Lake Cocytus

Communication

2011-12-12T18:34:00.003Z

Communication skills are important. We're sociable beings and reach out to communicate from the day we're born. One gentleman was explaining, fervently, that he does not need to pay his telephone bill 'cause he never uses it. He only speaks with the dead (he is a medium) or to people far away by telepathy.

He communicates with neighbours, his wife, the rich and famous and healthcare professionals through his mind. He sees this as a rich and desirable source of support, they're endlessly referred to as his, "telepathic friends."

Communiating with the dead or those geographically distant, he asserted he "never uses a kiosk" so didn't believe he should pay his 'phone bill.

He uses his mind. He thinks his messages. In his view, it's not good to talk.

Stairway to Heaven

2011-12-09T21:55:00.002Z

I was due to see a patient who I've known for a long time, she was due in out-patient clinic but did not attend. My secretary checked on the patient administration system and found out she had unfortunately passed away.

It was with sadness that I saw the message, in bold, that the patient was deceased.

Next to this was also the comment, "Transport not required."

I guess she can now find her own way, to where she's going. With thoughts of fondness, and knowing her impish humour, that brought me a smile. Happen PAS is right and she's found her own stairway to heaven.

Detention

2011-11-03T22:21:00.003Z

Walking across the hospital grounds I overheard a couple talking as they returned to the ward.

He was saying to her how grateful he was that his Consultant Psychiatrist, ". . . had sectioned me that night, getting me into hospital," because he felt, "I right needed to, if I didn't I'd have been pissed and in [a nearby large city] and right violent."

The psychiatrist in me thought, how wonderful, he got the right care when acutely unwell and now has insight. But then I also thought, what a shame his Consultant Psychiatrist hasn't heard that and, probably, will never know. I also thought how great it was that he could reflect on it and freely talk through how being "sectioned" was a positive thing for him.

Although a formal Advance Decision can only define what treatment can't be given, he could craft an advance directive framing how he'd like future care to be orchestrated, which has no legal power but at least gives a steer as to his preferences, should the situation arise again. It could either be a discrete statement or part of a wellness recovery action plan (WRAP).

I was mildly piqued by the glib "being sectioned" phrase, but that's because in my training that was seen to be a cardinal sin. Detention under the MHA 1983 is a formal, serious business and "I'd section" a patient was seen as a careless, casual, trite comment at variance with the import and formality of the act. We were also scolded over how inaccurate that is, since doctors can't detain patients, we only make recommendations which ASW/now AMHPs choose to accept or decline, with hospital managers receipting the paperwork and then they formally detain the patient. But that's a personal foible I've hung on to, and labour over with my trainees, so in the cold light of day I'll concede that I shouldn't really be piqued that a patient talks of "being sectioned" instead of "being formally detained under the Mental Health Act 1983."

That was my moment of pondering today . . . hearing a patient's comment, thinking of the positive, thinking of his possible futures, thinking of the terminology used and thinking how he was expressing being grateful for the care he'd received.

Odd how but a few moments of snatched conversation can stir thoughts!

Generosity

2011-09-24T16:00:00.008+01:00

I'm interested in how we think, in what internal and external processes impact 'pon how we see ourselves, how we value ourselves, how we perceive ourselves to be. A positive sense of self is important. TED talks are often engaging, this one on generosity (and social change, challenging poverty, altruism, philanthropy and business) is worth shamelessly snaffling and displaying here :

Sasha Dichter: The Generosity Experiment from TED Blog on Vimeo.

Humour

2011-09-15T19:51:00.002+01:00

I saw a young patient who has had obsessional ideation for some time, but it's now well managed. They still have to arrange towels in order, folded just so, arranged by colour and shade in a certain order. They still have to have the groceries and tins in certain places, with the labels facing a certain way.

But there's no more checking, no more repetition, no more repeated routines intruding unhelpfully for hours a day. She has a sharp and witty sense of humour and an enormous sense of living a life full of joy.

I saw her today with a junior doctor, with a view to discharging her. She was explaining to the junior doctor that she has CDO. He asked what that was. "It's just like OCD, except the letters are in the right alphabetical order, just like they should be."

Priceless!

Insight

2011-08-18T11:38:00.002+01:00

We used to assess and document insight a lot, routinely for every patient. It's become more of a trivial afterthought now (and rightly so) with more appropriate and sophisticated consideration of decision/situation specific capacity replacing the concept of insight being present/absent.

I was musing this over with an AMHP as we discussed what insight means, how it's been mis-used in the past in tribunals as a proxy to not being capacitated, how it's seldom relevant now. She raised this because in all her time in the multidisciplinary team it dawned on her that she's never heard us discuss insight. She saw this as a good thing and I'd agree. Insight as a concept has been of enormous import and done rightly is fine, equally it has historically oft times been a shorthand that's too superficial/medical to have the utility it needs. Patients' formulation of their experiences, understanding of needs, engagement with informal family/friends/support and formal health/social servcies can be framed in terms of insight but invariably is better considered in terms of understanding and capacity.

Having chewed the cud with an AMHP and stirred thoughts on the concept of insight at length, I moved on half an hour later and to my shame, I lacked insight.

I met with our Trust's Chief Executive. I do so fairly often. Our Chief Executive is an agreeable, competent, grounded and incredibly sensible soul. I'll frequently meet the Chief Executive and talk through stuff over coffee. Or email stuff that merits Board level consideration. Or the Chief Executive will come see me, which happened yesterday.

Because our Chief Executive is so approachable and engaged with Consultants, I rather fear I've done them a disservice.

I'd always thought the Chief Executive to be influential. I was naive. The Chief Executive has great influence over a great many things, but it's finite and in some ways is actually quite narrow. I'd not really appreciated the constraints that Monitor and CQC and SHA and DoH and others shackle the Chief Executive with. The Chief Executive has responsibility but Executive Directors have their own portfolios and they, not the Chief Executive, sort those. After deciding how things shall be, the Chief Executive then has tiers of managers whose Chinese whispers distort the detail and implementation of the intentions, horribly. Can the Chief Executive direct me to prescribe Mrs Smith olanzapine 5mg velotab at night? No. That's a clinical not a managerial decision, the Chief Executive has no direct influence on what clinicians do in their work.

