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June 30, 2008

Psychiatric services in Britain are being destroyed by an apparatchik class which has already undermined our schools, univeristies and police service - argues Theodore Dalrymple

Posted by Theodore Dalrymple

Psychiatric services are the latest victims of an apparatchik class which is inexorably taking over the public - and, indeed, the private - sector, argues Theodore Dalrymple.

When trying to understand wider trends in a society, it is often useful to examine what is happening within some small and comparatively hidden or unimportant corner of it. This is what one might call the emblematic method; one sees more clearly in miniature what is happening everywhere on such a scale that it is difficult to grasp.

Psychiatric services in Britain are one such small corner worthy of examination. This is because they are peculiarly susceptible or vulnerable to some of the destructive processes that, termite-like, are eating away at the social fabric.

A paper ("Wake Up Call for British Psychiatry") in July 2008's British Journal of Psychiatry, signed by many psychiatrists, draws attention to the progressive reorganisation of psychiatric services in Britain. Of course, most people hope fervently, and probably expect, that they will never have reason to call upon them, however well or badly they are organised; but the fact is that they have been so reformed that they are now a bureaucrat’s dream and a patient's (and, as importantly, a patient's family's) nightmare.

Doctors have lost all power and even influence; in the National Health Service, a general practitioner can no longer refer his patient to a psychiatrist directly, but must refer him to a team, that is to say, in practice, to a bureaucrat who then decides whether he should see a psychiatrist, a nurse or an occupational therapy student. Indeed, it is the aim of the organisers of the service that the most senior psychiatrists should never see any patient at all, or at least as few as possible; that is regarded as a waste of their time, which (supposedly) is much better spent on administration and on giving advice down a telephone.

Meanwhile, patients must see an assortment of "mental health workers", of varying levels of intelligence, education and commitment. While the changes in the service have been brought about in the name of "Person-centred services" (what, one wonders, were they before?), even in very small matters the wishes of patients are disregarded and dismissed with lordly indifference. For example, it has been established over and over again that patients would like to be known as patients rather than clients or "service-users". But the latter terms are used, because the former would imply the necessity of medical rather than bureaucratic leadership.

The authors of the paper ask us to perform a very simple thought experiment. Would we, they ask, desire a psychiatrically unwell relative of ours to be treated by the service as it is at present organised? The question answers itself. My wife long ago put it another way: would anyone with the money to pay for treatment pay for what is now on offer? Again the question answers itself: in other words, the government expropriates money from us to give us what no one wants.

The authors of the article refer quite rightly to the acquiescence of doctors in what has happened. Why have they done so in so supine a fashion? I think there are two factors. The first is that any group contains its careerists who, in order to achieve personal advancement, will agree to anything the powerful wish to do or impose. The second is rather more intangible: the traditionally leading sectors of society have lost their belief in their own right to lead, combined, perhaps, with a certain gentlemanliness.

Thus, doctors have been extremely reluctant to draw attention to their own high levels of intelligence, training and philanthropy by comparison with the army of bureaucratic intriguers by whom they have become increasingly surrounded. Of course there are bad doctors, both in the technical and moral sense; like the poor, the incompetent and the wicked are with us always.

But precisely because they have so much contact with human suffering, there are very few doctors, in my experience, who have no interest whatever in the welfare of patients. Removal from the front-line, however, makes unadulterated self-interest much easier. By contrast, the self-aggrandisement of clinicians (and I have seen a lot) almost always has at least some connection with the improvement of care for at least some patients.

The doctors loss of faith in their own right to lead has coincided with a social revolution brought about wittingly or unwittingly by the government: that is to say, the irresistible, or at any rate the unresisted, ascension of what one might call the apparatchik class.

What are the characteristics of this class, which has expanded enormously in size thanks to the unwarranted increase in the numbers of people receiving a prolonged education? In the first place it is driven by an ambition which is unhappily unmatched by ability, at least in anything other than the dark arts of bureaucratic infighting. Ruthlessness is therefore accompanied by an indifference to real, as compared with procedural, outcomes, with the latter of which there is a self-interested obsession.

In order that the apparatchik class should take power, it must push aside the professions, in the process destroying any vestiges of self-regulation. Authoritarian centralisation is in its interests, since, of course, freedom or a free society (in which it would necessarily play a very minor part) is of no interest to it. Generalised mediocrity - or worse - is the result.

What has happened to the psychiatric services is a microcosm of what has happened and is happening throughout society. Academia is far from immune from the process; the police service has been all but destroyed by it; our schools have been undermined by it.

The reason that some parts of our services still work - for example, the accident and emergency departments of our hospitals - is that the apparatchik class is sufficiently astute or alive to its own interests to realise that if they did not work there might be social unrest, and its own power therefore threatened. By contrast, it appreciates that there will be no social unrest whatever if a quarter of our children emerge from eleven years of compulsory attendance at schools unable to read or add up. Likewise, psychiatric services can be destroyed with impunity because neither patients nor their relatives will ever be able to cause sufficient trouble to threaten bureaucratic power.

Is there any way back? A first step would be to scale back tertiary education; but beyond that, we need to find some way of counteracting the power-worship that seems so thoroughly to have infected our society, that has turned so many professional and personal relationships into power struggles.

Theodore Dalrymple is a writer and worked for many years as an inner city and prison doctor. He is the author of the author of Junk Medicine: Doctors, Lies and the Addiction Bureaucracy.


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I noticed this while web-searching yesterday. It seems to describe the mindset of those who are inflicting this situation upon us, the "moral" force by which the blob overpowers its victims.

Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.

- C.S. Lewis "God in the Dock"

Posted by: Robert H. Olley at July 2, 2008 06:02 PM
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Thanks for another excellent article.

Can we apply Public Choice Theory to this problem, which is indeed a kind of bureaucratic cancer growing through private as well as public services?

In Public Choice Theory, special interests benefit from activity that is not worth other people's effort to oppose: i could make millions buying a monopoly on shoes that would make me billions, but it's hardy worth an individual's time to fight it if my monopoly will only cost him another fifty pence a pair.

Do the smarter, more empathetic and better educated people, doctors, retreat to treat patients and abrogate the bureaucratic challenges mounted by bureaucrats who are paid to do little else but manufacture complexity to justify hiring more of their own kind and growing their little empires?

I am not a doctor, but the process sounds similar to cancer to me.

Posted by: s masty at July 3, 2008 05:53 PM
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