How many psychiatrists?
By
ANDREW SMITH OF THE YORK CLINIC
The majority of medically qualified specialists in mental disorders work in the National Health Service in crowded hospitals or busy clinics, granting the patient only brief interviews. In a typical outpatient clinic, new patients are seen for threequarters of an hour on the first occasion for their major assessment, and in most cases later interviews are of only fifteen minutes' duration. A few patients can be, and are, seen for longer sessions, but this is bound to lead to more widely spaced interviews for others or to longer waiting lists for the first assessment, as the volume of outpatient work has been and is rising rapidly. There are a comparatively small number of psychotherapists, of varying orientation, in private practice, who are able to spend far longer with their patients, but they can treat few at any one time. And there is a small amount of such intensive psychotherapy available in the NHS, but the patients are strictly selected and may endure very long periods of
waiting. There are psychiatrists who deny psychotherapy in mental disorders, often advocate other techniques such
the value of instead they as behaviour therapy, which are in their turn extremely timeconsuming, although admittedly they allow of partial delegation to non-medically qualified staff. There is agreement, therefore, that we need more psychiatrists. Meanwhile the psychiatric care is rationed. Writing recently in the American Journal of Psychiatry, Professor G. M. Carstairs pointed out that it can be rationed in a number of ways: by price, where the well-off get the best treatment; by giving first priority to the most seriously ill; by delay on the waiting list; by reducing the time allotted to each patient; and by working through non-psychiatric staff and institutions. In this country we are already employing all these methods to varying extents, and as the demand for treatment is ever-increasing, we shall need more stringent rationing or ever-increasing numbers of psychiatrists. Professor Walsh McDermott, Professor of Public Health of Cornell University, USA, has suggested that we need less investment in personal physicians, and more in administrative ones who, although themselves few in number, can, in certain conditions of society, implement far more improvement in health?as in directing malaria eradication, mass 14
or immunisation of susceptible populations. Can this idea be applied to present-day psychiatry? The difficulty here is the comparative lack of the necessary knowledge and techniques for effective application by the administrative psychiatrist. This is because, in its short history* psychiatry has been closely linked with the medical profession as a whole, especially in this country* and has been interested in the problems of the individual patient who consults a doctor and in
X-ray
the methods of treating him. Only since the Second World War have we been noticeably influenced by social psychiatry, although this influence is now' strong and increasing. What, then, has been done and could further be done along these lines? The influence of psychiatrists and psychologists in publicising the supposed effects of parental deprivation in childhood has to bring about more personal handling in
helped orphanages
and similar institutions and a policy of smaller units. It has also helped to further the unrestricted visiting of children in hospital. The study of human relations in industry now includes some social psychology, and group discussions are sometimes offered to trainee managers to help them realise the emotional conflicts liable to arise. Group projects and discussions are held in prisons
and are sometimes supervised by psychiatrists. The training of members of many professions involved in social work includes individual and social psychology. We have organised sheltered work-shops for the rehabilitation of partially disabled patients, and started on the preparation for retirement and the improvement of community services for the elderly, although much more could be done along these lines. Yet little is known of the efficacy of some of these methods, and one is left with the feeling that, though beneficial, they are only small contributions towards improving mental health. Let us consider the present rationing of psychiatric care, and the strains which may cause it to break down. Rationing by price, where the rich obtained by the pay for better treatment than is the American scene, with its dominates poor, numerous analysts in private practice and the state hospitals comparatively poorly staffed. This system must be inequitable, for the well-off do not suffer more ill health than the poor.
There is a danger that in this country the system J?ay change towards the American pattern, for, as r-
J- R. Searle has pointed out, when the amount available for private practice greatly "greases, as it is here with the rapid expansion of Pr'vate health insurance schemes, doctors will ?llow the money and transfer from public to Private practice. This begins a vicious circle, for "e departing doctors leave a National Health ervice further depleted of staff, its services bec?me even more inferior to the private ones, more People take out private health insurance, which more doctors, and so on. Fortunately this trend is scarcely evident in psychiatry in this coun-
money
^tracts ty
so
far.
