There was no advertisement, or job interview, but somehow I found myself reading and answering the letters of comment and complaint addressed to the College. I took over from Kurt Schapira who had been similarly invited some years earlier. In this article I sum up 10 years of experience, largely derived from the days before the Patients and Carers Committee and also before emails became commonplace.
Most letters came addressed to The President, Royal College of Psychiatrists or a variant on that theme. A few came apparently only by the kindness of the Royal Mail or forwarded by a hospital or doctor. These tended to be the ones, apparently written with considerable difficulty on scraps of paper, used letters, or the borders of a newspaper, which in general were hard to decipher and usually impossible to answer, both in terms of content and return address. I made every effort to transcribe them and to reply.
More commonly, letters were clear, albeit showing signs of mental disturbance. I always sent a reply, thanking the writer for his or her comments and offering some hopefully emollient comments.
The bulk of letters received were those setting out some problem or difficulty that the writer wished to bring to the attention of the President or the College. Not surprisingly, a number of these were complaints about treatment received, often quoting individual psychiatrists, some known to me. I rarely contacted any of these doctors to elicit further information unless there appeared to be a need for clarification that could be in the interests of the patient. An example here was when a patient explained that their brother had been killed and the hospital had covered it up, saying it was an accident. This seemed to justify wider enquiry and in that instance I was able to trace the notes. It turned out that the man had been found at home, unconscious, having suffered what was described in the notes as ‘a cerebrovascular accident.’ He died later in hospital and there was no suggestion of foul play. I was able to clarify the matter for the patient.
The most common topic of the letters was an enquiry about various forms of treatment. The one I had most difficulty with was someone who had received deep insulin treatment for schizophrenia in the 1950s. This had proved very successful until recently when the patient had relapsed and wanted to know the name of a hospital where this treatment was still available. Lithium provoked many enquiries, usually related to the effects of long-term treatment and the need for monitoring of thyroid function and similar problems. It was difficult to give clear answers about antidepressive drugs, because of the range of drugs in use, the confusion between trade names and official names, the involvement in trials, and problems over misinterpretation of alarmist newspaper reports.
There were many letters on electroconvulsive therapy (ECT), mostly complaints about the after-effects. It was also one of the more difficult topics to deal with. I could mention the way in which ECT was carefully monitored and controlled, or consider the possibility of preventing suicide, but in the end I generally suggested that the person concerned should return to discuss the treatment with the practising doctor, who was the only person who could set out the arguments for and against ECT or any other type of treatment for that individual. I did sometimes suggest taking my letter to the clinic.
Some letters questioned the professional competence of the treating psychiatrist and, more rarely, other members of the clinical team. The idea of a team approach was relatively rare at that time and members of the public expected to see ‘my doctor.’ A question, now more current, asked how elderly doctors managed to keep up to date, particularly if they had retired but still practised. The whole topic of professional ability tended to be related to suicidal behaviour, successful or otherwise. It might be raised by survivors or by relatives.
In general, I would suggest going back and discussing any matter of concern with the relevant professional, whether general practitioner (GP), psychiatrist, psychologist, community psychiatric nurse or social worker. But clearly this would not always be possible. Alternatives were to ask the GP if a different referral could be made (difficult where there is strict sectorisation) or if there was a different process of treatment.
A number of enquiries and complaints were related to Mental Health Act issues, particularly detention without adequate reason (for example ‘The police and a social worker just came and took me to hospital’). If possible, I explained the way the Act worked and, in particular, the opportunities to seek second opinions, review sections and advice from lawyers. I also made clear the systems of complaint for all people who had such problems, usually to the service manager or the chief executive of the trust. I included the address of the Mental Health Act Commission and, if appropriate, the Mental Health Review Tribunal office, briefly describing their function and the circumstances of referral. If there was a serious complaint about a doctor I also offered the name and address of the General Medical Council. On occasions, I suggested obtaining further information from the College website, and also gave the names of some of the many support groups available, for example Alcoholics Anonymous, Narcotics Anonymous, as well as organisations for phobias, anorexia, and so on. Another source of further information is the College public education materials, and I sent out many copies of these leaflets.
I believe the patients, relatives and other enquirers received a useful service and one that added value, as we say these days, to their relationship with the health service.