We see them every day — the lost souls wandering into traffic, ranting into the air or sleeping in their own waste. And we wonder why there seems to be so much more untreated mental illness on the streets of San Francisco these days, and why City Hall doesn’t seem to be doing much about it.

A new report from the Board of Supervisors’ Budget and Legislative Analyst gives some alarming answers, and here’s hoping it spurs action from the politicians who could make a difference.

The report examines conservatorship — compelling mentally ill people into treatment even if they’re too sick to realize they need help.

Despite the growing crisis on our streets, the number of conservatorship referrals in San Francisco plunged by almost 50% percent between 2012-13 and 2018-19. Per capita, San Francisco has a smaller conservatorship caseload than nearby counties including San Mateo, Marin, Alameda and Contra Costa — and a smaller per capita caseload than California as a whole.

Progressives may say that’s a good thing since conservatorship arguably takes away civil liberties. But in doing so, they’re fighting, in some cases, for people’s freedom to deteriorate and die on our streets.

And we actually have more people per capita on short-term holds lasting up to 30 days than other counties, perhaps signaling San Francisco is OK with whisking troublesome people off our sidewalks but unwilling to ensure they get the long-term treatment they need. That may also explain why seeing clearly mentally ill people stumbling around our sidewalks in hospital gowns and ID bracelets is sadly not uncommon.

Supervisor Rafael Mandelman requested the report and plans to hold a hearing on the subject this fall. He knows the heartache of watching a loved one fall into a mental health crisis. He was raised by a single mother who was diagnosed with bipolar disorder, schizoaffective disorder and borderline personality disorder.

She suffered psychotic episodes, spent days in bed, and was in and out of the hospital throughout his childhood. Mandelman had to find food for himself by age 9 and left her Laguna Beach home at age 11 to be raised in San Francisco by a string of extended family, foster parents, classmates’ parents and teachers. She died in 2017, and Mandelman, his half-brother and aunt plan to scatter her ashes next month in Big Sur.

Despite his progressive bona fides, Mandelman vehemently disagrees that it’s compassionate to prioritize a very sick person’s civil liberties over helping them get better.

“It’s completely inhumane,” he said. “If you have known a friend or a loved one and seen that person in psychosis and seen how far that psychotic individual is from their true self, you cannot believe keeping that person in that state is somehow honoring their autonomy.”

The report Mandelman commissioned looks at San Francisco’s response to the state’s Lanterman-Petris-Short conservatorship law. The law, which took effect 50 years ago, was intended to end the indefinite commitment of mentally ill people against their will, but some think the pendulum swung too far the other way because of the long, complicated legal process it created to obtain a conservatorship.

“From a civil rights perspective, it’s good, but in terms of what’s best for the patient, it’s not,” said Dr. Paul Linde, who used to work in the psychiatric emergency room at San Francisco General Hospital.

Under the law, people causing an immediate danger to themselves or others or who are gravely disabled and cannot secure their own food, clothing and shelter because of serious mental illness or chronic alcoholism can be compelled into treatment.

Under a complicated process, an initial 72-hour hold can be extended for 14 days and 30 days and then become a temporary six-month conservatorship before becoming a renewable, one-year conservatorship.

There are many safeguards in the law. Conservatorship starts with a recommendation from a psychiatrist and involves an investigation by the city’s public conservator within its Human Services Agency and a hearing before a judge.

If the one-year conservatorship is approved, the Department of Public Health is tasked with coordinating the patient’s care including placing him or her in a facility, which can range from a locked hospital to an unlocked board and care home. The public conservator makes decisions on the patient’s behalf during the conservatorship.

It’s not clear if the law itself is the problem or rather San Francisco’s loose interpretation of it. The report describes how some counties have more tolerance than others when it comes to referring patients to conservatorship. Counties also have different takes on the term “gravely disabled” and just how dire someone’s mental health must be to meet that standard.

San Francisco has a low tolerance for conservatorship. Fewer than 1 person per 10,000 San Francisco residents is part of the county’s conservatorship caseload versus more than 5.5 people per 10,000 in San Mateo and more than 4 people per 10,000 in Marin.

San Francisco in 2017-18 referred 141 people for conservatorships, a big drop from 284 people in 2012-13. Its overall caseload has decreased by 13% in that time.

The report says that one reason conservatorship may be dropping is that there aren’t enough beds to treat those who are held. The number of acute inpatient psychiatric beds at San Francisco General Hospital dropped from 88 in 2008 to 44 in 2011 — and they haven’t been restored during the economic boom. The number of sub-acute mental health care beds fell by a third between 2012-13 and 2017-18 to 241 treatment spots.

Jeff Cretan, spokesman for Mayor London Breed, said the mayor has added funding for 212 additional beds throughout the city for patients with mental illness, drug addiction or both. All those additional beds will be open by next year.

“There are too many people suffering on our streets who cannot care for themselves, and we need to get them the care and services they need,” Cretan said.

Another problem the report found is that the public conservator’s staff has shrunk due to retirements and delays in hiring, meaning there are fewer people to handle ongoing cases. The under-staffed office isn’t coordinating well with the Department of Public Health. The two departments are only now starting to share data on patients and to set regular meetings to discuss patient progress. (I recently called City Hall “sloth-like.” Perhaps that was too generous.)

Jill Nielsen, a deputy director in the Human Services Agency who oversees the conservatorship program, said she appreciates the report’s recommendations — and that she’s working to increase the coordination among various departments and that last year the number of conservatorship referrals rose slightly.

Breed has added two new positions to the public conservator’s office to allow for an expanded caseload.

Part of those expanded services will help address those who are severely drug addicted and can now be conserved under a change in the state law initiated by State Sen. Scott Wiener.

Wiener said he is glad the politics around conservatorship are slowly shifting in San Francisco, as evidenced by the Board of Supervisors voting to opt into his expanded conservatorship law.

“For the large majority of people on our streets, conservatorship is not the right answer — there are other tools that will help them like voluntary services or a shorter psychiatric hold,” Wiener said. “But for a small percentage of people on our streets, they are in such severe crisis, they can benefit from a conservatorship.”

“Allowing someone to deteriorate and die on our streets, allowing someone to sleep in their feces, that’s not progressive, it’s not compassionate, it’s frankly the opposite,” Wiener continued. “We need to help these people.”

San Francisco Chronicle columnist Heather Knight appears Sundays and Tuesdays. Email: hknight@sfchronicle.com Twitter: @hknightsf