Shocking Psychiatry

A continuing theme at NHS BLOG DOCTOR is going to be an analysis of covert government savings schemes being introduced into the NHS.

This is where we came in originally with details of airline staff savings schemes . You might call it “cheapo-cheapo” productions.

We would not be so vulgar. We call it “dumbing down.” And nowhere is dumbing down more rife than in psychiatry.

There is a national shortage of psychiatrists. Mental health has always been a twilight area of medicine. Glamorous it is not. Chronic mental illness is ignored.

It takes 10 years and a lot of money to train a consultant psychiatrist. But the Labour Government has realised that you don’t need to go to all that expense. If you send a nurse, or an occupational therapist (or in fact anyone, really, as long as they express an interest) on a weekend course they can deal with most cases of mental illness. Give them a protocol and the "Dorling Kindersley 3-D Pop-up book of Lunatics", and they can cope with anything.

What shall we call this pot-pourii of non-medically trained, well-meaning amateurs? Better make it sound plausible. Give them an important name, like…er…like the Community Mental Health Team. (CMHT). Gosh, that sounds good. And they are a team. Teams are friendly. Teams are politically correct. And they are cheap too. There is a psychiatrist on the team. Allegedly. But they are usually too busy to see urgent cases. The ancialliary staff see all the patients and free up the psychiatrists to do the really important stuff like…er…well, whatever it is that they do do now.

But just a minute. There is going to be a problem here. The GPs won’t like it. They look after most mental health problems in the community but, when they want a psychiatric opinion, they have this silly, old-fashioned feeling that getting a psychiatric opinion means seeing a psychiatrist. A random member of the CMHT will not do.

So how do we pacify these wretched, fussy GPs?

Anthony is 30. He has always been a rather brittle, aggressive difficult sort. Probably has a borderline personality order but no previous psychiatric history. Then one day, his wife eloped with her colleague from work, leaving David to cope with his 7, 9 and 10 year old daughters.

He became depressed. Counselling did not help. The girls started bed-wetting and school refusing. David was not coping. Anti-depressants did not work. Maybe it was just circumstantial. Then he bought a Stanley knife and started cutting his forearms at home in front of the children. The children were at risk. Was it his depressive illness, or his personality disorder? Did he need more medication or less?

Time to see the psychiatrists.

But the psychiatrists are too important now to accept referrals directly from family doctors. The referral was diverted to a nurse who is part of the CMHT. Team it may be, but you usually only see one or two of them. And you can ask for a psychiatrist but you only get one if the nurse thinks it is necessary. She saw David and said that there was nothing wrong with him. He was not ill. The GP should have realised that he was slashing his forearms because of the stress the marriage break up.

Phew! That’s all right then. Silly me for making a fuss.

She refused to provide any support from the CMHT. David was discharged. He moved out of the area. I complained to the psychiatrists. Without even seeing David, they rubber stamped the nurse’s assessment. That must be why they are so important. They can make a psychiatric assessment without seeing the patient. Wish I could do that; it would save so much time.

A month or two later, I got a letter from social services. They were having a case conference. David was hitting and abusing the young children. Should the children be on the at-risk register? Did he have a psychiatric history?

Thankfully, social services will sort it out. They usually do. The children will be safe, and David will get the help and support he needs. There has been no tragedy. But there could so easily have been. Distressed parents in this situation have been known to murder children to get revenge on their partners.

Thank God for social workers .

But what do the psychiatrists do all day now?