In Australia, moves are afoot to review and implement changes to the mental health services and programs on offer – including those offered to young people. Change always produces some tensions, and that will be the case again in this situation… but something had to give… change was needed to see equitable improvements, and none more obvious than for rural young people with mental health problems. So here we go – join me on the slippery slope of mental health care reform roller coaster!
The media have labelled the staged funding reductions to early psychosis services as “Futures will be lost. Health fears as youth pychosis program dropped” Read about it here: http://www.smh.com.au/federal-politics/political-news/futures-will-be-lost-health-fears-as-youth-psychosis-program-dropped-20160429-goi1hu.html
This begs more questions: The future of who…? Who will be advantaged…? And, who will be disadvantaged…? How do we achieve fairer and more equitable care for all of our young people throughout Australia? There are no easy answers or solutions… to suggest there are is to reveal a flippant disregard for the complexity of meeting the mental health needs of young people today.
I’m an optimist…
I hope that the government have got this right… and that a redistribution of youth psychosis program money will benefit young rural people more equitably as a result… Of course, advocating for the equitable mental health needs of young rural people has been my long-term professional activity of mine! So, I can only hope that this new direction to send funds to the primary health networks – will in fact work for rural and regional young people where the gaps are larger! There are some risks to note. For example, how will people be mobilised from their comfort zones to take up work in new geographical regions…? Will this be supported in the recruitment of appropriate servicing of populations? Will it really be equitable? Or just equal? Will health professionals be contracted using brokerage models as they are ‘commissioned’ for services? And, if they are, how will this new model ensure that health professionals are able to be fully employed at reasonable pay rates, in keeping with their level of expertise? How will we mitigate the risk of under-employment of people in low population communities yet maintain equitable service levels? How will the ‘gaps be filled’? Has this been fully considered?
I don’t think that the new approach to funding of youth mental health care this is such a bad thing for rural and regional young people. I have been calling for a more equitable and inclusive distribution of the mental health dollar for many years now… (eg https://www.researchgate.net/publication/275340216_Rural_nurses_A_convenient_co-location_strategy_for_rural_mental_health_care_of_young_people )
… it has not always made me popular…
The harsh reality is that rural youth often have much longer durations of untreated mental illness, poorer access to mental health services and poorer prognosis as a result… And, the largely urban-centric models of specialist youth mental health care have not met the demands for rural youth with mental health care needs. Something needs to give a little… perhaps this new funding model will be it… But – it needs to explain how it will include nursing expertise to promote mental health among young people at its core… Because, nurses are already there in all communities… and they represent a present resource that can be better engaged in primary care.
How will nurses be engaged in the primary mental health care of young rural people? The role of nursing in the models of care continues to be vaguely described at best in current strategy offerings… Only using nurses for managing chronic care (ie the Mental Health Nurse Incentive Program) is a sure-fire for short-changing the mental health of young people… becasue… young people have simply not lived long enough to have ‘achieved’ chronic mental illness status… rendering them ineligible for government supported nursing care in the main! Thus, how will this new model of funding utilise the expertise of nurses to deliver primary mental health care to young people and mitigate the early identification and intervention end of the care spectrum problems? Remembering of course that nurses make up the largest proportion of health professionals representing and the largest proportion of human resource for mental health service delivery throughout the country? Nurses need to be a large chunk of the journey towards successful new models of care – yet they seem to be overlooked in the latest iteration of change. Why?
I am not yet convinced the the Primary Health Networks will be the solution… but I am prepared to be open-minded about the possibilities… I hope we are seeing the beginnings of something substantially more useful than reshuffling deck chairs. I think closer federal collaboration with state health, education, family and community services and police/ justice services will bring more profitable benefits. But, while a two tier government approach persists in mental health service delivery (Federal and State/s), problems in administering equitable services will also persist with bureaucratic double-ups inevitable, ultimately soaking up some of the direct clinical and research spend potentials.
