Society of Clinical Psychiatrists – Annual General Meeting Chairman's address

November 2010

As we approach the end of the noughties it is time  again to take stock of the NHS broadly and of our specialty of psychiatry in particular.

I will start with a concern expressed last year, not by a psychiatrist, but by a general physician, Dr Mark Aitken, consultant at Colchester general hospital (Aitken M, Do the Brutish value continuity of care? J R Soc Med 2009:102; 168-169). He begins to answer the question by declaring current continuity of care as a ‘debacle’and points to two main obstacles: the European Working Time Directive (EWTD) and lack of appropriate inpatient beds. The last government expected Hospital trusts to be fully compliant with a 48-hour week in short order. He noted however that the Americans advocate strongly for 80-hours and not the EWTD 48.They claim that ‘continuity of learning’ becomes the main casualty of shift working, especially when those working the shift are under pressure and that ultimately patients of tomorrow suffer. (He suggests that 56 could be a practical compromise and some might well consider that also as too short, but let us not detract in any way from the main trust of this valuable paper).

Psychiatric practice has long identified good continuity of care as a gold standard. But I am not aware of any recent publication expressing concerns about this. Yet I recall just a couple of years back being perturbed to learn that in a hospital which I visited to conduct a second opinion that in at least one acute ward a consultant treated patients only when admitted to that ward and a different consultant took over their care when they were discharged back into the community. Did anyone else mind, I wondered?

In identifying shortage of appropriate beds as the second main problem Mark Aitken certainly touched on what has been a raw psychiatric nerve for decades. From a psychiatric bed complement (England and Wales) 0f 155 000 in 1960 to 87 000 in 1980. Such was the concern then about this reduction an All Party House of Commons Select Committee 1985 Report Community Care (with special reference to adult mentally inn and mentally handicapped people) HMSO exposed the already apparent fraudulent foundations for community care from the 1970s up to that time.  Its language was quite blunt....”Any fool can close a longstay hospital: it takes more time to do it properly and compassionately”. Yet numbers continued in freefall from the 1980 figure to 32 000 in 2003. Since then up to date statistics have been hard to come by.

On June 24, 2006 the then Chief Inspector of Prisons Anne Owers commenting in the Daily Telegraph, claimed that “Jails are reaping the harvest” of the closure of older mental hospitals because of psychiatric patients were being incarcerated rather than treated. Alas, our Society’s correspondence  identification and offer of assistance with her concerns failed to elicit any response for whatsoever reason. Way back in 1939 Lionel Penrose demonstrated a negative correlation between prison population homicide and availability of hospital beds.

Some medico-political voices have sought to justify dire situation of bed shortages by claimed huge advances in psychiatric practice. We do not accept this. Indeed it can be asserted that evidence suggesting the opposite is available. Let me cite three papers from 2010 which raise interesting contradiction to those clamorous claims of increased effectiveness.

1.      Efficacy of Cognitive Behaviour Therapy (CBT) for adult depression: meta-analytic study of publication bias, multi-centre: Holland, Belgium, USA, Germany and Sweden, (Cuijpers P, et al, BJP 2010, 196, 173-178. This large study by psychologists (NB, not psychiatrists) was undertaken because the researchers queried the benefits of CBT and other psychotherapies. They conclude that ‘The effects of psychotherapy for adult depression seem to be overestimated considerably because of publication bias’. 

CBT, (initiated by US psychiatrist Aaron Beck) has been promoted, especially by the clinical psychologists body certainly for broad spectrum of psychiatric and psychological disorders : almost CBT chips with everything. Psychiatrists have been cautious about its rather more limited application in psychiatric practice.

2.      It is frequently asserted that that there have been huge strides in psychotropic medication treatment of mental illness. However, a Scottish ‘Comparison of the effectiveness of depot antipsychotics in routine clinical practice, Polash S et al, The Psychiatrist (2010) 34, 273-777 is distinctly relevant. It acknowledged the therapeutic superiority of depot antipsychotics and included both typical (which date back to the 1960s) and atypical depot preparation and found that no long-acting injection was clearly superior in all outcome measures. This supports the continued need for a variety of long-acting antipsychotics: but no glowing superiority of the newer so-called atypical there.

3.      .The battle to restore ECT to its rightful place as a truly remarkably effective treatment for certain mental illnesses took a belated forward step in a US 13-centre study (Bifrontal, temporal and right unilateral electrode placement in ECT: randomised trial, Kellner CH et al Br J Psychiatry(2010), 196, 226-234. This was preceded by an editorial in the same journal issue on Electrotherapy, practice and evidence (Scott AIF, 196, 171-172). The last two sentences of the editorial state unequivocally, “The patients in the present study had already been ill for an average of 2.4 years. Why did they have to wait so long to be offered such efficacious treatment?” The likelihood is that 20 years ago those patients would have received their ECT within days or at most weeks of similar illness development: a 2-year plus saving of suffering patient time and with it the common improvement leading to hospital discharge in weeks.

In that cri de coeur for ECT reminds us how over perhaps the past 2-3 decades pleas for change and betterment of patient care overall have not only appeared to fall on deaf ears but ever more politically-driven flouting of decent practice service provision has seemed to be the norm. Perhaps the Coalition Government will surprise us all in a good sense as Health Secretary Andrew Lansley advocates re-empowering  doctors and axing bureaucrats. For those interested there is a piece on the Society’s websites, on some possible implications of the proposed NHS Reorganisation.

Mark Aitken’s ultimate paragraph strikes a note of despair when he declares ..”it is a mystery to me why the medical profession, which made the decisions about patient care before the NHS, now appears to be content to be frogmarched by the Department of Health and its sychophants down the road to perdition.” He detects a pressing need for strong leadership from the medical profession before continuity of care becomes a distant memory to those old enough to remember what it was all about.

Finally it is a pleasure to end on a thank-you note to Dr Mike Haslam our untiring Honorary Secretary, our Press Office Dr John Harding Price, Dr Moudi Elameer, Editor and the Society’s online Webmaster. The President of the quondam Suspended Doctors Group (renamed earlier this year Doctors Support Group-DSG) Dr Peter Tomlin continues as industriously as ever in that role which is so immediately helpful to doctors in employment distress: Dr Ray Parsons until recently Honorary Secretary of the DSG who gave so much of his himself to that group has (due to circumstances beyond his control) had to resign. We wish him and his family well for the future.It would be remiss of me not to mention Dr David Viniker, who as webmaster for the DSG has been unfailingly helpful not only to the DSG but to the Society also.

Dr Dermot J Ward.