David Ropschitz
Outside of the glamorous teaching hospitals, it is becoming almost impossible to provide a thorough psychiatric service. Frustration, delay, compromise and ‘make do’ seem to be the order of the day. In many places it seems the blue touch paper is ready and waiting for the match.
Reading perturbing reports every so often about conditions and incidents in mental hospitals, I am only surprised, frankly, that they do not appear more often. The psychiatric profession is reeling under the effects of excessive caseloads, insufficient recruitment and a chronic shortage of junior doctors everywhere but in the teaching hospitals, which very much limits the effectiveness of treatment. Added to this, during the past year, there has been the upheaval in aftercare, social work and service liaison arising from the establishment of the new local authority services departments.
The most serious factor of all is the shortage of junior trained psychiatrists or trainees in provincial psychiatric hospitals and units. It is a long-standing problem which has become acute in recent years and is mainly attributable to three factors: emigration, lack of attractiveness of psychiatry, compared with other branches of medicine, and the concentration of trainee psychiatrists in teaching hospitals. As far as emigration is concerned, this is as much because of better working conditions and greater opportunity for research as for the higher salaries offered abroad.
The severe shortage of junior psychiatrists, has led to the appointment of more consultants, many of whom have to carry the entire medical load of their service almost unaided. This is both a costly and illogical situation, as the special knowledge of consultants cannot be fully utilised, though of course, there is a need for many more consultants throughout the country, with proper supporting teams.
During the 11 years that I have worked at Storthes Hall Hospital, Huddersfield, we have never had a senior registrar, and there has been no registrar which is a trainee post - for the last 5 years, in spite of numerous advertisements by the Regional Hospital Board. One of my consultant colleagues, appointed last year, still works single-handed. Eventually, out of despair, an application was made to the Home Office to grant a doctor from abroad permission to enter this country so that he might work with this consultant. When such steps are necessary to obtain doctors, the situation can only be described as alarming.
Statistics from the Department of Health show that the neighbouring Manchester Hospital Region has a lower number of every kind of professional staff in the psychiatric service than any other region of the country. The same scarcity of junior medical staff in provincial psychiatric hospitals has prompted the employment of family doctors in these hospitals, if you are lucky enough to find them, since they too are overworked and in short supply. The trouble with this stop-gap tactic is that most GPs can only be available to the hospital for one or two sessions a week. By comparison, a registrar normally works 11 sessions a week, so that to provide the same amount of medical time, one has to employ 5 or 6 GPs.
A further complication is that while junior hospital doctors are entitled to 4 weeks, leave, general practitioners employed in hospitals can take 6 weeks, leave a year. If you multiply the number of GPs by 6, you end up with a great number of weeks without ade’ quate cover. In our psychiatric unit in Halifax we have 8 GPs, two of whom are experienced in anaesthetics. The Regional Hospital Board has laid down that two doctors should be present during electro-convulsive therapy, one of whom must be experienced in anaesthetics. Electro-convulsive therapy is an important psychiatric treatment and the GPs have been trained to carry it out efficiently. The difficulty in this situation is that 8 general practitioners are entitled to a sum total of 48 weeks, holiday a year, so that the ECT service is disrupted whenever one of the two doctors required for treatment is on leave.
This has serious implications for in-patients and even more for out-patients. The in-patients’ stay in hospital may be unduly prolonged, but unavailability of ECT for out-patients is just plain dangerous. Patients often have strong personal reasons against being admitted and whenever treatment is possible without taking a patient into hospital, we are often relying on an efficient ECT out-patient service.
But if the ECT service has to be frequently suspended, this intolerable state of affairs must eventually lead to family crises or suicide. Rather than expending time and energy in dealing with the consequences it would be wiser to prevent the possibility of tragedy by having adequate treatment services available all the time.
At one time in Halifax we were promised the services of a consultant anaesthetist for ECT but the service broke down periodically, owing to his other engagements. Whenever the anaesthetic service was short of staff, the axe fell first on psychiatry. The needs of other departments were always considered more urgent.
