Abstract
The RANZCP, in its role as a vehicle of influence and change within the psychiatric profession specifically and the mental health system generally, has recently and publicly recognised the implications of health system reform in Australia and New Zealand. In its strategic planning process, it has identified training and development of the fellowship as a critical component of preparing psychiatrists for their changing role in the new health environment [1]. The College has instigated a review (Review of Education and Training. 26 February 1999), with the objective of enabling psychiatrists to gain the skills, knowledge and attitudes which will equip them to work competently in a variety of emergent systems of delivery of mental health service.
One particular subset of this education review includes the Strategic Leadership and Management Skills Development in Psychiatry Project. The Project has the objective of creating an agenda for the discussion of leadership and management issues for psychiatrists in Australia and New Zealand. To identify processes to assist the acquisition of appropriate attitudes, skills and knowledge in leadership and management that enable psychiatrists to obtain the appropriate specialist skills and knowledge to work in area of management of their choice.
This paper discusses progress to date in thinking about leadership and management issues for psychiatrists. The ultimate goal of all such developments is improvement in patient care, not just at the individual level, but at the system level for population groups.
POLITICAL AND MACRO ENVIRONMENT
The issues of mental health reform within which potential changes to psychiatrists’ roles are occurring are articulated in the Second National Mental Health Plan for Australia [2] and within the founding documents that outline New Zealand's mental health policy, Looking Forward: The National Mental Health Strategy 1994 and Moving Forward: The National Mental Health Plan 1997. These documents describe the necessary structural reform of mental health services to achieve improved quality and effectiveness of service delivery. The key elements include; a reduced reliance on stand alone psychiatric hospitals; expanded delivery of community based care; mainstreaming of mental health services with other components of health care, and greater accountability for the mental health of the population including attention to prevention and early intervention wherever possible. There is also reinforcement of the need for improved consumer and carer participation in decision making, and there is strong advocacy for the development of partnerships in service reform and delivery.
The achievement of these goals requires that greater attention be paid to the collection and analysis of mental health information, the development of data systems, and to monitoring mechanisms. The comprehensive nature of the system of mental health service reform that is being described has been likened to an internal market comprising funders of services, providers of services and purchasers/consumers/ users of services linked together by networks of actual and quasi contracting processes [4]. Concepts such as purchaser/provider splitting, and shifting focus from inputs to outputs to outcomes are inherent in such market terminology. Such an analogy highlights the skills, which will be required to lead the changes. Both the Australian Plan and the New Zealand Blueprint emphasise the pivotal themes of education, training and development to ensure an appropriately skilled workforce to achieve these reforms.
Structural changes to service delivery, partnerships in change, and a population health rather than a mainly clinical focus, will have ramifications for health professionals including psychiatrists. We will require a different set of skills, competencies and knowledge from our primary clinical base.
IMPLICATIONS FOR PSYCHIATRISTS
Organisationally skilled clinicians
In order for psychiatrists as a professional group to be effective adapters to such change and to remain resilient in the context of reform, new approaches to training, education and continuing professional development for functioning in the new system must be considered. First, this must be recognised as a need, and second, the need must be addressed in a structured and systematic way. Some of the required skills and competencies for an efficient and effective role in this new system will include; multi-disciplinary team leadership and the ability to be effective in consultation, co-ordination and liaison with clients, consumers and carers, General Practitioners, primary health care workers, the non government sector, and with other health care agencies/services. We argue that this is a core set of skills that all psychiatrists will need in order to work as a clinician in complex organisations, provide clinical and population health input to strategic planning and formulation, and contribute to systems-level analysis, and to change management.
Clinician Managers
At another level, the increasing complexity of the mental health system has other concomitants. These are the creation of new positions at management levels, and a perception (possibly well founded) that an increasing proportion of mental health human resources being directed towards executive functions. These new positions and functions involve managing resources, systems and organisational complexity, strategic planning for populations and leading change. Additional skills include competency in building networks with consumers and other stakeholders and developing regional coalitions of provider groups. For some psychiatrists it will be essential to acquire ‘specialist management skills.’
