PRECIOUS

By Mickey Skidmore, AMHSW, ACSW, MACSW

There are a handful of primarily recognised specialty service programs operating within the mental health service at Liverpool Hospital. The Early Psychosis Intervention Program (EPIP); the Infant & Child Adolescent Mental Health Service (ICAMHS); the Perinatal and Infant Mental Health Service (PIMHS); and the Specialist Mental Health Services for Older People (SMHSOP). A noteworthy feature of these specialty services is that they were intended to specialise in providing treatment and services to their identified cohorts across the continuum of care — both in the community or in the hospital. During the past several years, I have encountered a pattern of contradiction that each of these specialty services have shared at one time or another.

EPIP

The EPIP team operates truly in a multidisciplinary fashion. When they round, or see their patients in the hospital setting, they do so with an entourage that often includes a Psychiatric Consultant or Staff Specialist; a Psychiatric Registrar; and a Clinical Care Coordinator (which can be a nurse, occupational therapist, social worker or psychologist). They review their patients and when need be their family as a self-contained unit of professionals in order to cary out their mission of early treatment of psychosis in young people. Likewise, they operate similarly when seeing people in the ambulatory care centre (an outpatient clinic) or when they do home visits in the community.

EPIP appears to be the only specialty service that operates as such, rather than being a “consultation service”. Thus, functionally, it actually assumes care and management for their patients, whether they be in-patients in the hospital, or within the community. Despite this, there have been a few occasions during my tenure at Liverpool hospital when the EPIP team attempted to stray from this understanding and requested the in-patient Social Work staff to become involved because their patient was homeless. At the time, it was suggested that this was an issue beyond their team’s responsibility despite their Case Manager being a Social Worker. This was a clear attempt to pass off this issue to a team that otherwise has no involvement with EPIP patients. 

This incident was escalated to the in-patient Social Work Team Leader and required involvement with the executive management before the EPIP team withdrew this request. More than another year passed before a similar incident occurred again, requiring a similar push back and retraction. Other than these two incidences, the EPIP service in my estimation has been the best model on how “specialty services” were intended to operated across the service.

ICAMHS

The ICAMHS team is also a specialty service emphasising its focus on treatment and service delivery of children. This specialty service is crucial when ambulances (inappropriately) bring minors to Liverpool hospital for psychiatric services only to find that the psychiatric programs at Liverpool are designed and intended to clinically serve adults — not children. The ED and PECC units in particular rely, depend upon, and yield to the expertise of this specialty service when minors find themselves in crisis at Liverpool hospital. 

One would think, as is the view of many physicians, that the understanding and expectation is for ICAMHS to take the lead in assuming care of their patients in these scenarios, much in the same manner as EPIP. Yet, sadly this is not the case, as ICAMHS is primarily a community based service providing only a “consultation liaison” service for scenarios that are clearly not community based. There have been instances and even noteworthy patterns when ICAMHS is reluctant to assume responsibility for their identified cohort when in the ED — and it often evolves around the issues of homelessness, or difficulty placing a minor when a family refuses to allow their child to return home. These are the times when ICAMHS becomes less engaged and even conveniently leaves such tasks and circumstances for the in-patient Social Work team to address. 

In December 2017 such a scenario occurred around a minor admitted to the PECC ward. And a formal complaint was made by an ICAMHS worker against the Social Worker who’s documentation reflected the frustration of such a scenario. Despite the fact that this was a hotly discussed and debated issue among the Staff Specialists with the executive management, this particular Social Worker endured the hardship of this complaint process which was both a distraction from the real issue (reflecting solidarity with the concerns of the Psychiatric Consultants) as well as an over-reach that was inappropriate. 

And while this pattern fades away at times and appears to settle from time to time, this issue continues to be debated.

