BY
STEVEN HIRSGN An American psychiatrist working at the Maudesley Hospital ?R an American who becomes acquainted with the Mental Health Service in Great Britain, I think the most vivid impression must be that here, mental services are provided with the patient fifst in mind, with equal benefits at every level of
s?ciety.
That Welfare
mental health service should have the of its patients as its basic premise may
a
Seern obvious to you if you have never lived with a"y other system. You may take such a point of for granted and regard my comment as odd. et, despite protestations of the American Medi-
al Association
to the contrary, this is not the case the United States. It is certainly the outstanding 'Jttportant difference between American and
?ritish psychiatry
as I see it. I can well remember working in the casualty of my university hospital in the United States when a very interesting and disturbed
^ePartment Patient
seen by the on-call Psychiatric the patient required urgent admission the registrar said he was a 'very unusual case', remember the registrar was pleased by this bemuse it meant that this patient, who could not afford the high costs of private in-patient treatment, might be eligible for one of the three or four Psychiatric beds (of about 90 private beds in all) ^hich were specially endowed for so-called 'ward' ?r public patients who would not be able to pay !he high hospital charges, but are of special '^terest from an academic or training point of was
*^egistrar*
view.
In this particular instance,
as in so many others, few beds for ward cases were full and the Patient was refused admission even though other Private psychiatric beds remained empty. As I was learn, this was the rule rather than the excepl.?n; one of the realities of medical practice I learn about in my pre-clinical years. As it the hospital was in the state of Maryand which provides better facilities than most
these
tp
^'dn't happened,
correct American term, which I have translate, would be 'assistant resident*.
taken
the
liberty
states,
so
the
patient
could be admitted to the
3,000-bed mental hospital which covered his geographical area, a system similar to that in Great Britain.
Nevertheless, this situation stands in
some con-
trast to that which I have found in Britain.
Though
England in a university post-graduate psychiatric hospital of international reputation, all I work in
beds are under the Health Service?no private beds at all?and patients are admitted either because they come from our local area, for which we share a responsibility like any N.H.S. psychiatric hospital, or because they come to us by special referral from outside our area, or present a particularly difficult clinical problem. If the beds are available, even these criteria need not apply. Thus there is no question of the financial circumstances of the patient being a determining factor in admission. Moreover, it was a pleasant surprise to find that the majority of my colleagues here whole-heartedly back this principle, while there would be considerable division and acrimonious debate over such ideas among psychiatrists in the States. I understand that the quality of mental hospitals and the supply of trained personnel varies greatly within England. Yet it was a great surprise to find that a patient could be referred from anywhere in the country and be transported, if necessary with an escort, at the expense of the Health Service, providing there is a medical indication to do so. For example, a young teacher was recently referred from Derby to our firm at this hospital in London for a second opinion which the local psychiatrist in Derby requested. I was amazed at first to find that it was not an exception for psychiatrists in the hospital in which I am working, who have been senior registrars for several years, to take appointments as consultants to large out-lying mental hospitals. These are highly qualified men and women, all of whom have post-graduate qualifications such as the M.D. or M.R.C.P. The fact that in the last 20 years wellqualified psychiatrists such as these are taking up our
appointments at less prestigious, large mental hospitals or in psychiatric units attached to district general hospitals means to me that mental health services for the community should be constantly improving, and indeed this seems to be the case. For example, reading British psychiatric journals I was interested to find that from a third to a half of the articles originating in Great Britain are written by people working at units in psychiatric hospitals and units under the control of Regional Hospital Boards, as opposed to university centres. Another example is the Open Door policy, a movement which got its great impetus from British mental hospital staff, both doctors and nurses. Further support for my supposition concerning the beneficial results of the injection of high grade talent into the mental health services comes from conversations I have had with colleagues who work on the staffs of several different mental hospitals near London, such as Netherne, Claybury and Belmont. Though their medical staff-to-patient ratios are relatively low, imaginative and sometimes unusual techniques involving milieu therapy, group therapy, industrial rehabilitation therapy, etc., are being employed, and often a similarly bold and vigorous approach is lacking, or only just catching on, at the more academic psychiatric teaching centres. Whether one agrees or not with one or another of these particular approaches, they do indicate vigorous and progressive attempts to improve services available for patients. There is another feature of the mental health service in this country which is a vital part of the service as I see it, yet may easily go unnoticed. This is the role of the general practitioner. Because 97% of the population are on the list of a