National drivers constraining the Chief Executive's options. Local commissioners directing the Chief Executive's choices. Tiers of managers running with the Chief Executive's wishes yet effecting implementation (or not) their own way. Managerial decisions' boundary with clinical decision making (and no direct managerial influence in this). Good grief. I'd not really thought through what a grim position it is to hold, having all the responsibility yet with much less opportunity to effect detailed sophisticated systemic change than I'd considered. Worse, I erroneously presumed that the Chief Executive is boss and can sort everything. Most folk do.

I lacked insight into the situation.

Time to remedy this.

Lithium

2011-08-16T16:09:00.002+01:00

How many older adults present, after retirement, for the first time with schizophrenia? Almost none. How many older adults present, in later life, with mood swings which are so significant that they need long term management with interventions which include a mood stabiliser? I don't know. But there aren't that many folk presenting in later life with major mood swings for the first time.

Why's this in my thoughts? It's because a number of folk, who have had significant mood swings (by which I mean, they've literally tried to kill folk, being consumed with rage or jealousy and felt righteous in their actions) have been referred to my door. And, to a one, all of them have asked for lithium.

Why?

Has there been a campaign about it? Is there new good press about it, somewhere? Has some celebrity trash mag carped on 'bout how it cured someone of mood changes? Enquiring minds need to know!

My patients had mood problems arising mostly from stroke damage within their limbic system and/or frontal lobes so they'd lost the bits to experience, regulate and control mood as effectively as they used to. In one patient lithium's had major benefit, resulting in a move from a very restrictive care setting back in to mainstream care services. In two others it's improved interactions and quality of life appreciably (that is, other than through speech, there's no expressed hostility) with both patients and their families feeling it's been transformational.

I'm not really sure why lithium should be so miraculous, especially when the problem's mostly structural brain change rather than purely chemical pathology (to which chemical solutions, like lithium, can be brilliant).

Still, they're better. That's good. It just puzzles me why they sought out lithium, why they were right to do so and why it's been so curiously helpful!

Extremes

2011-08-03T16:53:00.004+01:00

When articulating a point of view, increasingly I find myself being more extreme. Usually I'm seeking a view somewhere in the middle ground, but to shake the inertia in the system and effect any substantial change that's sufficient, invariably I'm having to shift from this tempered position to one of a more extreme position, to illustrate dramatically a striking comparison or extreme position in order to make a point/have a point understood and appreciated.

When I recently read a quote, it very much resonated with me.

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan, 1953

Within the NHS, which is brilliant at what it does well, management process seems increasingly to benefit from more extreme views that help clarify the need/importance/consequences. Those staying in the middle of the road are steam rollered over. Sadly, more balanced and moderate views simply seem to be lost in the drone of organisational noise and chaos and process.

Ho hum.

Medicine

2011-08-01T11:58:00.004+01:00

We go in to a vocational career, such as medicine, for many reasons.

Here are 10 reasons why we fair well in a job.

Sometimes I read articles that are unwelcome, I sigh, but I let it go and move on. This pernicious utterance is one such lamentable article. Would you give medication to/stick needles in a woman who's just walked off the street?

She writes that she said, "But this is an emergency." There seems to be little unmet clinical needs that are urgent/immediate that need attention. Oh I'm not unsympathetic, I'm also mindful that health is a state of physical, social and mental wellbeing. Getting to work and crack on with global journalism is important to her. What piques me is her contention that NHS resources should be deployed to assuage her inconvenience, rather than prioritising resources according to clinical need. If both can be done (and often they can) then you can generate a responsive, patient centred service that meets clinical needs well. But to strop 'cause a GP you're not registered with won't instantly attend to non-urgent care aggrieves me, it's perhaps a desired expectation but it simply not reasonable to demand this.

For her to then generalise this and contend in her headline, "The caring professions? They just don't seem to care at all," well that's just provocative and vexatious. She didn't get what she wanted and is having a strop, unwelcome though this is I shan't lose sleep over this since medical care wasn't poor, it simply was her organisation was and her expectations were unreasonable.

Professor Sir Bruce Keogh, on the other hand, has worried me more. I've been in a couple of conferences with him and each time he's spoken of innovation and quality and laudable evolution of NHS services, but the medical role in this has been scant. By scant, I mean absent. As the Medical Director for the NHS, this dismays me.

The GMC revalidation plans will have massive impact on medical workforce. CQUINS, QUIPP, CRES, SHA Clinical Pathways and Foundation Trusts all impact on us a lot already, the amount of data collection and form filling is vast. I was incredulous to find the computer entry on seeing a patient is now 3 hours in our Trust, it takes one hour to see a patient. We spend three times as long doing form filling as clinical care. That's all patient contact stuff, that's excluding meetings and policy generation and supporting activities. The NHS informatics systems are not supporting clinical care, they're dominating. Did nurses become nurses to spend an hour seeing a patient then a whole afternoon tippity tapping away at a computer? And they say it's my patients who are mad . . .

Then we've NICE guidance, DOH guidance, Royal College guidance, Trust strategies and policies and protocols and standard operating procedures, Monitor, CQC standards, NHS LA standards and we've to evidence we're compliant with such.

Now our local commissioning consortia wants data on what we do (not activity data, which we already give the PCT each month, but new data on what outcomes we achieve, too). The APC and Medicines Management Committee want data on pharmacological interventions, in great detail. Who gets the drugs, who doesn't, how are patients assessed, how is consent considered, what reviews are in place, how is local Shared Care used, can we demonstrate adherence to care pathways.