PIMHS

The reputation of the PIMHS team at Liverpool, is that despite established criterion for accepting clients in their specialty service, they tend to be rather fluid with the age requirements (or as some have stated, “move the goal posts” in such a manner that is difficult to refer patients that would seem appropriate). While I have been involved with patients that were already involved with PIMHS, I have never observed a single referral initiated by our treatment team that has been successfully accepted. Additionally, Women and Children’s services are also frequently involved with such cases, and it often appears that the two services are at times competing and overstepping each other to provide similar services. This team operates in a similar fashion to ICAMHS, in that it does not appear to assume responsibility of care in the inpatient setting, instead offering more of a consulting role to the in-patient treatment team, with emphasis on the issues associated with the complexities of antenatal care of mother’s of psychiatric patients.

OPMHS

The aged care category is the newest specialty service to Liverpool which emphasises mental health service delivery for the elderly. I found this specialty service is perhaps the most perplexing and controversial, as for the past several years I believed this service was responsible for the aged care cohort. Only recently did I clearly discover that this service too is primarily a community based program that operates only as a “consultation liaison” service to the in-patient psychiatric wards.

I began writing about aged-care issues more than 20 years ago (Skidmore, 1997; Skidmore, 1998), from an epidemiology and macro perspective. And while Australia does not have a population of more than 350 million people, my sense is that proportionately Australia is or will soon be under siege with a similar dynamic. A large cohort of the population (the baby boomers) are becoming elderly, and will tax the medical system in disproportionate ways than other identified cohorts, straining the resources of the current medical system. The purpose of writing about these issues 20 years ago was to bring attention to these issues and concerns in order to develop proactive responses to this eventuality. My sense is that OPMHS may be a response to this realisation. However, in its current form, this effort is far too little and much too late. 

This specialty service was identified and developed to care the mental health needs of the elderly. They begin with an age-related criteria for patients. However, this age is inconsistently reported to be either 65 or 70. This seems to be a point of contention for all aged-care services. The emphasis on the age (a number) rather than the functionality or context is troubling, and excludes a growing number of individuals who would seem to otherwise benefit from this service. 

Despite the guidelines describing their specialty service, they engage in significant obsfucation seemingly to avoid caring for the very population they were intended to serve. There is overlap, inconsistency, subterfuge and much confusion between this service and other aged-related services (i.e. geriatrics; psycho-geriatrics; ACAT; etc), resulting in considerable contention with the manner they operate. They debate the validity of dementia diagnosis’ to their advantage and at the expense of patients; imply that a patient’s condition is more in the realm of neurology or medical specialties to avoid becoming involved with their care; and suggest that other services or departments are “dumping” patients on them, when their services are intended to care for these very patients.

Perhaps the most disturbing statement that I attribute to first hearing from an OPMHS staff person is “dementia is not an age-related condition”. While there are certainly occasions when people younger than 65 or 70 could develop dementia, the vast majority of those afflicted with any of the dementias exhibit this condition in their later developmental years. It is alarming that the ACAT assessment team of the hospital (the service that determines whether patients are appropriate and/or suitable to be placed in aged care facilities or nursing homes) has also begun to use and thus reinforce the same statement. That the executive leadership of Liverpool’s mental health service would acquiesce to this view to gain credibility and take root in the hospital culture is unconscionable. 

Braeside is the intended specialty hospital unit for psycho-geriatric or elderly patients designed to manage this cohort of patients. It is part of the aged care resource network enabling OPMHS to assume care across the service. However, this unit is limited to 14/15 beds. And “unofficially” it has been said that they aim to operate on an 80% occupancy model. Moreover, I have recently discovered that Braeside hospital is not even part of the SWSLHD. It is owned and operated by Hammond Care — a private aged care provider, which is the likely explanation why there are limited or seemingly no successful escalation pathways from within Liverpool hospital. In the meantime, in early 2018 nearly 25% of the acute care and PECC wards were filled with geriatric patients awaiting transfer to Braeside.

