A little piece of mental health reform

Part one

I sat looking at the Minister of Health, and I could hear what he was saying, but it seemed so wrong; such a bad ending to a huge effort to make things work better for people affected by mental illness. ‘Sorry David, but we have no choice—we need a circuit breaker for a situation that’s got out of control. You are being dismissed today. You will be suspended on full pay while we consider if there is alternate employment for you in the public sector.’ My part in the change process was closing, at least for a few years, and there was no way left for me to cling to the wreckage of a good and necessary plan.

Four years earlier, in 1988, I had moved out of my childrens’ welfare job to become Director Mental Health Planning for South Australia. The drive towards better services in the community had stalled, and the incumbent was being asked to move on. She actually dug in—locked her office door and refused to give back the key. As so often, big bureaucracies are paralysed in the face of the unusual, and she got away with it for a couple of weeks while we all waited. A year or so later, she and I were to become good friends, partly because I had come to appreciate the obstacle course on which she had stumbled and fallen.

Prima facie, the logic of reform was simple. Most patients were now ex-patients, but the hospital resources, mainly staff, had not followed them. The move out of institutional care had begun twenty years before, as the availability of new drugs combined with new policies of ‘least possible restraint’ began to create new options. In Adelaide, the patients had morphed mainly into ‘psychiatric hostel residents’, moving to suburbs with plentiful supplies of large old private homes that were converted into boarding houses. I came to realise that many of these were cheerless, crowded places ruled by untrained owners who treated their paying clients like unruly children. Each week-day, residents could take the special bus back to the mental hospital they came from, to attend a day program for a few hours, and see their psychiatrist as required.

As a first step in the 1960’s, this had seemed like a revolution. By the time I came on the scene, more than 1000 people who had been inpatients were living out of institutional care. But in 1988, almost everyone involved agreed that these people and many others with severe mental illness had a right to much better community-based options, and we knew this would involve extensive support being available to people wherever they wanted to live. The zeitgeist across the Western World was for more and better ‘de-institutionalisation’, and in South Australia we were determined, as always, to claim our place as reformers delivering ‘world class health care’. I was to find that was a pretty vacuous phrase when it came to describing in detail what funders, practitioners, and individuals and families affected by mental illness actually wanted to happen.

I began my job, as senior bureaucrats so often do, by touring the country looking at progress across Australia. My predecessor, and the CEOs of both our mental hospitals, had done world tours, so I can at least say my junkets were modest affairs. I read widely and corresponded with leading figures in this movement internationally. My conclusion was that we were about in the middle of the reformist pack; well ahead, for example, of most states in the USA, but a long way behind some European countries and two states in Australia—New South Wales and Victoria. In at least some inner metropolitan areas of Sydney and Melbourne, resources were being moved out of mental hospitals into community support teams, and significant new funding was being added to speed up the process.

Everywhere this change was being attempted, the forces of resistance made themselves obvious. ‘Mental patients on the streets’ and similar headlines ratchetted up public fears, which in turn made politicians nervous. The various unions representing everybody from cleaners to doctors to social workers, nurses and administrative staff all said they were in support, as long as none of their members had to be re-located—which of course they did. In South Australia, the government, specifically the Treasury, wanted to close wards in mental hospitals to save money, not to spend it on new services if they could help it. And psychiatrists as a group were determined to control the whole game, always saying ‘Of course we all have the welfare of patients at heart’, while going slow on most efforts to achieve the real change needed to deliver on that welfare.

One psychiatrist, who was also CEO of one of the mental hospitals, was proud of what he saw as ‘One of the best hospitals in the world, and certainly the best in Australia’. His major pre-occupation seemed to be obtaining the term ‘Royal’ in front of the hospital’s name. He had the coat of arms approved by the English College of Heralds on display in the board room, and said it was only a matter of a few months before this honour would be granted by Her Majesty. So when I said that his hospital was staffed for about 1000 patients, but had no more than 200 on most days, and that this could not be allowed to continue, he saw the beginning of the end of his proudest achievements. No matter that he had to agree that 750 or more staff attending to 200 patients looked like a major misuse of public resources. Putting his hospital’s ‘world’s best practice’ at risk was not something he could even think about.