For those who choose to make this transition from predominantly clinical positions to positions with more prominent management responsibilities, adequate preparation becomes imperative. In this era of transparent accountability, failure to address the unique and different needs of this group of psychiatrist managers and executives amounts to professional negligence or denial of change.
CLINICIANS’ SUSPICIONS OF MANAGEMENT
There is a background, however, of psychiatrists’ mistrust of management and administration.
‘BAD’ MANAGEMENT IS EQUATED WITH MANAGERIALISM: AN EXCUSE TO ADOPT AN ANTI-MANAGEMENT STANCE
The steering committee for the RANZCP leadership and management project engaged in animated discussions about this issue and several scenarios were generated as examples of common experiences, which feed such mistrust (see Box 1).
(The scenarios outlined are an amalgam of real experiences, modified to maintain anonymity/privacy.)
BOX 1
Scenario: Loss of Registrars’ Interview Room Psychiatry registrars in a major teaching hospital emergency department were allocated a new room for interviewing patients. This room was described as being the size of a cupboard and was located in an isolated part of the building. The psychiatrists and registrars expressed concern about the safety risks of this room, as well as its unsuitability for adequate clinical assessment. The room allocation was interpreted as another example of the lack of understanding and respect for medical staff and mental health in particular, thus relations between psychiatrists and the management of the hospital deteriorated further.
Scenario: We no longer have a Doctors’ Room During an overnight change within an inpatient ward environment, the ‘doctors’ room’, which had previously been used as an informal meeting room by psychiatrists and registrars, was re-allocated for the use of the Nursing Unit Manager. The room had been used previously for a variety of purposes including supervision and mentoring, offering informal peer supervision and provision of collegial support in the exchange of ideas and clinical experience. Whilst it was recognised that there was a need for accommodation for the Nurse Unit Manager, psychiatrists were unable to convey their view that the room served a symbolic function as a venue for transmission of professional culture. The event was interpreted as a situation where doctors’ and nurses’ needs were being weighed against each other and relations between these two groups deteriorated.
Scenario: Resource Reallocation Decision
A traditional community mental health team had resources moved from case management to a preventive intervention service with youth. Psychiatrists felt that their views had not been adequately weighted and that management was undertaking a trendy but not particularly effective development. They believed that the solution lay with changing back to a psychiatrist-lead service where such decisions would not have occurred.
ANACHRONISTIC PARADIGMS STILL EXIST: MANAGEMENT IS ABOUT BAD THINGS BEING DONE TO PASSIVE RECIPIENTS. THESE PARADIGMS DO NOT SERVE PSYCHIATRISTS WELL
There are four key themes that can be drawn from these scenarios. These are:
failure to negotiate;
lack of a comprehensive understanding of the core business of mental health and it's particular occupational health and safety implications;
lack of adequate human resource management processes; and
failure to develop alliances and networks for change.
These all represent failures of good management and are impediments to good quality clinical care. It is unfortunate, however, that they are interpreted as specifically antipsychiatrist, or economic rationalism, or managed care or pure managerialism.
Thus poor management provides the justification for some psychiatrists to adopt an anti-management stance. Such a stance must be challenged if psychiatrists are to participate effectively in every level of leadership and management.
CLINICIANS CAN INFLUENCE MANAGEMENT APPROACHES
Management is not ‘managed-care’ or ‘economic rationalism’ and it is more than taking a clinical leadership role, or personal and professional responsibility for clinical processes and outcomes. Clinical expertise and practice must inform effective and efficient management. Failure to recognise it's relational and contextual aspects, and merely seeing management as wielding power or control or occupying a certain position, will lead to a failure of effectiveness [5]. For this to occur, clinician psychiatrists need to be aware of management language and perspectives, and psychiatrists in management positions need to have well-developed skills in formal management and leadership. It should be recognised that management is a discrete body of knowledge and skills. A specialist arena in itself. It is different from psychiatry, and there may be less transferability of skills between the two fields than some clinicians have understood.