Although
the existence of a system of rationing to those most seriously ill may e a scandal, the actual administration of such a it might be thought, could be left to the octors who would act justly in the light of their 'nical experience of the different diseases. But in y
giving priority
^Vstem,
PsYchiatry
Iri?rtality
the situation is
exceptionally difficult;
rates cannot be used
as
an
index be-
muse, fortunately,
few patients die, so decisions ^Ust be based on the severity of distress and disablement, which is hardly the most objective While the boundaries between normality, stress and mental ill health are so ill-defined, the ?ctor cannot be envied a task of deciding
Jethod.
Priorities.
Rationing by reducing the time spent on each Patient dominates a large part of the public sector, ut it is subject to the law of diminishing returns, ?r the psychiatric value of an interview tends to vanishing point as it becomes very brief, and r?ach j en the patients fail to get better and the work-
ed is not, after all, reduced. Not much more time ?an be saved in this manner. The introduction of ?roup therapeutic methods potentially gives more Patients the opportunity of a longer session with doctor, although they each have only a partshare in him. The training of ancillary staff and members of .lied professions to undertake tasks akin to and some cases identical with psychiatric treatment
j*1
striking feature of recent British pracjtes ^1Ce> closely connected with the trend towards c?mmunity care of the mentally ill. Psychiatric ^fses have been, until the last few years, rare in been
a
Community
work, but the mental welfare officers
Seated by the 1959 Mental Health Act are now receiving increasing psychiatric training, and are er>couraged to undertake casework and counselling.
Probation officers, too, ^frning a task similar to
chotherapy'.
are now
sometimes per-
that of
'supportive psypsychiatric social
For many years undertook to help the mothers of children ^tending child guidance clinics by psychotherapy,
^?rkers
under the supervision of the doctor in charge. This role tends to spread to other forms of casework, sometimes involving the use of relatively advanced knowledge of psychological mechanisms under
minimal medical supervision.
The process of training other groups to take on and hospitals some of the tasks of the doctors comcan be carried even further in enthusiastic even the patients' which in care projects, munity families may receive instruction in the handling of interpersonal problems to help them cope with their disturbed relatives. The whole concept has earned the criticism of Professor Richard Titmuss that the care of patients is being transferred from the hands of professionals to amateurs. This criticism hardly applies, however, to the schemes pioneered by the Tavistock Clinic, for training in sophisticated methods of
general practitioners treating their neurotic patients.
One more professional group remains mentioned?non-medical psychotherapists,
be who
to
but flourishing are few in number in this country in the United States. The possibilities of this profession were discussed and criticised by Freud. are also the analogous psychologists practisof behaviour therapy on patients methods ing medical supervision. Such use of allied under and yet dilutes the psychiatric extends professions with it numerous further and brings care available, problems such as the limitation of physical-medical assessment and examination, and ethical difficulties
There
professional
secrecy. to the present discussion than the disadvantages of our methods of rationing is the realisation that none of them will enable us to have enough time for our patients. For there Parkinson's diseaseoperates what may be called the number of ailments that states which law, care available. increases to overwhelm the medical as day hospitals and outsuch facilities Increasing of staff have patient clinics and increasing numbers failed to give us more time to treat a fixed number of patients or a greater chance of relieving them. Rather, it has been found that an increasing with less severe, or at least different,
over
More
important
population complaints, which had through these channels,
not
is
formerly sought help
now
making
use
of the
psychiatric services. In some ways this may be admirable, in indicatthe people's ing in a relatively affluent society but not all view of happiness, high expectations the prospect with satisfaction. For increasing numbers of psychiatrists can only be provided by increasing the share that they claim of the counin competition with try's highly trained manpower, the demands for scientists, technologists, and other doctors, so that society as a whole will have to decide
priorities. 15
L
By
ANDREW SMITH OF THE YORK CLINIC
