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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 25-January-2008, Vol 121 No 1268

Mind games (continued)
I am indebted to Professor Roger Mulder for his lucid analysis of the situation regarding the psychiatric service. See his response to my first letter published in the previous issue of the NZMJ (http://www.nzma.org.nz/journal/120-1267/2882).
I was looking at it from the point of view of a GP who remembered better days. Effectively, the collapse of private psychiatry triggered my exit from medical practice. In recent conversations with active GPs, I have learned that things are as bad as ever around Wellington, and they are a source of considerable anxiety to them.
Whilst Professor Mulder summed up some of the difficulties, I am hoping he may be willing to help us with two further points.
  • With almost all psychiatrists now on the State payroll, it would enlightening to know just what sort of lure any one of them would need to leave the public hospital that employs him/her, and take up private practice. Since the practice of the specialty does not require a lot of expensive equipment, we could make some valid deductions if we knew what a consultant psychiatrist thought the hourly rate for the job ought to be. Every practicing lawyer knows, so why shouldn’t they?
It may be that private practice is of little interest nowadays, but there are a few doctors doing it and we need a few more. What would they expect to earn?
  • I would also welcome Professor Mulder’s view on another problem. That is the certification of mentally ill patients. Many years ago, any GP could (with the assistance of a colleague) certify that a patient needed to be detained in a mental hospital, until such time as a psychiatrist took the next step and either permitted the discharge of the patient, or recommended a longer stay and more thorough treatment. Both in my private practice, and in my work as a police surgeon for the city of Wellington, the system worked perfectly.
Somehow, somewhere, somebody decided that GPs were incapable of identifying even fairly severe degrees of mental disturbance, and their rights in this area were terminated. With their habitual lack of courage, the GPs made no protest, but the police, who often cope with the frankly homicidal and the grossly deranged, were subjected to a lot of extra trouble and difficulty.
On a number of matters there needs to be more dialogue.

Roger M Ridley-Smith
Retired GP
Wellington
(r.sdekka@actrix.gen.nz)

Response from Roger Mulder (Professor of Psychological Medicine and a NZMJ Subeditor)

Dr Ridley-Smith is correct in his view that the lack of private psychiatrists is a source of considerable frustration for GPs. However, I do not think there is a simple solution to the problem.
One part of the difficulty may be in financial reward but possibly of more importance is the lack of collegial support and the absence of facilities to arrange private admissions. Performing one-off assessments for third parties such as ACC and insurance companies circumvents these problems but leads to a less than satisfying practice which most psychiatrists would only wish to do in a very part-time manner.
Private psychiatric practice in Australia thrives because payment is via the government; there are large group practices, and ready access to psychiatric beds. In Australia the case might be made that public psychiatry is suffering because of the success of private psychiatry.
The balance is very difficult to obtain. I suspect it would require major changes in funding and attitudes to obtain a critical mass of psychiatrists who would be comfortable working largely in private practice.
As to Dr Ridley-Smith's second problem (certification of mentally ill patients) I do not feel qualified to comment on changes in the Mental Health Act. I have some sympathy with his view but he would need to contact those involved in changing the legislation to understand the rationale behind it.

Roger Mulder
Professor
Department of Psychological Medicine
University of Otago, Christchurch
     
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