PROFESSIONAL VANDALISM: Part Two (External Issues)
By Mickey Skidmore, AMHSW, ACSW, MACSW
“If honour were profitable, everybody would be honourable.”
Liverpool hospital has always placed high value on the role of “external stakeholders”. In many of the job descriptions throughout the SWSLHD there is often a reference emphasising the importance of collaborating with external stakeholders. In the 8 years of my employment, I have sadly come to view such statements or comments as “code speak” for allowing external stakeholders to use the public system as their own personal door mat, and that when they abuse us and dump their garbage at our front door, we were only allowed to say “thank you.”
This month’s “Perspective” reviews the practices and professional vandalism that occurs in the day-to-day interactions with several external agencies, and how such dysfunction wreaks havoc on the public service and consumers along the way.
It is a strange, convoluted and upside down system indeed that has psychiatric patients in the lobby of a Department of Housing office that are floridly paranoid, delusional and responding to unseen stimuli, while an endless queue of homeless consumers are clamouring in the ED to be hospitalised in order to get accommodation.
THE LEGAL SYSTEM
The legal system all too often appears to “look the other way” in dealing with mental health patients or drug abusers that have significant and alarming forensic histories, instead dismissing or ignoring charges and bringing them to Liverpool hospital for admission. Far too frequently patients will be brought to the ED of Liverpool hospital for “evaluation”; subsequently discharged; only for the police to re-schedule them again due to their lack of desire to deal with the legal infractions committed by these individuals. It would be compelling research to study the number of people the legal system attempts to manage via the healthcare system rather than the legal system. The ambiguity and lack of clarity around the co-morbid issues of mental illness and illicit drug use (Skidmore, 2020) only serves to keep the waters more muddy than ever.
Immigration detention centres — who despite having their own psychiatrists and medical staff, routinely impose admission of their detainees to Liverpool hospital. This appears to be about legal minutia as apparently such centres are not able to impose or force treatment on non-Australian citizens. Yet somehow, by their being in Liverpool hospital they can be legally detained and treated under the Mental Health Act. Perhaps the most obscene aspect of this is that per detention centre policy, each patient from their centre is accompanied by two security guards that are paid up to $80 per hour to sit outside in the lobby during the day shifts at the tax payers expense, while the patient is on a closed, gazetted unit, far removed and unaccompanied by their security guards, that essentially is providing no security whatsoever. If ever there was a clear need for a legal/political solution to an absurd over-sight, this would be one. A political/legal adjustment enabling detention centres to provide treatment in a similar manner to Liverpool hospital would address this issue once and for all.
THE FORENSIC SYSTEM
There is an entire system developed to manage and care for forensic patients with mental health or psychiatric issues who have been adjudicated by the legal system. Yet a concerning number of patients with considerable legal histories are admitted to the psychiatric wards of Liverpool hospital. Moreover, when consulted about their patients in Liverpool hospital they often dictate unrealistic and stringent recommendations that are beyond the hospital’s ability while refusing any accountability for these recommendations.
In December 2017 a 72 year old male was admitted to Liverpool hospital in a near catatonic state after he ceased his clozapine medication — resulting in a likely rebound psychosis from his non-compliance with his medication. He was under a forensic order and conditionally released to his family in the community. This was his second hospital admission since 2000 with similar presenting circumstances. While re-stabilising his mental status, it was discovered that the odds were that he also had prostate cancer as well.
After approximately two months, in contrast to his presenting condition, he had demonstrated significant overall progress. While he was not symptom-free, from the treatment team’s perspective he was dischargeable. However, the community forensic team took issue with this. They voiced concerns that his family could not adequately supervise him or ensure medication compliance, given this was his second admission in the context of non-adherence with his medication regime. In effect, they essentially blocked his discharge, and insisted the hospital investigate alternative accommodation options (which would be subject to their approval). However, ACAT refused to assess him for consideration of aged-care placement because the treatment team felt that he was capable of residing in the community.