Consider the following specific example of a recent mental health patient at Liverpool hospital. Historical review, and comprehensive investigation of this case revealed compelling evidence that lead to our treatment team to make a referral to SMHSOP. 

A consultation from a Psycho-Geratrician made the determination that this patient “has had a progressive cognitive decline over the past few years, due to a combination of brain injury, vascular disease, and possible early Alzheimer’s disease. There has been a corresponding functional decline as well, which has increased the burden of care of his wife to care for him and their young family. He has had significant difficulties with frustration tolerance as a result, and has had two instances of self-harming late, last year”. Diagnosis: Dementia – mixed aetiology (traumatic, vascular, Alzheimer’s) of young onset, with reduced frustration tolerance.

This evidence was further supported by a SPEC scan as well, conveying “the scan findings are consistent with vascular disease, history of depression and history of multiple head injuries. Concomitant early Alzheimers’ disease is not excluded and if clinically indicated a progress study may be performed”. A Neuropsychological Assessment referred to a previous MRI that noted “scattered age related deep white matter ischaemic changes”. The conclusion of this report also confirmed previous findings that “the profile is consistent with vascular cognitive impairment coupled with the residual effects of multiple brain injuries … and other differential diagnosis which implicate Alzheimer’s disease cannot be completely ruled out.” 

During his extended admission, the OPMHS physician and team leader refused multiple requests to attend meetings with the in-patient treatment teams. Rather, they sent lengthy email responses where they were spinning the same evidence with slightly altered language in an effort to obsfucate their involvement, or otherwise attempted to undermine the rationale for our referral. Some of these examples include:

“The neuropsychology assessment … did not support a diagnosis of possible Alzheimer’s disease”. The exact wording however is as printed previously: “other differential diagnosis which implicate Alzheimer’s disease cannot be completely ruled out.”

Referring to the SPEC scan that conveyed “it could not exclude early Alzheimer’s” suggested that a SPECT alone does not provide meaningful diagnostic information and requires clinical correlation. I suppose the additional supporting documented evidence cited above somehow does not qualify as any type of correlation for this doctor.

“I agree that there is evidence of traumatic and possible vascular related cognitive impairment but these deficits are static. This is supported by the neuropsychological testing that was done”. While I concede that such a statement was supported by an OT Assessment, however, I cannot find the supporting evidence in the neuropsychological assessment to which he refers.

“There was no evidence of pervasive mood disorder during our (previous) engagement with him”. Yet he spend 4-6 weeks in an acute care in-patient psychiatric ward, where the primary treatment he received was anti-depressant therapy to stabilise his mood.

“There has been no evidence to suggest he has a progressive neuro-cognitive disorder”. Again, he apparently has discounted all the evidence outlined in this essay to the contrary.

This physician then copied the extensive point by point email and entered it into the patients medical record. I arranged for a Complex Care Meeting to discuss these matters and formulate a viable discharge plan. However, the Medical Director arrived with a clear bias, having already either communicated with the OPMHS physicians or otherwise determined that regardless of what was said, he would be supporting the OPMHS position. (Apparently, this is what qualifies as a consulting service). Perhaps even more disturbing than this, is that the outcome resulted in the hospital deciding that he did not have any mental health diagnosis, and would not allocate any of its teams or services to take responsibility for his follow-up care.

None of the psychiatric units at Liverpool hospital were ever designed or intended to provide in-patient treatment for geriatric patients. These wards are acute care units for adult patients, often with severe and persistent psychiatric conditions. Psycho-geriatric patients often have unique conditions such as dementia and/or other cognitive impairments, that require specialised consideration and treatment approaches that is not suited and clinically inappropriate for the general acute wards. Moreover, the risk of incidental harm to these patients from other unwell patients, that increasingly reflect illicit drug us, is also greater. 

