December 11, 2024

parliamentary inquiry

A mental health system in crisis

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Recently, I spoke before a parliamentary inquiry into the ‘Equity, accessibility and appropriate delivery of outpatient and community mental health care 
in New South Wales’, on behalf of the NSWNMA.

As a mental health nurse, it was a privilege to be given a voice in what is a very important inquiry. I arrived at the inquiry hoping to shed light on the inequity of access experienced by mental health consumers in the community and outpatient settings. This is something I witness in my everyday working life.

I used this opportunity to speak about burnout for frontline mental health workers, and the support required for nursing staff in this field. I stressed the reality that this is often traumatising work. There was also discussion about the Mental Health Telephone Access Line, which has been privatised in some LHDs. We also examined the opportunities, including financial support, for mental health nurses to further their studies and gain higher grade positions by accessing postgraduate study.

While I was initially nervous about the prospect of speaking before a parliamentary inquiry, I found the overall experience to be not quite 
as intimidating or as unfriendly 
as I expected.

I sincerely hope the panel members listened to my evidence and take action to address the dire state of our mental health system.

Victoria Norris, RN

Long COVID inquiry report calls for national long COVID database

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In response to the challenges faced by patients and healthcare professionals dealing with long COVID and repeated COVID infections, the Australian House of Representatives’ Standing Committee on Health, Aged Care and Sport has handed down a report with nine recommendations, including the establishment of a national long COVID database.

The report is the result of an inquiry which aims to improve Australia’s response to long COVID, a condition that may affect hundreds of thousands of Australians.

Committee Chair, Dr Mike Freelander MP, emphasised the difficulties faced by both patients and healthcare professionals, who are grappling with a lack of information and treatment options for long COVID. Deputy Chair, Mrs Melissa McIntosh MP, noted the mental health impact of long COVID, with many sufferers experiencing isolation, disbelief, anxiety, and depression.

The committee made nine recommendations on the Australian Government’s management of long COVID, including:

  • Establishing a national long COVID and COVID-19 database;
  • Defining long COVID for use in Australia and creating evidence-based living guidelines, co-designed with patients with lived experience;
  • Launching a nationally coordinated research program;
  • Developing a COVID-19 vaccination communication strategy;
  • Increasing access to antiviral treatments for COVID-19;
  • Increasing support for primary healthcare providers;
  • Increasing indoor air quality and ventilation;
  • Increased funding for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) research and patient support; and
  • Considering a comprehensive summit into the COVID-19 pandemic and Australia’s past and current response.

During the inquiry, the committee held four public hearings and received nearly 600 submissions from individuals, organisations, and government bodies. The report and additional information about the committee can be found on its website.

Find the full report and recommendations here

Short-staffed and ‘a culture of fear’ in rural health

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It’s official – health services outside the state’s biggest cities are chronically underfunded and critically short of staff who are ruled by “a culture of fear”.

A NSW parliamentary inquiry has delivered a damning indictment of regional, rural and remote health services and NSW Health.The inquiry found that people outside Sydney, Newcastle and Wollongong face “significantly poorer health outcomes, greater incidence of chronic disease and greater premature deaths” as a result of chronic underfunding and critical staff shortages.

After 15 public hearings and more than 700 submissions, the inquiry’s final report called for a review of funding needs and gaps in services.

“There has been a historic failure by various NSW and Australian governments to attract, support and retain health professionals, especially doctors and nurses in rural, regional and remote areas,” it said.

The inquiry reserved its harshest language for NSW Health’s treatment of staff.

It found there is “a culture of fear operating within NSW Health in relation to employees speaking out and raising concerns and issues about patient safety, staff welfare and inadequate resources.”

It said NSW Health and rural and regional Local Health Districts (LHDs) “lack transparency and accountability” while LHD boards and management show “a lack of communication and genuine consultation” with the communities they supposedly serve.

Inquiry chairman Greg Donnelly, a Labor MP, said staff were “pushed to breaking point” by “unsustainable working hours, poorly coordinated recruitment and retention strategies, inadequate remuneration, lack of resources, threats to physical safety and a culture of fear”.