The intersection of this turf war battle resulted in the patient being caught in the cross hairs. The treatment team of Liverpool hospital is obligated to provide treatment services under the legal framework of “least restrictive care”. Whereas the forensic team operates on a completely different and separate legal framework. It was clear to me that despite this man’s advanced age; which would be further compromised/limited by a probable cancer diagnosis, their intention was to detain him in an institution for the rest of his days based on a legal decision for a crime that was committed more than 20 years ago.
Now, this gentleman was under a current forensic order. So, I do not question the authority of the forensic team to make such a determination. However, what I don’t understand is, if this is the determination of the forensic team, why wouldn’t they transfer him to one of their forensic facilities to carry out this recommendation? I curiously asked this question numerous times, and each time it was received as an inappropriate, unconscionable and blasphemous suggestion. Yet this patient has remained at Liverpool hospital for months, held hostage by the forensic team and otherwise blocking a bed for the service — all the while, with the psychiatric leadership offering no escalation or intervention.
THE TRUSTEES OF THE OPG
In recent years there has been significant re-structuring and re-organising in the OPG, in particular regarding the process of managing Financial Management Orders from the Tribunal. From my perspective this has resulted in a significantly reduced emphasis on customer service. When I first began working at Liverpool hospital in 2012 it was common-place to accompany the patient to a local branch in order to meet the Trustee that would oversee the management of their finances. In some cases, the Trustee would even present to the hospital ward so as to meet the patient. In either case, the primary purpose was to link the patient with their trustee — to meet with the patient and from their conversation negotiate an initial or basic budget for them.
Over time, there has been a noted shift in these practices. Once an FMO has been ordered, a letter is sent to the applicant (often the unit Social Worker) requesting them to provide them with detailed financial information and background in order for them to initiate a budget, or to forward this request to someone who can assist them with this task. This is a clear shift attempting to get anyone else to do their job for them. Frankly, I do not understand how a Trustee can properly establish a budget or manage someone’e finances if they refuse to engage in even a single conversation with their client.
This is simply beyond the role of a Social Worker. There is no reason for them to have or know such information. They may have broad information or understanding regarding what entitlements they are receiving or what reporting requirements are in play to receive such benefits. However, the only way they would have access to such information or knowledge is to have an in depth, detailed interview with the patient and/or his family. There is no reason why a Social Worker would need to have such information to carry out their duties. It would seem however, that the Trustee clearly requires such information in order to fulfil their basic duties. While this appears to be self-evident, it is alarming to see that in the world of the Trustees, this is the job of the Social Worker in the hospital or anyone else rather than the Trustee. While I maintain my willingness to arrange for a meeting with the patient and the Trustee (whether that be a conference call; transporting the patient to their office; or arranging an appointment for them to visit the patient in the hospital); I do not have time to do both my job and the Trustee’s as well.
And even after a budget has been established, many Trustee’s seem to increasingly play a role in triangulating the Social Worker into the issue of managing a patients finances. Patient’s routinely ask me to contact their Trustee to request additional funds, or they report that the Trustee tells them for the Social Worker to contact them in order for this to happen. I am extremely uncomfortable being placed in the middle of such a position. I make clear to both the Trustee and patient alike, that it is not the role of the Social Worker to make decisions about their money. This is precisely the role the Tribunal has ordered the Trustee to do. The Social Worker can confirm the dates of hospitalisation, and can provide a view (if requested) about comfort money allowance during a patient’s hospitalisation, but ultimately the issue is between the patient and the Trustee despite either the patient or the Trustee’s efforts to draw the Social Worker in the middle of this dispute.
I am aware that FACS routinely faces enormous challenges; and often is on the front lines of receiving complaints from multiple sources. As a result, it has developed a singular focus in its mission — the protection of young children from eminent harm. While the acronym for FACS is Family and Community Services (which has recently changed yet again), given this one-dimensional focus, it is unapologetic that the consideration of the child’s functioning in a healthy family system is simply not its highest priority.
