tip of the iceberg to shine a light on the fact that the day-to-day functioning of the public mental health system at Liverpool Hospital is nothing short of a train wreck. Many of the problems originate with political underpinnings. However, the executive psychiatric leadership of Liverpool hospital routinely does not abide by or adhere to its own policies, procedures, guidelines, rules or protocols. They employ top down, bullying tactics in order to manipulate KPI data so as to appear that they are managing these issues. While every other service in the medical continuum within the hospital operates with admission, discharge and exclusionary criteria; the executive leadership of Liverpool Hospital does not endorse or support the psychiatric service to operate in this manner. Instead, they continually make exceptions to admit and keep patients that are beyond the parameters of inpatient psychiatric service. The frequently do not abide by the least restrictive level of care directive (unless it suits them). They offer lip service to the principles of the recovery and strength-based models. They pretended to provide a 3 month structured Psychiatric Rehab service as a pre-tense that is exploited by after hours bed managers and the executive leadership for long-stay patients that require no inpatient treatment and more realistically reflects a de facto institutional care setting that was dissolved by the national government years ago. And the taxpayer is footing the bill for fraudulently psychiatric treatment while essentially being a psychiatric hotel or day care service rather than a psychiatric hospital, containing patients illegally with substance abuse problems while the Tribunal looks the other way.
The culmination of this poorly managed train wreck results in a toxic and hostile work environment that clearly puts a low priority on patient care, and has little regard for the professional values and integrity of those who work in this highly dysfunctional system.
I note sadly that in February 2015, four trainees in a Melbourne hospital tragically died — suicided (3 psychiatric trainees and a hospital intern). One cannot generalise, nor is it reasonable to suggest that such dynamics are present throughout the national mental health system. Although an initial review acknowledged work stressors and high work load demands, it may not be much of a stretch to speculate that some of the chaotic dysfunction identified in this essay could also be underlying variables that contributed to the perfect storm for such a tragedy. The unacknowledged dark cloud that shrouds the chaotic dynamics that are pervasive in the systemic functioning of the SWSLHD mental health service adversely affects both patients and professionals alike. The problems are so pervasive and profound that an internal complaint to official visitors or even the health minister is unlikely to yield any significant change to these concerns. Thus, a persistent on ongoing expose from the media is the best chance for any real or sustained change in the mental health system.