“On the issue of nurses and midwives, the evidence has shown a disconnect between the reality of the daily challenges faced by them working in rural, regional and remote areas, and NSW Health’s perception of the situation,” Donnelly added.

“In order to expand and develop the workforce, the committee has recommended that NSW Health expedite its review of the nursing and midwifery workforce with a view to urgently increasing nurse and midwifery staffing numbers based on local need across rural, regional and remote NSW.”

The NSW Opposition pledged to act on the inquiry’s recommendations “from day one” if elected in 2023.

However, both Liberal and Labor MPs – accounting for five of the seven committee members – refused to back Greens and Animal Justice Party MPs in calling for mandated nurse-to-patient ratios in regional and rural hospitals.

A spokesman for Labor leader Chris Minns told the Sydney Morning Herald the Opposition would not allow other parties to dictate its election policies and there were no up-to-date costings for increased staffing.

NSW Health Minister Brad Hazzard declined to comment on the report to the Herald.

However, the new Minister for Regional Health Bronnie Taylor said: “We need to be able to look at (workforce issues) in a courageous way and a different way. I certainly don’t want to keep doing the same thing because then you can only expect the same outcomes.”

The NSWNMA called on the government to immediately adopt the committee’s recommendations.

Acting General Secretary Shaye Candish said that while the union welcomed the committee’s recom-mendation for a workforce review, “the urgent implementation of safe staffing ratios is paramount and would help to address these issues.”

Shaye said services would remain at risk until the government adopted safe staffing ratios.

“The NSWNMA will continue to fight for safe shift-by-shift ratios regard-less of which party is in government,” she said.

“The goodwill of nurses and midwives to continue working under-staffed and keep the doors of their rural and regional hospitals open must stop being exploited. It’s not safe for our members; it’s not safe for our communities.

“Nursing and midwifery under-staffing in rural and regional health must change. The poor skills mix issues must change. The lack of enough clinical nurse and midwifery educators to provide supervision and mentoring must change.”

‘On the issue of nurses and midwives, the evidence has shown a disconnect between the reality of the daily challenges faced by them and NSW Health’s perception of the situation.’ – Committee Chairman Greg Donnelly MP

What the RRR inquiry recommended

The parliamentary inquiry made a number of recommendations specific to nursing and midwifery in rural, regional and remote parts of the state. It called on NSW Health to:

Work with the federal government to establish a 10-year plan, to improve health outcomes and address staff shortages including GPs, nurses and midwives, nurse practitioners, mental health nurses, psychologists, psychiatrists, counsellors, social workers, paramedics, allied health practitioners and rural generalists.

Expedite its review of the nursing and midwifery workforce with a view to urgently increasing staffing numbers based on local need.

“Widely implement” the nurse practitioner model of care by funding the recruitment and training of additional NPs, particularly in facilities without 24/7 doctor coverage, or that use virtual medical coverage.

Employ a geriatric nurse in all peer group C hospitals in addition to peer group B hospitals. Where a geriatric nurse is not employed, NSW Health should give staff members annual training in geriatric care.

“Formalise and remunerate” on-call arrangements for nurses and midwives across all rural and regional public health facilities “in accordance with industrial awards”.

Implement professional, financial and career enhancement incentives for nurses and midwives who work in rural and remote locations.

Commit to a model of care “under which virtual care technology is used to supplement, rather than replace, face-to-face services.”

More staff the key to better rural healthcare

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The NSWNMA has given MPs a set of proposals to improve the dire condition of rural and regional healthcare.

A NSWNMA submission to a state parliamentary inquiry into rural and regional healthcare says people outside of Sydney experience health outcomes “substantially poorer” than their Sydney counterparts.

“It is not acceptable that residents in the rest of NSW are provided with an inadequately resourced, substandard system of healthcare while metropolitan Sydney residents enjoy far superior access and outcomes,” the submission says.

The NSWNMA represents 35,000 nurses and midwives employed in Local Health Districts outside Sydney.

