By my count there were:
2 psychiatrists
1 psychologist
1 GP
1 mental health nurse
1 carer rep
1 consumer rep
4 mental health bodies
6 bureaucrats
At the meeting, this diverse range of stakeholders raised a multitude of views and concerns, particularly the lack of mental health consumer and carer input into private health network.
| Adjunct Assoc. Prof. Kim Ryan | CEO, Australian College of Mental Health Nurses |
| Professor Malcolm Hopwood | President, RANZCP |
| Professor Lyn Littlefield | Executive Director, Australian Psychological Society |
| Professor Morton Rawlin | Vice President, Royal Australian College of General Practitioners |
| Dr Bill Pring | Private Mental Health Alliance (PMHA), AMA Observer |
| Mr Frank Quinlan | CEO, Mental Health Australia |
| Ms Georgie Harman | CEO, Beyondblue |
| Ms Sue Murray | CEO, Suicide Prevention Australia |
| Ms Marita Cowie | CEO, Australian College of Rural & Remote Medicine |
| Mr David Meldrum | Executive Director, Mental Illness Fellowship of Australia |
| Mr David Butt | CEO, National Mental Health Commission |
| Ms Janet Meagher | Consumer representative National Mental Health Consumer and Carer Forum |
| Ms Eileen McDonald | Carer representative National Mental Health Consumer and Carer Forum |
| Mr Stephen Brand | Senior Manager, Policy & Advocacy Australian Association of Social Workers |
| Professor Tom Calma | Advisor Australian Government Department of Health |
| Ms Natasha Cole (Chair) | First Assistant Secretary, Health Services Division Australian Government Department of Health |
| Ms Colleen Krestensen | Assistant Secretary, Mental Health Reform Taskforce Australian Government Department of Health |
| Dr Anthony Millgate | Assistant Secretary, Mental Health Services Branch Australian Government Department of Health |
| Ms Emma Gleeson | Acting Assistant Secretary, Mental Health Early Intervention Branch Australian Government Department of Health |
AMA Psychiatry Newsletter April 2016; AMA Qld submission to the Office of the Health Ombudsman
The Office of the Health Ombudsman (OHO) was established by the Queensland Government in 2013 to strengthen the health complaints management system. It replaced the Health Quality and Complaints Commission (HQCC), an organisation that had been criticised for fundamental deficiencies in the way it handled complaints, as well as unjustified delays in dealing with complaints against medical practitioners. Plus ca change plus la meme chose!
Highlights:
I have written previously about the problems forensic psychiatrists have had with vexatious notifications to the Medical Board. Two of our colleagues had had four notifications each, three of them had been shown to have no merit but it appeared that four notifications required action and so the two psychiatrist had a practice visit from two other psychiatrist over a period of a day. I thought this was questionable with regard to ethical practice in particular the psychiatrist roared through all the medical records not just those to do with the notifications and apparently sat in on one or two interviews.
Complaints were made to the Medical Board of Victoria by our representatives and as you will see there has been dialogue with the AMA. Some information about this was provided in the April newsletter of the Medical Board of Australia. (See below)
Improving the notification process
Continuing our work on a fair and timely process
Senior leaders from the Board, AHPRA and the AMA met in February 2016 to look at ways in which doctors’ experience can be improved when a notification is made about them. This was the second workshop with the AMA about this. The first workshop was held 12 months ago.
There was positive feedback about changes we have made in the last 12 months to improve the experience of doctors involved in the regulatory process. Improvements include:
The workshop also explored what we are doing to support good regulatory decision-making including:
The Board and AHPRA agreed to explore how we can most usefully ask practitioners for feedback about their experience of the regulatory process when a notification has been made about them, so we can improve our processes.
There was also good discussion about how the experience of the National Scheme1 can better support the profession to deal with practitioners whose performance is not satisfactory.
The Board and AHPRA appreciate the AMA’s commitment to continuing to work constructively with us to improve the process for practitioners, in a fair way, with clear information.