So many sources add so much administrative procedural activity to our day. For really rather dubious benefit, much of the time. It's planned that the GMC revalidation will need doctors to evidence their outcomes, mapped on to the 12 Good Medical Practice domains. Their outcomes. Not the team's, or Trust's or GP Surgery's performance/outcomes, but the individual doctor's practice. Needless to say, we don't currently collect data on an individual doctor's performance and outcomes in all 12 domains. We do it, but we look at teams and systems.

The NHS managment costs have escalated stratospherically from about 5% to about 25% with more managers generating more management activity which necessitates more infrastructure and support, so it's a self perpetuating beast that grows and grows. A bit like a neoplasm.

What I'd hoped for from our NHS Medical Director was a bit of sanity, common sense, perspective. A bit of hope that some of the 10 helpful factors I linked to previously of Little hassles, Perception of fair pay, Achievement, Feedback, Complexity and variety, Control, Organisational support, Work-home overflow, Honeymoons and hangovers and being Easily pleased could have been touched on.

More, when talking of quality and innovation and modernisation and change, I wanted to hear that we'd be liberated with greater freedom and less constraint, we'd not be on our knees with yet more process.

Ho hum.

Cured

2011-07-31T11:48:00.002+01:00

Picture an elderly gentleman, living on his own, in his own flat, for 10 years.

He's been a recluse, family bringing him all his groceries, the dentist visiting him there, he's literally not been out of the property for a decade. He had lived in gloom (the curtains always had to be closed). Then his GP (who's not been able to see him for years) refers him to me, worried he might have dementia since he's not functioning and he's become paranoid and feels the man above him is wafting smoke at him, he's being watched by people, neighbours try and set him on fire, they're tampering with his water. He now feels afraid in his own home.

He agrees to stay with family, crossing his doorway for the first time in so many years. In their home he's no better. Pictures talk to him. The pets are telepathic. The family are variously helping him, or poisoning him, so he lashes out with a walking stick.

He was unwell. He needed an antipsychotic to make him better. This was done. He recovered. He's now relaxed, happy, sociable and active. He's no longer housebound, he goes to shops and the seaside with family. He was going to go back to his flat but he's such a great sense of humour and so fun and so good with the grandchildren the family have moved him permanently into their home, which he's delighted about.

He wasn't acutely paranoid. He's been unwell for at least a decade. He's been appropriately referred, treated and most of all supported by family, and now he's well. Cured. From housebound and antisocial and afraid, sitting in the gloom, he's now happy and well. He doesn't have dementia. He's had no acute illness at all. He's simply been mentally unwell for over a decade and now he's had the combination of care he needed to help him. He's cured. It's not often I get to say that.

Patient Safety

2011-07-23T21:02:00.004+01:00

We have been told (by the General Medical Council) how doctors' revalidation will improve patient safety, back in October 2010.

The sagely Jobbing Doctor muses over whether nurses' revalidation/governance will tighten up, querying what the fallout will be, here.

It truly isn't a cynical comment, it's simply an observation, that I really can't see how revalidation will make any difference to patient safety. Post-Shipman we've had rigorous annual appraisals, taking literally days to do each time. And Consultant peers looking at our cases for Case Based Discussions. And Peer Groups (which should have happened anyway) actually happening, looking at our learning objectives and what we're doing/what we've done. I really can't say patient safety's any different.

Realistically, how would you spot someone like Shipman? We frequently have very different outcomes with different clinicians. A real example from my training : one surgeon wants low mortality rates and only operates on those who will have good outcomes, leaving most to no active treatment/palliative care, so those with moderately advanced cancer are denied surgery and go on to die. But those he operates on do very well and his perioperative death rate was incredibly low, since he only operated on those with early cancers and decent health. Another surgeon would try his hand at even the most desparate cases, figuring that death was inevitable and pretty immediate if he didn't. Many (indeed most) of his patients did very well, but some of course died soon after surgery. His perisurgical death rate was stratospherically higher. But understandaly so. He was still the better surgeon (and arguably the better clinician). Mortality rates alone are just numbers, we need context and understanding of the patient population, the interventions, others involved in care, comparative data with others, understanding of norms and bell curves and variability, it's not simple to speak with a doctor and dichotomously allocate them in to a "safe" box or "murdering" box.

What it boils down to is, usually, over a coffee, hoping to trip up the bad apples through slipping in a question such as, "Well Bob that about covers things. Oh, by the way, d'you have any urges or are you planning on murdering large cohorts of your patient population, within the next year?"

It's as good as governance systems would seem to be . . .

Cash

2011-07-21T19:43:00.003+01:00

I've finally accepted the truth of it. Personalised Budgets were constructed with willfully malign glee and, clearly, are naught but the machinations of the devil, made real.

I can not begin to rant over the hideous, hideous consequences 'pon vulnerable folk with dementia that the change to Personalised Budgets has inflicted.

Access to care is now beyond grim.

General Practice

2011-06-27T19:55:00.004+01:00

I was out at a local Chinese restaurant with Mrs Shrink, after a fatality within the oven in our kitchen wrote off a nutitious evening meal, 'less your idea of nutritious involves burnt unidentifiable charcoal clumps.

Out we went. We ordered lots of nibbly things. Very nice they were, too.

The owner kept looking at me. I couldn't think why. He came over to thank me for treating his daughter, in the 1990's sometime, when I was working out in GP land. Apparently I'd diagnosed her skin condition correctly as eczema, I'd given her the right creams and oils and she'd been cured.

He remembered that. He remembered me and what I'd done for his child. Patients do that, with GPs. The current NHS changes invite discourse on what GPs do that's important, what GPs do that's delegable, what GPs do that can be displaced to other services. This contact stirred thoughts that, frankly, that's all missing the point. The gentleman approached me 2 decades on to offer his gratitude because that consultation and care within General Practice had rich meaning to him. It mattered. And that's the bottom line . . . what GPs do makes a difference to peoples' lives, is valued and deeply meaningful.