The submission says rural and regional members are concerned about poor healthcare, not only from a professional perspective.

Their concerns also flow from “a deep commitment to their community and the reality that they and their families are also reliant on a system they know is under-resourced.”

People living in regional, rural and remote parts of NSW have higher rates of coronary heart disease, stroke, chronic kidney disease, mental ill-health and diabetes, but less access to health services.

Their health services are characterised by poor staffing and skill mix, with nurses and midwives routinely working in isolation.

They have limited access to continuing education, rely on colleagues to provide unpaid on-call support, suffer from inadequate security and transport services, and lack of medical cover.

Changing population numbers cause fluctuations in demand for care in regional, rural and remote health services. These spikes in demand have implications for workload, staffing and patient safety.

Some health services are impacted by transient employment models such as fly-in, fly-out (FIFO) workers in the mining industry.

Similarly, large tourist events, festivals and “grey nomads” all rely on regional, rural and remote healthcare services.

Staffing is the number one issue

Staffing is the number one issue raised by NSWNMA members trying to deliver care in regional, rural and remote parts of NSW, the submission says.

“On a routine shift they are expected to care for more patients than they have capacity to attend to safely, and when emergencies arise, they are woefully unsupported.

“There is also limited access to a casual workforce, which means that it is difficult to replace nurses and midwives who require short-term leave.”

There are significant concerns about inappropriate skill mix, such as large numbers of new graduates working in high-risk areas with insufficient supervision and support, or assistants in nursing (AiNs) being used to replace RNs.

Many rural and remote services can only operate because staff provide on-call coverage in the event of emergencies.

This is almost always unpaid – a “flagrant breach” of Award entitlements, the submission says.

“If a service cannot operate without a reliable on-call roster, then this needs to be formalised and the cost of paying these allowances must be factored into operating costs.”

The submission says a nurse-hours-per-patient-day (NHPPD) staffing formula has been implemented in parts of the health system with good effect.

The submission recommends that NSW Health adopts the NSWNMA 2018 Ratios claim as the minimum nursing numbers required on each shift.

It also recommends that every aged care facility have a minimum of one RN on duty 24/7.

Burden of doctor shortage falls on nurses

The lack of on-site medical coverage puts “a huge burden of responsibility” on NSWNMA members, who experience widespread problems with accessing on-call and tele-health doctors.

The submission acknow-ledges that the virtual model of care is a necessity in circumstances where no medical coverage is available.

However, facilities that rely on virtual medical officer coverage must have the option of calling in an on-call RN who is within 15 minutes of the site, for support, it argues.

The submission notes that, while nurse/health managers are on call, they are often not physically available when needed in the emergency department (ED).

Also, unreliable internet coverage impedes access to clinical information systems, telehealth consultations and the delivery of safe, high-quality health care.

The submission recommends recruitment of more nurse practitioners to work in rural and regional areas, particularly at sites that rely on virtual medical officer coverage.

It says every ED open 24/7, regardless of how it is classified or described, should have at least three nursing staff rostered on duty, two of whom are qualified to attend to an acute emergency presentation.

Access to education difficult

Rural, regional and remote practice requires nurses to manage higher complexity interventions such as chemotherapy and dialysis while maintaining generalist skills, including “low frequency, high-risk clinical capability such as trauma response”, the submission says.

However, nurses find it difficult to access continuing education outside of metropolitan areas.

Most significantly, the degree of understaffing means that staff cannot be relieved to attend professional development opportunities.

Afraid to speak out

The NSWNMA submission to parliament’s rural health inquiry includes statements from members across the state.

These firsthand reports move beyond official statements and statistics by capturing the experiences of the people on the ground.

The submission says it is a fundamental principle of safety and quality in health care that individuals feel empowered to raise concerns about issues that impact on patient safety.

However, the submission says many contributors were worried about potential repercussions including “a punitive response from management” if they raised concerns.

This was despite the NSWNMA’s “assurances that advocacy is included in both the nursing and midwifery codes of conduct”.

For this reason, the submission does not identify individuals.

