One psychiatrist raises concerns about proposed back-up arrangements as health officials rush to fill staffing gaps
More than 60 mental health beds in public hospitals are temporarily closing in New South Wales as some hospitals are being given directives to limit psychiatric assessments because of mass resignations.
A senior psychiatrist told Guardian Australia that the emergency plans to manage psychiatric patients will mean decisions on discharge or the need for further care will be delayed, causing bed blockages across the health system. The doctor spoke on condition of anonymity.
More than 200 psychiatrists in the public system indicated they would resign after the government refused to agree to a 25% pay increase in a single year, which they say is needed to attract new doctors and retain those now working in the public system. The dispute will be heard by the NSW Industrial Relations Commission from 17-21 March.
The state minister for mental health, Rose Jackson, said on Thursday that 43 psychiatrists had resigned and that number was expected “to rise over coming days”. Ninety-nine doctors had delayed their resignations, she said.
Jackson said the government had secured 23 locums to fill roles and another eight were still being processed. “As a consequence of that, we’re not seeing the significant disruption of mental health services at the local level.”
However, Guardian Australia – which has seen various leaked documents outlining the contingency plans of major hospitals in the state – understands psychiatrists are concerned about the back-up plans.
The chief executive of Sydney Local Health District, Deb Willcox, wrote to the mental health executive and emergency department managers at the Royal Prince Alfred hospital on Monday to outline an “escalation pathway for Psychiatry matters”, limiting psychiatrists being called between 10pm and 8am to assess patients in a memo seen by Guardian Australia.
Under normal circumstances, when a mentally ill person attends a major hospital after hours or on weekends, they are seen by a psychiatry registrar, who is a trainee doctor. The registrar can contact the on-call psychiatrist to discuss if the patient needs to be admitted.
To reduce the burden on the limited number of psychiatrists left in the system, the memo states that the emergency department is required to contact the executive on-call “to ensure other options are exhausted prior to contacting the psychiatry registrar on-call”. The executive on-call is usually not a doctor.
The note outlines that the executive will be required to sign off on contacting the psychiatry registrar in one of two urgent situations: for involuntary patients who are “intoxicated or sedated, who then improve” which would enable them to be discharged from the emergency department; or those “already on an admission trajectory and there is a bed available”.
A psychiatrist speaking on the condition of anonymity told Guardian Australia they held concerns about the arrangement,particularly given it appears “people who often have no experience in clinical medicine will now be making health-related decisions. And people who present outside normal working hours mostly do so because it is urgent.”
A Sydney Local Health District spokesperson said “plans are in place” to ensure best quality care. “The executive on call will act as an escalation point of contact for emergency department staff and will not be involved in clinical decisions about any patient,” they said.
The Western Sydney local health district chief executive, Graeme Loy, wrote to colleagues on Tuesday in an “executive broadcast” seen by Guardian Australia detailing “changes which will take effect in a phased approach from this week”, including the number of beds in Westmead hospital’s medical psychiatry and older person’s mental health unit being temporarily reduced.
The mother and baby unit at Westmead will temporarily close, but there will be an offset of beds in the women’s health ward. “Proposed additional beds will be secured through a private provider contract for this specialist model,” Loy wrote.
Guardian Australia last week revealed contracts with the private sector were being considered, despite concerns from experts about the appropriateness for high-risk patients.
Loy also states “we have identified opportunities with private providers to replace the temporary reductions in capacity at Cumberland hospital” where the Riverview mood disorder unit, the Willow Cottage rehabilitation unit and the Cumberland Assessment Centre have all temporarily closed.
Loy’s letter states other wards at Westmead hospital will operate under a “psychiatry consultant liaison model”. This means patients will be managed under other teams and psychiatrists will be called for consultation but not be responsible for their care. To offset psychiatry bed closures at Westmead hospital, additional beds will be made available in the endocrinology unit for eating disorder patients as well as additional beds for psychiatric patients in the neurology unit.
A psychiatry consultant liaison model will also be used at Blacktown hospital under the governance of the drug and alcohol unit, Loy’s letter states.
Guardian Australia understands there are 20 beds closed at the Riverview unit, 20 at the Willow Cottage, and eight at the mother and baby unit at Westmead. However, the government has emphasised that there is a transfer of care and that numbers of beds closing are “fluid” and cannot be confirmed as beds open and close daily.
An email to all staff at Northern NSW local health district states that the mass resignation of psychiatrists “mean we will have to temporarily extend the changes to mental health inpatient services, initially introduced for the Christmas and New Year period”.
The email seen by Guardian Australia states they will maintain a reduction of 24 beds from 18 at Tallowwood adult acute mental health unit at Lismore, and a reduction of 25 to 23 beds at Kurrajong adult acute mental health unit.
Guardian Australia has also seen a draft for a “crisis plan” at St George hospital which states: “This plan is a temporary, worst case scenario, non-sustainable, guide for continuing services during a period of severe acute psychiatrist shortages.”
It acknowledges “face-to-face reviews by psychiatrists will be less frequent” in the mental health unit. The draft said they intend to “re-deploy 6 PECC [psychiatric emergency care centre] beds” which Guardian Australia understands means the closure of beds for some of the most at-risk suicidal patients.
For mental health patients in the emergency department, the document states there will be “no governance” from a psychiatrist, except in “genuine cases where the [emergency doctor] feels expert advice from a psychiatrist is needed”.
At Jackson’s press conference on Thursday, when asked about bed closures, she said: “At the moment there have been no ward closures. I’m advised that statewide, there’s been a reduction of eight beds [at the Prince of Wales hospital].”
NSW Health deputy secretary, Matthew Daly, said: “Every hospital will be doing similar reconfigurations.”
Asked about further bed closures in Western Sydney, Daly said there had been “no net bed reduction in terms of ED accessible beds.”
Additional reporting by Rafqa Touma.
