Hello again travelers. You may recall in the last issue I told you about the wonderful and nostalgic (who cares what the rest of the world is doing) French mental health system, free to all who want it. This time we cross the channel to find out what is going on in an English speaking country. You will also finally discover what I’m talking about when I refer to the "tea leaves". Of course all Americans are familiar with the British habit of drinking tea (that’s why we drink coffee). It was, as you know, the defining moment in the history of our colonies when our tired-of-tea ancestors dumped the tea into Boston Harbor 226 years ago. Nevertheless, to understand the British system we need to talk about tea. In 1983 I spent several months along with my family on sabbatical living in Cambridge dividing my time between The Maudsley hospital in south London, Julian Leff’s lab at Friern Hospital in North London, and Fulbourn Hospital near Cambridge. I used to commute on the train to London about three days a week and spent Thursday and Friday in Cambridge. It was a very exciting time to be there since change was in the air. For example I was there at Friern when Julian got the word from the newly re-elected Thatcher government that the huge Friern and Claybury hospitals were to close. The thousands of patients living there were to be moved to the community and Dr. Leff was given the assignment to study the whole thing to assure it was successful. The tone of the response at that time was somewhat similar to Michele Baker’s "Tin Hospital" article in the Fall 2000 Community Psychiatrist.

Fulbourn however was spared and there was no such order. There, time continued to sort of stand still. And it was there, on Thursday mornings, where I used to attend a series of "therapeutic community" meetings between 8:30AM and 12:00 noon each week. They were known prosaically as the 8:30, the 9:30, and the 10:30 meeting. For example at 8:30 we discussed what happened on the rehab ward (otherwise known as "long stay") overnight. "Mrs. Murphy’s cat fell off a ledge last night and screeched for several minutes. The patients were very upset". At 9:30 we discussed discharges and transfers. "Who wants to go to Nottingham to pick up that fellow who ran off from the children’s ward last month, then turned 18 last week and now he belongs to us". (For three months no one ever went). And finally the 10:30-12:00 meeting which was run by the ward staff and was sort of a therapeutic meeting for staff. There were 40-plus folks in the room and on the agenda was David Clark’s retirement after 35 years as Medical Director. But first announcements: each of us would get to say something (20 minutes), then apologies (we had to apologize for those who weren’t there and one of us knew why) (20 minutes), and then quickies (45 minutes) which would go half way around the room and then always get hopelessly stuck when someone would say: "When are we going to get the tea leaves off the ceiling at Burnet House?" (The patients drank loose tea, and when they finished they would toss the leaves up out of their cups and they would stick to the ceiling). Administrator: "Well did you put in a requisition?" Staff: "Of course I put in a requisition I did it months ago!" Administrator: " Well did you put in an emergency requisition?" etc. etc. etc. (20 minutes) and so on, and so on, etc. etc., so that it was 12:15 and we never got around to the agenda to discuss David Clark’s leaving and as you might have guessed the tea leaves remained on the ceiling at least for the three months I was there. I have always wondered what happened to those greenish stalactites that grew down towards us from those ancient ceilings. So I returned to London this past summer and was able to spend a day discussing how things have gone and are going. Here’s what I think I found out:

It is now nearly impossible to get yourself into a long stay hospital bed in England just as it is in the States (unless you happen to be guilty but insane). Perish the thought (and I never thought I’d say this), but the English are becoming more like us! It’s sort of the McDonaldization of the world, which the French view as American Imperialism but the English seem to quietly accept in their stiff upper lip manner. In fact, the resemblance between the English and the American systems has never been so great. Two countries divided by a common language have mostly been the opposite of one another for the past couple of centuries. Now, courtesy of Mrs. Thatcher and Mr. Reagan, Mr. Major and Mr. Bush, and Mr. Blair and Mr. Clinton, they have become uncomfortably similar when it comes to mental health care. To me it seems a bit odd. For example 18 years ago if you got admitted into a state hospital in England you were not going to get out for at least 3 months no matter how quickly you recovered. They would have slowly titrated your medicine (none of that rapid tranquilization the Americans were using). Then they would help you find a job and reconnect with your family. And finally they would see to it that you found proper housing if your old place was lost. So if you were just a little depressed, or severely mentally ill, you got about the same treatment scheme (with slightly different pills). People who continued to be ill got intermediate stay wards 3-6 month. And those who were disabled were placed on the "rehabilitation" wards for long, sometimes indefinite, stays. These folks were not at all unhappy about this. From their perspective they were treated well, had a roof and three squares, someplace to sleep and a wall to hang a few pictures. It was home dormitory style. One lady in Fulbourn hospital told me; "the Queen has her palace and I have mine".

Apparently, now those palaces are in the community and these folks live in public housing and get a visit now and then from a mental health nurse who could give them a shot or some good nursing advice. If they need hospitalization it’s still free but they are likely to go to a private hospital contracted by the health service and be in and out in a few days with little discharge planning, poor follow up, and might then have to return again soon. Sound familiar? Private for-profit hospitals (some run by American managed care companies) are now doing most of the inpatient work and charging exorbitant amounts. They are not hooked into the public system and have trouble doing appropriate discharge planning. Primary care MD’s have been grouped together by the government and paid in advance (capitation) to serve a catchment area. Nearly all long stay hospitals are closed, so there are no beds. They are planning to use nurses for as much of the follow-up as possible but don’t as yet have nurse practitioner prescribers. CMHC’s have reorganized and nurse case managers, who used to go into homes and give shots and advice, are being absorbed by GP groups and assigned to less severely ill patients or replaced by OT or social workers.

Alas, in England I believe the tea leaves have come down from the ceiling. I think instead of washing them off they just knocked the buildings down, just like in Boston. Friern hospital in north London where I once studied 18 years ago was turned into condominiums. Since those buildings are historic the facades were left and they were given an elegant new name. But the beautiful historic front gates, which for nearly 150 years were kept open while it was a hospital, are now locked (to protect the rich). No evidence and no markers except the facades remain to commemorate the previous century and a half use as an insane asylum.