I agree with McGorry, that many gains have been achieved through the concentrating of specialist expertise in a small number of specialist services, and that it would be a shame to lose this. But, having built this considerable national human resource – if it were mobilised and dispersed across the country (for example, the experts geographically relocated) this have a benefit of authentically redistributing the talent and in doing so benefit more people over time. Is it time to mobilise the specialist population for greater good in health service delivery? A question for health geographers and health ecologists to ponder. Will redistribution of funding trigger a wider set of conditions in communities such that mental health is more effectively promoted? I think that this is possible: https://www.researchgate.net/publication/280134451_Rural_Mental_Health_Ecology_A_Framework_for_Engaging_with_Mental_Health_Social_Capital_in_Rural_Communities
It is not all bad news, a new model could bring with it ‘catch-up’ conditions to more vulnerable and harder to reach young populations who should have convenient access to local mental health support where and when they require it. The challenge is for mental health professionals to work together using digital technologies to bring us together, it is after all what we expect of our clients these days! That is, to be satisfied with e mental health/ telehealth and digital gateway (triage) delivery….
Perhaps health professionals will also need to adapt our practices in the ways that we work and collaborate with each other – building virtual centres of excellence rather than geographical catchments of excellence. In doing so, some castles will be dismantled – and new ones will emerge… shifts in the sands of time across the landscape of mental health service and evidence development and delivery are inevitable.
It is clear that the health budget in Australia will never be able to fund sufficient levels of mental health service delivery for Australian young people – our present budgets don’t go near sufficiency. Finding ways to squeeze a few extra drops of oil out of the rag are always going to be critical… the challenge is out for mental health researchers to be prudent in devising ways in which we can continue to do more, with less, and for politicians and policy makers to take heed of evidence as it emerges… And finally, for clinicians to be ready to adapt to the changing times as they evolve. None of that is easy!
Relevant other links:
I heard a leading rural public health professor speak last night (at the Robb College (@robbcollege) annual Health Lecture and Dinner – University of New England @healthune) about the challenges and opportunities that exist in rural and regional health in Australia and across the world. I was spurred on… motivated… inspired… to keep pressing forward in contributing to rural health progress. Professor Ian Wronski, Deputy Vice Chancellor – James Cook University, shared some of what he has learnt along the way while working in public health in rural Australia.
Some of what got me thinking…
- When you get stuck without many resources… try new things!
- Rural politics… often not enough marginal seats to attract funding and resources…
- Sustainability in the primary care workforce is vital for the health of rural communities. Not limited to a sending-in style of health care delivery… but embedding and internally generating health workforce within rural communities.
My entire health career has been played out in rural committees… These three points struck a chord with me because they aligned with what I know of rural communities. A dollar, please, for every time I have had to innovate my practice because the oily rag needed to be squeezed a little tighter!
Trying new things is something that rural people are good at! Using our strengths! That is, the skills that are so much second nature to us that we sometimes forget that they are indeed special skills. Trying something new, and finding a way to make something work, finding the work-around solution, finding a new way using the resources we have at hand… that is innate rural culture. That is… what rural people do extremely well… but of course – there are limits!
Rural people conduct themselves resourcefully. They are not wasteful of resources because they work hard to obtain the resources that are carefully matched to the needs, ensuring they get the last drop of ‘oil out of the rag’. They make do! Where I grew up we had one (thinking back – very small!) water tank to collect rain water for household use. Nobody wasted a drop – it was valuable, it was used wisely and recycled where possible. Never a tap was left to drip… the sentiment permeates and translates to rural life and culture in general. I think these are key characteristics of rural people and communities, and these attributes help to make up the social capital and the human ecology of rural communities. I have written a bit about that... and have explored the contributions that nurses in particular make to the mental health care of young rural people.
There is something to be said about the dynamics of rural politics though. Political pressures underpin resources allocation for public health and especially in regard to mental health of rural people. The national and state spend on rural mental health (or mental health generally) is consistently poor. Nationally this bears out with a stable suicide rate over the past ten years – not a reduction… but rather a complacent stability, with rural communities bearing a disproportionate burden. The reality is that many rural political seats are ‘safe’… and one of the limitations that is associated with this political condition impacts adversely on public health resource allocation. It is a bit like the water tank of my childhood never benefiting from sufficient rains to fill it up… and for us constantly monitoring the water level by tapping the sides of the tank to listen for the tympanic changes to signal volume levels. Worrying about how much water was left and guessing how far it might need to go before the rain came again… reducing our use to reflect the remaining residue, and not having enough to do anything extra. I could still show you the corrugation groove around the one third full mark that changed the mood in our family to austere use of water and restrictions for our family – indelibly marked in my psyche! When the rain doesn’t fall in the rural mental health budget – there is never enough resource to do the prevention, mental health promotion and early intervention care because those elements of health care provision can be thought of as when the tank is only one third full – so restrictions need to heeded and the valuable resource only used for the most serious circumstances – often too little, too late. But – in marginal seats – it appears that the weather forecast is often more promising… Try someone new might be a good rural political slogan for the future… ?