general practitioner important consequences follow. For example, an enormous amount of supportive work is done, both consciously and unconsciously, by the general practitioner in giving consultation, advice, tranquillisers, anti-depressants and so forth. I have noticed that more than
half the patients who eventually come under my care in hospital have already been maintained for some considerable time by their family doctor. The extensiveness of the G.P.-patient association has other important consequences. The local doctor is in closer communication with the patient and can often detect a psychiatric problem before the patient or his family are able to realise it. Moreover, after a patient has been in a psychiatric hospital and is eventually discharged from the outpatient follow up, continuity and contact can be maintained by the general practitioner, as well as by community after-care personnel such as a health visitor, mental welfare officer or the hospital's psychiatric social worker. Thus, in a sense one
could say that a potential life time of continuity is established between the patient and the mental health services by the general practitioner, priof to and following specialised psychiatric treatmentMention of social workers brings me to the area of ancillary social services and rehabilitation services with their community care approach. This has impressed me a great deal because I have found it such a tremendous help in the management of
patients. I do not think it is up to me in this article to extol the virtues of social workers, occupational therapists and their colleagues in local authority Child Care, Mental Welfare, and Health and Welfare departments. The services they perform would be the basis for another set of articles. 1 will mention only two brief overall impressionsFirst?because of the statutory provision of these services by hospital and local authorities, I find it is possible to make plans for after-care with greater confidence in what can be arranged and with considerable confidence in the quality of facilities which will be provided.
Shop
around
Similar social services provided by the state or local authority in the United States were mainly concerned with the financial problems which resulted from medical care. Though excellent services exist in the community, because they are mostly private, one must shop around much more in the hope of finding a Catholic organisation for a Catholic patient or Jewish organisation for a Jewish patient, or whatever, who will provide the services needed. My second point is that psychiatric social workers in Britain, like in the United States, are grossly underpaid?only much more so in BritainI find it totally incomprehensible that some of the most highly trained and qualified people in their profession should be paid so little because they are employed by a hospital board rather than a local
authority. A quite
different area of emphasis and point of view which I have found in the health services in Britain is related to the hegemony which psychoanalytic thinking has in American psychiatry in almost all of the important training centres at present. This is true even at centres which like to think of themselves as eclectic?which I found means that they are principally psychodynamic but use other methods as well. Emphasis on the psychodynamic point of view is a contributing and perpetuating factor in the very different orientation of American mental health services. Most of my peers in psychiatry in the States espouse a 'psychodynamic' point of view from which they draw the conclusion that any treatment short of psychoanalysis is only a patch-up job, not
doling
'real' problem. This freleads them to the conclusion that the 8enera^ psychiatrist, such as treating , with drugs and programmes of refutation so that they can return to the comunity or supporting patients through their deprespossibly with the aid of physical methods Uch as E.C.T., etc., is not 'really' psychiatry, or orthy of their talents. Such a view supports these young psychiatrists their erstwhile choice to become a psychoerapist and not have to deal with the large group Patients they regard as being too ill, and therenot amenable to psychotherapeutic treatment, this need to deal with patients' psychoynamics, which they regard as the source of all with
patient's
a
quently
\
k^phrenics
!
^l0ri
^oreover,
Psychopathology,
impractical keeping patients in hospitals for long periods?the rationale being at, though they seem and feel well, the causes ave not been dealt with adequately as they have ?t received an adequate course of psychotherapy. may be all right so far as it goes, but not
? Us'ons
such
often leads to
con-
as
|^?rdinately
,
Jis hen
are to keep beds of the centres filled with what amounts
the consequences
etter treatment
0
Moderately
^red
patients,
Merely
disturbed and considerably while excluding large numbers of recov-
ill.
British psychiatry,
rmly
on
the
I find, has its feet more ground. Even advocates of the approach?at least those I have
^Vchodynamic et in the health service?by and large limit their to the sector of the patient community j^hniques ?st suited for rather than unrealistically ,
them, image of intensive psychotherapy the great panacea which, regrettably for a Umber of reasons, is only feasible for the few. A different aspect of the health service which I ?Und interesting is the position of the doctor in
?lding
s
,
out the
Many of my colleagues training gaining. ?uld prefer not to take consultant
here
appointments
J Regional
Board Hospitals or work at Mental elfare or Child Guidance Clinics not connected llh teaching hospitals. A minority would prefer Parley Street private practice earning a larger ancj dealing with patients who, on the ^'ary u?le, are less acutely ill, just as their American
c?Unterparts do. ^ore stimulating such th ^?Wever> .