The majority of medically qualified specialists in mental disorders work in the National Health Service in crowded hospitals or busy clinics, granting the patient only brief interviews. In a typical outpatient clinic, new patients are seen for threequarters of an hour on the first occasion for their major assessment, and in most cases later interviews are of only fifteen minutes' duration. A few patients can be, and are, seen for longer sessions, but this is bound to lead to more widely spaced interviews for others or to longer waiting lists for the first assessment, as the volume of outpatient work has been and is rising rapidly. There are a comparatively small number of psychotherapists, of varying orientation, in private practice, who are able to spend far longer with their patients, but they can treat few at any one time. And there is a small amount of such intensive psychotherapy available in the NHS, but the patients are strictly selected and may endure very long periods of
waiting. There are psychiatrists who deny psychotherapy in mental disorders, often advocate other techniques such
the value of instead they as behaviour therapy, which are in their turn extremely timeconsuming, although admittedly they allow of partial delegation to non-medically qualified staff. There is agreement, therefore, that we need more psychiatrists. Meanwhile the psychiatric care is rationed. Writing recently in the American Journal of Psychiatry, Professor G. M. Carstairs pointed out that it can be rationed in a number of ways: by price, where the well-off get the best treatment; by giving first priority to the most seriously ill; by delay on the waiting list; by reducing the time allotted to each patient; and by working through non-psychiatric staff and institutions. In this country we are already employing all these methods to varying extents, and as the demand for treatment is ever-increasing, we shall need more stringent rationing or ever-increasing numbers of psychiatrists. Professor Walsh McDermott, Professor of Public Health of Cornell University, USA, has suggested that we need less investment in personal physicians, and more in administrative ones who, although themselves few in number, can, in certain conditions of society, implement far more improvement in health?as in directing malaria eradication, mass 14
or immunisation of susceptible populations. Can this idea be applied to present-day psychiatry? The difficulty here is the comparative lack of the necessary knowledge and techniques for effective application by the administrative psychiatrist. This is because, in its short history* psychiatry has been closely linked with the medical profession as a whole, especially in this country* and has been interested in the problems of the individual patient who consults a doctor and in
X-ray
the methods of treating him. Only since the Second World War have we been noticeably influenced by social psychiatry, although this influence is now' strong and increasing. What, then, has been done and could further be done along these lines? The influence of psychiatrists and psychologists in publicising the supposed effects of parental deprivation in childhood has to bring about more personal handling in
helped orphanages
and similar institutions and a policy of smaller units. It has also helped to further the unrestricted visiting of children in hospital. The study of human relations in industry now includes some social psychology, and group discussions are sometimes offered to trainee managers to help them realise the emotional conflicts liable to arise. Group projects and discussions are held in prisons
and are sometimes supervised by psychiatrists. The training of members of many professions involved in social work includes individual and social psychology. We have organised sheltered work-shops for the rehabilitation of partially disabled patients, and started on the preparation for retirement and the improvement of community services for the elderly, although much more could be done along these lines. Yet little is known of the efficacy of some of these methods, and one is left with the feeling that, though beneficial, they are only small contributions towards improving mental health. Let us consider the present rationing of psychiatric care, and the strains which may cause it to break down. Rationing by price, where the rich obtained by the pay for better treatment than is the American scene, with its dominates poor, numerous analysts in private practice and the state hospitals comparatively poorly staffed. This system must be inequitable, for the well-off do not suffer more ill health than the poor.
There is a danger that in this country the system J?ay change towards the American pattern, for, as r-
J- R. Searle has pointed out, when the amount available for private practice greatly "greases, as it is here with the rapid expansion of Pr'vate health insurance schemes, doctors will ?llow the money and transfer from public to Private practice. This begins a vicious circle, for "e departing doctors leave a National Health ervice further depleted of staff, its services bec?me even more inferior to the private ones, more People take out private health insurance, which more doctors, and so on. Fortunately this trend is scarcely evident in psychiatry in this coun-
money
^tracts ty
so
far.