Professor Wronski had Six Tips to enhance rural public health:
1. Invest in locally driven solutions because local proximity to the problem drives finding solutions. (Rural people are close to the problem so they are likely to also be close to the solution)
2. Take intellectual risks. (Think about things and then do things!)
3. Use evidence to drive decision making. (Not whims and hunches… but take the time and effort to generate and gather the evidence – then apply it!)
4. Fail fast and use it to learn from. Then, Retry, Retry and Retry again. (Fail fast… I like that… but don’t give up especially if you are doing 3 & 4 above… learn more – try again… love it!)
5. Facilitate collaboration and co-creation. (Working together)
6. Identify scalable solutions that will have disproportionate impacts as you scale them up. (‘From little things – big things grow’)
A lot of good advice! Some good signposts for keeping public health on track – out back!
A colleague paramedic ( Buck Reed ) has just published a paper about rural people and use of the ambulance…. his research showed that rural people are less likely than urban people to call the ambulance… there is a disparity between urban and rural… why might that be? stoic? cost? rural people help other rural people in need more readily? rural people don’t know when it is appropriate to use the ambulance? stigma?…. I am wondering why there is a gap!!!! Thanks Buck for the heads up on the gap…. and for helping us understand rural health needs better!
Here’s his paper: http://ajp.paramedics.org/index.php/ajp/article/view/142/241
Nurse bloggers… hadn’t thought of myself like that – but I guess I am!
I had an email from a journalist – Dallas who asked: “I’m writing a feature on nurse bloggers. I was wondering if you would be able to answer the following questions for me:” I thought the best way for a nurse blogger to respond – was…to…blog! So here I go… (challenging the frontiers of journalism and nursing… at the same time I guess!)
• What led you to start up a blog?
I started my blog https://rhondawilsonmhn.com/ Rhonda Wilson MHN: Rural mental health nurse, just before the last federal election. I had previously established a professional digital profile across a number of other social media platforms (eg Twitter, facebook https://www.facebook.com/ruralMHnurse, LinkedIn, ResearchGate) and I had watched a number of other nurse bloggers from around the world for sometime too. What I noticed was that a blog provided an opportunity to contribute to a nursing conversation, and to participate in and initiate conversations about nursing/health broadly, but rural mental health nursing specifically. At that time I was particularly focussed on contributing to a rural perspective on the delivery of mental health care to rural people, and I wanted to ensure that I had done what I could to advocate for a fair representation for rural people to have good quality mental health care when it was needed; especially, for young rural people. I think it is an important professional responsibility for nurses to advocate for the health of people in their community – for me that is advocating for rural mental health care. The blog gave me a new way to advocate. Since then it has developed further to bring together conversations about rural mental health on a wider range of topics.
• What do you post on your blog and why do you choose to discuss these types of things?
I try to blog about real life situations because that brings an authenticity to a conversation. I use to think that rural nursing was not very important –and nurses in big metro hospitals must be better than rural nurses… because everything we do seems to be on a small scale in the bush, and we don’t have as many resources to draw from. That belief affected my confidence to some extent, and it has taken a lot of study and practice to come to the realisation that rural nurses are very often the backbone of health care delivery in rural communities – that nurses are a critical social and health capital in rural communities. We are often not seen in upfront roles, and we are sometimes not valued for the important contributions that we make… but rural nurses are the glue that holds health together in rural communities. We are very often specialist generalists. We can cover all bases and do it well… I have only ever worked in rural and regional communities and if you need advanced life support – I can do that, if you need a scrub nurse for an emergency caesarean – I can do that. If you need triage in emergency – I can do that. If you need a paediatric nurse – I can do that. If you need a palliative care nurse – I can do that. If you need someone to home visit and do a dressing on a leg ulcer – I can do that. If you need a drug and alcohol health promotion at the local high school – I can do that. And, if you have a young person with a escalating psychosis – I can sort that too! Rural nurses have skills sets that are eclectic and valuable – different to urban nurses – but critically important in their rural communities. I thought it was about time that rural nurses started to speak up – a blog helps me to do that and to tell the stories of rural mental health nursing in a down to earth way.
