Letters Slashed consultant posts

There is no short cut to psychiatric assessment

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1010 (Published 19 February 2013) Cite this as: BMJ 2013;346:f1010
  1. Andrew Blewett, consultant psychiatrist1
  1. 1Devon Partnership NHS Trust, Wonford House Hospital, Exeter EX2 5PF, UK
  1. andrew.blewett{at}nhs.net

The redesign of mental health services by Norfolk and Suffolk NHS Foundation Trust poses so many questions that important detail may be lost in the process.1 One such detail is the chief executive officer’s opinion that cost effectiveness will be improved by the reduction of multiple assessments, presumably a reference to patients being asked similar questions by different people in a single care pathway.

This seemingly desirable rationalisation reflects a fashionable view that psychiatry can be short cut by accumulating information on electronic systems. Psychiatric assessments include several functions: creating relationships, gathering information, examining and diagnosing the patient, explaining, and catalysing change or “being therapeutic.” The first of these activities is generally a prerequisite for the last, but an apparently fixed “history” may not be so fixed. Recent examples I have seen in clinic include undisclosed childhood abuse, unacknowledged children, and covert drinking, all of which completely changed the understanding and treatment of allegedly well known patients.

The act of taking a history has to be patiently repeated and is unlikely to be resented unless carried out in an insensitive, uncaring way. The notion that a psychiatrist can read the “core assessment,” have a brief conversation with the patient, and safely recommend a package of effective treatment is generally incorrect. Rather than teaching clinicians how to make a therapeutic contact with a mentally distressed patient, the pressure is on to crudely simplify without consideration of what might be lost in the process.

The risk for mental health services is that organisations inadvertently discourage the emergence of difficult information and do not recognise the skill and importance of an empathic engagement that can make even a single consultation into a healing experience. Good psychiatrists work with patients using all the “soft” tools available at every encounter—an approach that is too easily seen as expendable rather than central to practising psychological medicine.


Cite this as: BMJ 2013;346:f1010


  • Competing interests: None declared.