Supervisor Mandelman wants more locked treatment beds, faster.

Board of Supervisors Mandelman President Rafael Mandelman has been the most consistent on mental health and healthcare in City Hall: he strongly supports expanded conservatorship laws, and he has worked to hold city agencies accountable to producing more treatment beds as a part of the way to help the severely mentally ill. Now leveraging the bully pulpit of his powers as President of the Board of Supervisors, Mandelman is continuing the unenviable task of holding lagging departments’ feet to the fire. 

Before getting into the latest from City Hall, it’s first important to define what exactly constitutes a “locked treatment bed.” Our city defines this as beds in treatment centers that offer 24/7 psychiatric care, nursing care, and psychosocial rehabilitation services to adults with severe mental illness and/or placed under conservatorship.

By Supervisor Mandelman’s estimation, the city is not making sufficient progress fast enough in expanding our locked treatment bed capacity. And he’s not alone in wanting to know why.

At a twin series of hearings on June 26, Supervisor Mandelman focused on two areas: 

1. Our utilization, or lack thereof, of conservatorships since the state expanded who can be conserved. 
2. An update from the Department of Public Health and the Office of the Controller to report on the expansion of supply of locked treatment beds for mentally ill people with the use of state funds through Prop 1.

The findings of the hearings were consistent with the past few years of hearings on this topic: “we’re trying our best, but our best isn’t that great.”

It’s not because of restrictive laws. In fact, the State of California passed a law (SB 43) that expanded the definition of “gravely disabled” (which is the legal threshold at which someone can be placed under a conservatorship, the equivalent of an involuntarily psychiatric hold) to include those with severe and crippling drug addiction. Not only did the State make the laws more expansive so that we could commit people to psychiatric care facilities (a feature of which is a locked treatment bed) - San Francisco was one of two counties in the State of California (in addition to San Luis Obispo) to implement this expanded definition of “grave disablement” ahead of the required implementation deadline of January 1, 2026. In short, the City of San Francisco said, “yes, we recognize that drug addiction, street conditions, and mental health are intertwined challenges, and we want to start solving this faster than we’re required to.”

Yet despite embracing this expanded definition, we aren’t seeing it being used to help more people. Because the treatment beds don’t exist. This is something Mayor Lurie has also publicly leaned on as a major shortcoming in how we address the mental health and addiction crises - and why he’s committed to adding significantly more treatment beds (both locked and unlocked)

While we are moving the new state funds through to deployment (and creating more beds), as we know, it takes a long time to build in San Francisco. And we aren’t talking about simply building more housing. We are talking about complicated buildings with specific needs - essentially, hospitals. It’s not easy to build the capacity we need to create - even when the state is the one footing the bill. 

Our best path to bringing more locked treatment beds online faster is to repurpose and convert already-existing beds to be locked ones. And the state already gave us money to start working - $27.6M, to be precise. Of that:

• $6.3M was allocated to re-open 333 7th Street as a 16-bed enhanced dual diagnoses treatment facility (one that can handle both mental health and substance used disorder cases)
• $21.3M was allocated to convert existing unlocked capacity and build more at San Francisco General Hospital.

Seems simple enough, right? 

Not exactly. Unions are quietly (and not-so-quietly) organizing against this strategy - because converting unlocked beds to locked ones means that the existing union labor covering these patients will need to upskill to meet the more complex patient needs. The conversion of beds is viewed as a lose-lose for the union: it either means jobs get eliminated, or jobs get more complex and require more training. And thus, the union is putting their members’ interests ahead of the needs of those suffering. 

Unions play an important role in protecting workers. But when political interests get in front of the needs of the people their members are meant to serve, it hurts our city. It perpetuates the episodes we’ve all seen from Market Street to the MissionThere are people truly suffering on our streets, and the city should  be doing everything we can to improve our capacity to help them. It’s just the right thing to do.

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