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The sabbatical year that I took from my psychiatric practice in Sydney has
come to an end and it was spent working in NHS in the United Kingdom as a
Consultant Psychiatrist.  It had been 29 years since I worked full time in
Community Psychiatry and I expected to find many changes from the Community
Services that I had been involved in developing based on what is now the
Macquarie Hospital north of Sydney.

Communication between the community and hospital staff is still a problem
but is an essential element to providing continuity of care.  It seemed to
me the attendance of staff at both the hospital and community meetings was
an essential ingredient to improve this communication.  Thus I made a point
of either myself or my junior attending community meetings, insisting that
there should always be a community staff member in the hospital rounds.  So
long as this happened things went well.  The United Kingdom has tried to
formalise such communications by making it law to have a discharge planning
meeting before the patient leaves hospital.  These meetings must be minuted,
as well as attended by most staff involved with the patient as well as the
relatives, the appointed key-worker from the Mental Health Team (CMHT) and
the patient.
The new United Kingdom Mental Health Act may include compulsory treatment orders as most States of Australia have had for many years. This enables such treatments as depot injections and other treatments to be compulsorily monitored to prevent relapse.

In Community Psychiatry there has been, and continues to be, a problem
concerning “role blurring”. This is produced by poor acceptance by various
professionals that others may have knowledge of what has been traditionally
been their domain.  An example are doctors who become distressed that others
can also have knowledge of medication issues.  Generally, doctors in the
United Kingdom are now more tolerant of such problems. In Australia I have
found that most of the doctors working in the increasing number of
integrated Community Mental Health Teams have also come to terms with this
now, compared to the early days of community psychiatry in Sydney.

One of the factors recognised in the United Kingdom in the success of an
integrated community psychiatry program is the size of the population for
which each team is responsible. The Royal College of Psychiatry has said a
population of about 30,000 ­ 40,000 is the largest that such a population
should reach  - however this figure is widely ignored and the population that I
was involved with was closer to 60,000.  This size is a critical question
asked by UK psychiatrists applying for positions and often not asked by
psychiatrists coming in from the antipodes.   The workload in high
populations is too great although I had a most competent junior and GP
working sessions in the community centre where I worked.  I was also
fortunate in having a highly efficient and large (29) staff at the CMHT to
work with.  Some problems arose because the CMHT was 20miles away from the
hospital but there was an excellent motorway that connected the two.
The current United Kingdom Mental Health Act is a bureaucratic nightmare,
but hopefully the new one should ease some of the duplication and professional time
wasting that goes on with the old Mental Health Act.

In order to cope with the more severely disturbed patients within the
population, “assertive outreach teams” have been promoted. However, most
staff feel the money would be better spent on the CMHT’s which could deal
just as well with these populations if better staffed. There is continued
use of case management despite the Cochrane Data, which indicates case
management is is currently not showing any  evidence of being superior to
other follow up methods, especially Crisis Assessment Teams.

Community psychiatry in general seems to me to involve the practice of good
psychiatry in a community setting whether it is forensic or general
psychiatry. Most psychiatrists should be able learn in a year or so the
added skills in management and team work needed to be involved in CMHT
because basically the clinical skills are the same. What has changed are the
rules, regulations, laws, fears of litigation and increasing bureaucracy but
these factors have changed many other aspects of the practice of medicine. 
Community psychiatry enables disciplines such as social work psychology,
occupational therapy, dietetics etc. to be brought to bear on patient’s
problems.  There is also an enormous advantage for the safety of patients
and the community in the long-term follow-up, and perhaps assertive follow
up, if needed.

The NHS is coming under much criticism in the United Kingdom as the managers
and other “spin doctors” find it increasingly difficult to paper over the
widening cracks in NHS services.  Many NHS institutions are operated on a
knife edge clinically and  many services have been cut to the bone.  Empire
building seems rampant in the middle level administration both in major
cities and in rural areas.  The Times editorial (9.1.00), reported “Britain
spends £1,000 a head annually on health care, 1/ 6 privately funded. Germany
spends $1,600 per head based on a compulsory insurance system.  In the
United Kingdom only 13% of the population have private insurance”.  In
psychiatry the poor coverage means that although dangerous psychotic
patients are well cared for, GPs are largely left unsupported in dealing
with the remainder of the psychiatric entities in the nearly 60,000,000
people in the United Kingdom.  I believe that similar clever targeting of
media-prominent diagnostic entities happens in other medical specialties and
one is suspicious that it is starting in Australia also.

The United Kingdom has however showed the world that integrated community
psychiatry can be widely applied and can work well if properly supported. 
Working in a well supported integrated community psychiatry setting in
Cairns, Australia now, has been much less frustrating experience as one can
treat almost any seriously disturbed patient no matter what the diagnostic

Psychiatrists that seem to cope well with community psychiatry strike me as
being socially appropriate, having a good experience of clinical psychiatry
and, maintaining a certain humility in accepting other disciplines as being
as important. In many cases, perhaps other disciplines are more important
than psychiatry as traditionally applied.   As consumerism continues to be
of significance, community medicine is here to stay and doctors have to
consider all relevant factors affecting patients. This can only be done in a
team setting.

Dr Brian Boetttcher
Community Forensic Psychiatrist for North Queensland,


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