The AMA has also published information about the workshop at A refined way to complain.
For more information about notifications, AHPRA has published guides for practitioners on the notifications process (performance assessments).
Western Australia is pressing ahead with its 2013 plan to replace the State Workers’ Compensation and Injury Management Act 1981 with a new statute, WorkCover WA has confirmed.
“The drafting of the Bill is a significant undertaking and is at a preliminary drafting stage with Parliamentary Counsel’s Office,” a spokesperson said yesterday.
The State Government has been quiet on the proposed laws since approving the drafting process in October 2014 .
The spokesperson confirmed that the new statute will be based on recommendations from WorkCover’s June 2014 report on the old Act, and the Government will consult broadly on the Bill before introducing it to Parliament.
“I cannot confirm when it will be introduced to Parliament at this stage,” he said.
WorkCover’s 171 recommendations included: replacing the “complex and highly prescriptive” 1981 Act with a new Act; redefining “worker” as “an ’employee’ for the purpose of assessment for Pay As You Go (PAYG) withholding” under Commonwealth taxation laws; enforcing whole person impairment thresholds for common law claims; and significantly increasing death benefits
I came across some advice to claimants about how to increase their psychiatric impairment rating. It had to happen. I thought you might be interested. Of course is much easier in New South Wales where people can access ePIRS and test out different scenarios to see what produces the best score.
I found an Ontario Law Report clarifying use of AMA 5 Chapter 14 there. As you know I disparage the AMA Guides from the 3rd to the 6th edition. In this case, the plaintiff claimed ‘Catastrophic Injury’ on the basis that she had an Adjustment Disorder with Depressed Mood, Specific Phobia, and Pain Disorder with both Psychological Factors and a General Medical Condition. The health practitioners who assessed Ms. Pastore concluded that she had a class 4 (marked) impairment in the activities of daily living category- Marked impairment ‘significantly impeding useful functioning’. Leaving aside that this is a measure of disability, nevertheless one score of 4 or above is sufficient to reach this threshold. Maybe the AMA Guides are not useless after all.
I have previously posted about bullying in March 2015. Since then the impression I have gained is that claims of bullying are on the rise. Bullying seems as prevalent now as RSI was in the 1990s. My concern is that many claims of bullying are completely overstated, here are some recent examples:
My boss yelled at me when I accidentally closed the door on his hand.
I told my manager that my seat was uncomfortable and she did nothing about it.
A male co-worker put up a calendar on the noticeboard. It had pictures of girls in swimsuits. I felt angry and humiliated and tore it down. He swore at me. I left work. Management had not been supportive.
My boss made critical remarks about my work performance in my work appraisal. I felt angry and humiliated.
I told my boss that I had to leave early for a hairdressing appointment because it was my sister’s wedding on Saturday but she wouldn’t let me go early. I was really upset!
In each of these situations the person had ceased work and had made a WorkCover claim. One wonders what planet they came from.
On the other hand all of us have heard stories of what appears to be very clear verbal and sometimes physical abuse, discrimination, phone calls at night, trashing a person’s locker and so forth. These are genuine instances of terrible behaviour that all of us could identify with. The shame about the trivial complaints is that they diminish the impact of the serious complaints.
I have provided a link to an article quoting an anti-bullying website and to a recent decision at Fair Work in which a claim of bullying was rejected..
The Fair Work Commission has found an anti-bullying applicant couldn’t be at risk of future bullying because she had elected to be “treated as being dismissed” in 2012, and even launched an unfair dismissal claim.
Commissioner Peter Hampton found that despite confusion around the worker’s employment status, it was apparent that both her and her employer had “treated the employment contract as being at an end for some years and the litigation between them has been conducted in that light”.
The Commissioner also rejected the worker’s request to refer the matter to SafeWork NSW.
The worker was employed by a NSW online healthcare business as a marketing director in early 2012. In July that year, she was denied access to work emails while on extended sick leave, which led her to believe she had been sacked.
