This is madness

Mind

31st 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.


  • Jack Dawson

    Spot on, Dr D. The ‘fostering of dependence’ implicit in the therapeutic relationship has now become taboo. Discontinuity of care is actively encouraged. Treatment consists of the impersonal delivery of interventions, all of which are evidence-based, of course, but none of which is tailored to the individual patient.

    It is not only in psychiatry. A relative of mine recently died in a large teaching hospital. The large ward had three nursing stations and the nurses were rotated round them every three days, so any personal attachment was impossible. My relative was going to die anyway – he had advanced pancreatic cancer – but it would have been better if he had been humanely cared for in his final days.

  • Filling in forms in very important… if you don’t fill them in and file them correctly the auditor, if there’s an audit, will have to put in his form that your forms were incomplete and you and the auditor will have to collaborate on a form and your manager will have to fill-in a form too. If you’d filled-in the forms properly in the first place you wouldn’t have had to fill in so many forms.

    • Alphonsus_Jr

      Wow. You completely missed the point.

      • Macwully

        Certainly someone has missed the point!

  • Grandma

    I wouldn’t assume that the service is filled with good people frustrated by bad systems. Avoidance of responsibility and accountability is very attractive to bureaucrats – it’s one of the few things I’ve ever seen any work hard at!

    • Marie Louise Noonan

      I don’t think that’s fair. Psychiatry differs from other specialisms in that there is no blood test you can administer to rule mental illness out. Diagnosis is by means of close observation. And that entails writing copious notes. (I’m referring to ‘functional’ rather than ‘organic’, obviously.)

      And bureaucrats are a necessary evil, I’m afraid.

  • Marie Louise Noonan

    Suicide contagion?

    It’s not just the NHS. Private hospitals aren’t all they are cracked up to be either. Especially when the half trained nurses use you as a means of improving their own peculiar brand of psychotherapy. At that point, you are a mere pin cushion.

    I should be more grateful.

  • Judy

    So much my experience as a mother. But the more you speak up the more you are ignored (at best). There are no other services so you have to try to work with the system while your heart is breaking. There is also an underlying belief (I think) that suicide is a life choice and if someone really wants to do it there is nothing anyone can do, The patient has to learn to take responsibility for themselves….so as far as the system is concerned it is always the ‘service user’s’ fault.