Psychoanalysing the Health System
Auspsyc list. 14 December 2003
Message
3295
Lay the Australian Health System on your couch, cast
a Kleinian eye on her, and what do you see, Doctor?
I reckon there is good evidence for a serious case of the Schizoid Position,[1] don’t you? The system as a whole divided into two parts, one for the poor, and the other for the richer. The public hospitals and publicly funded community mental health services, like the NHS in the UK, are a shemozzle. Frequent reports and scandals document their dysfunction and chronic failure. [2], [3]. Meanwhile, on the private side of the ‘bipartheid’ system, there are scandalous examples of extravagance and waste. I have previously criticized psychiatrists I dubbed the ‘IDD squad’ who devote their time to treating ‘Iatrogenic Dependency Disorder’, and enjoy a fat public subsidy whilst seeing one or two new patients a year.[4] Make an interpretation of a patient in the Schizoid Position, and you will quickly see why it is sometimes called the Paranoid-Schizoid Position. Let’s examine the public side of the equation. First, some principles. 1) A ‘bipartheid’ system with one hospital service for the rich and another for the poor is intrinsically objectionable. 2) A system that resolves this split at the expense of freedom of choice is also intrinsically objectionable. 3) Ivan Illich’s distinction between education and schools, transport and cars, health and hospitals, etc, is important. Publicly funded health does not have to mean publicly funded hospitals. The Australian Medicare card is a good example of an alternative. 4) Karl Popper’s insistence on the importance of falsifiablity in science, and destructibility of organisations, is also important. Unless it is possible for dysfunctional organisations to fail and die, dysfunctional organisations will persist. Hence the importance of democratic processes to eliminate governments that have lost the trust of their populations, and market, or other mechanisms, to eliminate organisations that don’t work. 5) The tragedy of socialism as an ideology is that it failed to adequately incorporate principles of freedom and destructibility into its designs. Its failures cannot be removed without huge risk of suffering and chaos. Gorbachev managed to do it for the Soviet Union. The process is occurring in China, and its success or failure will doubtless dominate the global political landscape for the next several decades. 6) We urgently need a Gorbachev to help wind up the failed experiments of the NHS and the Australian Public Health system. The difficulties of achieving this are not trivial. :-) 7) Foremost among them will be the tendency of many people to believe that small changes can be made to fix the problems. One more manager here. An extra committee or enquiry there. Better management here. More money there. Some shift in the tug-o-war between oral subordinates “We need more blah-de-blah”, and anal superiors “We can’t afford blah-de-blah”. 8) When the problems are fundamental and structural, the ‘fixers’ and ‘fiddlers’ are the main obstacle to genuine reform. The unreconstructed neo-Stalinists will be vocal, but relatively easy to defeat. Focussing on the Mental Health System, there are several symptoms of the Schizoid Split. a. Widely disparate levels of professional gearing between public and private sectors. In the public sector, one psychiatrist might carry responsibility for 10 or more allied health professionals, such as psychologists, social workers, psychiatric nurses, etc. [5] In the private sector, there is effectively no clinical gearing, with there being a one-to-one ratio between psychiatrist and patient. 10:1 is too flat a triangle for effective supervision. 1:1 is extravagant. b. Selective elimination of project leaders occurs in the public sector. Sociologists describe two types of leader: project leaders and process leaders. The former is goal directed and visionary. Dad says to the family: ‘C’mon, we’re off to the beach!’ Process leaders ensure the group relationships are functional. Mum checks there is a cut lunch and all the kids have togs and towel. When an organization has both types, it tends to work well, being both cohesive and effective. Think of the Hawke-Keating government. Bob Hawke believed in consensus. Paul Keating believed in moving into Asia, and sorting out indigenous problems. When an organization has project but not process leadership, the troops get fractious and undermine the leader. The word ‘arrogant’ gets used a lot. Think Keating on his own. When an organization has process leadership alone, there are lots of caring meetings, but little success in meeting extroverted goals. Talk of ‘lack of policy’ or ‘ticker’ is heard. Think Beasley. Psychiatry is the best profession to provide project leadership in the public mental health system. Yet psychiatrists who attempt to fill that role have to cope with a multitude of forces that militate against their contribution being accepted. Disparity of income generates envy. Doctor bashing has always been a popular sport among nurses. If the doctor is male, add feminism and stir. Outside the capital cities, large numbers of psychiatrists are immigrants. Toss in a bit of xenophobia. The word ‘arrogant’ starts to appear. So what happens to the psychiatrist project leader whose leadership is challenged? An easy and more lucrative alternative exists down the road in a private practice. Natural selection in action. He or she resigns, and leaves behind an oxymoronic ‘multi-disciplinary team’ with endless meetings and process discussions, but limited effect on the population whose mental health needs are supposed to be served. Staff needs may be met. Patient needs are not. c. Not enough money is spent on mental health. Of that I am sure we can all agree. But why? I think a major reason is that mental health is a Black Hole. It could consume an infinite amount of money, and much of it would have negligible effect on measurable indicators of mental health. Sensible politicians realise that mental health is a bucket with a huge leak in it. Expanding the mental health budget is a plan that evokes the cry in the corridors of power: ‘Don’t go there!’ And what are the leaks? There are two in particular, one actual, and the other potential. The first is the money spent on highly trained psychiatrists who engage in extravagant modes of service delivery such as seeing patients for 50 minutes, 3-5 days a week, for an average of 6.6 years at a time each.