But does the doctor know best?

In the world of mental health care, must the psychiatrist always be king? Susie Green thinks not

In psychiatry, progress into the community moves inexorably on. Dispensing with the buildings is comparatively easy, but the institutional attitudes which professional groups carry with them represent a more intractable problem. These attitudes are being reinforced by a system of education and training which relates more to safeguarding professional interests than to addressing the key question of whether patients’ needs are being met.

It is a well known fact that in psychiatry there is a 72% readmission rate — i.e. the psychiatric services are failing to meet the ideal objective in 72% of cases. Would this be tolerated in any other speciality? And at what cost? Does it really need the full range of multi-disciplinary input to result in a record of achievement which in cost-effectiveness terms has managers wringing their hands in despair?

With minimum staffing levels the norm in the NHS, and a chronic shortage of paramedical workers, some professions are heavily dependent on unqualified assistants to keep their departments afloat. They argue that because of staff shortages, it is impossible to do the job properly and produce a high quality service. Recent attempts to develop training initiatives for ‘assistants’ have gone down the generic road with full professional status as the ultimate goal.

Whether this is necessary to meet the needs of patients is a question which nobody dares ask for fear of finding themselves dispensable. In fact, insecure professions are busy attempting to elevate their status with a spiral of academic incrementalism which itself generates exclusivity and further reinforces the staff shortages. Their role model in this academic spiral is the doctor whose knowledge base brings the rewards of power, money and status.

However, monopoly control over an area of work is the classic way in which a profession increases its power and pay — and psychiatrists, who are just as anxious as anyone else not to be found dispensable, are no exception.

For example, the Royal College of Psychiatrists is putting forward a collection of reasons as to why psychiatrists should spearhead community care. First, it suggests that the performance of local authorities, ‘bedevilled by politics, preoccupied by child abuse and... (with)... a patchy record of developing community care for the mentally ill’¹, has been poor.

Second, it points to the need for psychiatrists to be the hospital gatekeepers — even though the reasons given, such as people having underlying physical illnesses, needing physical methods of treatment or the care of a medically qualified person within the provision of the Mental Health Act, could all be met by any doctor, not specifically a psychiatrist.

Third, it restates its belief in the importance of having a psychiatrist to supervise the work of the rest of the psychiatric team. And yet by its own admission, other aspects of psychiatric illness, requiring attention to social relationships, can be carried out by any member of the psychiatric team providing they have tact, sensitivity and appropriate training.

One is left asking by what right psychiatrists sit in judgement on problems which they acknowledge can be social.

It is interesting that many of those presently occupying psychiatric beds are defined as ‘sick’ by virtue of being a hospital patient, not because of their symptoms which may long since have evaporated, only to be replaced by a chronic dependence on the institution. If people are regarded as mentally ‘ill’ — as patients — then logic demands that their case should continue to be supervised by doctors. But if psychiatrists still wish to maintain their supervisory function in the community, away from the hospital, the nature of the doctor/patient relationship is sustained and they are responsible for perpetuating the prejudice of the psychiatric label.

All this has the effect of consolidating a medical model of practice, and preserving the position of the psychiatrist as leader of a multi-disciplinary team even though we do not know whether this is the best way of meeting patient needs. Where is the evidence that a fully constituted multi-disciplinary team can do anything to reduce that awful 72% re-admission rate?

There is an assumption that the multi-disciplinary team is sacrosanct and that its composition and efficacy should not be challenged. Any attempt to do things differently is met by an impenetrable barrier of ethical codes, statutory requirements and local policy which, although successfully protecting the patient, the professional and the organisation from mutual abuse could be said to result in managerial impotence.

Professionals have squealed at the market model which has been imposed on them, but enforced change may be the only way to break the stranglehold which they have on our present provision of psychiatric care. This is not to suggest that change should be a glib recipe for dispensing with necessary skills, but it could be a way of reorganising them more effectively. We need to look broadly at how best to meet people’s needs, the skills and training necessary to do so and the nature and relevance of the boundaries between different members of the workforce involved.

The restructuring of the NHS should have been a golden opportunity for a radical rethink of the traditions underpinning psychiatric care. Instead, wrangling for responsibility and resources continues. Models of care based on traditional assumptions and the perpetuation of professional power are unchanged. We should be taking the needs of the patient as a starting point, and asking how they can best be met. I suspect that the answer to this question would not be the professional pecking order with which we are saddled at present.