Sunday, 7 March 2010


After I just posted about referrals, the Jobbing Doctor posted about how referrals are then managed by teams, writing about it here.

His account is familiar to me, I've trained in teams that function in this manner. Many of them did. Well, in truth, almost all of them did.

There're comments on the Jobbing Doctor's blog that are critical. This is appropriate, blogs are a place to vent grim experiences of what really happens and tell it like it is. As regular readers will know, although I can moan and whine with the best of 'em, and my working world is immersed in the misery and despair that my patients grapple with, being down and negative about it all isn't my style. If we're not hopeful, if we can't think how we can do it all a little bit better, we've kind of missed the point. Sure, there's lots we can't change. But equally, there's lots we can.

In mental health, it's not like much of health care provision where we need machines that go "bing" or bits of kit with sharp spiky bits or infusion pumps/theatre time/guided ultrasound/spirometry/whatever so if we want to do things differently it's much easier to do so.

We've shifted services a few times over the last few years, which really hasn't been that hard to do. We've an active patient forum who tell us what could be done better. We've two active carer forums who're very active within our Trust, locally and politically. Our staff on the shop floor all know what's going well and what could be improved. So we said what we wanted to change (had to have meetings with GPs and commissioners and our Trust managers which did take some time) but then changed it for the better.

I'm bemused by what people think Consultant Psychiatrists do. I suppose I shouldn't be. Our timetables are varied and often diverse. Working age adult services tend to have psychiatrists with pretty fixed and full timetables (although this can change, if there's a will to do so) but other disciplines already often have changed.

What do Consultant Psychiatrists do? Really! How does a Consultant Psychiatrist fill their working week? The short answer is patient contact and meetings. The longer answer is the detail to this.

Other than ward round and clinics, most Consultants have few fixed clinical sessions. Even a full day of both only eats up 2 days of a week. For most Consultants, they've half the week free to do whatever.

For me, although I've a full sector that's a higher patient population than the Royal College of Psychiatry guidance for one Consultant Psychiatrist, and there's no Staff Grade and no ST4-ST7 specialist registrar or any senior medical support at all, I tend to average one in-patient at any one time so my in-patient work takes literally just about 2 hours a week. My out-patient clinic is one morning for 3 hours, once a week. That's 5 hours a week. What do I do with the rest of my time?

Quite a lot - my formal timetable (my Job Plan) goes on over 6 pages, with no sentences or explanation at all, just lists of what I do and where I do them and how much time it takes on direct clinical care or supporting activities. But with just 5 hours a week of fixed activity, it's easy to do other stuff with flexibility.

So I can meet the team every morning and discuss what work they're going to do, that day, and whether there're any medical dimensions I want them to explore when they see their patients. I've no fixed committments in the afternoons so we meet every afetrnoon too, to discuss every patient seen, with discussion on any medical management in care that we need to progress. With no fixed sessions in the afternoons, most of my afternoons are spent in liaison work, in care homes or on joint visits with CPNs or social workers.

My Job Plan's so long because of other stuff we do. Clinical audit, research, clinical effectiveness. Case Conferences. Supervising junior doctors and filling out assessments for them. Preparing interview questions and model answers. Statements of testamentary capacity. Strategy discussions with police. Meeting GPs. Meeting carers every month. Journal Clubs. Safeguarding meetings. Work with the health promotion and neurologists on district wide vascular dementia pathways. Several hours a month spent in supporting nurses in their training. Teaching ward nurses in the acute Trust. s136 assessments. Generating references. Teaching the Consultant physicians and surgeons in the acute Trust in their formal lunchtime training sessions. Joint work with neurology. Mandatory child safeguarding training. Meeting patient reps every month. Discussing care options with PCT commissioners. Work with staff in the hospice. Monthly Consultant meetings. Supervising nurses in non-medical prescribing. Peer group CPD meetings. Letters to the DVLA. Working with community matrons/district nurses/health visitors. Management nonsense. Input into the local APC meetings. Training Primary Care teams. DOLS meetings. Mandatory CPR training. Interviewing nursing, OT and medical candidates for posts in our teams. Medical student seminars. Court of Protection letters. Helping secretaries, nurses and STR workers get the right A4C band. Adding common sense into governance meetings. There's more, but it starts getting a bit specific. Equally, a lot could be expanded upon (the amount of time I spend reading journals, extracting bits for teaching in different forums or taking to different management meeting, is very significant).

But what I'm seeking to convey is that a Consultant Psychiatrist can have some fixed time seeing patients some mornings, can also spend most afternoons seeing patients, but there's flexibility to support teams so referral pathways and input into clinical care always involves a Consultant Psychiatrist, even if I don't always see the patient.

We've not that much fixed sessional activity. We've no expensive kit or resources that limit how we can work. We invariably know what's going well and what isn't. So I really can't see why we can't change things, for the better.

1 comment:

The Shrink said...

And I'd agree with A&E Charge Nurse that waiting lists can be harmful.

We have a wait in some bits at some times (memory clinic, at the moment) since inevitably there are peaks and troughs of activity.

But for CMHT visits or my out-patient clinic or a DV by me or psychology assessment or social work input at the moment there're no waits.

We have to do the work anyway, so why not do it next week, instead of in a few months' time? Waiting lists stress me out and aren't good for patients. If a service has enough capacity for the demand, there shouldn't be a waiting list. If there is, and this dissauades referrers because there's a wait, the service is no longer accessed on clinical need and it becomes part of a gatekeeping barrier.

In some disciplines in health there are rate limiting steps (like access to MRI scanners or endoscopy time or whatever) but in mental health, if we're honest about what we're doing, I really can't see why we should have substantial waiting lists.