Uh-oh, we had a little oopsie yesterday in Montpelier…

Gov. Peter Shumlin announced on Tuesday that his administration plans to replace the Vermont State Hospital in Waterbury with a decentralized, “community-based” plan with 40 inpatient beds in four locations around the state. …

The unveiling of Shumlin’s proposal came on the same day a top mental health psychiatrist called for almost the exact opposite of what the governor proposed. Dr. Jay Batra, medical director of the state hospital since 2009 and a professor at UVM, told lawmakers at a hearing on Tuesday that the state should have one central mental health facility serving 48 to 50 patients in order to provide the best clinical treatment and best staffing model. 

The preceding account from Vermont Digger, which has a long and detailed report on Shumlin's new plan and the mixed reaction it has received. Now, Tonstant Weaders* already know where I come down on this issue. I believe there is a need for a central state hospital to treat the extremely tiny number of Vermonters who are truly severely mentally ill. Some of them violently so. And I'm aware that this issue splits the GMD community. I invite your comments, but in the meantime hear me out.

*Obscure Harlan Ellison reference. Now who's the biggest nerd on GMD?

It was certainly embarrassing to have VSH's medical director unknowingly contradict the Governor on the day of his big policy announcement. But, aside from the entertainment value, it points to a serious flaw in Shumlin's decision-making process. It seems obvious that Dr. Jay Batra was not a key player in the process. And that's just stupid and shameful.

If Batra had been fully involved, wouldn't Shumlin have wanted him on hand to share the spotlight and answer questions? Of course. The fact that he was absent suggests that his opinion was not valued.

A doctor friend of mine, who supported Shumlin in the 2010 Dem primary and in the general election and is now somewhat disillusioned, told me, “Shumlin doesn't think doctors and nurses have anything to contribute to this discussion.” A believable assertion, given how Jay Batra spent his Tuesday. And given the kinds of folks who did share the spotlight with the Gov:

The governor made the announcement at an unusually crowded press conference on the Fifth Floor, with several dozen advocates, lawmakers and hospital administrators in attendance 

Advocates, lawmakers, and administrators. I'm glad the advocates had a foot in the door. But no VSH doctors, nurses, or social workers?. Possibly an oversight by Vermont Digger, but I only know what I read.

Now, as for the merits of the Shumlin plan…

Community-based care is the preferred option for those who can benefit from it. But there is a tiny minority of people who need the best possible care. Replace mental illness with, say, asthma and see what you think: “Governor Shumlin calls for the replacement of Fletcher Allen's pulmonary department with community-based treatment facilities in different parts of the state.”

Or, let's say the good folks at Dartmouth decided that they don't really need the Norris Cotton Cancer Center anymore; they think they can deliver better care by splitting their resources among four widely-scattered clinics.

Stupid, no? If you're dealing with a severe, obscure, devastating illness, don't you seek out the greatest expertise? Go to the Mayo Clinic if you can? Well, the same applies to the most serious cases of mental illness. The Vermont State Hospital was sometimes depicted as a warehouse at best, and a Cuckoo's Nest house of horrors at worst. Maybe it was that way once upon a time, but not in recent years. And new and better facilities are clearly needed. But there's a tremendous amount of experience and expertise in the staff. Sending them here and there across the state will dilute the quality of care, not improve it.

In return for decentralizing hospital services, Shumlin dangles the carrot of an improved community-based system. As Floyd Nease of the Vermont Association for Mental Health and Addiction Recovery said, the plan has the potential to work if it is “executed well.” But look at Vermont's track record: has mental health ever gotten the resources it needs? This is a state that allowed its hospital to decay and decline to the point where the feds raised hell. Do you think the situation will improve now, given a struggling economy, the expenses of post-Irene recovery, and Shumlin's opposition to any tax increases? (And given another news story from Tuesday: the filing of a lawsuit over the state's huge backlog of uninvestigated cases of elder abuse?)

And above all, given Shumlin's emphasis that the new system will be “more affordable”? I think State Rep. Anne Donahue (corrected my mistake, sorry Morgan) hit the nail on the head:

“I think now we've shifted to expediency: What can we do with FEMA and insurance money instead of paying attention to what quality care means.”

Shumlin talked of a new system that would “deliver the best quality care of any state in the country.” Well, his system would certainly be different. Even before the closing of VSH, Vermont was near the bottom among the 50 states in mental health care hospital beds per capita. No state has developed an alternative to hospitalization for the most severely mentally ill. Somehow, I doubt that Shumlin and his “advocates, lawmakers and hospital administrators” have come up with a revolutionary new, better, cheaper system without consulting those with the most expertise and the greatest commitment to care: the mental health professionals.