|December 2000||Opinion and Reality: Bridging the Gap|
diagnostic and therapeutic interventions. Measuring what we do is not easy; nor is explaining it to others, be they patients, family members, other health professionals, policy-makers, politicians, or the general public. Yet that is a crucial task if we are to generate the attention and resources for mental health that we seek.
Winston Churchill’s advice should not be forgotten—“The farther backward you can look, the farther forward you are likely to see” (1). Depending on one’s mathematical grasp, this year 2000, or 2001, is the millennium. Amidst all the hype we should, within our own profession, take stock of some of our past endeavours and consider how we might avoid repeating our mistakes.
During my final residency year, a research experience in psychiatric epidemiology with Alexander Leighton, I was given a copy of his book Caring for Mentally Ill People (2). Rereading that book, a case study of a psychiatric service, was an eye-opener for me last year. Having worked in a mental health service, and having been an enthusiastic player in trying to revamp the system, I was shocked by the similarities between 1952 challenges and those I’d experienced in the 1990s and frightened by the revelation that we continue to ignore lessons of the past. One example from Professor Leighton’s analysis, which I will use to illustrate this, concerned the difficulties of lay boards directing community mental health programs. In that discussion, I saw unsettling parallels to my own jurisdiction’s experience with regional health authority governance 40 years later.
Recently, across Canada, we have seen the emergence of regional health authorities—an effort to decentralize and make more responsive local health services. Board governance has received considerable attention. “The psychology of boards is as yet unstudied. It is not in the textbooks. The best of them get wooden . . . . All boards age rapidly and acquire young the senile characteristics. They assimilate with difficulty and abhor change . . . . Yet no one thinks these honest gentlemen either stupid or undutiful. They merely do not know their business and do not know that they do not know” (2).
It would appear, however, that over a century ago observations about the discrepancy between well-intentioned public service and operational effectiveness were being recorded but then forgotten or ignored.
Over the last several years, I have participated in numerous debates about the role of boards within the health sector. Should they be elected or appointed? Should representation from health professionals be encouraged or forbidden? Is the board to operate under Carver-style governance, focusing on “board ends,” or must it be more directly involved in the operational issues facing the administration? Do governments really want regional authorities to assume control of such
politically sensitive decisions as shutting down services to adhere to budgetary realities, even with election rumours circulating?
More recently, Rudolf Klein and Janet Lewis have studied British community health councils and the politics of consumer representation (3). “It is often assumed that locally controlled services can be equated with accessible, responsive, and open services: what might be called a democratic style of administration . . . . It cannot be taken for granted that that the result (of decentralization) would be to encourage these particular values. The little evidence that is available points in the opposite direction: it suggests that local authorities are perceived to be less responsive and less open than central government” (3).
My own experience in a small community has been that policy decisions that may very well be in the public interest at large can get derailed because of the intimacy of the environment, where any decision is seen as a personal enhancement or, more commonly, deprivation of some service to an individual or small group.
To return to the title of this address, “Opinion and Reality: Bridging the Gap,” an old cover of the Sun tabloid illustrates several points that I will develop during this talk. Initially I was drawn to the headline about the tragic dog-baby born as result of a mix-up at the animal and human sperm bank—the subtext was “hospital orders cover-up,” but another story illustrates the repetition-compulsion of the bridegroom about to embark on marital quest number 28. Ask yourself if he has considered what the previous disappointments might say about his choice of partner or his possible shortcomings as a spouse. Persistence is generally considered a good quality, but only if one keeps learning and adjusting to changing circumstances.
The CPA has devoted significant resources to our needs to keep apace of research developments and best practices in psychiatric care in the last few years. Clinical practice guidelines, revamped annual meetings that reflect the movement away from passive listener to active participant in learning, development of the International Continuing Professional Development (ICPD) conferences, improvements to the Journal and the Bulletin, and ongoing efforts of standing committees are aimed at getting good information to us. But what do we do with that knowledge?
Studies of the length of time it takes for physician practice to reflect current knowledge are somewhat discouraging. And maintaining good practice requires reinforcement or we often return to old well-entrenched behaviour. To illustrate, we have seen the data on the lack of improved efficacy of higher doses of typical neuroleptics, yet audits continue to show dosages in the range of 20 mg or more of haloperidol per day are