Suicide

2011-06-23T21:17:00.003+01:00

Back from holiday and there's always mountains of stuff to sort. Busy busy busy. But the nuisances and inconveniences pale against that adversity that some patients endure. A number of patients presented with different backgrounds causing the same presentation and experience of wishing to die in an active intentional elective manner. Indulge me in merging details of several patients into one vignette.

A patient's got severe COPD and is breathless just sitting around doing nothing. He's got lungs full of coal dust. He's got knackered joints all over, he struggles to mobilise at all now. He's scalded himself, dropping cups of tea on himself through arthritic and somewhat numb hands (his GP reckons past machine use has caused vibration white finger). He's long standing angina, blood pressure and mild heart failure, he's getting older and renal function's starting to decline too but a recent diagnosis of Parkinson's Disease clinched it.

He described how he reckoned he'll get iller, frailer, more dependant, physically and mentally deteriorate and explained he'll die, "buggered, a cabbage." Those were his words. Grim. He'd been a proud man, proud of his working class roots and life, grafting to earn everything and asking nothing from anybody. When he came into hospital he'd not even allowed his family to look after his dog, he asks nothing and puts nobody out. Except inadvertently a social worker, who sorted kennels.

He feels it's not right for him to lose his dignity and independance, he's wishing to end it all before it comes to that. He's not awfully cheerful but he's not clinically depressed. Specifically, he's not mentally disordered (within the meaning of the MHA 1983) and he's a capacitated adult (within the meaning of the MCA 2005). His psychological wellbeing's not cheery, but there's no frank psychiatric condition to attend to. Mental wellbeing's supported, protective factors are explored, support's considered that may engender more hope and help him endure over the longer term. Or maybe it won't.

Killing himself won't be a happy ending for me. Or for his family. But it may be the ending he wants and needs, in the way and time he chooses. I don't want it to happen, but it's not my choice. I can't have a happy ending every time . . .

Antipsychotics in Dementia

2011-06-01T11:45:00.002+01:00

Dementia is a gruesome disease.

It robs you of your dearest memories, your personality and sense of self, your vocabulary and communication, function and what you can do, and life. Unlike cancer, there's no drug or surgery or intervention that we have which can prolong life/delay death by even one day.

Broadly dementia is said to cause both cognitive problems (changes in memory and thinking) and non-cognitive problems (behavioural and psychological symptoms of dementia, BPSD).

Cognitive changes can be managed, fairly successfully, most of the time. Non-drug strategies (practical support, carer interactions and psychological interventions) make a huge difference. I'm not amazingly sold on Cognitive Stimulation Therapy as the bees knees (that NICE advocate in their clinical guideline CG 42), but a host of simple practical suggestions can help non-demented and demented folk alike, like these. Acetylcholinesterase inhibitors have significant benefits to most folk with Alzheimer's Disease (and related dementias) most of the time. We can't stop cognitive change over time, but we can manage the symptoms of it and the impact of it, fairly well, most of the time.

What's much more problematic is managing the non-cognitive BPSD part. Wandering without purpose day and night, mood changes and frustrations with anxiety or utter unconsolable despair, shrieking and screaming in public, disinhibition trying to kiss strangers and masterbating in public, suspicion of partners/carers with consequent hostility and violence. Much harder to manage than cognitive changes such as forgetting a hairdresser's appointment.

Our weekly carers' support group rarely focuses on cognitive problems, mostly it's BPSD that takes carers to their knees, it's BPSD that they need help managing. Without the intensity of the BPSD they miraculously could (and usually do) cope well in truly dismal circumstances.

Delusions, with paranoid persecutory thoughts, mood disturbance and seemingly irrational beliefs, how can these be managed?

In America the FDA have said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

This can be harsh.

You can have psychosis, this can torment the patient and torment the carer, you've antipsychotics to treat the psychosis but you don't. Kind of galls me, that.

The reasoning behind the FDA's reticence to entertain antipsychotic medication in dementia care is sound. It's not homeopathy, it's proper medicine that has proper benefits but also proper risks/side effects (like ramping up risks of a stroke in the next year by 2%). The medications can cause significant harm.

Originally work was mostly focussed on risperidone and olanzapine since there was sufficient research to evidence consequences of use in dementia care (both good and bad), with such medication evidencing great benefit as well as great risk. Subsequent research shows older adults in care homes experience similar risk from which ever antipsychotic drug you use. They all have side effects and can cause harm, it's just some are more likely to cause a heart attack, others more likely a stroke, but the over all risks are pretty comparable.

Knowing that the medication has a modest risk:benefit ratio and can cause significant harm, such medications need to be carefully considered and used judiciuously. Careful consideration of what the issue being treated is, what the target symptoms are, what the level of symptom burden is before treatment, what it is after introducing medication and is there objective gain through the medication's use? The time necessary and sophistication of assessment, reasoning/rational prescribing practice, carer input/management of frequently incapacitated adults (with respect to the treatment decision and valid consent), initiation, titration and evaluation of medication is usually outwith the scope of Primary Care or acute hospitals and sits better within mental health services for older people.

With that in mind, and seeing the grim consequences for patients and carers of not treating BPSD and dementia related psychosis, I'm increasingly aligning with this view, ". . . that antipsychotics may be justified using a palliative model."

Evidence Based Medicine (EBM) informs the discussion but to then elect to use antipsychotic medication, for some patients, some of the time, that somehow feels much more humane.

Horse Riding

2011-05-25T19:35:00.005+01:00

I've had a number of folk who I've seen who ride horses. That wasn't the reason for referral to my door, it's a benign enough past time and not a behaviour that generally merits treatment. Although I recall an A&E Consultant lecturing on how there were more accidents per mile when horse riding than when motor racing. Her point of contention was that horses were more perilous than Formula One racing and children/young adults jaunting along on a hack was oft times seen in far too cavalier a manner.

