M ental I llness C oncerns A ll	A difficult engagement Why did it take so long to get an appontment to be seen by a Consultant Psychiatrist? The family doctor referral letter was sent on the 20th june; the appointment finally achieved was for ten weeks later. That is the question. The Report does not adequately discuss nor go into this sufficiently. It refers to the Consultant own assessment of his duties in post as well known to be overburdened and over extended, but the account given does not sufficiently sustain this. He has four sessions for clerical work. Their description of his week programme is hard to follow. That is likely to be under the constraint of compressing 500 pages of 'evidence' down to a forty page Report. What the Reports present is selective - as is this Comment.But something more needs to be explained. An important consideration receives inadequate explanation here. This is not fair to the Consultant. Something like - how many new referrals were made from this catchment area compared with other areas? How many of these had to be passed on to the junior untrained help, with little supervision, and was this known to management and to the referring primary care services? JP had been chosen by a family doctor of long experience to be referred to specialist Consultant. His progress was stuck in long depression, confirmed by his family. Somewhere in the Report is a remark made by the Consultant - that forensic cases should require the attention of specialist Forensic Psychiatrists. Had this referral come to be seen as a matter of forensic decision? Was it seen only as a matter of disposal or of assessment of potential risk. The referral here was from the family doctor - an ordinary referral to an ordinary OP appointment - on the basis of observed resistant mental illness. Dealing with that basis has the priority, and that should not be overtaken by the importance of a subsequent or coincident Court referral. Prior to the change in service, this would have been a straightforward Out-patient referral seen on first attendance by the Consultant, maybe after preliminary preparation by his junior. Or by a domiciliary visit from the consultant if there were further worries in the meantime, or discussion with the family doctor on the phone about a change in medication, with perhaps subsequent monitoring by a community mental health nurse. If a HealthCare Trust allows a service to be so over-stretched that well tried referral procedures cannot be instituted appropriately, are not available as previously, then some additional care has to be taken to substitute a responsible level of specialism. The level of skill of a two year community mental health nurse, as a first gatekeeper advising a family doctor on depression resistant to treatment, in aggravating personal circumstances and preoccupations, is not an adequate replacement. At least what should be in place is a thorough and readily and quickly available line management supervision, and the opportunity to raise difficult matter promptly with better qualified clinical psychiatric colleagues - best in the setting of the regular catchment area weekly forum - where everybody knows each other - for settling uncertain situations. This was not the case here and JP got a poor service only explicable by ... 'this is all we have got to offer' ...everybody knew that 'Was that the case? Bowron; Piccolo	E-mail reaction is welcome mica@didgy.freeserve.co.uk

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