[6] This group’s prominence represents a major political handicap to any attempt by psychiatrists to reform the health system in the direction of a more rational egalitarian system. The second hole in the mental health bucket is the possibility of allied health professionals, such as psychologists and social workers, getting access to Medicare funding. Whilst this would be a rational way of increasing the pool of mental health workers with less expense than psychiatrists, it still carries a risk of a major budget blow-out, especially if direct access (without medical referral), or unlimited numbers of sessions were permitted. Some moves in this direction have recently been tentatively made, with the new ability of Sphere Project trained GPs being able to refer to publicly funded psychologists and social workers in the ‘Better outcomes in mental health care initiative.’[7] Any attempt to reform the Mental Health Service will need to attempt to eliminate the leaks in the bucket, and engage allied health professionals to gear psychiatric expertise without causing a major budget blow-out. So what do I propose? Firstly, that we recognize that the publicly owned and staffed model of health delivery has been a failure. It’s broken. All the Royal Commissions and all the peoples’ taxes won’t put it together again. It belongs to a failed ideology (State Socialism) and should be gently abandoned. All hospitals and community health facilities should be privatised. Secondly, we should celebrate the aspect of the Medicare system that has worked remarkably well, in spite of abuse by some doctors and patients. The Medicare card, as distinct from the parts of Medicare that concern federal funding of State Health services, works well to channel funding and market power through patients into the free medical market. The Medicare card should be extended to cover a proportion of hospital costs. Thirdly, steps should be taken to encourage the development of efficient well-led teams of different professionals working together to meet the important mental health needs of the population. A good working size for such teams would be between 5 – 10 members. They must be subject to financial discipline, and their efforts should maximally be directed towards the middle part of the triage, people who will benefit if treated, but won’t if not. I suggest that psychiatrists be permitted to charge Medicare for services carried out by up to 5 allied health professionals they employ. I envision a group practice with, say, 2 psychiatrists, 2 psychologists, 2 social workers, 4 nurses, and some secretaries. Item numbers would be created for services such as: ’30 - 45 minutes with a psychologist under the supervision of a psychiatrist, where the patient has been referred by a medical practitioner.’ Special item numbers might be defined by the patient’s characteristics, eg ‘Home visit by a psychiatric nurse under the supervision of a psychiatrist, where the patient has ever been regulated under the Mental Health Act.’ Fourthly, we should support efforts to mend holes in the health budget bucket. A purely oral attitude to tax-payers money is immature and leads to our credibility being eroded. Steps to promote actual consulting by psychiatrists being remunerated as ‘Consultant Psychiatrist’ should be supported. And do I imagine any difficulties with these proposals? Funnily enough, yes. I modestly suspect that it would take more than a rave on the Auspsyc email list to produce a ‘Eureka moment’ that would ripple through the body politic and emerge as radical changes. Pity, though! The system I propose would have some snags. I think none are insurmountable. EDUCATION. At present, the overwhelming amount of education and training is done in public health institutions. It is possible to do it in private hospitals and consulting rooms, although there is an intrinsic conflict of interest if a patient is paying to have their needs looked after, and the time and concentration of the teacher is being devoted to students. If the students were to pay for the privilege of being taught, the balance of interests would be more manageable. Patients would understand that student’s fees were contributing to keeping their own costs down. I don’t really want to elaborate on this too much now. But much of the case against publicly funded health institutions can also be made about publicly funded education institutions. In the long run I favour the privatization of all schools and universities, with some sort of Educare card being used by parents to pay some or all of the school fees. Tertiary education could be funded by the government providing scholarships for a certain numbers of different degrees. Students would compete for these scholarships, which would be used to pay their fees at university, teaching hospital, or in specialists' private rooms. In other words, the problems of funding education and training would only really exist if one system was reformed, but not the other. Best to reform both. EQUALITY The second general problem which dogs all attempts to reform social services is the issue of social equality. For too long it has been dealt with as a second order issue. Socialist approaches have been tried, but consistently failed. Subsidies have been used. Unfortunately they have a major effect on the rate of consumption of the subsidized good or service, but a relatively trivial and token effect on equality. I believe that governments should address equality as a direct issue, and specify targets of wealth gradient across society. Policies aimed at achieving them should be pursued by things such as death duties, negative taxation, tied grants, marketable licences etc, rather than the issue complicate all attempts to reform social services rationally. I would welcome discussion of these ideas. David Straton REFERENCES [1] An Introduction to the Psychoanalytic Play Technique
and a Psychoanalytic View of Early Development. Chris Mawson, Psychoanalyst
Member of the British Psychoanalytical Society. [2] NHS Report. Managing not to Manage – Management
in the NHS, The Centre for Policy Studies. 57 Tufton Street, London SW1P
3QL. UK. [3] Exposing a tragic mess. By Paola Totaro and Ruth
Pollard Sydney Morning Herald. December 13, 2003. Health Care Complaints Commission Annual Report 2001/2002 [4] Iatrogenic Dependency Disorder. D. Straton [5] Mental Health Services in Australia 1999-00 Specialised mental health care labour force and establishments [6]Doidge N, Simon B, Brauer L, Grant DC, et al. Psychoanalytic
patients in the US, Canada and Australia: DSM-III-R Disorders, indications,
previous treatment, medications and length of treatment. (2002) JAPA,
50:575-614 [7]Requirements for General Practitioner Referral of
Patients for Focussed Psychological Strategies. |