A & D

Of course there is another specialty service that is rarely mentioned in this context, and that is the Alcohol and Drug service. While they are often involved in overseeing the heroin substitution programs (i.e. methadone, saboxone), they too typically function as a “consultation liaison” service, providing guidance and recommendations regarding substance abuse medication, and assistance in referrals to substance abuse rehabilitation treatment programs. Given the high percentage of patients in the hospital with drug-related issues or co-morbidities, it would seem that this specialty service might have the most compelling advocacy for a substance abuse ward or a dual-diagnosis in-patient unit. As this has never been seriously considered during recent times, one speculates if it may be due to the fact that the in-patient psychiatric wards at Liverpool hospital may not be credentialed or accredited to provide such an in-patient service.

CONCLUSION

I find it difficult to understand why it seems that so many (specialty) services or departments in Liverpool hospital is able to set limits and parameters on who and under what conditions they will serve consumers. Yet, subjectively it seems that the psychiatric service in particular, is rarely if ever able to say NO – even when they are at or even beyond capacity. They are quite simply the door mats of the area service. A second class, less-than, underrated, “throw away” service that must capitulate to every other service when they don’t want to deal with the consumers they were designed and intended to care for. Why does any specialty service not have a duty of care to look after their own patients?

The disturbing pattern that nearly all of these specialty services have demonstrated (some more than others), is that they have tragically and ironically placed themselves in the position to avoid serving the very cohort or population that they were intended to serve. Or at the very least allowed to function within narrowly defined parameters that highlight significant limitations. They have been allowed to perceive their service as being highly valued; esteemed; and beloved — so precious and excessively refined, that they are untouchable and without recourse. Permitting such practices to endure clearly reflects poorly on the executive management for allowing such preciousness to become normalised in an already dysfunctional system.

It has been suggested by some in the service that OPMHS currently operates in this manner because of two reasons. First, they recognise the enormous cost associated with caring adequately for this cohort, and while never clearly acknowledging it, have opted to distance themselves and back away from providing a comprehensive service to this group. Another view is that they do not have adequate allied health staff allocated to their service; thus it is difficult, or in effect impossible to provide the specialty services that this cohort deserves and requires. No Occupational Therapists; no Neuro-Psychologists; limited or no Social Worker’s. If accurate, this is clearly a concern on several levels. However, “pretending” (Skidmore, October 2020) to provide a specialty service at the expense of other services is not a viable work around for the patients or other departments in the hospital. I also note that in Liverpool Hospital’s strategic design for the next two years cites similar concerns and realisation regarding the impending age-related issues that I began writing about more than 20 years ago. Yet I see little evidence that the services is making any meaningful strides or efforts to adequately address this issue (other than the construction for a psycho-geriatric ward at Campbelltown hospital). To hide behind the excuse of being a “consultation liaison” service is shallow and lacking response to the current reality for an increasing number patients, not to mention disrespectful to the psychiatric service who is forced to care for the patients intended for a specialty service.

Imagine that you work for a service intending to provide specialty service to the elderly, but instead you spend more time, energy and resources to strategically avoid, obstruct and otherwise manipulate the system to avoid providing service to the elderly. Sounds pretty outrageous doesn’t it? It’s like it comes right out of a fictional novel … like when a hospital proposes to provide a short-term psychiatric rehabilitation service in order to have millions of dollars of funding allocated to build a new ward. However, for periods longer than a year, there are no qualified staff specialists to provide any rehab services or programming; the patients are required to pay room and board for a service they are not receiving; and the “rehab” ward is over run with acute care or long-stay patients that the hospital can’t otherwise serve. I mean, who in their right minds would ever allow such professional vandalism to go unabated?

REFERENCES

  1. Skidmore, Mickey.  “DILEMMAS IN GERIATRIC PSYCHIATRY: A Critical Exploration of Health Care Delivery for the Elderly” (May 1997).
  2. Skidmore, Mickey. “DILEMMAS IN GERIATRIC PSYCHIATRY PART TWO: Society’s Treatment of the Elderly” (February 1998).
  3. Skidmore, Mickey. “Pretending” (October 2020).