Abstract
In this edition of the rural news we present a round up of activities from around the countries to give you a glimpse of the diversity in the life of rural practitioners.
Western Australia – in training
News just arriving (by pony express – or is that e-pony!) from the West is that the 10th Annual Rural and Remote Mental Health Conference was held at Muresk Agricultural Campus in Northam from the 19th-21st of November 2002, with delegates hearing of various innovations in R&R Mental Health. The conference was designed with a practical focus, aiming to share information about work being done in WA that other services and providers could pick up and use. The delegates also took up networking opportunities and a chance to catch up with far-flung colleagues.
In other news, from March through to May 2003, the State-wide Clinical and Service Enhancement program will be providing the next in a series of training courses via videoconference – this time in CBT and management of personality disorder. This program has provided valuable training to clinicians in the public sector through a videoconferencing format, and is a good example of innovative approaches to the continuing education of R&R clinicians.
New South Wales – Wild & Crazy Things
The New South Wales Centre for Mental Health and the New South Wales Branch of the RANZCP has established a rural psychiatry project, the committee of which is licensed to try ‘wild and crazy things’ to improve all aspects of rural psychiatry. One such concept is the establishment of Area Psychiatrists Councils, the first of which has just been formed on the Mid-North Coast of New South Wales. All psychiatrists who provide psychiatric services to a geographical area (in this instance the area served by the Mid-North Coast Area Health Service) are invited to be members. This includes resident psychiatrists, ‘fly in’ psychiatrists, psychiatrists who provide video link consultations and includes public and private sector psychiatrists, as well as academic and administrative psychiatrists. Until recently these psychiatrists have largely worked independently of each other and their efforts have not always been coordinated. At times misunderstandings have developed between different psychiatrists, often through lack of contact, and this has caused increasingly professional isolation which has amplified geographic isolation.
Previously psychiatrists operating in isolation had little ability to influence health planning policy and resource allocations in their Health Area which has sometimes made the work of psychiatrists more difficult. The Mid-North Coast Area Psychiatrists Council, which will be operating as an autonomous body with support from the Area Health Service, has the capacity to resolve problems between psychiatrists and develop suggestions on how psychiatrists can work in a coordinated and mutually beneficial way for themselves and their patients. The Area Health Service has undertaken to not develop policy without the input of the Area Psychiatrists Council.
The challenge now for the Area Psychiatrists Council is to be useful both to the Area Health Service and to all psychiatrists, particularly those who are already most isolated and most sceptical of involvement with the Area Health Service. Another Area Psychiatrists Council is being developed in the Greater Murray Region with the interests from other areas of the State including Orange and the Far West. While the concept of Area Psychiatrists Council may be most useful in rural areas, the concept should be equally applicable in metropolitan areas where in some ways the divide between ‘public’ and ‘private’ psychiatrists can be even greater than rural areas.
The New South Wales Rural Psychiatry Project Steering Committee chaired by Grant Sara
New Zealand – frontier land?
Marlborough Country, New Zealand! Cocky country not cowboy country. Where the smoke is more green than nicotine. World famous in New Zealand for wine, mussels and for shooting pigs. For four months I have had the privilege of being the Marlborou psychiatrist. I am beginning to discover the lessons to be learned from being a country psychiatrist, a distinct role that Brian Parsonage pointed out at the first gathering of the Rural Special Interest Group in Brisbane. No longer am I the rural psychiatrist from Christchurch, – the town toff descending into the backblocks to dispense the technicological fix, then driving or sometimes flying back off into the sunset, – but I am a psychiatrist living in his own shit. I exaggerate for effect.
I am working with a clinical team of 11 community psychiatric nurses, two psychologists, a young medical officer with the experience of a senior registrar and a not-so-young-now unit manager with the presence and the people and management skills of Santa Claus. Overall, the team is quite young, but it has gained a lot of experience dealing with a caseload of over 200 patients from age 16 upwards, including emergencies and referrals from the local hospital, without a regular psychiatrist. I make the ninth psychiatrist they have had in five years, including 16 months with no psychiatrist at all. And such is the difficulty these days of ‘finding good staff’ to work away from the city, they have had at times to deal with more that the foibles of a temporarily incumbent shrink. One elderly psychiatrist's brain was indeed shrinking, dementing even before he was employed. Another psychiatrist was found out not only to be a fake, but she turned out not to be the woman she purported to be. (A fact discovered early on in the piece by the unit manager, whose office adjoins the loo: he would hear the loo seat going up when she went for a pee!) So this is a resilient team, used to depending on its own strengths. Despite its setbacks, it has a reputation in New Zealand for providing an excellent service – one of the factors attracting me to apply for the position here, quite apart from the wine, mussels, etc.
Practising rurally has reminded me acutely of one important lesson of all good psychiatric practice: it depends on good relationships. Relationships between the mental health team and other Marlborough services are good. For example, there is an excellent understanding with the police here, compared with the relationship with the police of a neighbouring mental health team, who experience major difficulties. We also meet regularly with residential and support services here which benefits continuity and consistency of care. Despite the many changes in psychiatrist, and perhaps because of the relative lack of psychiatrist input, this team has kept good liaison with the local GPs, who have in many cases maintained responsibility for the prescription of psychotropics in the management of their psychiatrically unwell patients.
In a small community, of course, good relationships can mean close relationships, neither bad nor good of itself, but raising issues of personal and professional boundaries. At a recent get together at ‘the Police Bar’ one of the community team was banned from the bar for inebriated behaviour: the silly man went for a run after work, had nothing to eat and joined his colleagues to replace lost body fluid with beer! Tolerance and forgiveness must sometimes be part of a good relationship. At a farewell do with another local service team, the personal relationships of more than one team member became exposed and this led to consequent tensions within the team. There are few guidelines available for teams in handling such matters and helping prevent transgressions across the personal/professional boundary in a small community. Certainly the shenanigans of Shortland Street on the TV are not to be emulated!