His solution was to propose a ‘beehive’ model, where most of the staff, and certainly all of the 70 or so medical staff, would continue to be based in the hospital, but buzz out to the suburbs visiting community clinics, where their patients would be waiting. All the interstate and international reformers I was talking to said it was crucial to base the staff in the communities where the people with mental illness actually lived. This was not just about being more available; it was also a necessary disruption of the narrowly medical views of mental illness that life in a medically-run institution will inevitably lead to. The ‘bee-hive’ model was likely to be more of the same with a bigger car-fleet. I said that, more or less, and we locked horns from then on.

We—my little team and all the affected ‘stakeholders’–stayed stuck in fruitless debate during 1989 and 1990, writing ever-more detailed descriptions of a future system, while working parties, task forces, steering groups and reviews proliferated. Health bureaucracies can spend amazing amounts of time, and prodigious sums of money, while doing very little to deliver better health services to actual people. My bureaucratic bosses were reluctant to generate a brawl with the unions, especially the medicos, and I could see that the leaders of psychiatry were not too worried about the risks to their status quo. My job had seemed like a great opportunity to help achieve important change, but by now I was feeling rather impotent most days. Two years of no real progress was beginning to make me wonder if I was part of the problem.

One day I was invited by the unofficial patriarch of psychiatry in South Australia, a professor at Adelaide University, to come and ‘have a good chat’. We sat in his office, and he asked me to explain what I had in mind for the future of mental health care. By then, I could do that without notes for as long as required. He listened for 10 minutes or so, apparently with rapt attention, then said ‘How interesting’. I wasn’t sure what that meant, but he jumped up and said ‘Come and meet a few of my colleagues’. We walked along a corridor, and came to a door which he opened and ushered me through quickly. We were on the stage of a large lecture hall, and serried rows of doctors and nurses, perhaps 100 of them, were waiting for their special guest, me, to speak at their ‘grand round’ for the week. The professor said, ‘Ladies and gentlemen, let me introduce David Meldrum, who has some interesting plans for our future. I’ll leave him to explain them to you.’ Then he sat in the front row, and smiled up at me innocently. He had given me no warning, and he knew it. It was a blood-freezing moment.

After what may have been five long seconds, I went for it, thanking them all for taking the time to come to listen. I talked about the basics, which I knew most of the younger doctors would at least be curious to understand, although most of them were going to leave the public system as soon as they could in any case. I stuck to a few real examples of individuals and families affected by mental illness who were doing it tough without community supports, and tried to stay away from statistics. After about 15 minutes, I noticed that the professor’s face had turned to stone, and I knew I was making progress. The questions came thick and fast, the most insightful ones mainly from nurses. As so often, it was more about ‘What’s in it for me?’ than ‘Will this deliver better services?’ After 30 minutes, people started leaving, so I wrapped up quickly with an invitation to talk more any time. The professor walked off, leaving me to find my own way out.

The next week, I was asked to come to lunch with four professors of psychiatry including my tormentor from Adelaide University. All went well with social chit-chat until their spokesperson said ‘We have been discussing this reform process David, and we want to offer you our full support, as long as you agree to work closely with us as your sounding board. Some of the suggestions you’ve made, like leadership by health professionals other than psychiatrists just aren’t going to fly, unfortunately, but in general we think you’re on the right track.’ I made some vague commitments, and it ended awkwardly. But they hadn’t finished yet. My ‘mole’ in the professors club told me they spoke after the lunch, and decided ‘We will let it run for now, keep an eye on David, and if we think it has to be stopped, we will make sure that happens.’ They would get me later on, but they would fail to turn back the historical tide.