Although
the existence of a system of rationing to those most seriously ill may e a scandal, the actual administration of such a it might be thought, could be left to the octors who would act justly in the light of their 'nical experience of the different diseases. But in y
giving priority
^Vstem,
PsYchiatry
Iri?rtality
the situation is
exceptionally difficult;
rates cannot be used
as
an
index be-
muse, fortunately,
few patients die, so decisions ^Ust be based on the severity of distress and disablement, which is hardly the most objective While the boundaries between normality, stress and mental ill health are so ill-defined, the ?ctor cannot be envied a task of deciding
Jethod.
Priorities.
Rationing by reducing the time spent on each Patient dominates a large part of the public sector, ut it is subject to the law of diminishing returns, ?r the psychiatric value of an interview tends to vanishing point as it becomes very brief, and r?ach j en the patients fail to get better and the work-
ed is not, after all, reduced. Not much more time ?an be saved in this manner. The introduction of ?roup therapeutic methods potentially gives more Patients the opportunity of a longer session with doctor, although they each have only a partshare in him. The training of ancillary staff and members of .lied professions to undertake tasks akin to and some cases identical with psychiatric treatment
j*1
striking feature of recent British pracjtes ^1Ce> closely connected with the trend towards c?mmunity care of the mentally ill. Psychiatric ^fses have been, until the last few years, rare in been
a
Community
work, but the mental welfare officers
Seated by the 1959 Mental Health Act are now receiving increasing psychiatric training, and are er>couraged to undertake casework and counselling.
Probation officers, too, ^frning a task similar to
chotherapy'.
are now
sometimes per-
that of
'supportive psypsychiatric social
For many years undertook to help the mothers of children ^tending child guidance clinics by psychotherapy,
^?rkers
under the supervision of the doctor in charge. This role tends to spread to other forms of casework, sometimes involving the use of relatively advanced knowledge of psychological mechanisms under
minimal medical supervision.
The process of training other groups to take on and hospitals some of the tasks of the doctors comcan be carried even further in enthusiastic even the patients' which in care projects, munity families may receive instruction in the handling of interpersonal problems to help them cope with their disturbed relatives. The whole concept has earned the criticism of Professor Richard Titmuss that the care of patients is being transferred from the hands of professionals to amateurs. This criticism hardly applies, however, to the schemes pioneered by the Tavistock Clinic, for training in sophisticated methods of
general practitioners treating their neurotic patients.
One more professional group remains mentioned?non-medical psychotherapists,
be who
to
but flourishing are few in number in this country in the United States. The possibilities of this profession were discussed and criticised by Freud. are also the analogous psychologists practisof behaviour therapy on patients methods ing medical supervision. Such use of allied under and yet dilutes the psychiatric extends professions with it numerous further and brings care available, problems such as the limitation of physical-medical assessment and examination, and ethical difficulties
There
professional
secrecy. to the present discussion than the disadvantages of our methods of rationing is the realisation that none of them will enable us to have enough time for our patients. For there Parkinson's diseaseoperates what may be called the number of ailments that states which law, care available. increases to overwhelm the medical as day hospitals and outsuch facilities Increasing of staff have patient clinics and increasing numbers failed to give us more time to treat a fixed number of patients or a greater chance of relieving them. Rather, it has been found that an increasing with less severe, or at least different,
over
More
important
population complaints, which had through these channels,
not
is
formerly sought help
now
making
use
of the
psychiatric services. In some ways this may be admirable, in indicatthe people's ing in a relatively affluent society but not all view of happiness, high expectations the prospect with satisfaction. For increasing numbers of psychiatrists can only be provided by increasing the share that they claim of the counin competition with try's highly trained manpower, the demands for scientists, technologists, and other doctors, so that society as a whole will have to decide
priorities. 15
L
