Mental Health System Is Called Mismanaged, Underfunded in Report

A team of private doctors who spent a year studying San Diego County’s mental health system have concluded in a sharply critical report that the network has been crippled by a “non-system” of management in addition to its chronic problem of underfunding.

The San Diego County Medical Society task force reported this week that it found the system devoid of strategic planning, isolated from the expertise of private professionals and guided less by long-term strategy than by “non-expert consensus.”

Using the system’s central screening area as a keyhole into the network of clinics and hospitals, the group characterized that central function as disorganized and inefficient--”bedlam,” in the words of one doctor who has worked there.

“We don’t think it would serve any purpose just to blast CMH,” Dr. Jay Shaffer, the task force chairman, said Tuesday. “Our point is there are some very clear things that can be done that don’t necessarily require great amounts of money.”

Those include improving communication with the police agencies that deliver some 40% of the patients needing emergency screening, tightening ties with other hospitals that refer patients and revamping the entire case-management system, the report states.

Call for Political Action

The task force also called for political action “to overcome 20 years of mismanagement (and) administrative and fiscal neglect,” as well as changes in state licensing laws and hospital-bed allocations to ease the burden on CMH.

“What is needed is an aggressive, creative and innovative advocate for the care of the poorest and sickest among us,” the report stated, urging the county to fill the vacant position of system director with “an expert at managing with limited resources.”

County health officials, however, had some criticisms of the 17-page report.

Dr. David McWhirter, medical director for the county’s mental health hospital in Hillcrest, said the report contained some inaccurate figures and out-of-date information, making him “fearful of how it was put together.”

He said the report implied that certain rare aberrations were the norm--such as instances in which suicidal patients were released and committed suicide. McWhirter acknowledged that the screening unit may be “bedlam” at times, but said the report suggested it was always bedlam.

‘Very Inaccurate Perception’

“Just to say (the problem) is no long range planning and it’s all due to local leadership, I think is a very inaccurate perception,” said McWhirter, who was hired last spring and was praised both by Shaffer and in the report. “We’ve had to roll with the national picture.”

Dr. William Cox, director of the county’s Department of Health Services and a new appointee praised in the report, defended the system and suggested that its principal problem is chronic underfunding under the state’s system of allocating funds.

“You can’t get blood out of a turnip,” Cox said in an interview. “The biggest problem is we do not have the physical facilities right now to deal with the severely mentally ill who are our obligation in this county.”

The task force report, said to be the first attempt by a county medical society in California to assess the functioning of a public health-delivery system, was intended to raise awareness of the system’s difficulties and generate political pressure to fix them, Shaffer said.

It was compiled by the group after 12 meetings during which task force members took testimony from people involved in the system. Many of the allegations in the report are attributed to physicians and others who testified.

Recent Efforts Praised

The group did praise recent efforts to improve administration of the system.

“We have some optimism . . . that with some changes this dysfunctional non-system can be made more functional,” the report states. “Recent efforts by new physicians and administrators in this beleaguered system are heartening.”

Among the group’s other findings:

- Overloading of the emergency screening unit has forced police officers to wait 2 to 5 1/2 hours for evaluation of people they have brought in--people often severely disturbed, suicidal or homicidal, and unable to care for themselves.

- Similarly, general hospital emergency rooms throughout the county, lacking the ability to do psychiatric screening, are often forced to hold dangerous patients for as long as six to eight hours, endangering the physician, hospital and patient.

- Fifteen percent of the patients seen in the screening area have been there recently and been referred to outpatient clinics. But because of waiting lists at the clinics, they have had to return to the emergency unit to have their supply of medication replenished. Each time, they must undergo a complete, new work-up.

- Some 40% of the 60 inpatient beds for acute psychiatric patients at the Hillcrest hospital are filled by patients who don’t need acute care--that is, patients with brain damage or chronic psychiatric problems requiring a locked facility.

Hospital administrators are trying to place those patients in other facilities. But there are insufficient beds in homes licensed to care for such patients in San Diego County. In addition, the county has a disproportionately low allocation of beds in state-run hospitals.

- Patients referred from emergency screening to county-run outpatient clinics face waiting lists of up to six weeks, the report states. “These clinics seem to be unable to integrate or prioritize the severely mentally ill in their systems,” the task force found.

Responding to some of those findings, McWhirter said police officers have faced long waits only in “rare instances.” He said 17 other facilities in the county, in addition to CMH, have the capacity to do psychiatric evaluations for general hospital patients.

He said it was true that patients were coming back to the emergency screening unit for medication: “It’s simply because the outpatient facilities don’t have enough psychiatric services to satisfy their needs.

“I think the evidence that I see from around the country is that we’re in the same bucket of bad fortune that the rest of the country is in,” McWhirter contended. That bucket, he said, entails “not enough resources to handle the people.”