> gwschulz@sfbg.com
San Francisco is a beautiful place. But it’s also a city where an extraordinary number of people suffer from mental health problems, sometimes quietly, sometimes visibly. City government has always taken on the burden of caring for those who really need it, but the Gavin Newsom administration has been trying to outsource that obligation in recent years.
Department of Public Health director Mitch Katz has tried for years to trim the number of psychiatric-care beds maintained by San Francisco General Hospital. He proposes to replace those services by contracting them out to local nonprofit Progress Foundation, which earned most of its $11.5 million in revenue last year from government sources.
The proposal is for Progress to develop and operate a community-based psychiatric treatment center as an alternative to SF General’s emergency-room and inpatient beds. A key difference would be that the alternative treatment would be voluntary and cater to those without severe symptoms.
Katz wants to eliminate 14 of SF General’s beds and reduce the number of patients it assesses by 30 percent. Add to that seven other beds that were stripped of funding two years ago, and it’s clear that mental health treatment in San Francisco is changing.
"It’s a problem we have to solve by coming up with alternatives," Katz told the board’s budget committee Oct. 10, "because it’s not right for that person, or for the cost to the system, that [they] be in a locked ward. It’s more downstream alternatives."
Opponents of the cuts, however, including psych nurses at SF General, led by the hospital’s chief of psychiatry, say the Progress proposal might complement SF General’s services but it would be dangerously shortsighted to think it can replace them.
Private-sector hospitals in San Francisco have already cut a combined 100 psych beds over the past 10 years, leaving behind only 75. Patients relying on Medi-Cal subsidies end up at SF General more than ever. Admissions, in fact, have climbed by as much as 50 percent in the past decade.
"I don’t want to be alarmist," said Alfredo Mireles, a psychiatric nurse at SF General who is opposing the cuts, "but we have this one guy who’s been in and out of here since his teens. He’s in his 30s now. He’s smart, college educated. But he has these violent outbursts with no remorse."
The man had assaulted a police officer just the night before, Mireles said. He recalled another patient who was so paranoid he wouldn’t come out of his room to eat. He had ended up in the emergency room after not eating for eight days.
Nonetheless, SF General’s psych ward maxed out last December for the first time in its history, forcing police offers to divert patients to jail or to hospitals unprepared to deal with them. All those facilities can do is strap down the patients or lock them in seclusion until a slot opens at SF General.
"You have to be very acute to get admitted," psych nurse Stacey Murphy said, referring to SF General. "But then we can’t get rid of people, because nobody wants them. They’re not acute enough to technically belong in our hospital, but they belong in a locked facility or in board and care."
Murphy explained that Progress won’t be able to handle certain patients now living in a sort of gray area at SF General — between being willingly and unwillingly hospitalized — such as the drug addled or violent. And that’s one problem with privatization in general: corporations and nonprofits will gladly take over profitable services, but the hard or expensive cases often fall to government … or simply through the cracks.
Progress argues that SF General spends too much time and money on patients who have serious mental health problems but aren’t so acute that they need to be locked up. Its idea is to put psych patients back into the city but help alleviate the misery they might otherwise endure alone or in a maddeningly sterile hospital. It seems to think the hard cases aren’t that hard.
"The time and resources devoted to this group of clients in a psychiatric crisis who are not hospitalized represents a cost to the mental health system that is unnecessary and avoidable if the intervention, triage, assessment, and treatment can occur in a community setting," the Progress Foundation’s June proposal reads.
"To the extent that there are people who would do better if we really wrapped services around them, shouldn’t we all focus on those people who would accept services voluntarily?" Katz asked the committee. "I think to focus a lot of our resources trying to convince people to take treatment against their will as outpatients when so many people would benefit from more loving, positive care, I don’t think it’s the right priority."
Piers Mackenzie still views Katz’s plan as poor public policy. His daughter, then 22, required a brief stay at SF General’s psych ward during a sudden mental health catastrophe four years ago. The event politicized Mackenzie, and he has since agitated against attempts by Katz to scale back psychiatric services at the hospital.
"I couldn’t think of a more retrogressive step, simple as that," Mackenzie said. "When there’s a proven need for more beds than there are presently, to cut them is just plain idiotic. I don’t understand it."