General psychiatry, still in no-man's land after all these years: commentary, Pelosi

Response

Martin Deahl has written eloquently – albeit anecdotally – about current problems with general psychiatry.¹ One of his main concerns is that ‘continuity of care is no more, with a merry-go-round of patient “pass the parcel” between several teams, often never seeing the same consultant twice’. Is this others’ experience? I have been hearing about such problems from psychiatrists throughout the UK for almost three decades. I can never be sure if I am just being told about temporary organisational difficulties or whether there are structural problems that are impossible to resolve and that inevitably lead to fragmentation of care for people with serious mental disorders. I suspect the latter.

Deahl calls for research into ‘how psychiatry got into this mess in the first place’. A couple of issues in his editorial and in a previous article may go some way to explaining the mess.^1,2 He describes, with justifiable pride, how he provided hospital and community consultant care during the 1990s for 18- to 65-year-old patients from a catchment population of 50 000 in Hackney, London. At that time, the Royal College of Psychiatrists recommended that a full-time consultant general psychiatrist should usually cover a base population of 35 000–40 000 but that this should be markedly reduced for those working in inner-city areas such as Hackney. If Deahl and his colleagues in the community and inpatient teams had had proper staffing levels, I am in no doubt that they would have provided safe, comprehensive, and sustainable care of the highest quality. There would then have been less pressure to make radical changes to community services.

I hope Deahl will accept that sincere compliment, because I must take him to task about another part of his editorial. He reminisces about looking after a young patient with a first episode of psychosis while he was a junior trainee in the mid-1980s. She remained in hospital and untreated for two months while Deahl carried out painstaking detective work into her background. This was followed by a formal case presentation to the consultant. Only then were decisions made about diagnosis and treatment. This hangover from the heyday of the asylums was all too common at the start of moves to care in the community.³ It was – let's face it – totally bonkers. This style of practice was an important factor in allowing a handful of charismatic psychiatrists and psychologists, mainly from Australia via North Birmingham,⁴ to persuade policymakers and health service managers that ordinary British psychiatrists did not have a clue how to do psychiatry. Unfortunately, those colleagues had somehow got it into their heads that a plethora of subspecialist teams and ‘functionalised’ hospital wards were the only solution to the challenges of providing modern psychiatric care.

If the current situation as described by Martin Deahl is widespread, then there is an urgent need to reshape British psychiatry. The Royal College of Psychiatrists should team up with the professional bodies of our multidisciplinary colleagues to carry out a review of services, armed with the knowledge and experience that we have all gained since the start of the era of care in the community.