Health: First aid for the mind in a hospital prefab: Veronica Groocock on an emergency psychiatric service for people who simply cannot cope

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A YOUNG man of about 30 peers anxiously through the transparent plastic partition that divides the office from the waiting room. 'Hello, Terry. Take a seat. See you later.'

David Thompson, a social worker, greets him from the other side of a shabby prefabricated hut in the grounds of Charing Cross Hospital, London. This is the setting for the hospital's emergency psychiatric service, an unusual walk-in facility for the distressed and distraught in west London.

Terry is a regular visitor. He has been admitted as a psychiatric in-patient about 20 times over the last dozen years. He cannot cope at home because of his illness: he suffers from severe sleep disturbance and feelings of isolation and he has difficulty making friends. Every so often he turns up requesting admission.

The service was founded more than a decade ago by Dr Sam Baxter, a consultant psychiatrist, in response to what he saw as a gap in the provision of care for people with mental health problems.

These days it sees growing numbers of people who have been hit hard by the recession, are unemployed and living in bed-and-breakfast accommodation. Many, says Dr Baxter, are in dire poverty and may not be sufficiently 'together' to claim all the benefits to which they are entitled.

For some the hut is the last port of call. And, as in any emergency service, tempers can run high. On the wall is a list of known 'aggressive' patients. On one occasion both Dr Baxter and Mr Thompson were attacked at the same time by the same patient. 'He lunged at Sam, so I went behind him to pull him away and he threw me over his shoulder,' says Mr Thompson.

The two of them ended up sitting on the man. The panic button was on the other side of the room. They tried shouting, but the soundproofing worked wonderfully efficiently. The whole incident lasted only five minutes - 'but it felt like for ever'.

Such incidents are infrequent, Mr Thompson stresses - verbal abuse is more common. None the less, there is a strictly enforced policy that staff must work in pairs: a psychiatrist with a social worker or community psychiatric nurse.

'Before I came here I was working in Hackney,' says Dr Baxter. 'I did some research there into how psychiatric patients got into hospital. What came out very clearly was that an enormous number of distressed people had been seen out of hours by junior doctors in casualty departments with very little supervision. Their training had been with patients on the ward - quite inappropriate for seeing people in an emergency setting.'

Loosely speaking, the unit is a 'first aid' service with the emphasis on immediate help. 'We are not here to speculate about long- term treatment needs. One of the key questions we ask everyone who turns up is: 'Why are you here today?' Many have long-standing problems and it's not immediately clear why they are so much worse today than yesterday, or last month. If we have some idea of 'why today', we are in a position perhaps to do something now.'

The unit is open from 9am to 5pm Monday to Friday, and used by 10 to 20 people a day. Causes of distress include depression, anxiety, schizophrenia, alcoholism and drug overdoses. Men outnumber women by 54 per cent to 46 per cent. This is partly explained by the unit's follow-up work with alcoholics - a detoxification service is available.

About a third of those seen are referred by their GPs. Others come via the Samaritans. Twelve per cent are admitted to hospital as in-patients. Dr Baxter says the work has given the team 'a limited sense of the wandering, inner- London psychiatric population'.

Around half the patients who arrive will, like Terry, already be known to the unit. Unfamiliar faces call for careful judgements by the staff. Drug users in treatment programmes elsewhere may attempt to top up their methadone supplies, although some will genuinely have lost their prescriptions. Each request for drugs is checked. One male drug user hurried out the minute he saw Dr Baxter pick up the telephone to check his identity.

The catchment area is the borough of Hammersmith and Fulham, which has a large commuting daytime population. Mr Thompson cites a London Transport employee who, on arrival at work, sat staring at the wall. A colleague brought him into the unit and it emerged that he had a history of depression. It was then a question of liaising with a hospital that had previously treated him.

Help for residents calls for local expertise: 'I need to know what's available in the area so I can plumb patients into the available services, whether it's Mind counselling or our own social services' mental health projects,' says Mr Thompson.

But with all the resources and goodwill in the world, there will always be some people who cannot or will not be helped. Dr Baxter had just seen a woman who was 'very distressed by all sorts of aches and ailments.

'She had seen innumerable doctors, each of whom had told her: 'It's all in your mind', so she'd come to us in order to get the 'truth' - that it wasn't in her mind. We couldn't help her, because she really didn't want our help.'

Some people arrive at the unit pleading that they need to be admitted to hospital for a rest - a request unlikely to be granted.

A proportion of patients would have been in long-stay psychiatric hospitals had it not been for the change in policy to close the majority of such beds. Dr Baxter does not see these people as victims of the Government's 'care in the community' policy, even if they live on the margins in appalling conditions. 'If you ask them, they want to be in their own flats.'

He stresses that violent behaviour is not a major feature of the unit's work - but that an upgraded clinic would be welcome. 'If people have reasonable surroundings to sit in, and are not devalued immediately they walk in because of the poor conditions, then maybe we can deal with potential violence in a better way.'

He reckons there is 'probably more violence in the queues in the local DSS office or housing department. We don't worry about it. We are sensitised to it.'

(Photograph omitted)

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