2023-12-19 12:05:52
The grants for psychologists in the public service, on which the Ministries of Health and Finance agreed with the Histadrut last week, are the first step in a broader plan to strengthen the mental health system during the war and in general. But the attempt to solve in a short time problems that have been created for many years, such as an acute shortage of personnel, raises a series of dilemmas and tensions: between a one-time expenditure and an investment in the long term; between outsourcing and expanding the public system; and between different branches of psychology.
The program, which is currently taking shape and is expected to be budgeted at approximately 2 billion shekels for the coming year, is intended to respond to the extraordinary needs following the war, alongside responding to the hardships that existed there even before it. It includes grants for psychologists who will join the public service or expand their position, raising the salary of psychologists in the public service, encouraging specializations in psychiatry, a mechanism for sorting those seeking treatment, and the unification of psychiatric hospitals with general hospitals.
Israel came to the war with a shortage of 400-500 psychologists
The attack by Hamas on October 7 and the war created an unusual and urgent need for psychological assistance: tens of thousands of people were directly exposed to an unusual terrorist attack, from the residents of the kibbutzim and cities that were attacked and evacuated from their homes, the participants of the Nova party, the family members of the murdered, the kidnapped, the fallen and the conscripts, to millions of residents who are exposed to the attacks Missiles and residents of the north who were also evacuated.
In the first days after the disaster, the Ministry of Health tried to provide psychological support through volunteer psychologists who came to the evacuees’ centers. Later, the ministry formulated an outline for permanent employment, which allowed psychologists to be absorbed by the health insurance funds, resilience centers or mental health hospitals as employees, freelancers or volunteers. At the same time, the state funded the victims of hostilities for psychological treatment of 12 sessions at the resilience centers, for which a fee is normally charged.
But these moves are not enough to deal with the severe lack of manpower that the mental health system faced even before the war. According to the State Comptroller’s report from 2020, there is a shortage of 400 psychologist positions in the public service. In a position paper of the Movement for Public Psychology and the Berel Katznelson Foundation from last February, the shortage was estimated at about 500 positions. The State Comptroller’s report emphasized that the problem is not a lack of qualified psychologists in Israel, but Abandoning the public psychological service to the private market. The national plan formulated by the Ministry of Health aims to address these shortages, and other difficulties that existed in the mental health system even before the war.
Immediate response: grants for psychologists, requirement to include educational psychologists as well
The first element agreed upon is grants for psychologists in the public service. In the agreement reached last week, the chairman of the Histadrut concluded Arnon Bar-DavidMinister of Finance Bezalel Smotrich and the Minister of Health Uriel Bosso On a line of one-time grants as an immediate response. These grants will be given to psychologists in the health system who commit to remain in the public system, to psychologists who will expand the scope of their work in the public sector, and to psychologists who will be absorbed into the public health system. The amount of grants is expected to reach tens of thousands of shekels per psychologist. According to the words of Health Minister Uriel Bosso in the Knesset Health Committee, about 200 million shekels were allocated to grants, 10% of the total amount allocated to the program.
The grants will be given only to clinical psychologists, and not to the educational psychologists employed by the local authorities, a decision that has provoked criticism. Chairman of the Local Government Center, Haim Biebs, this week appealed to the Ministers of Finance and Education with the demand to also include educational psychologists among the recipients of the grant, “The shortage and difficulty in recruiting psychologists, the burdens on the existing psychologists and the need to strengthen the educational psychology system is the property of all the shafahim (educational psychological services) in the State of Israel, which are under the local authorities . Awarding financial rewards only to some psychologists will even exacerbate the gap and deepen the crisis in the local authorities.”
Salary increase: expectations are lowered in the government, the psychologists call for “treating the root of the problem”
Along with the grants, the Ministry of Health also refers to the salary agreement for psychologists in the public service, which is expected to be renewed, as a component of the national mental health plan. The hourly wage for a psychologist employed by the health insurance funds, hospitals, or local authorities is today about 50 to 70 shekels an hour, compared to hundreds of shekels an hour in the private market. In the position paper of the Public Psychology Movement and the Berel Katznelson Foundation, they recommended a 50% salary increase, at a cost of NIS 300 million per year. The Minister of Health also said in the Knesset plenum that in his opinion a psychologist in the public service should earn NIS 400 an hour.
In practice, government officials estimate that wages will not be raised dramatically. According to Health Minister Bosso, NIS 53 million will be earmarked for the salary agreement of the psychologists, which will translate into an increase of about NIS 5 in the hourly wage. In his words in the Knesset, Bosso said that the expected increase in wages in the upcoming agreement will not be enough to attract workers from the private market to the public system. In the meantime, despite repeated appeals by the Histadrut Mahhar, which represents the psychologists in the public sector to the salary commissioner at the Treasury, no date has yet been set for the start of negotiations on the salary agreement.
This means that even before the negotiations have begun, the government declares a preference for funding a short-term solution (one-time grants), over a long-term investment that will upgrade the status and income of the public psychologist, and give him high financial certainty. Chairman of the Movement for Public Psychology, Yifat Sade, doubts the ability of the grants alone to attract workers to the public system. “There is no obligation on the part of the state to rehabilitate and treat the root of the problem,” she tells Davar, “No matter how big the grant, psychologists will not come for grants that there is no guarantee that they will continue after the next year, and they will not close a private clinic for one-time grants when the base salary for the service The public sector remains low. If we intend to continue this funding and put it in the base of the budget, then why not put it in the salary base?”
