Personal views: How many psychiatrists does it take to change a light bulb?
Authors: Neill Simpson
Journal: BMJ (2000)

Ileft Manchester at the end of March 1999 after 14 years as a consultant in psychiatry of learning disability. My former clinical director looked dismayed when I said I intended to write a personal view. “Please don't say anything that will make it harder to recruit a replacement,” he said.


Recruitment in this specialty in the north west of England has always been difficult, with the worst consultant:patient ratio in the United Kingdom. Before 1987 there were no senior registrar posts. In 1985 I was appointed to an innovatory community based service, which provided a mental health service for people with learning disabilities from the resources used by the rest of the population. Patients needing hospital care were admitted to the unit where I also worked half time in general psychiatry. The service showed that specialist skills can be provided without segregating patients from mainstream services. 


Seventeen months after I left neither post has been advertised



As the service developed, it achieved recognition. Collaborative research with colleagues at the Hester Adrian Research Centre, University of Manchester, led to the publication of reliable diagnostic instruments for research. In 1993 the Royal College of Psychiatrists invited me to chair a working group on mental health services for people with mild learning disabilities. I was approached by the Department of Health and in 1994 became a part time member of the Learning Disability Client Group Team. By 1998 the Manchester deanery had five specialist registrar posts, filled at a time when other parts of the country were failing to recruit. Two recent trainees attained higher degrees. I obtained a research training fellowship from the NHS Executive, and undertook epidemiological research.

In 1994 the health authority decided that community services should not be provided by hospital trusts, and transferred learning disability services into a newly established trust. Mental health services remained in the existing trusts. I had to decide whether to move with non-medical colleagues into the new trust or remain with other mental health services. I felt that if I moved I risked professional isolation, lack of access to hospital facilities, and management by an organisation that had no understanding of the requirements of a mental health service. I stayed with mental health services.

The new trust promptly changed its catchment areas and shuffled its teams, so that I was no longer working with the people I had known for years. Then it changed its service eligibility criteria. I was still expected to see patients with all levels of learning disability, but I had no team to work with people with mild learning disabilities. My bid for a specialist nurse to work with me was not funded.

The ward where I worked was closed. From that day, it became impossible to admit patients to the local unit when they needed it. Patients experienced serious delays in admission, or were sent to hospitals in other parts of England and Wales. Working on-call became extremely stressful because of the frequency of having to call consultants at other hospitals in the middle of the night to ask them to take our patients. Most of the consultants I contacted were helpful, but some were hostile and some told me they had no beds for patients from Manchester.

In 1997 a second consultant was appointed for Manchester. Candidates were told at interview that the supporting medical staff had not, after all, been provided. Neither, it emerged, had an office and other promised resources. The consultant left Manchester soon after me.

In 1998 my research colleagues left Manchester and moved to other fields of research because there were no grants to support their salaries. My fellowship came to an end and I was asked to return to general psychiatry or find another source of income. I chose to work part time for another trust, which is dedicated to providing specialist health services for people with learning disabilities. It was wonderful to work in an organisation whose business was to make it easy for me to be productive.

Why did it all go wrong in Manchester? In 1985 there was a district plan for a comprehensive mental health service, including psychiatry of learning disability. Everyone was keen to make it work. By 1995 planning meetings had ceased, and market forces were doing what market forces do. I have learnt that two psychiatrists cannot change a light bulb which does not want to be changed.

Psychiatry of learning disability is a small specialty. Conferences of the faculty attract more than half of the consultants and specialist registrars in the United Kingdom. Is it likely that any candidate worth appointing would fail to ask why both consultants left within weeks of each other? I think candidates will want to know what the problems were, and will ask if they have been solved. Seventeen months after I left neither post has been advertised. The service has closed.