She subsequently launched several legal proceedings including an unfair dismissal claim, a workers’ comp claim, and complaints to the Australian Human Rights Commission.
The worker also sought anti-bullying orders against the healthcare business’s managing director, telling Commissioner Hampton that she hadn’t been dismissed from the business and was at risk of being bullied in future because she was seeking to return to work there.
She argued she was still an employee of the company because, among other things, she wasn’t paid out any termination entitlements, and the company CEO sent her an email in late July 2012 stating she hadn’t been dismissed.
The employer argued that in launching an unfair dismissal proceeding, the worker clearly believed she had been dismissed, and had abandoned her employment in electing to be treated as being dismissed for the purposes of her unfair dismissal claim.
Commissioner Hampton rejected the worker’s application, finding she was no longer an employee of the company, there were no prospects of her returning, and there was no “foreseeable future risk” of her being bullied by the managing director.
“The employment contract concluded in consequence of the election by the [worker] to be treated as being dismissed and the subsequent events and conduct by the parties,” he said.
“I am also not satisfied that any potential return-to-work arrangements, or other circumstances, exist in this matter where there is a foreseeable future risk of the [worker] being subject to bullying conduct as a worker whilst at work by the managing director of the employer.”
Commissioner Hampton noted that the worker had also sought for the FWC to refer the alleged ongoing risk of bullying faced by other workers at the business to SafeWork for investigation.
“[There] is no basis to deal with this under this application,” he said.
In June last year, Commissioner Hampton found the FWC only had jurisdiction to formally refer bullying incidents to the relevant work health and safety regulator if the applicant was at risk of future bullying (see related article).
KM [2016] FWC 2088 (18 April 2016)
The Workplace Injury Rehabilitation and Compensation Act (the WIRC Act) recasts the Accident Compensation Act 1985 ( the ACA Act) and the Accident Compensation (WorkCover Insurance) Act 1983 (ACWI Act) into a single Act that is simpler and easier to use.
This link gives you a table that indicates where the provisions of the Accident Compensation Act 1985 can be found in the Workplace Injury Rehabilitation and Compensation Act 2013 that became operational on 1 July 2014.
Of particular significance is section 91 (6) in the ACA Act that has been replaced with Section 64 (a) and (b) with regard to psychiatric impairment assessment.
There has been action on two fronts with regard to reviewing the current system of medical complaints. The Senate has established a wide ranging review (see below) and AHPRA has provided some insights into a KPMG independent review of that system and processes for managing notifications in Victoria. I reckon I could have written this in my coffee break. It includes such mind-boggling new ideas such as:
better risk assessment
Management of high-risk matters
greater transparency
culture
performance
You will notice that the item to do with “culture” refers to ” address perceptions of being pro-practitioner”. That has certainly not been our experience. Our experiences that you are guilty until proven innocent.
These are astonishing glimpses of the obvious. Go to the section below to read the full document.
On 2 February 2016, the Senate referred the following matter to the Senate Community Affairs References Committee for inquiry and report:
The medical complaints process in Australia.
The terms of reference are:
Submissions should be received by 13 May 2016. The reporting date is 23 June 2016.
Committee Secretary
Senate Standing Committees on Community Affairs
PO Box 6100
Parliament House
Canberra ACT 2600
Phone: +61 2 6277 3515
Fax: +61 2 6277 5829
community.affairs.sen@aph.gov.au
AHPRA has provided some insights into the findings of a KPMG independent review of its system and processes for managing notifications in Victoria.
The report recommends actions in five main areas, including a more systematic, data informed approach to risk assessing notifications:
I thought you might be interested to see 4 recently written papers
This is a brief overview of this interesting paper. You can find the full document here.
Work-related mental disorders, each year on average:
I have written about problems with impairment guides several times 1,2.3. Recently I have compiled data on the answers to 5 case studies by 114 psychiatrists who have completed the GEPIC training program. Although we assert face validity in other words we think it measures psychiatric impairment, the critical issue is reliability, do different psychiatrist come up with the same numbers with the same claimant. We have a statistician looking at this. I will be presenting a paper on the findings of the study at the Congress in Hong Kong.
