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Five months after psychiatrists resigned en masse in New South Wales (NSW), the pay dispute is still wending through the courts, further destabilizing a fraught mental health system.

“The resignations have weakened an already stressed, understaffed system,” psychiatrist Louise Nash, MD, PhD, told Medscape Medical News. “Let’s not forget that we already had over 30% staff specialist psychiatrist vacancies across the state before the resignations.”

Without a full staff, psychiatrists are facing longer working hours, significant overtime, and burnout, said Nash. There’s a risk that trainee psychiatrists will not accrue enough hours of supervision to get accredited, she said.

In April, some patients waited more than 3 days for emergency mental health care at Sydney’s Westmead Hospital, ABC News reported.

“I have worked in state health systems for 40 years and was very saddened to make the decision to resign,” said Nash. “I felt that things needed to change, and talking had not been met with action.”

Public sector wages were capped during the 12 years that the Liberal Party was in power (between 2011 and 2023). As a result, NSW psychiatrists now earn 28%-39% less than those working in Queensland and South Australia. They earn 52% less than psychiatrists working in Western Australia. These disparities are causing a brain drain to other states and into private practice.

The government refused to accede to the psychiatrists’ demand for a 25% pay raise late last year, leading 206 psychiatrists to send letters of resignation. Most of the resignations were due to take effect on 21 January.

Five days of arbitration were scheduled with the Industrial Relations Commission (IRC) from 17 March to try to resolve the pay dispute, and 105 psychiatrists deferred their resignations until after the IRC decision. The hearings concluded on 19 June.

Primary Care Inundated

The disruption at public hospitals is causing patients with complex mental health issues to be redirected to general practice, Rebekah Hoffman, MD, PhD, NSW and Australian Capital Territory faculty chair at the Royal Australian College of General Practitioners, told Medscape Medical News.

“In the last week in my practice, we’ve had three teenagers attempt suicide,” said Hoffman. Only one was admitted as an inpatient. “That’s largely because there are not enough beds or staff,” said Hoffman.

The number of full-time equivalent psychiatrists working at Sutherland Hospital, Sydney, has dropped from seven to two since January. “Our acute mental health unit has pretty well closed,” said Hoffman.

Moral Injury

For the psychiatrists who remain in public hospitals, “morale is really low,” Amanda Cohn, MD, a member of the Parliament of NSW Legislative Council and the Greens NSW spokesperson for health, told Medscape Medical News. Public hospital psychiatrists were “made to feel so unheard and so desperate by the NSW government that they took this dramatic action,” said Cohn.

“It’s definitely worse” since the psychiatrists resigned, but “the system was already in crisis,” psychiatrist Kathryn Drew, MD, told Medscape Medical News.

Drew quit in January because she could not perform a management role without being able to recruit psychiatrists. “It’s incredibly disheartening to try and keep propping up a system that needs investment and resourcing from the government,” she said.

Drew is now earning about 25% more in her new role. “I’ve spent my life working in public health knowing that I could be earning more money elsewhere,” said Drew. “It’s never been about my income.”

‘Astronomical’ Costs

Of the 206 psychiatrists who threatened to walk out in January, only 29 withdrew their resignations, while 71 were rehired as temporary staff called visiting medical officers. About 41 were engaged temporarily as locums.

Locum psychiatrists on short-term contracts can cost 300% more per hour than staff specialists — up to $3050/d — but have fewer responsibilities and fewer leave entitlements.

“The irony is that some psychiatrists who resigned were then effectively headhunted to be brought in as locums at astronomical rates,” Andrew Holland, the executive director of the Australian Salaried Medical Officers’ Federation (ASMOF) NSW, told Medscape Medical News.

The NSW government recently stated that a 25% pay increase for psychiatrists would cost around $700 million over several years, apparently contradicting its own estimates from 2024 that put the cost at around $500 million over 4 years.

“If the NSW government were serious about resolving its dispute with staff specialist psychiatrists, it would be transparent about its costings” instead of “citing wildly inconsistent figures,” said Cohn.

“They’re not greedy doctors,” added Holland. “If you were a greedy psychiatrist, you wouldn’t be working in the public health system.”

Medscape Medical News contacted NSW Health but did not receive a response before publication.

Government Drags Its Feet

After three decades in public health, forensic psychiatrist Ian Korbel, MD, decided it was time to quit after he saw a woman who had killed her child during a psychotic episode get released into the community with inadequate follow-up.

The psychiatrist “rebellion,” which eventually encompassed around half of staff specialists in the state, started in mid-2023 when the Royal Australian and New Zealand College of Psychiatrists (RANZCP) brought the recruitment and retention issues to NSW Health.

In April 2024, RANZCP, the doctors’ union (ASMOF), and the Australian Medical Association organized an online meeting for NSW psychiatrists to discuss the lack of progress.

In October, a group of about 30 concerned psychiatrists gathered informally on WhatsApp to try to “improve the system that was falling over,” said Korbel.

In December, around 150 psychiatrists joined an after-hours online meeting and overwhelmingly rejected a counterproposal by the government to improve working conditions through a 6-month “productivity and efficiency pilot project” that would offer no pay increases.

By January, the government was offering psychiatrists a 10.5% wage increase over 3 years, but that still wasn’t enough to stop resignations from going ahead.

“It became so obvious when we were hearing the stories of hundreds of [psychiatrists] who were calling in that absolutely every single area in NSW was struggling,” said Korbel. “But it didn’t end up being a talkfest,” he said. “A couple of us took over the meeting.”

In 2024, ASMOF had been ordered by the IRC to “refrain from taking any steps to coordinate, organize, or facilitate” the resignation of staff specialist psychiatrists.

“Because ASMOF were not to have any role in this, we put forward that people should vote on whether we move on the resignations, which is what happened,” said Korbel.

But, instead of making a deal with the psychiatrists, the government “dragged this out in the courts,” said Korbel.

Nash, Hoffman, Cohn, Drew, Holland, and Korbel reported having no relevant financial relationships.

Felicity Nelson is a freelance science journalist based in Sydney.