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'Take a long, hard look': Senior doctors back whistleblower Mendoza

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Psychiatric and emergency doctors have backed the resignation parting spray of former Central Adelaide Local Health Network mental health director John Mendoza, saying he was voicing concerns “many people thought privately”.

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Mental health crisis

In a remarkably frank interview with InDaily yesterday, Professor John Mendoza unleashed on SA Health and the State Government, explaining why he could no longer stay in his position.

“I’m not going to waste my time in a sense pretending I’m part of some reform effort when it’s not there,” he told InDaily.

“I think it’s time this was called out. I think it’s time there is some accountability on the department and the chief executive and the minister.”

Senior figures in the mental health system in South Australia today backed many of Mendoza’s criticisms.

Dr Paul Furst, the SA branch chairperson of The Royal Australian and New Zealand College of Psychiatrists, said Mendoza was correct that not enough had been done to address the crisis in the mental health system.

“I think John has said what many people privately might have thought – said it out loud in public, which is good,” Furst told InDaily.

“I’m concerned the Government and SA Health haven’t done enough to address the mental health crisis.

“I think really this echoes the things we have been saying for some time – there is a crisis in SA Health, it is building and it will get worse.

“We’re not convinced that the department, the government, are fully committed to doing something about it – something meaningful that isn’t going to be little projects here and there. It really has to be deep commitment and major investment.

“John’s statements about the need for significant investment of resources are welcomed.”

Premier Steven Marshall said today that he “agreed” with Mendoza that the Government needed to do more to improve the mental health system.

“I think that we have very significantly increased our focus on mental health since coming to Government, but I think Professor Mendoza is right – much more needs to be done,” he said.

However, he said that when the Liberals came to Government there wasn’t a mental health strategy for the state – an omission that had since been remedied.

“We’ve fixed the design problems that existed at the Royal Adelaide Hospital – the primary area within CALHN for taking those acute patients. Don’t forget, when we came to Government they couldn’t go into the new Royal Adelaide Hospital because of those design flaws.”

He also pointed to an increase in the number of mental health beds and the recent opening of a new Urgent Mental Health Care Centre in the city.

“I think we’ve made good progress – I think there is much more work to be done.”

Marshall added that the COVID-19 pandemic had increased pressure on the mental health system and the Government was trying to understand the reasons for a “delayed” presentation of patients to the system.

In a statement, Health Minister Stephen Wade siad that mental health services were “a priority for the Marshall Liberal Government – while we have made significant progress in addressing it, there is still more work to be done”.

“We developed and are implementing a comprehensive Mental Health Strategic Plan,” he said.

“The release of that Plan marked the end of a seven year hiatus where Labor didn’t have a mental health plan in place. The plan will continue to drive system-wide reform.

“The Marshall Liberal Government has provided record funding for mental health, including $20.4 million over two years for mental health support in response to the COVID-19 pandemic.  

“Recent initiatives such as the establishment of the Urgent Mental Health Care Centre, and the mental health co-responder program which embeds mental health clinicians in ambulances, are already seeing positive results.

“The opening of the brand new Mallee Ward at the Women’s and Children’s Hospital is also supporting children and young people experiencing mental distress and crisis with the highest level of care.”

Mendoza told InDaily that while his decision to quit his three-year contract early was partly for family reasons: “If I felt I could continue to make a difference at a system level, if we could build on the work we’ve done here (in CALHN), if we could solve these systemic problems which South Australia has had for decades, I would stick at it. But there’s little prospect of that.

“The department is incapable of making a basic decision that enables the system to operate effectively.”

He said from February 2019 to February 2021 there had been a nearly 40 per cent increase in mental health presentations to the Royal Adelaide Hospital, but “no extra resources” from the State Government.

“When you have a month where you have a 40 per cent increase… in the number of presentations and you get no assistance, none from the department, no extra resources, no extra load levelling across the system, you cannot keep pushing your own staff to this breaking point,” he said.

“That mental health is a priority as stated by the minister, as stated by the chief executive of SA Health, is simply a furphy, to put a polite word on it.

“They’ve got to get their act together, seriously.

“The department couldn’t organise a chook raffle.”

He said there had been inadequate leadership and “no such commitment” from the State Government to reform the struggling mental health system.

When asked whether he agreed with that, Furst told InDaily: “I think the commitment has been really lukewarm. So I think I agree with him in the sentiment.”

There’s a lot of talk and talk about small things but there hasn’t really been a sign that they’re deeply committed to doing a proper investment.

Furst said “the reality is there needs to be significant investment across the whole system”.

“There needs to be a significant investment in rehabilitation and recovery-type beds,” he said.

“There needs to be more options for social housing so that you can place people with a mental illness in an environment where they can actually be managed in the community.”

Mendoza accused SA Health bureaucrats of ignoring his warnings and predictions that there was going to be a significant increase in mental health presentations to hospital emergency departments because of COVID.

Furst agreed the 40 per cent increase in ED mental health presentations at the Royal Adelaide highlighted by Mendoza “was quite predictable” and he reiterated that not enough had been done to prepare for that.

“We knew there was going to be a surge in mental health patients driven by COVID,” he said.

“When the back-end of the pipeline is blocked, when you can’t get people out of your acute wards into a lower acuity ward where they can have further rehab and recover, if you can’t get them into supported social housing then you can’t cope with a surge in demand because you’re bed-blocked.

So all your acute demand, there’s nowhere for it to go. It all has to be managed in the emergency department – that’s where bad things happen.

