When the final report from the Royal Commission into Victoria’s Mental Health System was first released, I had lots of initial thoughts – some positive, some negative.
But the area where I felt most disappointment was workforce.
At the time I planned to write something summarising my thoughts, but life got away from me. Since the report was published, I’ve now been involved in a number of conversations into the next, and most important, stage – how the recommendations are enacted.
And time and again, no matter what system issue we’re discussing, the conversation keeps coming round to workforce.
Under the current model of delivering mental health care in Victoria, there are chronic workforce shortages. These are extremely well-documented, and as the Royal Commission emphasised, are more pronounced in certain specialities and rural and regional areas.
The Royal Commission recommended an unprecedented investment to fix the problems of a broken mental health system. It worries me though that, given we already face shortages, how can we ever expect reforms to succeed without thinking about workforce resourcing? Systems are not an abstract concept – they are made up of people. If we place greater demands on systems, we’re creating greater demand for workforce.
And it worries me further that without serious consideration of what our workforce looks like then we are destined to repeat the challenges that plague our current system.
Put bluntly, people do not want to work in our mental health services. The system is under-resourced to the point where staff feel overworked and under-rewarded. All other things being equal, if you’re a health professional choosing which system to work in, why would you choose the Victorian public mental health system?
This has created a dangerous spiral where workforce shortages create exactly the kind of pressures that encourage people to leave, thereby exacerbating workforce shortages.
It’s vital that we recognise that this is not just about the workforce. Shortages have implications for the quality of care. Mistakes happen when people are tired.
More fundamentally, the extent to which the system can uphold human rights is dictated by the availability of a skilled, sufficient workforce. If Victoria is to get serious about eliminating restrictive practices and compulsory treatment, it needs to allow for a system where staff have the time and resources to support alternative treatment options.
The Royal Commission recommended a suite of alternative ways to deliver care, some which genuinely fill me with hope. But I think the whole thing unravels if we continue to try to solve workforce challenges with the same blunt instruments we’ve tried for years.
Typically, we view workforce challenges through a simple recruitment and retention lens: to solve a shortage, get more people, keep them for longer. But we all know the reality is more complex than that, so our response has to be.
Think creatively about who shapes workforce conversations
Who is in the room matters when it comes to workforce design. Professional disciplines, their trainings and cultures, are powerful drivers of how stakeholders shape their approach to workforce design. Typically, the ‘traditional’ mental health workforces are well-represented in these conversations – psychiatrists (and other doctors) and psychologists. Nurses and allied health professionals have also earned their place at the table.
Too often though, these conversations replicate the power imbalances that happen at a clinical level, where certain workforce groups are deemed to have more legitimacy than others. I should say, on the whole, this is not about individuals consciously power-grabbing, but it’s a natural consequence of dynamics in a system culture that values some signifiers of power over others.
If our conversations about what the future of workforce looks like are dominated by traditional workforce groups, then we get traditional workforce solutions.
To think creatively about the future of the workforce, we have to invite new voices in. That means including voices traditionally excluded in discussion about what care looks like. As the Royal Commission highlighted throughout, one of the most glaring historical omissions has been consumers of mental health services.
It’s also about more than consumers as representatives of their own care. We need to have other, often non-clinical, workforces around the table. The Royal Commission highlighted the central importance of the lived experience workforce, so peer workers (as a workforce in their own right) must be represented.
There are so many lessons that the mental health workforce has to learn from other sectors, particularly those who work in the tangential systems that shape mental health system access, for example frontline housing workers, lawyers, career coaches and financial counsellors.
I’d add that it’s not simply enough to have diverse voices in the room. It is difficult to challenge assumptions about what the mental health workforce model looks like, especially when the traditional power-holders are also part of the conversation. I hope that all of those involved in determining what the future of Victoria’s mental health workforce looks like bring a power-critical lens to their work.
Innovate what we consider to be the ‘mental health workforce’
One of the underlying themes of the Royal Commission and the reform of the Mental Health and Wellbeing Act, is the importance of supporting people to access the care that works for them. Our mental health system is medically dominated. While this approach to care works for some, there is a clear and evidence-based argument for a broader range of workforce types.
The Royal Commission report is clear that these new workforce cohorts should include trauma specialists and lived experience professionals. These are great recommendations, and it is vital that implementation is well-supported. Non-clinical workforces are not the ‘poor cousins’ to clinical workforces, and again, it is essential that a power-critical lens is applied to ensure implementation aligns with the spirit by which these recommendations were made.
There are also opportunities across the mental health spectrum to think creatively about what the mental health and wellbeing workforce is, particularly from a prevention perspective. For example, ‘community connector’-type roles link people into supports within their local community, facilitating the human connection that underpins wellbeing and recovery. There is a risk we limit our thinking to those workforces that already exist in our physical health services, missing opportunities to draw on existing strengths within the community.
The Royal Commission noted there are opportunities to optimise scopes of practice and improve training pipelines to address some of the existing supply bottlenecks. But with the best will in the world, it takes time to recruit and train ‘traditional’ health workforces. Tapping into a wider range of potential mental health roles and recruits, expands access to quality care, and can be done relatively quickly and cheaply.
Apply a workforce lens to all recommendations
Discussions about attracting and retaining workforce tend to focus on incentives. Financial incentives will be insufficient to solve the problems with the current workforce model. That said, there are many workforce groups in the mental health system who deserve a pay rise! Doing so would actually and symbolically represent the value of their roles in a system where power and salaries often correlate.
We need to make mental health services feel like safe and enjoyable places to work. Importantly, this means not looking at workforce issues independent of whole-of-system reform. An engaged and skilled workforce is both a system enabler, and an outcome of a system that is working well.
A workforce lens needs to be applied to implementation of all Royal Commission recommendations. What are the implications for this change for staff? What do they need to make change? How can we support them?
Workforce issues run deep in the mental health system. The current workforce model is broken. It harms consumers, it harms staff, and over decades, has contributed to systemic problems in the culture of mental health services. Culture doesn’t change overnight – it takes concentrated effort, creativity and effective resourcing.
We will not solve Victoria’s mental health system without fixing Victoria’s mental health workforce; but, we can’t solve Victoria’s mental health workforce without fixing Victoria’s mental health system.
Thank you to all of those who have informed my thinking around workforce issues throughout my career. In this piece I have drawn on my experience in workforce policy, and conversations with many of those working inside and outside the system for change.
I acknowledge that there are still many gaps in my thinking and what I could reasonably fit in this article. Two issues I haven’t discussed, but merit focus are: the cultural safety of the workforce (as experienced both by consumers and staff); and, the competence and safety of the workforce (similarly, as experienced by consumers and staff).
And a final caveat that this is not about individuals – naturally workforce conversations require generalisations. There are many amazing people working in Victoria’s mental health system, many of whom I count as friends, and others who have directly contributed to my wellbeing and of those I love.
Image credit – Centre for Better Ageing