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Leaked SA Health review: Staff shortages, "sub-standard" systems and "fractured relationships"

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A leaked external review of public mental health services in Adelaide’s south has uncovered “sub-standard systems”, staffing shortages and poor planning, amid a climate of anger among staff that has been years in the making.

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InDaily has seen the review of SA Health’s outer south (OS) mental health services at Noarlunga, ordered this year in the wake of continuing unrest among psychiatrists working in the unit.

The review, by health management consultant Lee Gruner of Quality Directions Australia, details frustration among doctors and nurses about the management of the service including concerns about a “lack of a clear and understood strategy, the transparency of decision making, the lack of clear standards for work with appropriate performance measures and varying levels of accountability”.

It paints a picture of a service divided between the different health professionals and its management and where patient care is being affected by poor planning and coordination.

Gruner’s review, dated May 2018, was ordered by SA Health after psychiatrists at Noarlunga expressed “no confidence” in the Southern Adelaide Local Health Network’s clinical director for mental health services.

The review details a “fragmented” service, which has suffered from ongoing staffing problems, including poor planning and patchy staff coverage. It comes as Chief Psychiatrist John Brayley conducts his own review of the SALHN mental health services amid growing concerns about how they are operating.

“The lack of planning for staffing has also resulted in uneven workloads with some days having a full complement of psychiatrists on site and other days virtually no psychiatrists available,” the Gruner review says.

The review finds psychiatrists have felt “devalued and disrespected”, “aggrieved and angry”, with their grievances stemming from a decision “some years” ago to replace a site-specific clinical director with an overarching manager based at Flinders Medical Centre.

Their issues were exacerbated by communication problems and a merry-go-round of leadership changes in SALHN and mental health management more generally in SA Health.

The review also contains assertions about the negative effects of broader changes to the health system, including Noarlunga being one of the first sites to introduce electronic records and the closure of the Repat hospital.

“Planning has been poor for changing needs, with the move of beds from the Repatriation Hospital an example of where planning has been suboptimal.”

While the Noarlunga mental health service moved to electronic records, Flinders Medical Centre was still using paper, meaning the “shared after-hours roster between the two sites disintegrated”.

The review raises serious questions about the quality of care being provided to patients at Noarlunga.

“The OS psychiatrists have experienced ongoing problems with staffing which has impacted on trying to run an efficient and effective service at Noarlunga and caused them to work more on call than at FMC and have difficulty covering leave,” the review says.

“In 2017, the lack of staff was particularly acute when one psychiatrist was on maternity leave, another needed special family leave and another on sick leave. According to the OS psychiatric team, repeated requests for assistance were ignored and one of the registrars indicated that he took on a large workload, which was triple what was expected and outside his scope of practice for a period of four months.”

The staff numbers have “for some time been at suboptimal levels and this has compounded the fragmentation problems”. While this has been “recently addressed”, “there is still an issue with many psychiatrists being part-time and some on very small fractional appointments”.

Chief Psychiatrist John Brayley is reviewing mental health services in SALHN.

While some areas were well-staffed, “on the other hand, there was no regular psychiatrist attached to the Trevor Parry Unit and no trainee in the Community MHS”.

The Trevor Parry Unit, according to the SA Health website, is for “clients who require intensive support to improve daily living skills and self management of illness. Support is offered through a voluntary live-in rehabilitation program for up to 6 months”.

The review says psychiatrists have long-standing concerns about their clinical leadership.

The appointment of the clinical director in 2016 “was a complex process with Health Department and SASMOA involvement and this caused a fractured relationship between the Inner and Outer South (Noarlunga) psychiatrists and the new CD”.

“This has not been forgotten in the Outer South,”  the review says.

Later the review says that the clinical director – unnamed in the report, but understood to be Professor Malcolm Battersby – has been in the position since 2016.

“It appears that the initial appointment may have been for one year and was then rolled over rather than re-advertised,” the report says.

Like the head of unit positions below him, the clinical director “was not provided with training for the role, despite his JPD (job and person description) clearly articulating a high-level degree of necessary leadership and management skills”.

“There have been concerns relating to his leadership style and this has resulted in fractured relationships with OS psychiatrists.”

There are problems within the multidisciplinary teams at Noarlunga, with the review finding “the role of the psychiatrist in the multidisciplinary team is still poorly delineated and poorly implemented”.

Mental health nurses and allied health professionals were concerned about “their inability to access psychiatrists for clinical review meetings, to access psychiatrists at all on some days, to interest some psychiatrists in the clinical review process even if they were in attendance”.

“They expressed concerns that this caused risk to staff, to patients and to the organisation.”

…. change has been based on the mistaken premise that a change in organisation structure will miraculously deliver desired outcomes

The review indicates some degree of change fatigue in the service, with doctors tending to protect themselves by burying themselves in their clinical work and seeking to “block out other aspects of the environment that could interfere with clinical activities”.

While this could lead to a sort of equilibrium in the work environment, this was at “high risk of disturbance if a crisis occurs”.

“The symptoms of this situation were evident in the OS over a period of years and might have been identified with stable senior leadership that had in place adequate performance and workload data, monitoring of clinical engagement and an understanding of the issues around multidisciplinary teams. However, it is not possible for rapidly changing leadership to have the time to develop this understanding, so it took a series of crisis situations for the full pictured to be revealed.”

So far, the review says, “change has been based on the mistaken premise that a change in organisation structure will miraculously deliver desired outcomes by changing behaviour, that just saying clearly and constantly that something should happen will actually make it happen and that if nothing changes that the fault is with the people who have changed their behaviour, not with the suboptimal process of change adopted or with the suboptimal system of governance of the service.”

The review’ recommends a raft of changes to the organisational structure of SALHN mental health services, noting that while the service is small compared to similar services in the eastern states, its medical management structure is “far more complex”.

The 21 recommendations include ensuring that “all substantive clinical leader/manager positions are openly advertised”.

InDaily asked SA Health a series of questions about how it had allowed the relationship breakdown to happen, whether it had accepted the recommendations and how it allowed staffing deficiencies to occur. We also asked about the appointment process for the clinical director.

In response, a spokesperson provided this statement from SALHN:

“We commissioned this report earlier this year in response to issues raised by some psychiatrists.

“We have and continue to work closely with the group, not only on the report’s recommendations but also on the significant reforms in response to a number of state-wide mental health reviews.

“While we are unable to comment on specific HR matters, we make every attempt to resolve matters that may arise between individuals or teams.

“We continue to engage with our mental health teams as we implement important reforms to Community Mental Health services across the south, which includes a new Workforce Model, to ensure we always provide safe and quality care to our patients.”

In September, SA Health was forced to distance itself from an email leaked to InDaily in which a SALHN mental health finance manager congratulated staff on savings made by failing to fill vacancies.

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