Abstract
Objective:
To provide a clinical update for psychiatrists and trainees on psychiatric workforce-planning in the Australasian context.
Conclusions:
There is a lack of detailed evidence regarding effective psychiatric workforce planning. Planning may be based on a foundation of psychiatrist-to-population ratios. This would be modified by needs assessment, understanding of service models and existing service demand. Given that it has recently expressed significant concerns about workforce shortages, the RANZCP should lead development of an independent Australasian psychiatric workforce planning model to inform policy advice to governments.
The President of the RANZCP, John Allan, stated (19 May 2021): ‘Now is the time for our governments to rise to the challenge that is before them and begin taking immediate action to provide the support needed to develop and grow a sustainable psychiatric workforce to meet increasing demand’. 1 The Victorian Psychiatry Workforce project highlighted the challenges facing recruitment and retention of psychiatrists in public mental health services, which included zealous regulation, blame culture and excessive demand. 2 The most recent report on Australia’s psychiatric workforce projected a shortfall of 125 psychiatrists per year by 2030. 3
There were over 3,400 psychiatrists employed in Australia in 2018, representing 3.5% of medical practitioners and 9.8% of specialists. 4 Australia had 13 psychiatrists (total public and private) per 100,000, varying from 12/100,000 in the Northern Territory to 15/100,000 in South Australia. Three-quarters of psychiatrists were aged 45 and over, and nearly 1 in 5 employed psychiatrists (17.2%) were aged 65 and over – and thus more likely to retire. The World Health Organisation (WHO) Global Health Observatory reports that high-income countries had a median of 13/100,000 in 2017. New Zealand reported 29/100,000, Canada had 15/100,000, the United States had 11/100,000, while Germany had 13/100,000, France had 21/100,000 and de-hospitalised Italy had 8/100,000 (https://apps.who.int/gho/data/view.main.HWF11v).
While the Australian National Mental Health Workforce Strategy is yet to report on consultations with states and territories, 5 the RANZCP President currently states: ‘Our workforce is in dire straits with lengthy wait times, maldistribution and lack of services’. 1 This crisis reflects an acute-on-chronic psychiatric workforce shortage. In the interim, the NSW government Psychiatry Workforce Plan commits to state-wide workforce modelling to identify workforce requirements to 2035, involving psychiatrists in design and implementation of local workforce initiatives. 6 The Victorian Mental Health Workforce Strategy is dated from 2016 and lacks detail on psychiatric workforce planning. 7 The Queensland Health Mental Health Workforce Plan specifically indicates that there needs to be evidence-based workforce planning, but lacks details of the process. 8 The WA Mental Health Commission Mental Health, Alcohol and Other Drug Workforce Strategic Framework 2020–2025 recommends workforce planning and development in general, but lacks specifics on psychiatric workforce. 9 We could not locate publicly available documentation on psychiatric workforce planning for South Australia, Tasmania, ACT and the Northern Territory. The New Zealand Mental Health and Addiction Workforce Plan 2017–2021 also references, without specific detail, that dynamic modelling of workforce is needed. 10 In the context of the lack of specific detail on workforce planning in the Australian and New Zealand National Mental Health workforce plans, as well as state/territory initiatives, we discuss the existing evidence-based models for psychiatric workforce planning.
Psychiatric workforce planning guidelines
The Canadian Psychiatric Association (CPA) has published most extensive evidence-based literature review and position paper (currently under revision). 11 Most medical practitioner human resource planning is predicated upon practitioner-to- population ratios. However, there are limitations with such ratios 11 :
The basis of the determination of specific ratios remains uncertain.
Ratios cannot account for variations in specific expertise (e.g. subspecialist), roles and service models.
Ratios will need to be adjusted for rural and remote regions of Australia and New Zealand as regional service models will differ from major population centres.
The achievement of recommended ratios across many services has not ever resulted in an excess of psychiatrists.
Accordingly, there are further considerations that have led to complementary models of workforce-planning.
Beyond practitioner-to-general population ratios
Benchmarking seeks to model resources based on the medical workforce within another jurisdiction/healthcare service, with the advantage that this is founded on real-world resources, albeit that there may be considerable differences in the demographics of regions. 11 However, this may also pin psychiatrist resourcing to a minimum level, which is less desirable. 11
A needs-based approach focuses upon epidemiologically based information about the disease-burden for psychiatric care, but is often constrained by a lack of local data. 11
A demand-based approach focuses upon service utilisation data to gauge needs, constrained by existing service models, as well as the fact that if a service exists, demand usually rises. 11
Service models will also have a significant effect upon on psychiatric workforce needs. For example, a consultation-liaison service will require availability of psychiatrists and trainees for inpatient and other outreach consultations. Such needs will differ from a short-stay psychiatric unit within an emergency department.