attitude is the rule rather our counterparts trainin the United States. So many times have my ^erican colleagues said to me?'of course tychotic patients are in one sense in greatest need ari the
an
exception among
^8 ?
care, and this should be provided, personally find individual psychotherapy tI ri?fe stimulating. Besides, one has a much better
Psychiatric
therapist in private practice, and I have my family. Anyway, there is not much too sick.'! you can do for these people, they're There is not a large market of private patients in Britain, possibly because patients can get equally good care (often better) on the Health Service. Consequently, the opportunities before the young doctor in training are mostly limited to Health Service appointments. These opportunities life to
as a
think of
are, to a
large extent, rationalised and allocated
to the needs of the community, with those who are acutely ill and most in need being tended to first, regardless of their personal desirability or circumstances.
according
Economic free-for-all I suppose that it is because the British doctor is now born, bred and trained with such a system around him that he takes up its values as well. Certainly the majority of my colleagues here, almost without exception, would not want to go back to the economic free-for-all of pre-1948 even though it would enhance their own earning
potential.
Yet it does seem to me that, from the personal point of view, the English doctor doss have a harder time of it. His post-graduate training is much longer, often unduly so, and at the end of it he often finds he must take up a position doing work he was not inclined to do, in a place or part of the country he would prefer not to be. Contrast the psychiatrist's situation in this country with that in the United States, where he enjoys enormous prestige in many circles, has a high income, and is in such short supply that after three years' psychiatric training he can go to almost any community and rapidly develop a successful private practice. I must say that the services here are orientated to serve the patient and community first, while the services in the United States seem orientated to best the interest of the medical profession, serve before that of the public. This is not to say that this is a matter of design in the States; of course it is not. But even if looked on as a mere cultural and historical accident, the medical profession does, with a powerful lobby, take what steps they can to perpetuate things as they are. From society's point of view, I have no doubt whose interest should take precedence. I see the development of community Mental Health Centres in the United States as an attempt to get around the intransigent resistance to any form of rationalised Health and Welfare Service. Yet it is precisely such an approach which has given this country the basis for a comprehensive and effective service which, from a community point of view, puts the counterpart in the United States to shame.
STEVEN HIRSGN An American psychiatrist working at the Maudesley Hospital ?R an American who becomes acquainted with the Mental Health Service in Great Britain, I think the most vivid impression must be that here, mental services are provided with the patient fifst in mind, with equal benefits at every level of
s?ciety.
That Welfare
mental health service should have the of its patients as its basic premise may
a
Seern obvious to you if you have never lived with a"y other system. You may take such a point of for granted and regard my comment as odd. et, despite protestations of the American Medi-
al Association
to the contrary, this is not the case the United States. It is certainly the outstanding 'Jttportant difference between American and
?ritish psychiatry
as I see it. I can well remember working in the casualty of my university hospital in the United States when a very interesting and disturbed
^ePartment Patient
seen by the on-call Psychiatric the patient required urgent admission the registrar said he was a 'very unusual case', remember the registrar was pleased by this bemuse it meant that this patient, who could not afford the high costs of private in-patient treatment, might be eligible for one of the three or four Psychiatric beds (of about 90 private beds in all) ^hich were specially endowed for so-called 'ward' ?r public patients who would not be able to pay !he high hospital charges, but are of special '^terest from an academic or training point of was
*^egistrar*
view.
In this particular instance,
as in so many others, few beds for ward cases were full and the Patient was refused admission even though other Private psychiatric beds remained empty. As I was learn, this was the rule rather than the excepl.?n; one of the realities of medical practice I learn about in my pre-clinical years. As it the hospital was in the state of Maryand which provides better facilities than most
these
tp
^'dn't happened,
correct American term, which I have translate, would be 'assistant resident*.
taken
the
liberty
states,
so
the
patient
could be admitted to the
3,000-bed mental hospital which covered his geographical area, a system similar to that in Great Britain.
Nevertheless, this situation stands in
some con-
trast to that which I have found in Britain.