One important relationship we have is one that we need to do a lot more work on, the relationship with the Acute Inpatient Unit 100 kilometres over the Whangamoa Hills in Nelson. This has been a tense interface for some time with changes in staff on both sides and, at times, a siege mentality which has led to distrust on both sides, heightened by the distance and difficulty in keeping regular contact. It is probably not helped by the age-old hill-billy tendency of Nelson and Marlborough to feud. Telepsychiatry, which we use at least twice a week, does enable communication, but it is not particularly helpful in bettering relations. Staff differences around times of admission and discharge do not enhance patient care. Not that I haven't seen this kind of problem elsewhere, but in a rural setting where there are no alternatives, it becomes tricky.
Australian psychiatrists may not know of a recent investigation into and report on adverse clinical events in Southland, New Zealand, as a result of which both the District Health Board and the management of the mental health service came in for severe criticism. It was also proposed by the investigator that the positions and competencies of several clinicians of different disciplines be reviewed. A significant area of concern centred on the processes of transfer of care between the inpatient and outpatient services. In the circumstance of limited and stretched resources for psychiatric services, which pertains throughout rural New Zealand, the events in Southland and the review of the outcomes are frightening. Southland is a provincial and rural area of New Zealand which has been perennially short of well-qualified mental health professionals, particularly psychiatrists. This particular rural psychiatrist did not find reading the 200 plus page report a pleasant experience, and I was forcibly reminded of the professional responsibility of my position for ensuring that processes and training are well in place in order to prevent, or at least minimize, the chance of such adverse outcomes in Marlborough. In a country practice, the psychiatrist can feel very isolated with no colleague who can directly share that responsibility. Only a supportive relationship with a good team, clear about their roles and the boundaries of those roles, can lighten that burden.
The psychiatrist working rurally has a central and most important role to play in leading the psychiatric team. But lest I get carried away with my own importance, I should remember that the Marlborough team has managed remarkably well without the likes of me for long periods of time. I don't want to become just another anecdote in another country psychiatrist's letter – at least not just yet!
Victoria on the move!
Access to services needs to be addressed in a variety of ways – the Rural Depression & Anxiety Research & Treatment (DART-R) group was developed to provide access to specialist treatments for people with anxiety and depressive disorders in the Loddon Campaspe Southern Mallee Region in Victoria. The region is 36,000 sq km stretching from Gisborne, just 50 km north of Melbourne, to beyond Swan Hill on the Murray River. Swan Hill and surrounds, not surprisingly, is the most difficult area for service provision. DART-R have developed a model and a method! The model requires upskilling of mental health case managers (mostly psychiatric nurses) in cognitive behavioural strategies. The expanded DART-R team then includes: the psychiatrist who allocates times for assessment on an ‘as needs’ basis (the rest of the consulting day being devoted to general psychiatric work); the clinical psychologist working one day per week who undertakes behavioural assessment and some individual cognitive behaviour therapy (CBT), and works with case managers to enable them to deliver CBT strategies; and case managers who may work as co-therapists with the clinical psychologist or work to support the patient completing homework tasks, etc. designed by the clinical psychologist.
What about the method? A key component of the model is training other workers and local capacity building. The method adopted has been one of on site ‘face to face’ activity. This has been achieved by weekly visits, of the ‘fly in fly out’ nature. This approach has had a variety of unexpected benefits – in vivo exposure has eliminated the flying phobia of one member of the team (yes, CBT does work!) and kindled an interest in learning to fly in another!! The team has also modelled visiting behaviour, leading to a stream of other programs adding Swan Hill to their ‘active’ sites list. For the DART-R visiting team, the rewards flowing from working with a small, dedicated, and previously isolated rural team have been enormous.
Tasmania enticing
North west Tasmania continues to rapidly lose psychiatrists to the cities and remains very shortstaffed, which of course makes it more difficult to attract new psychiatrists. On the positive side, the lifestyle on the North West Coast is superb and staff in the clinics form a mature supportive group. There have been some good MSOAP initiatives in the North West of Tasmania and the psychiatrists are excellent but the program suffers from the same problem as elsewhere in Australia – there has been insufficient consultation with the psychiatrists working in the regional clinics and services prior to implementation of the MSOAP services.
Nothern Territory – changes afoot
There have been major reviews of both the Northern Territory Mental Health Service and the Northern Territory Department of Health generally which may lead to a restructure of the mental health services next year. This is in addition to the appointment of a new chief executive officer for the NT Department of Health. These issues may possibly lead to a change in the provision of psychiatric services to rural areas of the Northern Territory.
Rob Parker, the Chair of the Aboriginal and Torres Strait Islander Mental Health Committee for the College recently contributed to the Aboriginal Medical Alliance Northern Territory (AMSANT) project for the development of an aboriginal emotional and social wellbeing strategic plan for the northern territory. The AMSANT proposal looks to improving the emotional and social well being generally of aboriginal people in the Northern Territory but this would also include the significant number of aboriginal people living in rural locations throughout the Northern Territory. The College submission looked at issues such as improved recognition of the role of aboriginal mental health workers and improved training in indigenous mental health for psychiatric registrars under the existing and new training by-laws as assisting the AMSANT process.
In the next edition of Australasian Psychiatry we will find out what's happening in New Zealand, South Australia and Queensland.
If you have any interesting rural snippets to contribute please send them to Gabrielle FitzGerald at: