Where There’s a Will: Dr John Hillery on new Lust for Life Podcast series

Mental health charity A Lust for Life has brought together some of the best and brightest minds in Ireland’s mental health sector to ask: why is our mental health system so dysfunctional? Who is responsible for fixing it? And what can we, collectively, do to create long-term, systemic change?

The six part podcast series podcast tackles the problems in the mental health system, covering stories of individuals failing to receive they help need and systemic challenges with policy and infrastructure from those on the coal face. In episode 2, released today, College President, Dr John Hillery, speaks about the mental health system and the challenges that led him to retiring early.

Listen below or read the full transcript of Dr Hillery’s interview below.

Dr Hillery: “I left my public job early. I haven’t had an exit interview, no one asked me, my exit interview was a presentation I gave to different groups, a group of carers and a group of lawyers and doctors, that was my exit interview, but it was me telling people things. No one took me aside and said look, you’re leaving before your time, you’re president of the College of Psychiatrists, this is kind of embarrassing for us, the president of the College of Psychiatrists should leave us, if you were a private company and the president of the national group in that area was resigning you’d want to know why wouldn’t you?”

John describes an all too common situation for psychiatrists because the issue with psychiatrists being responsible for all mental health in Ireland, with all other supports being seen as merely ancillary care affects their profession in a fundamental way.

“First of all I was in a service that had two consultant posts and the other one was empty so I was being expected to carry that load as well so that’s dangerous for patients, dangerous for me and the longer it goes on the more dangerous it gets. And then I was dealing with a subspecialty where I was dealing with people with intellectual disability and it’s not so much about the treatment, it’s often about the environment and I couldn’t affect the environment. Now I’ve been trying to do that by writing memo’s for 20 years and other things but it finally got down to asking myself what affect is this having on my health as I reach 60 and is there more I could do with my energy.”

I don’t see my duty and being to prescribe medication, I’m trained to prescribe medication but if my training is any good it should also show me when medication is needed, when it’s not.”

“One of the reasons I left work, I stated this quite publicly, is I was prescribing people medication to make up for service deficits. So I was trying to make people safe, you know, by putting them on medication it might help their anxiety and their agitation when I knew really that the main thing was environmental change or other interventions that aren’t available.”

“I think I’m not alone in that and we don’t have enough psychologists. A lot of my colleagues in psychiatry are trained in different therapies such as Cognitive Behavioural Therapy, DBT, Dialectic Behavioural Therapy for personality disorders, different things like that, but they don’t have any time to do them because they have a clinic with 50 people waiting to be seen and in our system the consultant psychiatrist in a geographical area is responsible for anyone in that area with a mental illness and that takes a lot of your time.”

“We’re trained to work closely with our colleagues in psychology, social work, and occupational therapy, but often people are left not having access to those people or else those people have long waiting lists too and so you do what you can at the time to help people. What I’ve always asked myself is, if I don’t think that medication is the first input here but I’ve no other access to the other inputs here for a few months, do I leave the other person distressed in the meantime when I know the medication might help them in the meantime? Or do I put them on medication which may give someone a chance to say, ‘ah well Dr. Hillery’s treated the person they don’t need to see someone else’.”

“So I have to do two things, I have to say, ‘well I think you need this type of intervention, I’m referring you for that, but you’re very distressed at the moment so I think this medication would help. In the meantime I want you to come back and see me in a few weeks and we’ll see how you’re doing on the waiting lists with for the other interventions’, and then I’ll send another letter saying this person needs to be seen, that’s part of our system, it’s not right, but it’s the way we try and get the system to work.

Dr Hillery then goes on to speak about the perception of psychiatrists:

“The media love these arguments, the fact that the doctors are evil and money grabbing but psychiatrists mostly work in the public sector, they’re paid a certain salary and if they sit and drink tea all day they get paid the same as the person who sees 200 people. And actually I think the person who sits and drinks tea all day is probably not doing as much harm as someone who sees 200 people a week.”

“We didn’t go into psychiatry to do either, shall I say, we went into psychiatry to have more time with people, to tease out the different issues and actually to be a good psychiatrist, and a friend of mine who is a GP says it very nicely. He says he thinks that psychiatry is the hardest part of medicine to practice well and the easiest part to practice badly. By that he means you get away with practicing it badly but what we see then when people are practicing it badly is people aren’t recovering and getting back into society.”

