Insanity plea

June 21, 1996

Their job involves fire-fighting, policing and door-to-door selling, but increasingly less of the role they were trained to do - psychiatry. Martin Deahl warns that the crisis in community care threatens the academic base of clinical neuroscience.

The United Kingdom has an excellent record in academic psychiatry. Since the war much of our understanding of the nature of mental illness, as well as many innovative psychiatric treatments, have been developed from research performed in Britain's teaching hospitals. Many of these hospitals and their associated university academic departments are in socially deprived inner-city areas, where the high incidence of mental illness has provided the clinical material for research.

This has meant young high-calibre psychiatrists have been attracted to otherwise unpopular inner-city posts to pursue research and teach medical students, enriching the clinical services available to the local population. But recent changes in the NHS, the practice of psychiatry and the universities threaten the future of academic psychiatry.

I became a psychiatrist because I liked talking to people. Now, if any of my patients need "talking to" I have to refer them to someone else. I just do not have the time. Morale in adult general psychiatry has reached an all-time low, especially in deprived inner-city areas where working conditions have become intolerable.

Most acute adult psychiatric wards have a bed occupancy rate of over 120 per cent and many of these patients are detained compulsorily under various sections of the Mental Health Act. There is no question of managing these cases in any other setting - all admissions are emergencies. At any time, around a third of the patients occupying beds in acute admission wards are there, not because of their disturbed mental states, but because they are homeless. Some patients, particularly those with a significant forensic history, are refused hostel accommodation or local authority housing and remain on acute admissions wards: no one else will have them.

Psychiatrists are continually "fire-fighting", unable to manage patients because of factors beyond our control. Adult psychiatry has no boundaries: we are the refuge of last resort for society's flotsam and jetsam, young and old, homeless or rootless, mad or bad. We take everything that is thrown at us. We have no choice. As a result, trusts face serious difficulties in recruiting and retaining high-quality staff. Young doctors are driven away from psychiatry when they see the working conditions of their seniors. The traditional strategy to make unpopular posts more attractive by the addition of one or two "academic" senior lecturer sessions offers cold comfort in a climate where academics themselves are under pressure to increase their research "productivity" and "publish or perish". The "carrot" has become a "millstone". Meanwhile, the average age of the consultants at the sharp end of NHS psychiatry becomes ever younger.

The past five years have seen an unprecedented decline in working conditions. Staff are demoralised thanks largely to the recent reforms in the NHS that have turned medicine into a business, increasing the powers of managers and diminishing the status of doctors. Psychiatry has its own peculiar problems, mostly arising from society's misunderstanding of the nature of mental illness and fundamental flaws in the mental health policy of successive governments.

Most long-term mentally ill people can be safely managed in the community. Nevertheless, the existing "community care" programme , under which patients have been moved out of asylums to live among the public, does place intolerable pressures on hospital-based psychiatrists. They have insufficient beds to admit severely ill patients who require hospital care. At the same time they are forced, under the regulations, to discharge patients prematurely. No one wants to go back to the asylum era when all and sundry were unnecessarily incarcerated, sometimes for life. But in closing the asylums we have thrown the proverbial baby out with the bathwater.

There are simply not the resources, manpower, or facilities to provide comprehensive community care. Moreover, there is a significant minority of mentally ill patients who require medium and long-term care which, unless they commit a serious offence, no longer exists. The crisis is most apparent in deprived inner-city areas, where homelessness, poverty and unemployment have caused increased rates of mental illness.

These have been added to by the Reed report on mentally abnormal offenders, whereby mentally ill people have increasingly been "diverted" from the criminal justice system into the NHS (up to a third of all prisoners are mentally ill). There have been few additional resources to cope with this influx. And bed numbers continue to decline in line with the received wisdom of "community care" for all.

The crisis is compounded by a trend towards "defensive" medicine which arises from the high media profile of community care "tragedies". We live in an era of professional "bashing": it is always convenient to scapegoat individual clinicians rather than admit that there has been a failure of policy. A few years ago patients were simply discharged to temporary accommodation as soon as their mental state permitted. Following the introduction of the care programme approach and the implementation of certain provisions of the 1983 Mental Health Act, patients may now only be discharged once a formal care programme is in place. For many patients the programme includes the provision of accommodation which is all too often unavailable, leaving them to languish on an acute admission ward, sometimes for months. Recent developments, including the introduction of supervision registers and supervised discharge do nothing to relieve the situation; indeed, they only make things worse.

Research has suggested that acutely ill patients can be managed successfully at home, avoiding the need for hospital beds completely. Much of this work is flawed, based on short-term projects that take no account of staff "burn-out" and the often intolerable burden on families forced to care for a disturbed relative. Psychiatrists who have promoted this research (eagerly embraced by the Department of Health for the credence it lends to Government policy) should know better. Even when patients are successfully managed in the community, little account is taken of the impact of this style of management on psychiatrists' working lives, including professional isolation from colleagues, the threat to personal safety and the increasing proportion of the working day spent travelling. On occasions I feel more like a door-to-door salesman than a doctor.

Long-term solutions to the crisis must go beyond a simple injection of funding. Initiatives such as joint purchasing of services for the mentally ill by health and local authorities and locally based funding would enable resources to be targeted more effectively. The Home Office and the courts must shoulder some of the additional financial burden imposed by the diversion of mentally disordered offenders into the NHS. Psychiatrists should "come clean" and acknowledge that medium- and long-term hospital beds are required for mentally ill patients for whom community placements are inappropriate. Perhaps, most importantly, we desperately need legislation to enable psychiatrists, when necessary, to compulsorily treat the mentally ill in the community. The Mental Health Act permits only compulsory treatment in hospital. All too often patients make an excellent recovery only to be discharged, at which point they stop their medication, relapse and require readmission.

Society must realise that a mental illness such as schizophrenia is a neurological disorder with a recognised pathophysiology that requires treatment, with drugs, by doctors and nurses. It has nothing to do with lay notions of "stress". These misconceived attitudes are reflected in the popular use of terms such as "client" or "user", euphemistically used to describe the mentally ill. Too many people naively believe that with suitable accommodation and community support, "clients" remain well. Without neuroleptic drugs (which can be conveniently administered by a community nurse in the form of a "depot" injection every few weeks) patients will relapse. Without this sanction psychiatrists are ultimately powerless to prevent patients relapsing.

Unless serious efforts are made to address some of these issues we will see a further decline in staff morale and a continuing exodus from the profession. In the short term there will be more failures of community care and more tragedies.

In the long term the consequences are potentially even more disastrous: understanding the biological basis of mental illness helps illuminate one of the great scientific mysteries facing us as the next millennium looms: the physiological basis of brain function and even consciousness itself. Without action, the academic base of clinical neuroscience is in danger of being further undermined and potentially damaged beyond repair.

Martin Deahl is senior lecturer in psychological medicine at St Bartholomew's Hospital, London, and consultant psychiatrist in the City and Hackney Community NHS Trust. A longer version of this article appears in the summer issue of the journal Science and Public Affairs.

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