Though
England in a university post-graduate psychiatric hospital of international reputation, all I work in
beds are under the Health Service?no private beds at all?and patients are admitted either because they come from our local area, for which we share a responsibility like any N.H.S. psychiatric hospital, or because they come to us by special referral from outside our area, or present a particularly difficult clinical problem. If the beds are available, even these criteria need not apply. Thus there is no question of the financial circumstances of the patient being a determining factor in admission. Moreover, it was a pleasant surprise to find that the majority of my colleagues here whole-heartedly back this principle, while there would be considerable division and acrimonious debate over such ideas among psychiatrists in the States. I understand that the quality of mental hospitals and the supply of trained personnel varies greatly within England. Yet it was a great surprise to find that a patient could be referred from anywhere in the country and be transported, if necessary with an escort, at the expense of the Health Service, providing there is a medical indication to do so. For example, a young teacher was recently referred from Derby to our firm at this hospital in London for a second opinion which the local psychiatrist in Derby requested. I was amazed at first to find that it was not an exception for psychiatrists in the hospital in which I am working, who have been senior registrars for several years, to take appointments as consultants to large out-lying mental hospitals. These are highly qualified men and women, all of whom have post-graduate qualifications such as the M.D. or M.R.C.P. The fact that in the last 20 years wellqualified psychiatrists such as these are taking up our
appointments at less prestigious, large mental hospitals or in psychiatric units attached to district general hospitals means to me that mental health services for the community should be constantly improving, and indeed this seems to be the case. For example, reading British psychiatric journals I was interested to find that from a third to a half of the articles originating in Great Britain are written by people working at units in psychiatric hospitals and units under the control of Regional Hospital Boards, as opposed to university centres. Another example is the Open Door policy, a movement which got its great impetus from British mental hospital staff, both doctors and nurses. Further support for my supposition concerning the beneficial results of the injection of high grade talent into the mental health services comes from conversations I have had with colleagues who work on the staffs of several different mental hospitals near London, such as Netherne, Claybury and Belmont. Though their medical staff-to-patient ratios are relatively low, imaginative and sometimes unusual techniques involving milieu therapy, group therapy, industrial rehabilitation therapy, etc., are being employed, and often a similarly bold and vigorous approach is lacking, or only just catching on, at the more academic psychiatric teaching centres. Whether one agrees or not with one or another of these particular approaches, they do indicate vigorous and progressive attempts to improve services available for patients. There is another feature of the mental health service in this country which is a vital part of the service as I see it, yet may easily go unnoticed. This is the role of the general practitioner. Because 97% of the population are on the list of a
general practitioner important consequences follow. For example, an enormous amount of supportive work is done, both consciously and unconsciously, by the general practitioner in giving consultation, advice, tranquillisers, anti-depressants and so forth. I have noticed that more than
half the patients who eventually come under my care in hospital have already been maintained for some considerable time by their family doctor. The extensiveness of the G.P.-patient association has other important consequences. The local doctor is in closer communication with the patient and can often detect a psychiatric problem before the patient or his family are able to realise it. Moreover, after a patient has been in a psychiatric hospital and is eventually discharged from the outpatient follow up, continuity and contact can be maintained by the general practitioner, as well as by community after-care personnel such as a health visitor, mental welfare officer or the hospital's psychiatric social worker. Thus, in a sense one
could say that a potential life time of continuity is established between the patient and the mental health services by the general practitioner, priof to and following specialised psychiatric treatmentMention of social workers brings me to the area of ancillary social services and rehabilitation services with their community care approach. This has impressed me a great deal because I have found it such a tremendous help in the management of
patients. I do not think it is up to me in this article to extol the virtues of social workers, occupational therapists and their colleagues in local authority Child Care, Mental Welfare, and Health and Welfare departments. The services they perform would be the basis for another set of articles. 1 will mention only two brief overall impressionsFirst?because of the statutory provision of these services by hospital and local authorities, I find it is possible to make plans for after-care with greater confidence in what can be arranged and with considerable confidence in the quality of facilities which will be provided.