The scenarios in ‘Box 1’ reflect an anachronistic paradigm which perceives management ‘doing (bad) things’ to psychiatrists and psychiatrists wishing management would ‘keep out of their hair’. Such passivity does not serve psychiatrists or their patients well. The scenarios not only reflect poor management practice, with inadequate consultation and decision-making, which are not informed by clinical practice.
They also reflect poor leadership by psychiatrists in adopting the passive stance.
MANAGEMENT IS A TWO WAY INTERACTIVE PROCESS
EFFECTIVE PSYCHIATRIST LEADERSHIP AND MANAGEMENT PRACTICE
The following scenarios illustrate effective management practice and a movement from psychiatrist passivity to either active involvement in management or demonstration of leadership.
BOX 2
Scenario: Clinical Leadership In a multidisciplinary team setting, concern is expressed that some patients are not receiving a comprehensive assessment and treatment plan. Psychiatrists were accused of only seeing patients who were of clinical interest to them. Far from being defensive about this, they took up the challenge and restructured their out-patient clinics to ensure that spaces were allotted for review with case managers of difficult, demanding and non responsive patients. Within a short space of time they were seen to have a significant contribution to make to improving care for patients with common and difficult problems. Eventually they were able to set the standard of clinical case review at a higher level than it had been.
Scenario: Local Systems Leadership In a metropolitan public sector service, which had a psychiatrist as director, the executive team embarked on a series of organisational restructuring decisions centred on multi-disciplinary clinical teams. The psychiatrists were involved at every step and developed a process for consultation that ensured their input. These psychiatrists set clinical standards for case review, had input to the policies and procedures, and established and facilitated an effective quality review process.
Scenario: Wider System Leadership: Influencing the National Agenda In several regional health services, local arrangements to facilitate networking between GPs, private psychiatrists and the public sector are underway. These are local collaborations that may provide models for consideration at the national level. In each of them a psychiatrist can be identified who is taking leadership in exploring this issue.
Scenario: Telemedicine: Bi-national Influence In certain Australian states and some parts of New Zealand, significant telepsychiatry initiatives are underway. These approaches demonstrate utilising technology advantageously to address the special needs of remote, rural and indigenous communities. In many of them the contribution of a psychiatrist has been valuable in ensuring clinical standards are appropriate, and in lobbying to make the initiative achievable.
Scenario: International Influence The influence of several prominent Australian and New Zealand psychiatrists has contributed to international concern about morbidity related to psychiatric illness. A prominent Australian psychiatrist has been recruited by the World Bank to advise them on international intervention strategies.
POWER AND CONTROL: CONTROVERSIAL CONCEPTS
A number of British and American authors [6–9] have portrayed a situation of conflict or tension between clinicians and nonclinical managers. The situation is seen as adversarial and territorial in nature, or as a transgression of rightful or historic professional boundaries, particularly that of clinical autonomy. From this perspective, the rationale for management education for psychiatrists is promoted as a basis of re-gaining of lost power. However this view is challenged by the ideology of partnerships between clients, consumers and clinicians, to improve individual or population levels of care. This radically alters the previous dependant relationship and power dynamics particularly between clients and clinicians [10]. We can no longer expect psychiatrists’ unique and extensive formal training to provide a mandate for the assumption of the role of manager of a mental health service, however, psychiatrists have both rights and responsibilities to influence the system. To do so they must put aside their distrust of management, and learn to work effectively with managers, or acquire the necessary skills and competencies to become effective managers themselves.
LEADERSHIP IS A RIGHT AND A RESPONSIBILITY
INADEQUATE TRAINING FOR MANAGEMENT COMPETENCY
We generally recognise psychiatrists to have little or no training in management. They are thus often ill equipped to be managers of a service in an era of strict accountabilities [11]. It has been argued that the structure of medical and psychiatric training is not conducive to developing the resilience and adaptation to change which is required for system reform. Perspectives are often in conflict; the individual client focus compared to the group/team and system-level focus, the rational logical scientific approach of the clinician, compared to the often-ambiguous processes of management and organisational life [12].