On top of these long-standing shortages and staffing Problems has come the Local Authority (Social Services) Act, 1970. The Mental Health Act of 1959 made the Medical Officer of Health responsible for mental health services in the community. He had a team of mental welfare officers who were generally experienced and specialised in their work. I have no quarrel with the aims of the Seebohm Report, on * which the 1970 Act is based. It argued that social Workers ought to be all-rounders, without separate groups specialising in mental health, child care etc.
is an ambitious aim and I sincerely hope that such advanced training will materialise in my lifetime; but what about the transitional period? Nobody becomes knowledgeable about psychiatric illness overnight.
What would happen, for instance, if it were suddenly decided to do away with physicians and surgeons and let psychiatrists - who after all are medically qualified take over their functions?
My criticism is of the lack of a sufficient transitional Period to allow for gradual change. In Halifax where services are less affected, we had 7 mental welfare officers; now we have only 3 and even they have to perform other kinds of social work.
Communications broken down
In the West Riding of Yorkshire part of out catchment area we had 5 mental welfare officers; now we have none of the old team. The senior officer was transferred to the central office in Wakefield, three others went to attend university courses and the fifth was transferred to another area. As a result, no continuity remained, and this in spite of the fact that mental health services are highly personal, with human relationships the keys to success! During the last 12 months, communications seem to have broken down altogether and what has ensued can only be described as chaos.
This is not an isolated case, since there are a number of areas where new Directors of Social Services have arbitrarily put an end to longstanding arrangements for social workers to take part in hospital case, conference or clinics.
Another factor in the confusion is that, whereas in the past, copies of our reports on discharged patients or those attending out-patient clinics were sent to the Medical Officer of Health, a medical man is now no longer at the head of the Service. Doctors are, of course, obliged to maintain professional secrecy and highly personal matters would only be communicated to other doctors, in general. It is one thing to report about chickenpox, or an appendicitis operation, and another to pass on details of sexual perversions, drunkenness, impotence, adultery, and so on.
We are fortunate to have reached a compromise solution in Halifax, thanks to a friendly agreement between the Director of Social Services and the Medical Officer of Health, who continues to receive our reports. Unfortunately, in the West Riding part of our catchment area, such a compromise solution has not been possible, with the result that one half of our patients benefit from effective follow-up and aftercare, while the other half do not to anything like the same extent. In spite of many efforts to get clear directions from the Department of Health, the Royal College of Psychiatrists, the Medical Defence Union and others,* we are still not much wiser about the correct procedure.
One bit of guidance can be gleaned from the reply to a
letter I wrote to the General Medical Council. The registrar’s reply ended, ‘the President wishes me to say that he considers it unlikely that the Council would regard the sending of psychiatric reports to senior social workers, in the interests of the after-care of discharged patients, as improper disclosure of confidential material’.
In many areas, in fact, it is accepted that social workers concerned with mental health should receive substantially the same information as used to be passed to the Medical Officer of Health. Even when this follow-up work was done within local authority health departments, very little of it was actually done by doctors.
Under all these circumstances it is not surprising that many psychiatrists - especially those in provincial mental hospitals - have become very frustrated professionally. Very quick and far-reaching measures ought to be taken to rescue the mental health services from further disruption. In particular, a more even distribution of available junior psychiatric staff is essential and some progress towards this aim might be achieved by upgrading certain provincial hospitals to teaching hospital status.
The concentration of young psychiatrists in the ivory towers of university departments and teaching hospitals is a luxury which the mental health service cannot afford. In addition, the young psychiatrist who has been used to all the amenities and facilities afforded by university departments will feel lost when thrown to the lions. All too often, he has not been trained for the job he will actually have to do in the main part of his working life. Clinical psychologists, psychiatric social workers, and other non-medical personnel will no longer be at his disposal and he will resent the contrast. The lot of the nursing profession is long overdue for a radical revision, too, not only the salary but the working conditions as a whole. Here again, regional hospitals are very much worse off than teaching hospitals.
Plea for mercy
I would like to plead with those who implement the Seebohm Report to show a little mercy; it is only in fairy tales that beanstalks grow to heaven in the space of one day.
It is also up to the Department of Health, other hospital authorities and bodies like the Royal Colleges to see that something is done about the disparity in numbers of doctors between teaching centres and other hospitals. For one thing, every trainee psychiatrist, other than just a small elite, should have the chance of working for part of this training in a teaching department.
Psychiatrists need to be able to get on with the job, but they cannot communicate to their patients a peace of mind which they themselves no longer possess.
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