As a result of the endless reforms and restructurings of both the NHS and local government, few things have improved on the troubled interface between primary health care and social services. One exception is the process of arranging the compulsory admission of a patient to a psychiatric ward under a section of the Mental Health Act 1983.
Once a protracted ordeal for GPs, “sectioning” a patient has now become as easy as prescribing an atypical anti-psychotic drug – and much easier than organising effective support at home for a patient with mental illness.
Not so long ago, organising a section was a day’s work for a GP. If you were alerted to a patient with an acute psychosis first thing in the morning, the process was unlikely to be completed before late into the evening.
The first task was to get hold of a psychiatrist and a social worker. In the days before mobile phones this invariably involved long discussions with switchboards, and disputes about the duty rota.
If fixing a time for an assessment took all morning, carrying it out would account for much of the rest of the day. Assessing the patient was often fairly straightforward the difficult part was the negotiations between the psychiatrist and the social worker. Psychiatrists in those days were entirely hospital-based and they were often strangely ill at ease in a council flat.
As there never seemed to be any difficulty in finding a hospital place they were generally keen on getting the patient behind bars where they believed the therapeutic power of major tranquillisers could be deployed.
Social workers, on the other hand, were usually firmly in the grip of the anti-psychiatric dogmas of psychiatrist RD Laing and they tended to regard mentally ill people as being in a higher state of awareness of the alienation of bourgeois society, and psychiatrists as agents of capitalist domination, specialised in the techniques of mind control.
The poor GP, keen to get back to a surgery full of non-threatening coughs and colds, was obliged to develop the arbitration skills of a conciliation counsellor in a third world conflict zone.
Now, all is changed utterly. The GP has merely to initiate the sectioning process and the roles of psychiatrist and social worker have become curiously reversed. Lacking hospital beds and more inclined towards community initiatives, psychiatrists are much more reluctant to endorse compulsory admissions.
Social workers, by contrast, their radical past long-forgotten, have discovered a new enthusiasm for sectioning. Oppressed by concerns about dangerousness and the principles of risk aversion, it seems that their first question now is about at what stage in proceedings to bring in the van full of riot police.
Progress? It certainly is for GPs whose surgeries are less disrupted and whose continuing relationship with the patient is often best preserved by keeping a distance from the sectioning process.
For the patient? This depends on whether coercion opens the way to more effective treatment: sometimes it does, sometimes it doesn’t.
Dr Michael Fitzpatrick is a GP in the London Borough of Hackney
Mental Health Bill: special report
Mad World (Examining the policies, decisions and events affecting the lives of people with mental health problems around the world)
This article appeared in the 12 July issue under the headline “Quicker process of sectioning patients makes GPs’ life easier”