TRANSITIONS
The transition from clinician to manager has been described as creating cognitive dissonance [13]. The transition requires a ‘shifting of gears’ and has be likened to a personal jolt or to being a ‘fish out of water’, with the loss of collegiality and peer support constituting one of the main obstacles. The move from clinician to manager, is a quantum step, the change not one of degree but of an order of magnitude [14], with many psychiatrists who have not received appropriate management development or support being at a loss. This view is supported by research on health care professionals’ stress and burnout which shows either pandemic denial or short-sighted dehumanisation [15–17]. Thus it may be argued that the personal cost of this lack of preparation for management is as debilitating as the professional cost to the inadequately managed organisation.
LEADERSHIP: AN OPPORTUNITY TO ENTER PARTNERSHIPS FOR INFLUENCE AND CHANGE
For many psychiatrists, already the most highly educated and extensively trained members of the mental health workforce, the prospect of further study may be daunting or overwhelming. Any such suggestions may be dismissed as unnecessary or just plain infuriating. There is a need therefore for such professional development to be provided in a format which is on-going, position-appropriate, career-relevant and based on individual choice.
Another important transition is that of clinical manager back to pure clinical practice. Providing a structured and supportive environment to facilitate this transition is necessary if we are to ensure career mobility. The fear of ‘getting rusty’ and losing core clinical skills needs to be addressed.
RECOMMENDATIONS AND OPTIONS
The steering committee recommends that a range of opportunities is required. These opportunities will vary according to age, and stage of professional development. For example, modules on population health issues, consumer partnerships, working with systems and multi-disciplinary teams and management of clinical processes, can be (and in some places already are) incorporated into undergraduate medical curricula. Similar topics should be available at a more advanced level, within in psychiatry registrar pre-fellowship training programs.
LEADERSHIP BY PSYCHIATRISTS: OPPORTUNITIES AT CLINICAL, SYSTEMS, ORGANISATIONS, GOVERNMENTS AND POPULATION LEVELS
Advanced training in management and leadership in mental health services could become an option for some fifth year psychiatry registrars. Already, some states have facilitated access by registrars and/or psychiatrists to accredited postgraduate management qualifications to assist with management and leadership development. For example, the curriculum for one such program is currently being designed as a pilot for the NSW system, in collaboration between the Institute of Psychiatry, the NSW Centre for Mental Health and an interested Area Health Service. The content will include population health, management and leadership theory, quality improvement in mental health, administrative skills and management of change.
Continuing medical education programs for clinical psychiatrists at bi-national and local levels should ensure that population/management/leadership issues of interest to clinicians are routinely included, in addition to the more traditional clinical content already offered.
Psychiatrists already in, or contemplating taking on, shared clinical/management positions should be encouraged to find a coach or mentor. This support person would encourage them to experience gradually more complex management tasks such as ensuring effective committee and task group function; undertaking consultancies, reviews, and specific project management. Linking up with the Royal Australasian College of Medical Administrators would be beneficial for this group, providing access to clinician manager short courses and a structured proforma for group learning.
MANAGEMENT: EFFECTIVE HANDLING OF RESOURCES, SYSTEMS, ORGANISATIONAL COMPLEXITY, STRATEGIC PLANNING FOR POPULATIONS AND LEADING CHANGE
Those psychiatrists wishing to embark on mental health system management at a more senior level need to consider further programs in addition to obtaining formal post-graduate qualifications. These programs should be directly related to competencies developed and agreed upon between funders, providers and users and, within them, structured work experiences including exchange/rotation into regional positions or ‘shadowing’ a Director should be included. Formal mentorship, and/or engagement in a small group ‘learning set’ program is an essential component of effective transition to senior positions.
This gradual and progressive undertaking of management education, training and skill development activities, congruent with the varying demands and expectations of management positions, will be based on career choice.