One example involved a man who was admitted to Liverpool hospital several times due to attempting suicide — the most recent time being discovered hanging from a tree limb by his wife and 12 year old son. After being in the hospital for 30 days, and approaching consideration for discharge, I received a phone call from FACS voicing concerns they had about returning him to the home environment with his children. I was first struck that it took them a month before they voiced any such concerns (which they brushed off as common place — a typical response time to such circumstances). The implication was clearly that if he were discharged back home, they may have to consider removing the children from this environment. Having seen no adverse interactions between this man and his children during regular visitation to the hospital, I inquired if he had any concerns about what the impact on the children would be to break apart a family, and being torn from one or both of his parents resulting from such an intervention?
When I first came to Australia I was stunned that the placement of minors in minimally supervised or unsupervised refuges had become an accepted alternative discharge practice due to FACS being inundated with overwhelming numbers of at risk children under the age of 14. I have filed FACS reports for minors who find themselves admitted to the PECC unit on several occasions. In reviewing these reports I was assured that they were appropriate, and justified. However, there would be no response from FACS, as they were safely sheltered and in care of a psychiatric facility. In fact, the majority of times when I do file a FACS report, there is rarely a definitive action that occurs from FACS.
Recently there has been the development of multi-organisational committee comprised of the Police; FACS; DOH; hospitals; and community mental health services mobilising around the issue of Domestic Violence. The SAM’s committee, (Safety Action Management) is a welcomed effort attempting to address DV in a better way.
In May 2017 a man was admitted to PECC due to of a breach of AVO in the context of domestic violence. At the time of admission, it was believed that a FACS report had already been made, and that he was to be discharged into police custody to go before a Magistrate to address the AVO breach.
During his admission, it was noted that his AVO reflected only standard conditions rather than the more severe special conditions prohibiting communication and contact. His ex-partner volunteered for visitation during his admission, and agreed to supervised visitation for him to see his daughter. The medical team granted him leave accordingly. He complied strictly with every guideline during his admission. When it was discovered by the SAM’s committee that this patient had been granted leave with his daughter, they insisted that a subsequent FACS report be made by a Social Worker, and requesting communication with the DV liaison officer with the local police department.
My interaction with this man was limited to providing details about accessing legal aid. Given the details, there was no indication that a subsequent FACS reporting was warranted. There was no eminent risk observed to a child. And while the doctors voiced concern about breaching his confidentiality, I suggested that there was likely a memorandum of understanding in place enabling us to communicate legally without such a breach, but that this had not been properly explained or presented properly to staff yet. Efforts were made by myself and the doctor to contact the DV liaison officer for several days unsuccessfully in an effort to address any concerns they may have had. Eventually, the man was discharged to police custody.
Two weeks after his discharge, I was again pressured by management to file a subsequent report to FACS, despite my misgivings and ambivalence in this regard. Not only did I feel there was no indication to warrant such a report, I also was operating on the understanding that a report had already been made, and there was no practical value in submitting a subsequent report two weeks after he had been discharged — especially given that I had never met his partner or daughter or witness anything untoward.
It was explained that had I spoken with the DV liaison officer, she would have conveyed that the partner and the daughter had presented to this committee seeking safety from DV from this man. It was their view that in light of this, given he was later allowed to have leave with his daughter, that it was not unreasonable to request for a FACS report to be made. I also learned that if this report was not made they were threatening to lodge a formal complaint/grievance. (It is unclear if this complaint would be filed against me or the hospital). My view, and that of the admitting doctor was that if they were so concerned they should have acted as a committee to ensure that the most severe conditions were reflected in the AVO. I would also eventually learn, that despite seven Social Workers being present at the committee meeting when the partner and daughter presented requesting protection against DV, that they only talked about a FACS report. None of them bothered to file a report themselves.
