This is madness

    31 May 2014

    Professor Sue Bailey, President of the Royal College of Psychiatrists, recently drew attention to the financial difficulties faced by the psychiatric services in Britain. Just like cows, no bureaucracy, such as that which oversees and directs our psychiatric services, favours the changeover from fat years to lean; but Professor Bailey would better have directed her attention to the often extreme and completely unnecessary cruelty of the services themselves, caused not by government cuts but by the callousness, indifference to suffering or even idiocy of some of the profession itself.

    My wife, also a doctor, long ago pointed out that nobody with the means to pay would part with their hard-earned cash for the kind of psychiatric services currently delivered by the National Health Service. They are, in effect, appropriate to a nation of paupers forced to accept what they are given.

    Needless to say, not all parts of the service are equally bad. Some are excellent, and everywhere there are good people struggling to do their best in circumstances that have been made unnecessarily difficult for them. Nevertheless, the way in which services are organised is often so absurd that it defies satire; and the fault is not the government’s but of psychiatrists and their bureaucratic hangers-on. Of all medical specialities, psychiatry, you might have supposed, is the one that requires the closest personal relationship between doctor and patient and the greatest continuity of care. But on the contrary, the services have been deliberately fragmented so as to become increasingly more impersonal. It is not uncommon — indeed it is routine — for patients to be passed from one psychiatric team to another like the parcel in a game of pass-the-parcel. This maximises the possibility, indeed the likelihood, of the famous ‘lack of communication’ that is always found by inquiries to be responsible for disasters after they happen; it encourages the various teams constantly to dispute whose responsibility the patients are, and thus is a means simultaneously of work creation and work avoidance.

    Once I was asked to inquire into the suicide of a patient who had been under psychiatric care for 11 months. In that time, he had been under the nominal care of 11 consultant psychiatrists and was visited at home more than a score of times by members of the various teams: but each time by someone different, only one person having ever seen him twice. It takes little imagination to realise how distressing this must have been for the patient, not to mention the gross clinical inefficiency of it: but this consideration never seems to strike the organisers of our services. It is as agonising for the relatives of the patients as for the patients: they do not know who to turn to.

    Not that they will be listened to anyway. They are either ignored altogether or treated as if they were the patients’ worst enemies with some discreditable ulterior motive. That they know the patients better than anyone else, and are therefore better able than anyone else to spot deterioration, is denied by psychiatric workers who in all likelihood have never met the patient before. This leaves the relatives bemused, frustrated and furious, as well as convinced of the unutterable incompetence of the services with which they have to deal.

    An important deformation of these services is their extreme bureaucratisation. An anthropologist visiting from Mars might conclude after his study that those who work for psychiatric services have such a belief in the efficacy of form-filling that they actually worship forms and ascribe magical powers to them.

    Not long ago I looked into several disastrous outcomes that occurred in the same place at the same time. I was immediately struck by the colossal number of forms that had been filled on each patient, often the same form asking the same questions, but filled with completely contradictory answers. It was clear that no one could possibly have read them (except me); for the persons who filled them, therefore, the filling of the form, not the welfare of the patient, was the purpose of their work. No doubt having filled in a form they thought that they had done some work that day.

    The overall impression was of time-servers on a job-creation scheme waiting for their salaries at the end of the month rather than of professionals whose concern was for patients. This would not be altogether fair, however, for they were forced to behave in this manner by the organisers of the services, so-called. Many of them probably wanted to do a good job but were actively prevented from doing so.

    Low standards are not universal, but they are common enough to cause much misery. Moreover, these low standards have nothing to do with a lack of funding. The impetus to low standards has come from within the services themselves, not from the government and protests from doctors have been muted, to say the least.