Wednesday, June 3, 2009

“Wake-up Call” to British Psychiatry

Nearly a year ago, on the 200th birthday of psychiatry, the British Journal of Psychiatry published a letter signed by 36 psychiatrists, lamenting the downgrading of medical aspects of care in a “wake-up call” to British psychiatry:

“The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.”

The Times (June 27, 2008) picked up the story in:

Mentally ill are 'jollied along' rather than treated by psychiatrists
“Treatment is often little more than jollying people along,” said Professor Nick Craddock, of the Medical School at Cardiff University, one of 36 signatories of a letter published today in the British Journal of Psychiatry.

“If a GP suspected a patient had cancer, he wouldn't dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That's what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there's every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

The desire not to stigmatise people has also done damage by implying that there is no such thing as mental illness. Patients are now known as “service users” rather than patients — even though, when asked, 67 per cent preferred the word patient and only 9 per cent service user. Treatments are provided at “mental health” centres, not mental illness clinics.

“For those with severe mental illness, to avoid medicalisation is at best confusing and at worst damaging or even life-threatening ... these individuals are being let down by the current state of affairs.”

Against this backdrop, it is not surprising that the UK Psychiatry recruitment crisis has come to a head.

Today’s Channel 4 Headline:
Psychiatry's UK recruitment crisis

“Britain's mental health services are facing a 'catastrophic' shortage of psychiatrists as the NHS increasingly has to rely on overseas doctors to fill posts.

"Mental health bosses say in some cases doctors are being appointed to posts despite reservations about their suitability, as fewer and fewer UK-trained medics apply for psychiatric posts and overall competition for places falls.

"The Royal College of Psychiatrists (RCP) says cultural awareness is essential to being a good psychiatrist, and warns of an over-reliance on overseas doctors to fill mental health jobs. “

In fact, this recruitment problem was already reported by The Times Higher Education a few days ago (26 May 2009):
Concern over shrinking numbers of UK recruits to psychiatry
“’The single most important threat facing psychiatry and the care of people with mental illness in this country is the inability to attract our own medical graduates into psychiatry,’ said Rob Howard, dean of the Royal College of Psychiatrists.

“Academically it’s a complete disaster because the very best people won’t think of coming into psychiatry, and scholarship won’t move on in this country.

“The proportion of UK nationals among the graduates sitting the college’s membership examinations has fallen from an average of between 15 and 20 % over the past decade to just 6 % last year.

“The changes came about under a scheme, New Ways of Working (NWW), established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist. “

This government (or the next one) must look at NWW again as the statistics speak louder than anything else. Why should junior doctors want to go into a profession where they see “service users” not “patients”, and where the consultant’s role is so much marginalised? It must also be noted that if psychiatrists are allowed to see only the severely disturbed, the emotional burden is extremely high. In time one will lose contact with the range of disturbances that one used to see in a more average psychiatric clinic so essential for the proper understanding of human nature. Also we need to learn how to tell the fakes from the real. No junior would want to be an expert on severe psychosis alone.

“Concern about the fall in applications is so great that the college has called on high-profile figures, including Stephen Fry, the actor and author who has spoken of his history of depression, to urge medical students to specialise in psychiatry.”

A sad day for psychiatry and a sadder one for psychiatric patients.
(Sorry, psychiatric patients do not exist anymore.)

Grand Rounds Vol 5 Number 38 : Jobbing Doctor
New Link:
Jobbing Doctor: What a way to run a service.
Dr Grumble: The BMA wakes up

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