This discovery only intensified my ire. I took issue with an external agent attempting to dictate actions to take place in course of an inpatient admission. It seemed to me that the committee was attempting to weaponise a FACS reporting process to influence the outcome of a political agenda. I found this to be a potential violation of professional ethics, considering the threat of a formal complaint to do something that was not warranted in my professional judgment — in particular given that it was two weeks post discharge — and that seven Social Workers on this committee prior to admission did not find it compelling enough to file their own report. And in the end, this man was adjudicated with little legal consequence. I had been subsequently informed that he continued to have regular access to both his (ex)-partner and daughter.
DUTY OF CARE
There are several things that these scenarios all have in common. They all look to the hospital to assume a duty of care, due to the strains and dysfunctions and limits of a broken system. And all too often this is allowed to happen, or there are instructions from management to bend, stretch, and violate their own policies and practice parameters in order to avoid unpleasant political realities of these facts. And when we do, we in effect rescue and enable the system to continue and persist in this manner. In other words, by ignoring, turning a blind eye, or pretending this is okay, we contribute to the perpetuation of this (external) professional vandalism.
I have inquired on numerous occasions why the psychiatric service of Liverpool hospital are not allowed to say NO. I have also pointed out on multiple occasions when an admission is beyond the parameters of our service; or it is not clinically appropriate for admission to our service. Often the justification that is often stated to defend such admissions is that we have a “duty of care”. Such justifications only serve to raise subsequent questions. Why do other hospitals that are frequently “full” not have a duty of care to look after their patients? Why does ADHC not have a duty of care to their Intellectually Disabled consumers? Why does the Justice system not have a duty of care to manage forensic patients? Why does FACS not have a duty of care to place minor children abandoned by their families to facilities other than psychiatric hospitals for adults? Why does it seem as though Liverpool hospital is held to the “duty of care” standard more than other organisations?
NDIS is the latest external stakeholder to infiltrate and in many ways overtake the psychiatric service at Liverpool hospital. Despite NDIS being a massive financial scheme second only in scope to Medicare, NDIS has outmanoeuvred the psychiatric service by having the public service administer many of the evaluations that are part of the NDIS application process to be accepted and offered services. Quietly and increasingly these evaluations are essentially funded by public mental health service rather than NDIS resulting from their hospitalisation. Moreover, this trend is fuelled by a steady increase in Occupational Therapy positions in the mental health service.
To be clear, I am not opposed to individuals who qualify and would benefit from NDIS to be accepted into this program. If this service would enhance the quality of their life and aid in their personal recovery I fully support this. My concern and objection is that the psychiatric service of Liverpool hospital should not be held hostage as a conduit to processing NDIS applications. My view is that any inpatient of the psychiatric services should be screened to determine if they may be eligible for NDIS services, and then referred and linked to NDIS as part of their aftercare arrangements for NDIS to follow through with post discharge from the hospital.
Unfortunately, this is not the process that unfolds in the psychiatric service at Liverpool hospital. When OT’s identify an inpatient’s eligibility, they initiate a range of assessments and evaluations that are often dictated and determined by NDIS. The result is that this process frequently becomes the focus of their admission. Additionally, then the hospital becomes a psychiatric residence while the NDIS application process plays out. In the cases where placement in 24hr supported group home facilities are indicated the waiting process for an appropriate placement can be extensive and lengthy. In many cases the entire process can be in excess of a year or more. And the cost for this is typically absorbed by the mental health service rather that NDIS.
In many respects this is a repeat of the ADHC playbook, where once again Liverpool hospital is outmanoeuvred by an external stakeholder. During my tenure, I raised potential ethical concerns around payment and funding issues of service delivery; and the service being hijacked as an NDIS admission and pre-placement facility to the Director of Allied Health. However, my concerns were dismissed out of hand — repeatedly.