This was early 1991, and a few months later the Government announced a ‘World class mental health plan’ for South Australia. We would largely close one mental hospital, and relocate the remaining patients to the other. There were more than enough beds for this to work. About 350 staff positions would be freed up for transfer to community teams around the state. 80 hectares of the hospital’s land would be sold off for housing estates, creating the capital for more community clinics and regional hospital mental health beds. Given Adelaide’s compact footprint, there were no real issues about access for families and patients, particularly since we were opening mental health wards in four general hospitals at the same time. The idea had to be kept under tight wraps until it had been thoroughly kicked around with my bureaucratic colleagues, and Treasury officials, and of course the Minister of Health. I spent time with a communications consultant who made me identify everyone who might have the ability to publicly support or criticise the plan, and it was my job to work my way through that list, talking to all of them, making sure they had a chance to be briefed in confidence just before it was made public.

The strategy was very successful, and for a short time we even had the newspapers on side. This was always going to be fragile, because it’s mainly conflict and fear that excites reporters, not social justice and better use of public money. The professors struck again, getting an audience with the Minister of Health. They were discomfited to be ushered in to find me sitting beside him, but ploughed on with a denunciation of the whole process, ending with the ‘shroud waving’ (‘Inevitably some patients will give up the struggle Minister’) that some doctors do so well. The Minister promised to thoroughly review the whole plan, then bade them goodbye. As soon as the door was closed he turned to me and said “David, was that the shrill cacophony of professional self-interest, or the clarion voice of the end user?’ I said I thought the former, and he said ‘I thought as much’ and asked me to press on with the plan. There was to be no review. With this guy in charge, I was in for a period of real progress.

Next the really scary bit. Death threats, aimed specifically at me, began. For a time I had an unmarked car, a silent phone number, and cop cars regularly cruising past our house. One incident began as a bomb threat, causing the evacuation of health headquarters. A phone caller told the terrified telephonist that the bomb would go off soon, and that it was aimed to ‘Get Meldrum’. An awful moment was coming out of the door on to the street and a colleague saying ‘Keep away from me David. I don’t want to get shot, it’s you they’re after.’ Walking across Hindmarsh Square in the open made me light-headed with fear. A colleague, one the good-guy psychiatrists, asked me who the threat was to, and when I said ‘It’s me’, his eyes widened and he stood beside me with his hand on my arm. Very brave. I rang my wife and told her to go to her mother’s place. She wouldn’t take me seriously, and I had to be more forceful than I wanted, which scared her enormously.

I thought the hospital staff were probably where the threats were originating, so I started going there in person, to talk with anyone who wanted more information. In the first ward I visited I was ‘sent to Coventry’ with all staff turning their backs on me. In another staff room I found a dartboard with my face on it, heavily punctured. To break this cycle, I upped the ante, and moved into the hospital. It was pretty ugly for a week or two, but gradually the word got around that I really did want to hear from everybody first-hand, and the oafish behaviour stopped. I often wandered the grounds, chatting with gardeners, patients, kitchen staff and health professionals, who all wanted to know what their future options would be.

At about this time, the hospital CEO came to see me in the rat-hole office they had found for me. He was agitated and hesitant at first, then blurted out, ‘I think I’ve been wrong David. What you’re proposing makes sense, and I am going to support you, at least till I can secure a job elsewhere.’ It was clearly agony for him to do this, but I didn’t take much notice of that. I thanked him profusely, and talked non-stop about what was going to happen next. I was feeling triumphant; my nemesis had seen the light, and I was going to have a great success. He left quietly after only 15 minutes or so, and I couldn’t get on the phone quickly enough to tell my bosses that all was well. It shames me now to remember what I found out months later. At the time he came to see me, his son had recently been diagnosed with schizophrenia, and he was being driven close to his own breakdown by his son’s rapid decline into un-remitting psychosis that would lead to a locked ward for years to come. Pride comes with a set of blinkers that stopped me from a chance to help a good man in great distress.

