I met with PCT commissioners and we talked through our services' activity levels.
We were congratulated on over performing, with an invitation to bring 2 presentations to next month's meeting to progress bids for additional funding for 2 bits of the service. All is good.
But . . . there were questions raised about the number of referrals to our service of younger adults who're assessed for dementia, but found not to have dementia. It's the majority. I reckon we know of 74% of those with young onset dementia in our district so there aren't loads and loads of folk left to find. Most referrals to this service don't result in a diagnosis of dementia. PCT sensibly asked about our referral process and care pathway and if, instead of more resourcing, we should tighten up on referral details and primary/secondary care work up before referral to specialist tertiary services.
The commissioners don't appreciate just how poorly psychiatry's seen or respected in medicine, thus how motivated (or not) folk are to put effort into psychiatric care.
Let's contrast two common referrals to two Consultants. One referral is to a Consultant Psychiatrist with depression. One is to a Consultant Cardiologist with heart failure.
A letter to the Consultant Cardiologist saying, "Please review this person's physical health" would be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health" is commonplace.
What if the referral is more specific? A letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest" would still be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood" is commonplace.
Even more specific. The letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest, I think it's his heart and needs sorting out" is still be laughed at and binned.
The letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood, which is low and needs sorting out" is commonplace.
The Cardiologist would expect examination (with pulse rate and BP at a minimum), conceding that cyanosis, clubbing, signs of biventricular failure, JVP etc although desirable are unlikely to be detailed.
The Psychiatrist gets no examination. Ever. Although psychiatry is a medical speciality, no medic ever refers with details of appearance, behaviour, speech, mood, thoughts, perceptions, cognition or insight of a mental state examination.
Having had a richer referral history and examination, the Cardiologist also gets a minimum work up of an ECG and sometimes structural imaging, to then progress further appropriate diagnostic investigation.
The Psychiatrist has had a scant and inadequate history with no examination and invariably no use of instruments or investigation.
Energy isn't invested in trying to progress salient history disclosed (symptoms), objective elements of presentation (signs), testing (investigations) and formulation (diagnosis). Yet symptoms, signs, investigation and diagnosis are ubiquitous to other disciplines in medicine.
I can't see how it will change.
I tried to explain to the PCT, who commission services from other medical specialities, that in mental health we just don't get sophisticated assessments in referrals that allow us to filter those with a high index of clinical suspicion for dementia vs those with cognitive deficits arising through mood disorder/neuropsychiatric sequelae of physical comorbidity/medication. We just have to accept all referrals then 'phone the referrer and patient and family and GP to get enough information to progress the right care. The PCT at first just didn't believe me. Then they believed me and thought medical colleagues should be doing great psychiatric referrals and if they can't it's a matter of poor training and poor practice.
Some days I just don't feel understood.