There're some reasons p'raps to support a ride in the great outdoors. Leave the urban sprawl and, where I work, we're blessed by verdent landscapes pretty much on our doorstep. Getting out and about can be therapeutic.

Kaplan's work in 1995 (The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169-182) was progressed in 2005, with consideration of such restorative environments. This has been advanced in 2008 with exploration of natural versus urban environments and consequences of this upon cognition.

Being outdoors and exposed to nature seems to be good for our brains.

The evidence of exercise on cognition and neurogenesis is compelling. Growing new brain cells as we get older, what's not to like?! So I should enthuse over folk striding out to be at one with nature.

I'm contracted to do really rather varied work. Unfortunately a number of folk I've worked with have had significant riding accidents. One teenager smashed up her pelvis spectacularly, changing overnight her opportunities and possible futures, as mobility and fertility are eclipsed in a blink. A number of back injuries, necessitating referral on for surgical intervention. Large numbers of exacerbation of existing painful backs. I fear the A&E Consultant had the truth of it, horses are not without their risks.

What's been surprising is the role of psychological therapy, physiotherapy and pharmacotherapy when combined. Looking at acceptance (and mindfulness, with mostly a CBT model) whilst also optimising function, looking at nociceptive/neuropathic analgesics and attending to mood disorder has yielded pretty good outcomes. Well, both evidenced functional outcomes and patient questionnaires post discharge suggest outcomes are good, which is heartening.

Through this, duloxetine seems to have been helpful. It's licensed for the treatment of diabetic neuropathy in the UK, and fibromyalgia in the USA, so is a reasonable treatment for pain. It's also licensed for the management of major depressive disorder and generalised anxiety disorder. Depression is a straight 60mg dose, so no titration or adjustments, meaning you know you're on the perfect dose from day one. Neuropathy may need titration from 60mg to 120mg, so is simple to manage too. Treating low mood, anxiety and pain, with a once a day drug, with just 2 strengths of dose so it's straightforward to get patients on the optimal dose, I guess it's unsurprising we're seeing decent outcomes. It's not miraculous. Often it doesn't work. But for some folk, some of the time, it's really been a rather helpful adjunct to their care.

Improvement

2011-05-23T15:52:00.003+01:00

I've a gentleman who lived in a flat, alone, for a decade. What was curious was that he never left it. His son did all his shopping for him. His GP and dentist managed him through home visits. He'd elected to be housebound. We never knew him, then.

He moved in with his son because his son couldn't keep visiting all the time. He was was confused. He thought he had paid tens of thousands for a penthouse to be built for him. He heard spirits talking to him, from animals. He spoke to photographs of the children, because they spoke with him. Voices told him bad things. He felt worried, suspicious, afraid, insecure. He took no medication because his GP, who he saw in the living room every day, told him not to. He ate little since he knew his son was poisoning his food. He never bathed because the water was tainted and would hurt his skin, transforming it. His son thought all this was odd, asked for help, we became involved.

His son and a community psychiatric nurse invested endless hours with him. He was started on olanzapine velotabs which he took haphazardly, but then reliably. 5mg initially, then 10mg once a day. He got better.

He's now well, happy, laughing and engaged with his son and family. He's been to the shops, to town, to appointments with his son.

From being tormented and housebound to being happy and active.

A good result.

Shambling

2011-05-20T19:58:00.004+01:00

I was reading through a lot of guidance today that's been published by the National Institute of Health and Clinical Excellence (NICE) since I've been drawn into doing some work on quality standards and care pathways and stuff. It's not an organisation directly controlled by the government, but it's funded by it. Sort of independent, but sort of State organised.

I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.

When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.

Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.

It's quite a formal organisation. Proper. Seemly.

In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.

Geeeenius!

Confusion

2011-05-18T15:52:00.002+01:00

I saw a lady last year, referred to me for assessment and management of her dementia. She was confused, her Addenbrookes Cognitive Examination (ACE-R) was poor, her functional level had declined (with constricted activities of daily living).

Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.

Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.

A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.

History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.

It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!

NHS Review

2011-05-15T18:10:00.002+01:00

I was reading the weekend papers with Mrs Shrink. Whilst she was musing over a lass who's gone all gaga, I was taken by the front page news, "NHS review chief: health reforms are unworkable."

Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.

The final report's due out at the end of the month.

The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .

. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.

Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.

Hurrah!

Leave

2011-05-03T22:51:00.003+01:00

I'm back after a bit of a holiday. Lots of people have enjoyed a break through the glorious sunshine we've been enjoying. I'm mindful when emails bounced back with "Out of office" messages, or when trying to sort out meetings, just how many people are away at the moment.

With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.

At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.

What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.

What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.

I wonder how many people noticed . . .

Complementary Medicine

2011-04-19T18:18:00.003+01:00

I can't recall who linked this YouTube video, it wasn't found by me. I chanced upon it on a blog which, to my shame, I can't recall. My wife thinks I read too many blogs. Meh.

Anyway, watch this :

"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."

Brilliant.

Art. Allegedly.

2011-04-18T20:04:00.007+01:00

My wife persuaded me to see some art she was interested in. An effort for the poor lass, since my interest in culture seldom exceeds the remits of what's grown within a petri dish.

I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.

A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.

Apologies for the images, they looked a lot sharper on my mobile 'phone!

Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.

Diagnostic Formulation

2011-04-12T20:16:00.005+01:00

The acute medical ward referred a patient to me, for urgent assessment.

The patient had been perfectly well until 2 weeks ago when she experienced left sided weakness and slurred speech that she and her husband have been very worried about. She'd become confused. The medical team referred her to me "with dementia" to sort it all out.

She's had a stroke.

The history, clinical course, clinical examination and structural brain imaging yield a diagnosis of a stroke.

She was perfectly well a fortnight ago. She does not have dementia.

