“ABUSE OF PROCESS”

By Mickey Skidmore, AMHSW, ACSW, MACSW

If there is a single dynamic that underscores the systemic dysfunction of the mental health service at Liverpool hospital, it would have to be that they do not follow their own policies, principles or guidelines with any consistency. One doesn’t need to look far before seeing a pattern of disconnection in this regard.

Whether that be the hospital touting a no smoking policy on its campus that it simply cannot enforce. Or the psychiatric service employing “leave” practices to essentially subvert the smoking policy and look the other way while patients openly smoke in areas throughout the campus. Or the extraordinary number of “patients” who have taken up residence in a psychiatric hotel that Liverpool allows while the process for appropriate placements for these individuals occurs no quicker under the NDIS model than it did under the previous ADHC model.

Beyond this are the huge numbers of patients that are admitted to the psychiatric wards that are clearly outside of the intend clinical parameters of acute care, such as a significant percentage of drug related patients even though I seriously doubt that the service is accredited to provide inpatient drug treatment. Or increasing numbers of geriatric patients being admitted even though there is a specialty service for older people, and it is far from ideal or even clinically appropriate for them to be on the acute psychiatric wards. It is also rather stunning to see TBI patients being admitted to the acute psychiatric wards because the head injury unit refuses to admit them to their service — even when the presenting issues are clearly associated with head trauma.

Those who were around when ADHC was a significant organisation will recall how they routinely out manoeuvred Liverpool hospital into admitting intellectually disabled patients that were beyond the parameters of an in-patient psychiatric service only for them to take up residence in the psychiatric wards, waiting endlessly for ADHC to find appropriate Group Home placements for their patients. The short-term memory of these lessons has resulted in NDIS essentially re-creating a similar dynamic. Increasingly, the psychiatric service is doing the work of NDIS, and in the meantime, more and more of their patients become extended residents of the Liverpool psychiatric hotel while once again waiting for NDIS to identify appropriate placements for their patients. Sadly, the leadership of in-patient mental health service does little to dissuade this, and allows this practice to continue and escalate — even though such a process may be an example of double-dipping into multiple payment schemes.

Even after the psychiatric medical staff established a new model of care for what was once a (sub-acute) short-term rehab ward, and outlined that the process for patients to be accepted to this ward would be done via a doctor-to-doctor process; the bed manager’s routinely block this process resulting in considerable confusion around what was to be a new step-down ward for sub-acute patients from the acute wards.

While there are numerous examples to support these observations, here are but a few:

In early 2020 on one of the 20 bed acute wards alone, more than 30% of the ward was comprised with intellectually disabled patients. For more than a month, the inpatient service essentially provided “group home level” or skilled nursing care (nursing home) in an acute care psychiatric facility to one of these patients in particular. Indirectly, such circumstances reinforces the notion to the family that when they are overwhelmed and require a respite, they can bring their family member for an extended stay in an acute care psychiatric facility. In my view the treatment team should have been having difficult conversations with the family, explaining that this was not an appropriate service to meet their needs. Rather, they needed to be provided education about the choices, options of a group home placement or possible NDIS services to further assist with additional supports in the home if they were opposed to group home placement of their loved one.

Recently, a relatively young patient in his 30’s had the misfortune of suffering two strokes in the span of 30 days. His presentation was marked by abnormal behaviours and anxiety after experiencing two CVA’s (which the neurology team documented as “post stroke psychosis”). Rather than the neurology service treating him and organise appropriate rehab from his neurological events, he was instead admitted to the acute psychiatric wards because he had a previous label of Asperger’s. I don’t deny that he may also benefit and even require psychiatric consultation and/or collaboration while undergoing his rehab. However, I saw little evidence that his circumstances required an inpatient psychiatric admission. My raising concerns about this was met with considerable push back. During the legal IPO process, the Tribunal inquired about the NDIS process, once again highlighting that there are multiple sources pressuring the hospital to do the work of NDIS.

In another example, a patient was transferred from the PECC unit to an acute ward over the weekend. At Monday’s morning handover, there was considerable confusion and consternation given there was a clear plan from the PECC team to consider discharge after a family meeting on Monday or Tuesday. The doctors insisted that the patient be returned for the PECC team to complete its work rather than start anew with a different team. In this process it was discovered that the after hours bed manager’s were responsible for making these decisions and moving this patient indiscriminately without input from any of the physician’s overseeing her care.

Not only is the psychiatric service of Liverpool hospital charged with caring for its own catchment area of Liverpool and Fairfield, they routinely admit patients from out of area and other hospitals that also have psychiatric facilities. Certainly there are medical circumstances where Liverpool provides specialty services that are beyond a local hospital’s capabilities. However, even when patients are sent from hospitals that have psychiatric services, they are rarely returned to the own communities. 

It is astonishing that the army of FTE’s dedicated to bed flow managers; after hours bed flow managers and CNC / discharge specialists only seem to “create” beds at Liverpool hospital. Sure there are more psychiatric beds at Liverpool hospital (roughly 100), however, the mathematical process of “creating a bed” would seem to be the same at Campbelltown hospital or Bankstown hospital as it is with Liverpool.

These are reflections of the NSW Health CORE values, that often seem to be little more than convenient talking points. Administrative exceptions to these values are handed down so often that these policies hold little validity. While employees are held to these standards, the leadership conversely seem to be held to a different standard, which to the outside observer appears to be arbitrary, inconsistent or based on the political winds that may be blowing at any given point in time.

The parameters in my own job description are rather deceptive as well. If I wanted to work with drug and alcohol patients, I would have applied for work in the drug service. If I wanted to work with psycho-geriatric patients I would have applied for a position in the older person’s mental health specialty service. If wanted to work with TBI patients I would have applied for a position in the brain injury service. If I was drawn to work with refugees, I would have sought employment with STARTTS. If I wanted to work with intellectually disabled individuals I would have applied for work in a group home or NDIS or previously — ADHC. 

What I have always wanted, is to be recognised as a Clinical Social Worker in an interdisciplinary team providing acute in-patient services to psychiatric patients. However, the pervasive systemic dysfunctions of the Liverpool mental health service consistently  exhibit an abuse of process and provide a glaring template of how a service lost its way; reflecting the symptoms of schizophrenia — ironically of the very patient cohort it was intended to serve.