It has focused my thinking on the problems caused by repetitive failures by the authors of the AMA guides to give us a reliable method of determining psychiatric impairment. Although I am one of the co-authors of the GEPIC I have some concerns particularly with regard to measuring low levels of impairment with any precision and especially with regard to class III that ranges from 25 to 50%. On reviewing the PIRS and cannot even be said to have face validity.
For this end for other reasons I have written an impairment guide called the RAPID MSE (The Rating of Psychiatric Impairment Determined by the Mental State Examination). I wrote a paper in 2014 about the various methods used in Australia. On rereading this paper I was struck by the idiocy of the methods described in chapter 14 AMA 6 and the metastatic spread of the PIRS.
I think there are fundamental requirements for any method of psychiatric impairment assessment.
I have written about this before but it has been highlighted by the program for the faculty conference in Perth in Perth in September 2016. The theme is
Goals, purposes and strategies for prisoner and staff mental wellbeing in custody.
In October 2015 I wrote to the head of the faculty:
More and more me and my colleagues are feeling marginalised by the juggernaut of criminal psychiatry. There is only one paper in Canberra at the November 2015 meeting of the Foprensic Faculty relevant to the work I and others do in the civil field “Expert evidence in mental harm claims’ ( I am aware of the plenary session on family law but few of us do that work now). I know you require people to offer papers but you need to be more pro-active. The same goes for the vexed question of suitable training for psychiatrists doing civil work but the views we have seem to be swamped.
The response I received was:
There are two issues, one regarding civil forensic content at the annual conference, and the second on training.
I had intended to table the email for discussion at the committee meeting.
I have forwarded it to Sophie Davison, convenor of the 2016 FFP conference for consideration. From the conference perspective, it would be best if a suitable keynote could be suggested. I suspect this may be too late for 2016 though nothing formal planned for 2017 yet.
It appears that the 2016 conference was set in stone some 11 months before it is to take place. There is nothing in the program about civil forensic matters!
The head of the faculty wrote further about the issue of training:
The training is a more delicate issue which I did raise at the recent college MAC meeting. While I think a formal training program in civil could lead to accredited faculty membership status, this does not fit with current college processes and may take a lot of work from a dedicated faculty committee to implement.
The Victorian Branch of the Faculty had a one-day conference two or three years ago. The conference was deliberately designed to cater for civil forensic psychiatry, criminal forensic psychiatry and those dealing with Family Court matters. We invited speakers and suggested topics. The conference was very successful, it can be done.
If this Faculty is to succeed there has to be an awareness of the legitimacy of the work done by civil forensic psychiatrists. this is not reflected in either the theme or the program for the conference in Perth where civil forensic psychiatry does not feature.
Today I received an email informing Faculty members of sessions in our area of interest at the College Congress in May 2016.
Several sessions may be of interest to members of the Faculty of Forensic Psychiatry, with highlights including:
Sunday 8 May Pre- Congress Workshop
· Civil Forensic Psychiatry Workshop
· Medico Legal Opinion Construction
Monday 9 May
· The Symphonie Fantastique: 3 Victims stories in respect to a person affected by Pseudological Fantastica
· Using Online Data in the Assessment of Psychiatric Disability
Tuesday 10 May
· Invited speaker Dr Scott Harden: Homicidal threats, ideation and behaviour in Adolescents – A clinicians view
· The injured motorist and the Psychiatrist
· A Survey of Mental Health Exclusion Clauses in Life Insurance Policies
· An assessment of the Reliability and Validity of the Guide to the Evaluation of Psychiatric Impairment for Clinicians (GEPIC)
The last session will be presented by myself! This is a step in the right direction but I believe we have a long way to go. For years we have been battling to be seen as a legitimate subspecialty. It has been very disappointing that the juggernaut of criminal forensic psychiatry appears to have ignored that.