Mental health starved of funds

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The NSW mental health system can reduce the use of seclusion and restraint only if it gets adequate support and resources.

Underfunding of mental health services over many years has hindered the adoption of measures to ensure optimum safety of patients and staff, says the NSWNMA.

A “tight fiscal strategy is now having an impact on clinical outcomes in mental health services,” says a union submission to the inquiry into the practice of seclusion, restraint and observations (see box).

It says increased use of seclusion and restraint cannot be seen in isolation from underlying problems within the NSW mental health service.

“A lack of leadership by government, along with budget constraints, has led to mental health services being poorly resourced.

“With a developing employment profile of a non-specialised and inexperienced mental health workforce, the level of safety for clients and staff is now at a critical level.”

Rather than addressing the issues, the government appears to have stepped back from its overall responsibilities and allowed local health districts to make decisions driven by strict budget constraints, the submission says.

“This has forced LHDs to resort to stopgap, low-cost measures in order to remain in budget at the cost of evidenced-based best practice that ensures better safety of clients.”

NSWNMA supports minimising seclusion

It says the union supports the work of many agencies to minimise the use of seclusion nationally in line with international trends and “best practice principles for patient centred care, trauma informed care and crisis prevention strategies”.

“Patient and staff safety has always been a priority of the NSWNMA and our members, along with evidence-based clinical practice that provides best care for the individual.

“Seclusion and restraint events hold many risks and appropriate measures to help reduce the number of seclusion and restraint episodes will also reduce the exposure of clients and staff to the associated risks.”

The submission points to research showing a small number of high risk clients are involved in most seclusion episodes.

“This research indicated that 84 per cent of episodes had harm to others as the reason for seclusion and with 20 per cent of patients accounting for 70 per cent of the hours for seclusion.”

The submission argues that seclusion must remain an option and is a necessary last resort to ensure optimum safety.

“The NSWNMA holds the view that the use of seclusion and restraint can be reduced in NSW, but only with the right support and resources in place.”

Loss of experience

The submission calls on the government to prioritise the recruitment and retention of suitably qualified mental health nurses.

Budget constraints have had a detrimental effect on staffing levels and skill mix in mental health units and community mental health services, it says.

The system has failed to acknowledge the competency, education and experience of specialist mental health nurses and ignored their calls for interventions that would improve service delivery.

This has led to them moving to other areas of health care or leaving the profession altogether.

It says managers of mental health services often have no mental health nursing background.

A number of LHDs no longer require mental health experience and qualifications when advertising for staff.

“With this acute decline in a qualified and highly experienced specialist mental health nursing workforce and an aging workforce retiring from the profession, we now have a generation of less experienced junior nurses that have inadequate mentorship and role modelling available for them to learn from.”

 

Report by December

The NSW government has announced it will examine the state’s mental health system via a parliamentary inquiry and a review by an “independent” panel led by chief psychiatrist Murray Wright.

The government says the parliamentary inquiry will look at “all aspects” of mental health care while Dr Wright’s panel will investigate the use of seclusion, restraint and observations.

The review will “consider whether existing legislation, policy, clinical governance and practice standards are consistent with national standards, international best practice and the expectations of patients and the community”.

The panel will visit NSW hospitals, acute mental health units, mental health intensive care units, and declared emergency departments and review past cases of seclusion and restraint.

The public will be able to make submissions and there will be “the opportunity for face-to-face consultations through public workshops”.

The review panel is to release its report by December. Other panel members are:

  • Kevin Huckshorn, CEO, Huckshorn and Associates
  • Karen Lenihan, NSW Principal Official Visitor
  • Julie Mooney, Executive Director of Nursing and Midwifery for Southern NSW LHD
  • Robyn Shields, Deputy Commissioner at the NSW Mental Health Commission
  • Jackie Crowe, Deputy Commissioner of the Australian Mental Health Commission.

More information

The NSWNMA submission on seclusion and observation is available online:

http://www.health.nsw.gov.au/patients/mentalhealth/Pages/default.aspx

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