The medical team (well to be fair, a junior doctor on the medical team) assert otherwise. She thinks I'm being unhelpful, not curing this woman or taking over her care "to manage her dementia." I explain she's not got dementia. The junior doctor continues to assert that she does.

I'd love to do this :

Care Pathways

2011-04-11T11:45:00.004+01:00

I've been throwing in my 2p worth to discussions 'bout how care pathways could be constructed. I was invited on whim. Folk thought I may know what was happening, what best practice guidance is and what could work. All that is true. They also thought that the discussions could then generate a care pathway so patients could receive services according to their oft repeated mantra of, "the right care, in the right place, at the right time, by the right person."

Mmmm.

One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.

Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.

The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.

Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.

Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.

Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.

Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.

The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.

Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .

Crisis Team

2011-04-10T21:21:00.003+01:00

I've had to work with a Crisis Team nurse, who was not Charlie Fairhead.

She was, in point of fact, a singularly unhelpful soul who would neither see a patient, nor give them advice, nor arrange any support what so ever.

Time for me to take deep breaths. Count to 10. Self medicate with alcohol, stat.

Drugs

2011-03-19T09:50:00.004Z

I've been seeing a patient for some time, withdrawing their benzodiazepines with them. Mentally well all his life, the patient had felt anxious and when he retired, then widowed, had declined talking therapies and sought medication to help. His GP is a sensible soul but over time and by accident and through locums whilst on holiday ended up with a patient being prescribed and taking very hefty doses of two benzodiazepines and wanting more.

The drugs weren't working any more. On mornings and after coming down off the drugs' peak effects, he was restless and irritable and more anxious. He'd started falling. Alcohol intake was modest (a couple glasses of wine a week) with normal liver function.

I had never seen the patient before being involved this time. I had not started the benzodiazepines. Our PCT has commissioned neither drug and alcohol services nor my corner to manage iatrogenic addiction (ie the doctor caused it), feeling if one doctor's caused dependence through their prescribing, they need to sort it out. I'm no expert at substance misuse at all. The patient had no wish to see me to reduce benzodiazepines, quite the opposite, he wanted more.

I've massive sympathy for the patient and for the GP. Both were trying to do their best at the original point in time, managing the few poor choices they felt were laid out before them. The GP wrote an excellent detailed helpful referral letter to me, asking if I could sort it all out. She's a good GP. She's helpful. We both collude in working to do what's best for her patients despite the local policies and care pathways and frameworks and shared care arrangements; she's sensible in ignorning most of the bureaucracy and instead we just crack on with what's best. I might prescribe when it should sit within her budget. She might prescribe when it hasn't been the exact blah months needed for a shared care to start. She's a good clinician and she works hard, very hard, to support her patients as best she can.

When she wrote saying she'd messed up and got herself into a tricky position, she knew I wasn't a drug and alcohol expert, but she felt stuck and uneasy, well as said within Jerry Maguire she had me at "hello" and I couldn't leave her to flounder.

The patient loves his GP, thinks his GP is ace. I've been involved for many months and soon will be discharging the patient, benzodiazepine free. The patient suffers my visits and has a less than favourable view of what I've done. He understands why, but it's not what he wanted. But as he 'fesses up, he was addicted. I won't need to see him again, hopefully. His GP hopefully will be seeing him for many years.

Even if it's not my mess, not my work, not my problem, sometimes it's better for the GP to be the good guy and me to be the bad guy.

I wonder if the new NHS commissioning and structures will facilitate helpful working arrangement . . .

Blame

2011-03-14T20:24:00.001Z

A banker, a Daily Mail reader and a Benefit Claimant are sat round a table, and there are 12 biscuits.

The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."

2011-03-09T17:46:00.003Z

Policy is a direction and framework we consider (and should strongly consider) in deciding our clinical practice.

But policy supports clinical practice. Clinical practice doesn't support policy. We do what's right, we don't do what's written down. That's why qualified staff take clinical decisions instead of unqualified staff delivering what the policy says with no decison making at all.

Pyjamas in Bananas has pointed out the flaws of trying to support and use policy documents.

Part of me, rather impishly, wonders how much I should follow policy guidance. NICE guidance should apply to about 3/4 of the population the guidance is generated for. The routine, standard care should typically be in accord with NICE guidance, but for 1/4 of patients specific bespoke custom care is likely to be more appropriate.

As a specialist within Secondary Care services, I'm seeing a patient population that almost by definition don't fit typical routine care pathways that GP and non-medical mental health colleagues progress. When something's unusual or complex, that's typically when it's brought to my door.

On that basis, if NICE guidance applies to 75% of patients, and over 75% are managed in Primary Care or within NICE guidance by nurse lead services in Secondary Care, I'm seeing a portion of all the remaining 25% who sit outside NICE guidance.

Shouldn't 100% of my workload by complex/atypical stuff meaning I'm never adhering to standard policy or guidance or protocol? As I said, it's an impish thought, but I have shared with my Chief Exec that I fear I'm far too compliant with guidance and need to be more maveric and eschew such constraints on my clinical freedom, nigh on 100% of the time. Food for thought . . .

Case Based Discussion

2011-03-03T08:05:00.005Z

We tell patients the truth. How much is valid consent, how much is coercion?

This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.

One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.

The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.

Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.

Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?

I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.

Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.

I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.

A pleasant surprise.

Lifestyle Advice

2011-02-26T00:04:00.001Z

Kudos to Dr Zorro for an article that's a bit hard to swallow.

Advice

2011-02-25T16:25:00.002Z

One of my patients with dementia has a son in a low secure forensic unit. I met the son to share news on how his mother's faring, wanting to maintain the family involvement in mum's care now she's becoming increasingly confused. The son's Consultant Psychiatrist felt I should share the news episodically (rather than other family members talking with him) so it could be done sensitively without de-stabilising the son's mental wellbeing.

I've mixed views on that.