“It is very complex as the discussions we’ve had would suggest because you’re talking about brain chemistry, you’re talking about sociological issues, you’re talking about family issues, you’re talking about genetic issues as opposed to something that’s a simple default in the body that needs to be fixed. It’s much more complex than that.”

Dr Hillery goes on to explain the major issues in the system from the very top at governance level to how the system measures what success looks like right down to basic administrative failures. John gives examples of these problems and how they played out in his experience working within the HSE system, starting from the very beginning when they’re looking for resources at a local level.

“If you hear people talk about health service delivery they say we opened 10 new Outpatients across the country this year, they don’t say we got 500 people back to work this year, we got 500 fathers back to their families, we got 300 kids back to school, we got so-and-so back to the GAA club who was afraid to go out of the house, you never hear that, but we have more and more clinics. If you can’t go to the GAA club because you have agoraphobia a clinic isn’t going to be very helpful…it’s difficult to put a KPI on it.”

There was concern a few years ago as the HSE brought in ‘never events’, these are events that are never to happen, one of which was Suicide; “We all strive obviously that we don’t have anyone who kills themselves but to say it is a never event, especially if you’re responsible for all of society not just for people who are deeply depressed, is impossible so I think people get frightened about what KPIs are going to be made up in psychiatry and do they actually capture what you need.”

If you were going to say no deaths, that’s not a great KPI really, what we’re talking about is quality of life, people living a life in society and committing to it and getting some satisfaction out of it, it doesn’t have to be happiness or joy but satisfaction…inclusion.

Dr Hillery pointed out the need to work harder on finding KPIs that suit Ireland; however, we need to ask if Ireland has the will to do that?

“We hear Michael O’Leary talking about how he’d run the health service and that’s all well and good, about getting the customers through, but if I as a psychiatrist, have five people with serious agoraphobia who can’t leave their house – seeing 300 people this week could be good for the person doing the balance sheet, but the five people left who want to leave their house need more than the five minutes I could give them on the phone. But I can’t even give them that if I’m meant to see so many people. So the KPI’s have to be relevant to people’s lives.”

Dr Hillery continued about the lack of communication, how there are no medical records and how an IT system is desperately needed. The system needs to be investigated properly and thoroughly in order to find out where there are gaps and inadequacies.

“The first thing that we need to do is to figure out why individual journeys are going wrong, we don’t have any information.” Why aren’t people getting the tests they need; why aren’t they turning up to clinics; why are they not getting respite when they need it? 

“We need to be asking ‘why aren’t our customers getting the service that they need?’ All we do at the moment is record that they are waiting for the service or that they are delayed in the service. Nobody is asking why and how can we do anything until we know why?”

We are wasting all this time and throwing money at something without knowing where we should throw the money. If you went to a bank with a type of business plan the HSE seems to have, you’d be told to go away and come back when you have something better.”

People are often put in a position within the HSE but not given the power they need to get the job done or they are given the responsibility without the power. This is a lack of governance.

Speaking on his decision to leave the HSE, Dr Hillery told of his experience working in a highly regulated environment throughout his career and how he believes in regulation, however it should be a regulation that encourages change for the better instead of just penalising people. He has seen people become increasingly afraid due to HIQA instead of trying to change things or voice what can’t be done unless there is funding, they are putting pressure on the staff: “We are meant to be in all of this together and to make things better for patients.”

“I’ve sat at meetings where I’ve been shouted at because a report about the risks to people or the risks to a patient was something that the administrator didn’t have the resources obviously to implement and was being questioned by HIQA for not implementing it. So instead saying to HIQA, I didn’t have the resources to do it, they attacked me and shouted at me and waved the report at me and said it had to be changed.”

This is part of the reason for his leaving; “I felt compromised in this way, that I thought I was going to be asked to put people at risk by administrators who were under pressure from HIQA instead of it all being something we all worked on together to make things better. But I’ve seen so many staff beat down, demoralised, crying because they are being shouted at for not delivering on something they can’t deliver on. One person can’t do all these things.”

When asked why there is huge shortage of psychiatrists, Dr Hillery said there are many trainees now but unfortunately the HSE lose them to private practice or they move away; “There are a lot of disincentives in the system at the moment. For instance…if you have a fully trained specialist in one of our services – they may have a temporary person working with them, who isn’t a fully trained specialist but is paid more because they are paid through an agency to fill an empty space. That’s a disincentive probably for the person who is full time, fully trained and went through all that and isn’t getting paid as much.”