I have had similar concerns recently about the Victorian Medical Panels where there has been an active program of recruitment of new young psychiatrists although, paradoxically, the work has been drying up. What has also been drying up is training for these new members. The high reputation of the Medical Panel in Victoria has come from outsiders recognition of the expertise of members of the Medical Panel. This is no longer the case, recently I did a training session for those people experienced in the use of the GEPIC, one young psychiatrist admitted that he had never used it. I asked him why he was there. He said he was a member of the Medical Panel and had been instructed to attend! I wrote to the convenor expressing concerns about his lack of expertise.
The response from the convenor was:
I can assure you that all of the psychiatrists added to the list ( which was only a small number to fulfil certain requirements ) are appropriately experienced and qualified. There is a wide range of issues that we need expertise in and impairment assessment is only one component
The view continues to permeate that the work we do requires no extra expertise and can be done by any experienced psychiatrist. Periodically various schemes bring an influx of psychiatrists to do this work but most psychiatrist find, to their dismay, that the work is difficult, often emotionally taxing, time-consuming and sometimes requires court appearances. There is a high dropout rate. The various schemes then revert to using the familiar faces, the problem is that there are not enough familiar faces, we need more of them.
I have argued and will continue to argue that there needs to be some system of training. The argument from faculty members has sometimes been that training in criminal forensic psychiatry has a component to deal with civil assessment and that that should be enough. This is nonsense.
So it goes
There have been a number of amendments to the Victorian Wrongs Act 1958 (Wrongs Act Amendment Act) that took effect on 2 December 2015. The major issue for us is with regard to psychiatric assessment. The threshold wording has been changed from “impairment of more than 10%” to “10% or more”. This applies to any climate to have been assessed before that date where the matter has not yet been finalised. Victorian forensic psychiatrists will be asked to submit a new certificate incorporating the changed wording. There are 5 changes in all of which the above is the only one relevant to us.
We operate in a vacuum regarding the impact of our decisions financially. Some recent data from Victorian WorkSafe gives us some idea of the cost in Victoria.
GEPIC psychiatry examinations…………………1310
Cost GEPIC exams…………………………………..$1 325 000
Average cost per examination………………….$1 011.45
Psychiatric claims with entitlement paid…. 33
The total paid for the 33 claims………………$2 502 441.40.
Total cost……………………………………………….$3 827 441.40
Today I received by email the AMA Psychiatrist Newsletter, 15th Edition. I must say that i was not aware of the other 14. Nevertheless I thought it might be useful and I might learn something. Such was not the case. The topics covered included the following:
Mental Health Reform
Medicare Benefits Schedule Review
Activity Based Funding on Mental Health
Private Mental Health Alliance
Operation Life Mobile Application
RANZCP-Message from the President
AMA branch roundup (with no content but with a sidebar referring to interviews with Dr Kerryn Phelps from 2003 when she was then president of the AMA!)
I am sure this is a worthy endeavour but I found it almost incomprehensible. For example the section on Activity Based Funding on Mental Health included the following acronyms:IHPA, AMHCC, ABF MHC DSS, MHCS, MHWG and MNCERG.
This gives you of flavour of this article here are the 1st two paragraphs:
The Independent Hospitals Pricing Authority (IHPA) is developing the Australian Mental Health Care Classification (AMHCC) including a supporting Activity Based Funding Mental Health Care Data Set Specification (ABF MHC DSS). The development of the AMHCC is intended to significantly improve the clinical meaningfulness of mental health classification, leading to an improvement in the cost predictiveness and will support the new models of care being implemented in all states and territories.
To date, the classification development work has been informed by the findings of the University of Queensland Definition and Cost Drivers for Mental Health Services project, qualitative feedback from participants of the Mental Health Costing Study (MHCS) and analysis of the MHCS dataset.
Since our last edition, IHPA has been working through its MHWG and its Mental Health Classification Expert Reference Group (MHCERG) to develop and refine the AMHCC. MHCERG comprises mental health subject matter experts, classification system development experts and data analysis expert.