Part two

The two hospitals and several community clinics had been completely independent for many years. Now a new state-wide organisation was formed, the South Australian Mental Health Services (SAMHS), which included hospitals and all the new community teams we were going to establish. I was much involved in that of course, so it was a bit uncomfortable applying for the CEO job that I had designed. Was I being impartial in proposing a new and powerful role? Mostly yes, but I did think about what a great career move this would be for me. My defence is that I didn’t expect to win it, because I knew there would be keen competition from across the nation. But I did win. With invaluable help from an ‘executive search’ consultant, I slightly re-invented myself (beard trim, new tie and belt, new shoes and a plan to win over each member of the panel) and I aced the interview. Since my current job would no longer be needed, after only a week or so of giddy pleasure while I negotiated a salary and conditions, I became the first CEO of SAMHS. I had a great salary, a new and rather luxurious car for work and personal use, and a much-coveted Motorola Microtac mobile phone, the best boy’s toy around in 1992.

And then it was down to the real work of closing a large hospital, moving about 170 patients to new accommodation, and finding new work or severance packages for hundreds of staff. For a couple of months there was a honeymoon period, where everybody could be involved in the planning if they wanted to be. But as the first ward closure grew near, a couple of the unions began to demand delays until they secured better pay-outs for their members. The Opposition in Parliament began to side with anybody who wanted the hospital left open, and they found no shortage of disgruntled staff who told them what they wanted to hear. My main concern, given that an election was not too far away, was that the Opposition might dig in and say they would scrap the whole process if they got into power. And it was so easy to frighten the public with the spectre of dangerous ‘mental patients’ roaming the suburbs, homeless, unsupervised, and unable to control themselves. In those days, public servants like me were strongly discouraged from talking directly to the Opposition, so it was difficult to build trust with them. I did break the rules and make a few useful contacts, but not to the level where favours could be called in when needed.

The biggest of many problems was the flight of doctors. At the start of 1992, there were about 70 full and part-time medical staff, with 33 in the training program for psychiatrists. By June there were less than half both of those numbers, and by November, a quarter. A dozen or so medicos were not going to be re-located, as they ran the older persons inpatient and day programs, for people with severe dementia. Those wards are still there, doing incredibly difficult work for few of the rewards enjoyed by other health professionals, especially psychiatrists. For the 18-65 year-old inpatients, the availability of medical staff, which had previously been in almost ludicrous over-supply, had now reached the point where it was touch and go maintaining good practice. I think we had about a dozen full time medical staff by the end of that year. As one doctor said, it was ‘tight, but do-able’. The medical officers union disagreed stridently, and found it easy to get the media interested. For me, the second half of 1992 seemed an endless round of negotiations with doctors and press interviews which almost never had a good result.

The best parts were the inputs from the fledgling consumer and carer groups, who were enthusiastic backers of the new community services. There were many bleak days when their voices were the only unmistakeably positive sign that the direction was right. I made friends there that I have today. I think that is largely because I regarded the end users as the true owners of the resources we were re-directing, and I told them so. Another bright light was those brave individuals who risked ostracism from their various professional tribes by publically supporting the pending changes. I know one who was physically threatened; told to find work somewhere else if he valued his safety. I had to find him a job in head office, but he suffered from PTSD for some years as a result of this thuggery. Others stuck it out, joining the planning groups and workshops that gave anyone a voice if they wanted it. The ‘Metropolitan and country areas mental health plan, 1993-1996’ was their plan, not mine, and it outlasted me to become a reality.

Nationally, the federal government was finally playing a useful role, after decades of pretending that mental health was nothing to do with them. The First National Mental Health Plan, which I helped to write, became the first of five five-year plans so far; documents that have been the backbone of mental health policy in all states and territories since 1992. I mention this because the South Australian reform process was completely in line with the first plan, which helped me to win many an argument.