“It’s when people can’t get a service and they’re sent home and that’s the danger. Whereas if they’re able to be admitted and people move through the system you can actually cope with a surge in demand much better.

“So we really need to invest in the back-end.”

Dr Mark Morphett, the SA faculty chairperson of the Australasian College for Emergency Medicine, said “we would echo some of those concerns” that John Mendoza raised.

“The Minister is ultimately responsible for… all the elements of healthcare in this state and as part of his portfolio he would do really well to take a long hard look at how we’re going in a number of areas that we’ve seen play out very publicly as areas of stress” he said.

“Clearly you can sense the frustration there in what John said and in his comments.

“We’ve had concerns raised by a number of clinicians and colleges over some time.

“Now you’ve got a very senior mental health figure in this country who’s made it very clear there are things we need to work on.”

Morphett said there had been “increases in demand on services everywhere” and “a lack of appropriate investment in core mental health areas in this state”.

He said he hoped Mendoza’s criticisms “provided a time to pause and reflect on what he said and an impetus to promote some change, to look at some funding and to look at some capacity”.

“We’ve all had concerns for a while that it’s the least sick that are being discharged rather than those that are well,” he said.

“There needs to be a combination of acute bed capacity and step-down bed capacity and forensic bed capacity.

“It’s not just about acute capacity, it’s about looking after people as they step out and helping them, supporting them back in the community.

“The other thing I think we desperately need is investment in that intersection between drug and alcohol use and mental health.”

Mental Health Coalition of SA executive director Geoff Harris said “what John’s calling out is a long-standing problem in health and mental health”.

“What we need now is some real carry-through,” he said.

“That requires whole of government. The minister can’t do that on his own.

“We just need to do a lot more to really provide the right kinds of services for people to avoid the crisis or to actually manage after the crisis, to get their lives back together.”

Harris said the new Urgent Mental Health Care Centre in the city, for example, was a good response “but in the scale of the kind of demand and the numbers going to ED, we need to really say ‘okay, let’s do more of this’”.

“I guess what John’s saying is there’s some good ideas around but why aren’t we investing more in them,” he said.

“Something like over 50 per cent of people who present to ED (for mental health issues) leave without getting significant treatment.

“We need to invest more in suicide prevention work.

“There’s this underlying problem of a massive level of unmet need that unless we actually invest in that space of community support to help people sort out those problems before and after crisis then the revolving door just keeps happening.”

Opposition health spokesman Chris Picton said “Mendoza’s shock departure shows the Government’s handling of the health crisis is now in complete disarray”.

“This is a real insight into what insiders truly think of Stephen Wade’s leadership,” he said.

“The Health Minister must explain how his mismanagement of the health system became so dire as to lose the confidence of an internationally regarded mental health leader.

“This comes as ramping has doubled and mental health patients are left stuck for up to five days in hospital emergency departments waiting for a bed.”

In a statement to InDaily yesterday responding to Mendoza’s criticisms, Wade said “the Marshall Liberal Government has demonstrated a significant commitment to addressing mental health issues in South Australia”.

“We recently opened Australia’s first adult mental health care centre for people in mental health crisis or distress – the Urgent Mental Health Care Centre (UMHCC),” he said.

“The UMHCC provides high-engagement support in a calm, lounge-room-like space to support people with urgent mental health needs. It offers an alternative to presenting at hospital Emergency Departments for a mental health crisis – it is the first of its kind in Australia.

“We have also established a mental health co-responder program that embeds mental health clinicians in ambulances, with paramedics. The success of this pilot program has seen it extended in the central Adelaide area, and expanded into southern and northern Adelaide networks.

“We have delivered the construction and opening of the co-designed Specialised Advanced Dementia Unit (SADU) and (Australia’s first) Neuro-Behavioural Unit (NBU) at the Repat Health Precinct.”

Wade said that in response to the COVID pandemic, “we provided $20.4m over two years for mental health support and to implement a statewide community wellbeing strategy for COVID-19 response purposes, including the Open Your World Strategy and services such as the COVID-19 Mental Health Support Line”.

“We have provided $2.61 million to support mental health resilience and support following the catastrophic 2019-20 bushfires in the Adelaide Hills, Yorketown and on Kangaroo Island,” he said.

“The opening of the Tarnanthi Unit has seen ten forensic mental health beds added at the Glenside Campus, increasing bed capacity across the system and helping to relieve pressure on metropolitan emergency departments.

“The Borderline Personality Disorder Collaborative, run by the Barossa, Hills and Fleurieu LHN, was opened in 2019 – a $10.1 million hub and spoke service for South Australians living with BPD, and their family carers.

“We have a $20 million commitment to develop South Australia’s rural health workforce, including mental health clinicians and staff.

“A five-bed temporary mental health assessment unit at the Lyell McEwin Hospital has been established while the new mental health unit is also being built.”

A spokesperson for SA Health said “we are committed to improving mental health care across the system”.

“The new $14 million Urgent Mental Health Care Centre provides range of mental health support services and out-of-hospital care, while and the new purpose built Mallee Ward at the Women’s and Children’s Hospital provides the highest level of care to children and young people experiencing mental distress and crisis a mental health treatment space,” the spokesperson said.

“A number of services to improve care in the community have been implemented, including Mental Health CORE, which embeds mental health specialists within SA Ambulance response teams.

“In addition, $15 million has been allocated this year across a range of mental health initiatives and drug and alcohol services in response to the COVID-19 pandemic.”

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