• Does it bring about any benefits for you personally or professionally?
I think broadening your network and respectfully listening/ reading and talking/ contributing to conversation about rural mental health brings both professional and personal benefit – but not in any tangible sense. Blogging helps me to reflect on my practice as a rural nurse and when other engage with my blogs (and other social media), then that has certainly been useful. The feedback from others has helped me to continue to develop as a professional nurse, and it is that conversation and dialogue with other nurses and health workers that is particularly valuable. Twitter (micro blogging) has brought some professional interactions and introductions that have been especially useful – networking at conferences, or with colleagues internationally has been great. I have one research project team that developed purely through Twitter interactions… the possibilities are endless. I have published a bit about nurses and social media too – I think it is an area of health progress and I wanted to bring some evidence to support new practices – so I have began to work in e-mental health areas – a new health frontier. I don’t know what opportunities might arise in the future – but I am a keen e-pioneer I guess!
• Would you suggest other nurses create their own blog? What opportunities can doing so open up?
Yes – I think nursing has incredible potential to influence health and well being of people everywhere using social media and blogs. My advice – start out my lurking (respectfully) for a while – checking out what other nurses are doing in the field. Then, figure out where your own niche is… what do you have to contribute to the disciple? Set up a professional digital footprint… If you want to know how – check this out https://www.researchgate.net/publication/257458308_Nurses_and_Twitter._The_good_the_bad_and_the_reluctant
This paper is a guide to help people figure out how to use social media in health disciplines and it makes some suggestions about how and why it is useful. A stong – ‘get on board’ message to nurses everywhere.
• Is this something that you see becoming more common among nurses?
I hope it becomes more common! I think that nurses contribution to e-health generally has a great deal of scope to do a great deal of good, in every corner of the world. Nurses should be prominent in the cyber community – because that is where people are increasingly hanging out – we nurses should go to the people with messages of health and well-being – it is the very heart of what we do! Never too old – if you don’t have a profile somewhere get one!
Please feel free to add any extra comment
Nurses who have been in the discipline for many years are sometimes reluctant to engage with social media. They are sometimes daunted by the unstoppable force of the internet. There has been a lot of bad press about the bad things that happen in cyberspace – (eg bullying, trolls etc). But, setting up a professional digital profile is much safer. What it takes is using common sense – behave in the cyber world professionally, and you will attract professional networks and conversations. Don’t engage with people who behave badly and with trolls and they won’t bother you. Other professionals will engage with you based on how relevant your posts are to them – play nice! If you don’t – no one will play with you. Be mindful of your code of conduct and stay within the flags!
I hope those responses to Dallas’ questions are of interest to others too! Good questions – thanks for asking! Cheers!
Big Hits & Near Misses: Developing Patient Safety & Culture
A shout out for my rural health & law friend and colleague – Donella Piper. Donella is a terrific advocate for quality and safety in health settings – a topic that I think is extremely important for rural communities.
The School of Health at University of New England, Armidale, NSW Australia, is hosting a symposium to address patient safety. Symposium Convener Dr Donella Piper has drawn together some leaders in quality and safety for health care in Australia. Quality and safety issues are critical issues for rural and regional health practitioners to consider carefully. Rural and regional health care consumers in Australia should expect to encounter high levels of quality and safety when they, or people they love, need to access health care in their local rural communities.
Quality and safety in regard to rural mental health care is a particularly important aspect in my view…. rural people tend to be grateful for lower levels of health care provision, and have lower expectations of service provision than their urban counterparts…. a trend that should see some change! People (regardless of locations) should anticipate quality and safety as a minimum standard of care…. and health care organisations and practitioners of all descriptions should strive to improve and develop the standards of care. Our rural people and practitioners should anticipate best practice, evidence-based health care all the time – a continuous changing dynamic.
I think it is exciting that we rural health practitioners have the opportunity to attend and discuss these issues in a rural and regional location and to advocate for the continuing development of patient safety in our own rural settings. Check this link – and try to attend, or send it on to someone who should!!!