By about September 1992, I knew my days in the top job were numbered, despite being ‘on time and on-budget’. Industrial action was accelerating, and the sugar-rush of positivity that each new service opening brought seemed to last only a few days before the next rounds of antagonism and new demands. This was no surprise—six of my interstate counterparts had been sacked or resigned under pressure in the previous 12 months. This was high risk work. But knowing that clarified my mind and paradoxically calmed my nerves. I decided to go for broke while I could, making every day one of irreversible change for the better. When wards were emptied, and the patients re-housed in other hospitals or new residential facilities in the suburbs, I had the old buildings bulldozed immediately. I froze filling of staff vacancies in the hospital, while accelerating appointments in the new community services. And I checked in as frequently as possible with the Minister and his staff, to be as sure as I could that they had my back.

That September, there was a double blow. The Minister of Health resigned suddenly, because of his wife’s poor health. His replacement knew nothing about mental health and seemed to care even less. I couldn’t even get a meeting with him, which was unnerving. In the same month, the long-serving Chairman of the Health Department, my bureaucratic boss, retired. These two had been steadfast true believers and wise advisors to me for the last three years, but from then on, I was on my own in the corridors of power. With a Labour government, and every union in the health sector declaring their lack of confidence in me, each complaint to the Minister became harder to deal with. Although the transfer of patients was nearly completed, and new services were opening in the community every week, I sensed that it was mainly inertia keeping the process going; inertia that would be swept aside if the political and industrial cost increased.

The Leader of the Opposition was having a field day. One day in November he came to the hospital and demanded to meet with all the staff. I rang my boss, but he refused to come to the phone, relaying a message via his staff for me to ‘Deal with it as best you can’. So I met with the man who the next year would become the Premier of South Australia, and told him he could not come into the hospital, although I was happy to meet with him any time in his office. His chief of staff spoke to me quietly while we waited for the official car. ‘We have long memories you know David; a bit of cooperation right now would be in your best interests’.

A few days later, the combined unions asked for a meeting of all staff in the hospital, except those essential to patient safety. I agreed as long as I could speak to them, and I again refused to allow the Leader of the Opposition to attend. He was not a legitimate player in an industrial dispute.

I was asked to stay outside until my turn to speak. I could hear people yelling and singing union songs about solidarity, as one union leader after another warmed them up. I walked on to the stage to loud booing from about 500 staff, noticing that my legs felt wobbly and my chest tight. The cat-calling continued for a raucous minute or so, until one very loud voice in the front row called out ‘Come on, he’s got guts coming in here, let’s at least let him his say his piece and go’. From then on it went well, because there were good answers to every question raised, and the heat in the room gradually faded. I thanked them for the opportunity to speak and left a quiet room.

But it was all too late. The flashpoint came early in December, when a doctor was stabbed to death in the hospital, by a patient she had been seeing for several years. It was awful, and we were all in a state of shock. The unions, especially the doctors association, decided this was the last straw, although her death had nothing at all to do with the closure of the hospital. I was warned by colleagues not to walk around the hospital re-assuring staff, because it was somehow my fault, and feelings were running high. A day later my bureaucratic boss called me and suggested a retired psychiatrist, who I knew disagreed with the whole process, should become my ‘co-CEO’ immediately. I said no, and to no-one’s surprise I was called to the Minister’s office the next day. Finally, I got to meet him, and his first and last words to me were that I was sacked. I could go back to my office, farewell my colleagues, and leave that day. I had been in the CEO’s job for 11 months. I found out the next day that the four professors of psychiatry had an audience with the Minister the night before, and persuaded him to be bold in this dark hour. It took a while, but they got me.

Because I fully expected this outcome, it didn’t hurt much. I was more concerned about my planning team, who were likely to find their colleagues turning on them next. I kept in touch with each of them, and the Human Resources boss in head office helped to make sure they were all OK. I was sad, but proud of doing a difficult job as well as I could. I had known what I was signing on for, and I had been well paid. It was a privilege to be really useful to thousands of people affected by mental illness. The hospital closure would be completed in the next three months by my successor, who talked to me frequently, although he didn’t mention this to anyone else. I knew I could re-build a career somewhere that mattered to me, so the important thing was the chance to see a modern mental health service being born. All the conflict, time-wasting politics, report-writing, setbacks and scary moments seemed pretty insignificant compared to that. They still do.

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