Okay, I'm used to breaking bad news. Telling someone they have dementia, and what that will do to them, is hardly a cheery act. I share news and discussion and seek input into formulation and decision making from patients and families every day. Speaking with a son about his monther's deterioration, about current options, about future considerations, without causing excessive upset, that I'm happy to do.

But don't his brothers and sister know him far better, aren't they just as capable/more capable to talk with him about their mother and from the options currently considered to then collectively form a coherent family concensus on suggestions of how care could be?

Anyway, I talk with the family and all's affably agreed, on this occasion, with fairly clear views of what's the best way medication options and residence and care package for their mother.

Whilst talking this through with the son, we discussed antipsychotic medication and how this had been tried but was unhelpful in his mother's care, so had been withdrawn. The side effects were significant, the benefit slight, so the decision was simple enough. The son, though, was ineterested. He was on similar medication, being given antipsychotic medication daily, which he felt was causing adverse side effects.

He wanted to discuss his medication, his experiences of how it felt, his side effects, his options for other drugs. I'm not his psychiatrist, I really can't do that. But I can't just ignore him. I ended up sharing my views on what some people find the benefits to be, what side effects could be related to medication, but ultimately it's between him and his own psychiatrist to make sense of how medication supports his care. I wrote to his Consultant Psychiatrist about what we'd discussed (both of his family and incidentally the concerns he'd disclosed on his medication) so hopefully everyone's informed on all issues.

Although there to support his mother's care, it seems fair for a Consultant Psychiatrist not to direct care/give an opinion but to proffer a little information, when asked to do so. Odd that boundaries of care are so explicit that it feels a little racy to do so!

Covert Medication

2011-02-16T12:59:00.002Z

Do we use this enough?

At the moment I've no patients who are receiving medication covertly. I have lots of patients who have a mental disorder, within the meaning of the ammended Mental Health Act 1983. I have lots of patients who have an impairment of, or a disturbance in the functioning of, the mind or brain, as set out within section 2(1) of the Mental Capacity Act 2005. In fact all of my patient can fit in to one of the categories of mental disorder/impairment/disturbance of mind/brain.

It was put to me that since all my patients are mentally unwell, if they stop taking medication, can't they be made to take medication? Well no, no they all can't. But it got me thinking that yes, some of the could, but I don't force this. This led to me being chided for not treating vulnerable patients who couldn't make valid choices on treatment.

If you're in a care home or hospital, say, and you have dementia, you probably are fine to make valid decisions on medication you're offered/continue to take. But you might struggle to make valid decisions on medication as dementia progresses or when you have a UTI, chest infection, constipation, pain, dehydration or other cause for acute confusion that makes your thinking worse.

What happens then?

Usually medication's offered to you, even though you're confused and can't give/withhold valid consent on the use of medication. If you accept it, you keep receiving it. If you refuse it, you're allowed to and it's documented as declined and you don't get medication. So whether you receive medication or not isn't based on clinical decision making, it's based on how stroppy you seem and how much nurses/care assistants respond to this. In acute wards it's also about pressures on qualified nurses' time which is now so pressured that even if staff wanted to sit down and explain/support a confused patient with medication, they don't have the 20 to 30 minutes that might take.

The pharmacist and manager givig me grief over this were reckoning that this arbitary giving/not giving medication on how compliant/stroppy a patient is seen to be isn't good. It should be on clinical evidence. If someone is confused and can't give (or withhold) valid consent, they're managed under the Mental Capacity Act 2005 framework and medication can be given when this is in their best interests. Rather than not giving it, the least restrictive means should be used. Instead of section 3 and depot antipsychotic given under Part IV of the MHA 1983, wouldn't orodispersible olanzapine in their tea be a much better option?

I rarely advocate for covert medication to be used. Maybe I'm wrong.

Transition

2011-02-01T12:23:00.003Z

I work with a lot of people.

Or more accurately, as I'm oft times reminded, I meet with a lot of people and they do a lot of work.

One area of work is prescribing. I'm a doctor, doctors have expertise in this area. Psychiatric drugs are contentious, I'm a psychiatrist so can inform on reasoned, evidence based rational prescribing practice. This means I'm often asked to attend Local Authority or PCT or APC meetings to talk through how medication should/shouldn't be used.

This has contributed to significant improvements.

Patients can access any class of drug without constraints placed upon prescribers, rather than being totally protocol driven our patients can access drugs at any stage of illness (so we can freely prescribe outwith NICE guidance), our use of contentious drugs (such as antipsychotics in dementia) is audited and is seen to be good, use of medication in care homes has dropped markedly with rich mental health staff input instead, Local Authority has funded use of support workers/day care to reduce carer stress (and reduce medication through staff input as a viable alternative), GPs 'phone me up for advice or drop a short letter with all the details as well as making formal referrals for input.

Over the last few years things have got a lot better in my corner, with much better medicines management.

A recent PCT meeting I was invited to caused concern. The folk advancing all the work to progress sensible care were no longer in post, within either the Local Authority or the PCT. With the writing on the wall for PCTs, everyone's leaving, sharpish. With Local Authority not able to cut front line Assessment Officers/Social Workers unless they're not needed (and they are!) it's managers/decision makers who're being lost.

But in this state of flux, work that's been gently but purposefully progressing for the last few years now comes to a hiatus.

In this brave new world of austerity and GP consortia, will it all get better, once again?

Anxiety

2011-01-27T14:41:00.002Z

We've had this and this paper look at antidepressant medication use in mild depression.

Yesterday we had updated guidance on the use of medication in the management of anxiety. NICE guidance now is that, "GPs should not offer benzodiazepines or antipsychotics to patients presenting with generalised anxiety disorder (GAD)," the one page summary is here.

Will that mean their drugs budget comes over to me, so I can treat them then? :P

Overheard

2011-01-25T13:57:00.002Z

A patient has great understanding of other people. She's worked in the hospitality industry so has worked with large numbers of people all her life. She's often been a kindly ear to those with troubled needs.

Recently she's needed a bit of help.