And on it remorselessly goes for another 8 paragraphs with equal incomprehensibility. Can you read it?
The NSW workers compensation guidelines for the evaluation of permanent impairment (4th edition) 1 April 2016 has just been released. It has been re-written to conform with the Safe Work Australia template. However there is no agreement by states using the GEPIC to use the PIRS and considering the disdain with which the PIRS and AMA6 are held together with the cost of training any such change is unlikely. The changes to the PIRS are as follows:
Psychiatric and Psychological disorders
Paragraph 11.4 from the 3rd edition, on the development of the PIRS has been removed to align to the Safe Work Australia national template guideline. The numbering therefore changes from 11.4 onwards (in comparison to the 3rd edition).
Clause Change
Introduction
Removed 3rd and 4th sentences that referenced s67 pain and suffering.
Removing the reference to s67 in this clause does not affect an exempt worker’s entitlement to claim for pain and suffering compensation. The reference to s67 in this clause was a case management tool which is now considered inappropriate in a medical guideline.
Co-morbidity
Removed the Alzheimer’s disease example. Replaced with a bi-polar disorder example.
11.10
Pre-existing impairment Minor change to second half of the paragraph for improved clarity, and to align with the wording in 1.28 in the Guidelines: Rephrased to:
The injured worker’s current level of WPI% is then assessed, and the pre-existing WPI% is subtracted from their current level, to obtain the percentage of permanent impairment directly attributable to the work-related injury. If the percentage of pre-existing impairment cannot be assessed, the deduction is 1/10th of the assessed WPI.
The Faculty of Forensic Psychiatry on the face of it, formally acknowledges that the work done by psychiatrists treating mentally ill offenders and those doing civil assessments constitutes a subspecialty. It is an odd subspecialty because court appearances are the only thing these two groups have in common. Furthermore there are state funded training programs in criminal forensic psychiatry with due recognition but there are no formalised training programs for psychiatrist doing civil assessments. We now have the odd situation where all those who are members of the former section have been grandfathered in as Fellows of the Faculty of Forensic Psychiatry but the only pathway to Fellowship now is through a training program and hence any newcomers involved in civil assessment can no longer become full members of the Faculty.
This was highlighted for me by the recent joint meeting with ANZAPPL that I did not attend because there were no sessions of any relevance to the work that I do. I wrote a letter of complaint to Ness McVie, the chair of the Faculty who provided a belated response, amongst other things she wrote “I have forwarded it to Sophie Davison, convenor of the 2016 FFP conference for consideration. From the conference perspective, it would be best if a suitable keynote could be suggested. I suspect this may be too late for 2016 though nothing formal planned for 2017 yet”.
I found this astonishing, an annual meeting of my faculty does not include any sessions relevant to the work that I do and will not have one in 2016 but may have one for 2017.
I was beginning to get heated about it until I began ruminating about whether or not it actually mattered. In one sense it is useful to have an opportunity to discuss the issues we face in common, to share ideas and to look at interaction with the court system and the legal profession. On the other hand, on a day-to-day basis it doesn’t matter a scrap. I have never been asked in court as to whether or not I am a Fellow of the Faculty of Forensic Psychiatry and I doubt whether anybody in the court room would know that it exists.
Increasingly I feel that the Faculty of Forensic Psychiatry has been hijacked to the exclusion of those of us who do civil assessments and I see no change occurring in the foreseeable future. Maybe it is time we start looking at setting up a Section of Civil Forensic Psychiatry and go our own way?
The New South Wales Workers Compensation Commission is seeking applications from suitably qualified specialists wishing to be appointed as Approved Medical Specialists for the Commission to undertake assessments of general medical disputes and disputes about permanent impairment. Appointments to the panel of Approved Medical Specialists are made by the President of the Commission. Approved Medical Specialists are required throughout New South Wales, including regional and rural areas and in a range of specialties. An information package outlining the selection criteria and selection process is available on the Commission’s website at www.wcc.nsw.gov.au. Applications close 9 September 2015.