Thursday, 4 March 2010

Referrals

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.

Tricky.

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.

2 comments:

pj said...

Heh, I'd love to refer to the psych team with 'seems a bit mental, can you sort it?', but to be fair there are not actually many good tests or instruments for psychiatric assessment, certainly nothing like an ECG.

On the other hand, we received a referral recently asking 'can you please optimise this patient's medical management' from our surgical colleagues, and that isn't far off.

Maggie said...

Very interesting post, thank you.

With some experience of being 'processed' through the mental health system, I've long been baffled by the absence of any useful structured info being recorded and passed on when I was referred to a different service.

As you say, with a physical issue there would be some facts and figures and test results available to the consultant when a patient was referred to his/her care, and a specific reason given for the referral. I appreciate that psychiatric issues don't lend themselves to neat numbers and factual tests in the way that physical ailemts do - but when I learnt about such things as the DSM I realised that great effort had been put in for many years to try and give some structure to psychiatric ailments. I thought the method of dividing and then assessing a person's issues into different categories was excellent i.e. clinical, affective, personality, physical disorders, social functioning, environmental factors. Even if the primary contact in the healtchcare system cannot diagnose, some essential facts can be gathered - such as social functioning. It is possible to gather some structured info which could be assessed, recorded, built upon and used as a person goes through the system (not only when going from one service to another but also when the patient stays with one service but the staff change and a new person needs to get up to speed on the cases in hand.)

Some of the issues affecting a person's psychiatric state DO have factual answers, yes/no answers or criteria which can be assessed against a scale (e.g. do you ( )never, sometimes, often, always) If these questions have been asked and answered at the GPs, or other service, and the case needed escalating to a more specialised service these 'test results' could travel with the referral, in the same way the results of physical tests do. I haven't ever seen this happen myself - maybe it does now? Is there a 'structured data' facts and figures method of communication within the UK psychiatric system?

The previous comment says there aren't many good tests or instruments for psychiatric assessment - and OK, there aren't purely objective processes such as ECG or 'test urine for X, if X found then Y' - but there ARE tests and assessment methods that have been developed to give efficient structured data to use in mental health care, both in first contact with system and over the following years if continued treatment is needed - and I'm puzzled not to have seen such assessment methods used - to save everyone's time and help efficiently evaluate each person's condition at initial referral stage and at progress reviews.

Anyway, enough comment from me :-) Just wanted to say it isn't just the consultant psychiatrist that inwardly groans when another vague referral letter appears - we 'service users' also sigh a deep sigh over the same issue ...