Shop
around
Similar social services provided by the state or local authority in the United States were mainly concerned with the financial problems which resulted from medical care. Though excellent services exist in the community, because they are mostly private, one must shop around much more in the hope of finding a Catholic organisation for a Catholic patient or Jewish organisation for a Jewish patient, or whatever, who will provide the services needed. My second point is that psychiatric social workers in Britain, like in the United States, are grossly underpaid?only much more so in BritainI find it totally incomprehensible that some of the most highly trained and qualified people in their profession should be paid so little because they are employed by a hospital board rather than a local
authority. A quite
different area of emphasis and point of view which I have found in the health services in Britain is related to the hegemony which psychoanalytic thinking has in American psychiatry in almost all of the important training centres at present. This is true even at centres which like to think of themselves as eclectic?which I found means that they are principally psychodynamic but use other methods as well. Emphasis on the psychodynamic point of view is a contributing and perpetuating factor in the very different orientation of American mental health services. Most of my peers in psychiatry in the States espouse a 'psychodynamic' point of view from which they draw the conclusion that any treatment short of psychoanalysis is only a patch-up job, not
doling
'real' problem. This freleads them to the conclusion that the 8enera^ psychiatrist, such as treating , with drugs and programmes of refutation so that they can return to the comunity or supporting patients through their deprespossibly with the aid of physical methods Uch as E.C.T., etc., is not 'really' psychiatry, or orthy of their talents. Such a view supports these young psychiatrists their erstwhile choice to become a psychoerapist and not have to deal with the large group Patients they regard as being too ill, and therenot amenable to psychotherapeutic treatment, this need to deal with patients' psychoynamics, which they regard as the source of all with
patient's
a
quently
\
k^phrenics
!
^l0ri
^oreover,
Psychopathology,
impractical keeping patients in hospitals for long periods?the rationale being at, though they seem and feel well, the causes ave not been dealt with adequately as they have ?t received an adequate course of psychotherapy. may be all right so far as it goes, but not
? Us'ons
such
often leads to
con-
as
|^?rdinately
,
Jis hen
are to keep beds of the centres filled with what amounts
the consequences
etter treatment
0
Moderately
^red
patients,
Merely
disturbed and considerably while excluding large numbers of recov-
ill.
British psychiatry,
rmly
on
the
I find, has its feet more ground. Even advocates of the approach?at least those I have
^Vchodynamic et in the health service?by and large limit their to the sector of the patient community j^hniques ?st suited for rather than unrealistically ,
them, image of intensive psychotherapy the great panacea which, regrettably for a Umber of reasons, is only feasible for the few. A different aspect of the health service which I ?Und interesting is the position of the doctor in
?lding
s
,
out the
Many of my colleagues training gaining. ?uld prefer not to take consultant
here
appointments
J Regional
Board Hospitals or work at Mental elfare or Child Guidance Clinics not connected llh teaching hospitals. A minority would prefer Parley Street private practice earning a larger ancj dealing with patients who, on the ^'ary u?le, are less acutely ill, just as their American
c?Unterparts do. ^ore stimulating such th ^?Wever> .
attitude is the rule rather our counterparts trainin the United States. So many times have my ^erican colleagues said to me?'of course tychotic patients are in one sense in greatest need ari the
an
exception among
^8 ?
care, and this should be provided, personally find individual psychotherapy tI ri?fe stimulating. Besides, one has a much better
Psychiatric
therapist in private practice, and I have my family. Anyway, there is not much too sick.'! you can do for these people, they're There is not a large market of private patients in Britain, possibly because patients can get equally good care (often better) on the Health Service. Consequently, the opportunities before the young doctor in training are mostly limited to Health Service appointments. These opportunities life to
as a
think of
are, to a
large extent, rationalised and allocated
to the needs of the community, with those who are acutely ill and most in need being tended to first, regardless of their personal desirability or circumstances.
according
Economic free-for-all I suppose that it is because the British doctor is now born, bred and trained with such a system around him that he takes up its values as well. Certainly the majority of my colleagues here, almost without exception, would not want to go back to the economic free-for-all of pre-1948 even though it would enhance their own earning
potential.
Yet it does seem to me that, from the personal point of view, the English doctor doss have a harder time of it. His post-graduate training is much longer, often unduly so, and at the end of it he often finds he must take up a position doing work he was not inclined to do, in a place or part of the country he would prefer not to be. Contrast the psychiatrist's situation in this country with that in the United States, where he enjoys enormous prestige in many circles, has a high income, and is in such short supply that after three years' psychiatric training he can go to almost any community and rapidly develop a successful private practice. I must say that the services here are orientated to serve the patient and community first, while the services in the United States seem orientated to best the interest of the medical profession, serve before that of the public. This is not to say that this is a matter of design in the States; of course it is not. But even if looked on as a mere cultural and historical accident, the medical profession does, with a powerful lobby, take what steps they can to perpetuate things as they are. From society's point of view, I have no doubt whose interest should take precedence. I see the development of community Mental Health Centres in the United States as an attempt to get around the intransigent resistance to any form of rationalised Health and Welfare Service. Yet it is precisely such an approach which has given this country the basis for a comprehensive and effective service which, from a community point of view, puts the counterpart in the United States to shame.