PSYCHIATRISTS MAY WISH TO MANAGE AS WELL AS DEMONSTRATE LEADERSHIP. THE FORMER IS OPTIONAL, THE LATTER IS MANDATORY
CONCLUSION
Changes in organisation structure and strategic direction of Mental Health Services in Australia and New Zealand have significant implications for the training, education and development of psychiatrists in generalist and specialist fields, as well as for psychiatrists whose positions include management functions. The professional context and ‘macro’ environment in which psychiatrists find themselves now has radically changed. The era is one where the profession cannot afford to be laissezfaire or haphazard; a more systematic, structured and staged process of knowledge, skill and competency acquisition is required if psychiatrists are to make a successful transition from clinician to manager and/or leader. Furthermore, influencing policy or decision making at more senior levels requires more complex management and leadership skills.
Through the selection, development and retention of psychiatrists in management and/or leadership positions, the profession will maintain a significant stakeholding in the organisations in which it's members serve, and will be able to exercise influence sufficient to achieve improvement in systems of clinical care as well as fulfilment in a professional and personal sense [18].
Education of psychiatrists in and for leadership and management is not a strategy to ‘regain lost control’, it is preparing forward-thinking resilient psychiatrists for reform.
ACKNOWLEDGEMENTS
In the preparation of this paper acknowledgement is made of the contributions by the following members of the project's steering committee and working party: (College fellows), Professor Peter Ellis, Head Department of Psychological Medicine, Wellington Medical School, Drs. Janice Wilson, Brett Emmerson, Louise Newman, Rosemary Sneider, Donald Grant, Wayne Miles, Aaron Groves, Adrian Keller, Jeff Snars, Paul Friend, Lyndy Mathews (trainee psychiatrist), and non-fellows Jennifer Alexander, Chief Executive Officer ANZHMN, Professor Bruce Dowton, Dean, Faculty of Medicine UNSW, and Ms Allison Weeks and Ms Judy Hardy, representatives of NOAC Network of Australian Consumer and Carer Advisory Groups.
Footnotes
RANZCP STRATEGIC LEADERSHIP AND MANAGEMENT SKILLS DEVELOPMENT IN PSYCHIATRY PROJECT
Chair: Dr Margaret Tobin Project Officer: Ms Jayne Wells.
The RANZCP Strategic Planning Group has commissioned the Strategic Leadership and Management Skills Development Project.
The project aims to investigate broadly the issues of psychiatrists gaining appropriate competencies in leadership and management through consultation with the broad fellowship generally, and clinician-managers specifically. The project intends to produce two position papers one for Australasian Psychiatry (this issue) and one for the Australian and New Zealand Journal of Psychiatry (within the next 12 months) and a final report with recommendations to the College by the end of 1999.
The project has a steering committee that has provided project direction. Membership comprises: College fellows Drs Janice Wilson, Brett Emmerson, Louise Newman, Rosemary Schneider, Donald Grant, Wayne Miles, Aaron Groves, Lyndy Mathews (trainee psychiatrist) and Professor Peter Ellis, Head, Dept. of Psychological Medicine, Wellington Medical School, and non-fellows Dr. Jennifer Alexander, Chief Executive Officer ANZHMN, and Ms Allison Weeks and Ms Judy Hardy representatives of NOAC Network of Australian Consumer and Carer Advisory Groups.
The steering committee is supported by a working party which undertakes some of the details of tasks required by the steering committee. The working party's membership comprises: College fellows Drs. Adrian Keller, Louise Newman, Jeff Snars, Paul Friend, and non-fellows Dr. Jennifer Alexander and Professor Bruce Dowton Dean, Faculty of Medicine UNSW.
Either steering committee or working party is open to receive additional input from any interested fellow, on an ad hoc or regular basis.
To prompt some broader discussion from the fellowship we have published the above mentioned article in this issue of Australasian Psychiatry. We would welcome your comments and those of trainees, in relation to the following questions and any other issue which arises from the article.