Working patterns for psychiatrists will also significantly affect workforce needs. 12 For example, continuing professional development, administrative work, teaching and clinical research, may impact upon face-to-face consultation time. Travel time between venues needs to be considered.
Service model challenges are exemplified in the UK, where ‘sector psychiatrists’ who cared for patients in both inpatient and outpatient settings for a given geographical region were restricted to either consultation in inpatient or community settings through the ‘New Ways of Working’ model, with devolution of direct care to allied health teams. 13 This is strikingly similar to the Australian experience. In the UK, this ‘New Ways of Working’ service model was an impetus to reduce psychiatric staffing with deleterious effects. 13 Improved models of care are needed to encourage psychiatrist recruitment and retention, such as better conditions within acute mental health inpatient facilities; closer integration of inpatient and community teams; and strengthening liaison and primary care psychiatry. 13
Recommendations
Mental healthcare services often struggle to obtain adequate resourcing, leading to severe constraints on workforce and infrastructure. 14 Unfortunately, this default under-resourcing has often been reinforced an existing formula for psychiatric workforce based on historical funding. 11
The CPA 11 has proposed consideration of parameters to improve measures of service demand to assist in assessment of the effectiveness of workforce planning:
Emergency department, outpatient, inpatient and outreach presentation and waiting times;
Time to follow-up from discharge from an occasion of service;
Travel times to access services, including outreach – from patient or psychiatrist end;
Occurrence of incidents while waiting for service (admission, adverse clinical events);
Psychiatrist job satisfaction, wellbeing and burnout – a particular issue in the Australian public sector with the option to move to a large private sector;
Patient satisfaction;
Diversion of patients to legal and/or social support systems;
Adherence to health quality and safety standards.
Building upon the work of the CPA, 11 we recommend consideration of the following in development of effective psychiatric workforce plans:
Psychiatrist-to-population levels yield a starting figure that must be adjusted with consideration of the other parameters below, and we consider the carefully calculated CPA levels of one psychiatrist FTE per 8400 (12/100,000) and an effective workforce of one licensed psychiatrist per 6584 (15/100,000). 11 Current Australian AIHW figures yield 1 psychiatrist FTE per 7518 (13/100,000); however, there are structural health system differences with Canada, in relation to the ratios and work models of private and public sector psychiatrists (e.g. 22.8% of Australian psychiatrists are in solo private practice). 4
Psychiatrist-to-population ratios will require specific needs and service-model based adjustment for rural and remote Australian and New Zealand regions.
The methodological basis of current psychiatric workforce planning, including, but definitely not limited to, existing service and funding models.
Management of psychiatrists from a talent and workflow perspective: identifying the desired competencies and behaviours that are required of the workforce. 12
Benchmarking workforce comparisons using jurisdictions with demographically similar populations, and being aware that there may be demand-based differences due to varying service models.
Complementing benchmarking with local epidemiological needs data, with awareness that disease ascertainment and severity estimates may vary between general and clinically presenting populations.
Calibrating all of the above with the local service utilisation data, while incorporating benchmark and needs data for those patients currently being under-served or not included in care models.
Reconsidering service models and psychiatrist roles in light of the above, including, but not limited to, improved working conditions in acute mental health units, better integration of acute hospital and community service roles, improved liaison and primary care psychiatry. 13
Considering push-pull factors for psychiatrist recruitment and retention, including, but not limited to, remuneration, access to career development opportunities, professional education, clinical training and supervision, health and well-being support. 15
Calculating a modified practitioner-to-general population level based upon 2-6, as a baseline for forward planning.
Benchmarking psychiatric workforce planning based on clinical research metrics of the above.
There are also challenges in the consequences of under-resourcing of mental healthcare services that affect the quality of patient care, as well as working conditions for psychiatrists, that will require substantial effective planning and implementation of change to improve.
Effective workforce planning requires collaborative work of health administrators, psychiatrists, academic experts in epidemiology and workforce planning, as well as being informed through advocacy by medico-political professional organisations such as the RANZCP and AMA.
In view of the urgency of the workforce shortages, 1 we recommend the RANZCP produce a position paper on psychiatric workforce planning to independently inform governmental mental healthcare policy and planning.
Conclusions
In the context of ongoing psychiatric workforce challenges in Australia and New Zealand, it is crucial to improve workforce planning, based on the evidence as it stands, and advocating for where more evidence is needed. Thus, we can advocate for an effective psychiatrist health workforce to provide high-quality patient care.