Recruitment of psychiatrists: 30 million for scholarships for interns
Another component of the program is the recruitment of psychiatrists into the public service, a profession that also suffers from a severe shortage. According to the State Comptroller, in 2020 there were 280 standards missing, but unlike psychologists, the lack of professionals in the field also exists in the private market. To solve the problem, it will be necessary to encourage the study of psychiatry among medical students. In order to attract students to specialize in psychiatry, the Ministry of Health will allocate NIS 30 million for scholarships to psychiatry interns in the coming year. Time will tell if the scholarships will attract specialized doctors despite the stigma attached to the profession, and the difficult working conditions in the fields of specialization of psychiatrists – psychiatric hospitals and psychiatric departments.
Resilience centers: strengthening a ‘semi-public’ response
As part of the plan, the Ministry of Health intends to expand the resilience centers, establish a ‘super-center’ for the resilience centers and increase the services provided in them. It is not clear whether the plan includes a discount on the treatments, as was done during the war. Today, many define the resilience centers as ‘semi-public services’ because receiving their services involves a fee (even with government participation), so the question arises whether their inclusion in the national plan will come at the expense of investing in the public services included in the health basket.
Permission to treat even those with a bachelor’s degree: “expanding the response” or “harming patients”
As part of the response to the lack of skilled personnel in the system, the Ministry of Health is also initiating the recognition of “psychological first aid providers”, a title that could hold a graduate of a bachelor’s degree in psychology and possibly also in similar professions, who underwent training of several weeks. The office says that the profession does not come to replace skilled personnel but to add a response in places where there is no response. The forum for public psychology warns against harming patients. “We oppose the introduction of less skilled professions,” says Yifat Sade, “it will increase disparities because people with fewer resources will receive less skilled service. This cannot be part of the solution to the problem of the public mental health system.”
Yet, Hadar Samuel, the health system researcher at the Brookdale Institute, thinks that if the move is carried out responsibly, it can strengthen the system. “You need to see how other professionals are integrated into the perfection of the mental response,” she tells ‘Davar’, “of course this needs to be done carefully, but not every crisis requires a qualified psychologist with all his years of training, some will be able to receive a response from a social worker.
A mechanism for sorting out applicants for mental health care: “graded torture centers should also be built”
Another component of the program is the establishment of a mechanism for sorting those who apply for mental health care. At this point, it is not clear what is behind this title, but such a mechanism can answer a number of problems that exist in the system today. Today, a person can apply for mental health care from a number of different sources: three phone calls through the health insurance funds; The series of psychotherapy sessions from the health insurance fund, which is provided free of charge, but due to the lack of psychologists in the health insurance funds, actually involves the purchase of a private service with a deductible; Referral to the Resilience Center, where the treatment is also subject to a fee; or referral to a psychiatric emergency room for hospitalization or discharge. The result is that some of those who seek psychological treatment at the clinic need urgent intervention and have to wait a long time for treatment, without an overall prioritization of the needs and resources in the system.
Samuel believes that the sorting of the applicants is only part of the solution, and besides that the diversity of the answers that the system offers is also required. “The mental health system today does not distinguish sufficiently between the needs of the patients,” she says, “A person waits for months, and then as soon as he is ‘inside’ he receives everything the system has to give. It doesn’t have to be all or nothing – the screening process needs to be improved And also to build graded torture, which will be more measured torture for people whose distress is less. Recently, the discourse is expanding on short-term treatments, but in Israel there is a tradition of long-term psychodynamic therapy, and psychologists here are not always taught about processes that do not take many years, how to define goals for treatment and a timeline Agreed to achieve the goals. There are places where they also talk about combining more group treatments to reach more patients with limited personnel, and sometimes this is also the right thing from a clinical point of view.”
The hospitalization system: raising the rate, and connecting the psychiatric hospitals to the general ones
The Ministry of Health also has an ambition to strengthen the mental health hospitalization system as part of the national plan. Here, too, this is a field that has been dealing with a budget and manpower crisis for many years, and the war sapped their vitality – the first teams of psychologists who arrived at the evacuees in the hotels were sent from the hospitals. The Ministry of Health says it intends to profit the inpatient wards, increase security in the wards (a move that requires staffing the missing security guards), and develop a model for hospitalization in a psychiatric home. Probably the main way to finance these goals is to increase the rate that the hospitals receive from the health funds for mental care. Today, the rates for psychiatric hospitalization are the lowest in all areas of hospitalization except geriatrics. The Ministry of Health has not yet published details on the size of the rate increase. Spacing the departments, which are crowded compared to developed countries, will also require construction budgets.
Another proposal by the Ministry of Health is to merge the psychiatric hospitals into public hospitals – which one psychiatric hospital director describes as a “catastrophe”. “The Ministry of Health has not yet understood the importance of psychiatric hospitals,” he says. “We are training the next generations of psychiatrists – without us there is no psychiatry in Israel. We are collapsing from overloads and under-budgeting, and the Ministry of Health should save us, not weaken us.”
A long-term challenge
Samuel and Sheda view the firm’s investment positively, but emphasize the need for long-term investment. “This crisis will not end in a year or two,” Sde says, “the system will have to deal with the consequences of the event in the next ten years.” Samuel emphasizes that “all the moves must be in the context of a national move to increase personnel, decent wages, and the mobilization of tangential systems that will prevent deterioration.”
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