IMAGINE THE POSSIBILITIES
In last month’s “Perspective” I suggest possible outcomes that could arise with the implementation of clear admission and exclusionary criterion. What would happen if we did the same with Developmental Disorders, Intellectual Disorders, and brain injuries? What if we assessed them in ED and acknowledged that they needed specialised care, but ADHC or the Brian Injury service would have to arrange for them to go to one of their facilities where again, their developmental therapeutic issues could be better addressed as per the standards of best practices. (And while we’re talking about this topic, I believe Liverpool hospital could have set a powerful message if they simply sent ADHC or NDIS the bill for every day that their patients are residing in their rehab/sub-acute wards awaiting for them to find the appropriate level of care to serve their clients. I imagine if this single action were taken they would miraculously discovered some alternative arrangements rather than be responsible with handing over $1000+ a day from their budget to Liverpool hospital).
Ironically, all I’m suggesting is for Liverpool hospital to do what so many others are already doing — saying NO. Enough is enough. Making a clear statement that they will no longer serve as the doormat for internal or external stakeholders because they are able to refuse to care for their cohorts. If Liverpool hospital were to discover their backbone, and clearly and consistently say NO to such admissions, it would throw a huge monkey wrench in the system that could not be ignored, and would force an examination and exploration that would lead to hopefully better solutions. Alas, I think we all know that this would require a monumental and nearly revolutionary effort, which at present is just another form of pretending. But it is inspiring to imagine, is it not?
I previously attended the Research and Innovation Showcase of 2018. Throughout the course of this event the CEO, Amanda Larkin was praised for her commitment to resources and research that fuels these events and the future of the health service — and rightly so. However, at the core of everything we do in the mental health service at Liverpool hospital, we engage and interact with people. Whether that be patients; staff; other hospital departments; HR; or external stakeholders. I have provided a number of examples reflecting the contradictions, cognitive dissonance, and corrosion of badly broken institutions that requires significant attention or these “innovations” of the future are nothing more than an ambitious exercise in wishful thinking.
In general, I find it difficult to understand why it seems that so many other services or departments in the hospital or surrounding areas are able to set limits and parameters on who and under what conditions they will serve consumers. Yet, the psychiatric service of Liverpool hospital is rarely if ever able to say NO – even if we are at or even beyond capacity. They are the door mats of the area service. A second class, less-than, underrated service that must capitulate to every other service when they do not want to deal with a consumer.
Yielding to the powerful influences of external stakeholders it is easy to see how the political exceptions for admission encroach on the limited number of acute psychiatric beds available at Liverpool hospital. It can easily be argued that the service is being exploited and often held hostage by these external forces. When nearly half of the admissions are related to substance use disorders; or admissions from other services who refuse to serve their own cohorts (geriatrics; head injuries; developmental disabilities; forensic); or if the service is commandeered by NDIS as admissions or placement portals; and in the meantime pretending to address a range of social issues (housing; legal; poverty; etc) that are beyond the capacity or ability of a psychiatric service to realistically address, one wonders if this is truely an inpatient psychiatric service any more. Such issues and dynamics bear witness to the reality that the predominant medical model of an inpatient psychiatric service is inadequate and incapable of realistically addressing the growing enormity of these issues.
The time has come to stop pretending (Skidmore, 2020) to be a psychiatric hospital when in fact, in very practical matters, the Liverpool inpatient psychiatric services operates more as a boarding house or psychiatric hotel, with a professional staff that serve more as house parents and seems to have a “duty of care” that is virtually limitless. They pretend to follow best practice procedures, but then blatantly violate the very CORE principles they espouse. They pretend to practice under the arching principles of recovery, yet in the patient’s eyes the hospital is the answer or solution to increasing amounts of day to day issues, thus paradoxically instilling increased dependency rather than independence — and doing little to dissuade these notions. And then there is a distinct layer of folks that seek hospitalisation to avoid legal consequences; enhance their bank accounts; for immigration purposes; workman’s comp or a range of other secondary gains far removed from treatment in a psychiatric hospital.In fact, during the past eight years I have often felt that I did not work for a hospital at all, but rather I worked at the NSW Sydney Hotel, Hostel, Concierge and Refugee Service.