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RANZC Psychiatrists Policy Forum - Christchurch 11 May 2004

RANZC Psychiatrists Policy Forum
Christchurch 11 May 2004

"The External Crystal Ball"

As Health and Disability Commissioner, I do not often get to stare into crystal balls.  Much of my time is spent reviewing and investigating complaints that a patient did not receive care or information of an appropriate standard.  As an investigator and decision-maker, my focus is necessarily retrospective.  I stare into the opaque haze of recollections (of patient, family and carers) and clinical facts (as far as they can be established from clinical records and other information) and form a retrospective view of what happened, and with the help of independent expert advice determine whether care was up to standard.  Mine is necessarily a retrospective view, though I try very hard to guard against the risk of hindsight bias (a particular problem in dissecting mental health tragedies) and to take proper account of resource and other constraints that impacted in the quality of care.

So today's crystal ball gazing is a pleasant change.  And it is not entirely foreign to my work as Commissioner.

In two ways, we seek to be forward thinking in our work at HDC: first, in crafting recommendations for mental health services that we review, which are intended to improve care for future consumers; and secondly, in our educational and advocacy work, seeking to better "promote and protect" the rights of customers.

I congratulate the College on the initiative of establishing a Policy Clinic and holding this inaugural policy forum.  I am familiar with the Policy Unit of the College of Physicians and I have read your former President, Jonathan Phillips', call for this College to take a similar initiative.  In his 2001 Presidential address, Jonathan argued that the College must have "a clear and powerful voice … in the health arena".

So, what would my trifecta be?  What do I see as three key policy issues for the college?

1.  The Media

How to respond in public to crises of confidence about mental health care.

The media is not going to stop reporting mental health tragedies - patient suicides and harm to others caused by mental health patients.  So a key policy focus must be:

First, better education of the media and key stakeholders (including MPs, Coroners and Commissioners) of the nature of mental illness, the difficulties in predicting dangerous behaviour, and the low and declining risk of violence posed by mental health patients − Sandy Simpson's valuable research.  This is not a new issue, but it remains a vital one.

Secondly, preparedness and responsiveness when a story breaks in the media.  I salute the leadership shown in this country by Janice Wilson, Wayne Miles, Margaret Honeyman and Allen Fraser wearing their College hats in the past.  This College must always be ready to front the media − not just by written statements, but by a face on TV and a voice on the radio.  The hard issues must be fronted and the perspective has to be a broad and strategic one - the College cannot simply offer an apology for its members and extend sympathies for the individual psychiatrist caught in the media spotlight.  In fact it will often be possible to reflect the complexity of the clinical situation, but at the same time strongly support the need for better mental health services and for learning from the lessons of mental health tragedies and subsequent inquiries.

2.  Quality of Care

The crystal ball tells us that the prevalence of mental illness in our population and the burden on our communities is growing.  You see that on a daily basis in your work (and I see some evidence in my daily complaints mailbag).  And we know that overall health expenditure is increasing in our countries, and that governments are finding it harder and harder to contain public expenditure on health care and are frustrated by the lack of evidence of real gains for additional investment.  The sobering recent figures from the Mental Health Commission - reporting stalled progress in meeting access targets - and Minister Annette King's (and Treasurer Michael Cullen's) concern at where all the extra mental health funding has gone, highlight this issue.

Inevitably, there will be increased pressure from funders for evidence of the effectiveness of mental health interventions.  This is not simply about rationing care.  Two decades of studies from RAND and the work of the Institute of Medicine and the Agency for Healthcare Research & Quality in the United States tell us that we have barely begun to tackle the "quality chasm" in health care.  The issue of patient safety - the harm to patients from inappropriate interventions or failure to provide necessary care - is the most visible part of the quality problem.  But underuse of effective interventions and overuse of ineffective interventions are also key problems.  Good quality care is essential because (1) patients want it; (2) your professional ethics demand it; and (3) it is the best use of scarce health dollars.

So the message for the College's Policy Unit is, what more can you do to keep quality of care at the top of our agenda - whether by developing guidelines, promoting outcomes research, or supporting peer review and quality assurance activities to constantly review what works.

3.  Patient Advocacy

Mental health is noisy − consumer alliances, carer groups, Mental Health Commissioners, academics, other mental health professionals, general practitioners, epidemiologists and policy-makers from across the spectrum of health, housing and welfare agencies all crowd upon the stage.  All compete for the attention of government and the media.  Yet the individual psychiatrist remains uniquely placed to speak for mental health consumers.  In your daily work, you see the suffering of your patients and the possibility of improved lives and recovery.  You can and must continue to speak out about the need for more and better services for your patients.  Patients sleeping on mattresses on the floor in hospital and kept in police cells overnight is an indictment on our society.  The physical health of many mental health consumers is shameful.  The avoidable suffering of patients (and their families) denied access to care is tragic.  Policy agendas will come and go, and issues such as workforce development and anti-discrimination will remain important, but this College should never underestimate the power of the human story.

 

 

Ron Paterson Health and Disability Commissioner