On discussing how she's an incredibly resourceful soul with plenty of ideas for others' problems, so has the tools in her toolbox to manage with a helpful steer, she smirked at me and told me, "It's easier to look into a goldfish bowl than to be in one."

Insight and genius, all in one.

Depression's Not Common

2011-01-13T11:11:00.003Z

Clinical depression's not common, to my mind.

Unhappiness is very common. Unhappiness is an emotion, not an illness.

A little bit of unhappiness, or a lot of it, is a varying intensity of one normal human emotion, so even intense unhappiness is but part of life's rich tapestry and unwelcome though it may be, it's not an illness or a disorder.

Although I'm not a slave to diagnostic checklists, they certainly have a place and shape my thinking. On discussing someone's experiences the details, the nuance, the context, they matter. On considering someone's mental state, eliciting psychopathology and ascribing significance to it/formulating it in other ways and discounting it matters. History taking and mental state examination are clinical activites, not check lists and tick boxes, so there's always room for inclusion of folk and diagnosis of depression for people who don't present with a perfect list for the diagnosis to be textbook.

With this caveat that diagnosis is clinical, contextual and will at times vary from diagnostic lists, I'd concede that most of the time diagnosis falls within accepted frameworks. My training and practice is using the World Health Organisation's International Classification of Diseases, 10th Revision (ICD-10).

It's very useful. It's not just determining what a diagnosis is, it also determines what a diagnosis isn't. For example, "alcoholic" and "alcoholism" aren't in there so aren't and can never be formal diagnostic labels I make. Using the ICD-10 framework engenders a more transparent, consistent, reasoned process to formulation and diagnosis which I find helpful.

Low mood is very very common. Endogenous functional clinical depression arising through abnormal serotin/neurochemistry balance, much less so.

Does this distinction matter?

People with clinical depression have abnormal brain chemistry, this causes illness which has physical and psychological symptoms and signs. By inference, the chemical pathology causing this upset can benefit from chemical solutions (antidepressants). Clinical practice illustrates this, clinically depressed patients do get better on antidepressants.

People may also have low mood because their situation's ghastly and gets them down. If you're down because you're lonely or hungry or in severe chronic pain or you're dying or your loved one's dying or you're abused then is your intense unhappiness clinical depression, caused by chemical illness, so will happiness come in a tablet? Unfortunately not.

People may have low mood through organic syndromes. Stroke damage within the base of the brain or poor blood supply causing ischaemic damage within the diencephalon damages the limbic system, the mood centre in the brain. I've patients who have had cheery dispositions, had stroke damage, are depressed and it's through structural organic brain damage caused by the stroke. Antidepressants have little place.

If unhappiness is sometimes situational and sometimes through structural brain changes, then how do we pick up those unhappy folk who have clinical depression? This matters since such folk with severe clinical depression usually profit from antidepressant drug therapy.

What are the ICD-10 diagnostic criteria?

You need to be depressed for 2 weeks. Being depressed for a few days, then being okay, isn't enough.

You need to be depressed in most situations, most of the time. If you're low for the whole day, but you're okay when your kids visit and take you out to the pub for Sunday lunch, that's not clinical depression. Neurochemistry doesn't rapidly shift as you change from one room to another, so shifting from alone in your house to company in a pub suggests a more reactive/situational cause for unhappiness, or loneliness, rather than being consistent with the chemical illness of clinical depression.

Okay, you've someone with low mood, they've had low mood for 2 weeks, their mood's persistent and pervasive, isn't that just them being unhappy? Yes, it is. To be clinical depression you need to have a number of features :
· Depressed mood that is definitely abnormal for the person, present most of the day, almost every day, largely uninfluenced by circumstances, sustained for at least 2 weeks
· Loss of interest or pleasure in activities
· Decreased energy or increased fatiguability
· Loss of confidence or self esteem
· Unreasonable feelings of self-reproach or excessive and inappropriate guilt
· Recurrent thoughts of death or suicide, or suicidal behaviour
· Diminished ability to think or concentrate
· Changes in psychomotor activity (with agitation or retardation)
· Sleep disturbance
· Change in appetite (decrease or increase) with corresponding weight change

How many of the features correlates with severity :

Mild depressive episode :
"Two or three symptoms are usually present. The patient is usually distressed by these but will probably be able to continue most activities."

Moderate depressive episode :
"Four or more symptoms are usually present. The patient is likely to have great difficulty in continuing with ordinary activities."

Severe depressive episode :
"Eight or more symptoms must be present. Symptoms are marked and distressing, suicidal thoughts and acts are common and a number of ‘somatic’ symptoms are usually present."

The additional somatic symptoms that usually are present would consist of :
· Loss of interest or pleasure in activities
· Reduced emotional response
· Waking in the morning 2 or more hours before the usual time
· Depressed mood is worse in the morning
· Objective evidence of psychomotor retardation or agitation (reported/remarked on by another person)
· Marked loss of appetite
· Weight loss (5% or more of body weight in the last month)
Marked loss of libido

This is important, I believe, because if we diagnose clinical depression when it isn't then people get the wrong treatment. We know from last year's JAMA paper that antidepressants work no better than placebo in mild, moderate or severe depression and only are shown to work better than placebo in very severe depression. We know from a paper in this month's British Journal of Psychiatry that, still, antidepressants don't work in mild depression. Okay okay, studies show us averages and trends, individual patients may respond brilliantly to antidepressants despite have mild or moderate depression, but on average response is the same with antidepressant or placebo.

If we need 2, 4 or 8 core features of depression, and typically there're also some of the 7 somatic features of depression, to my mind that's getting to a much more specific (and smaller) group than all people who have intense low mood.

It's also a harder way to work. If we equate intense low mood with depression, so refer for psychological therapy and start an antidepressant, then everything's done and is easy. If we're sleuthing out who has a depression that's reactive/situational, who has a depression that's organic/structural and who has a depression that's endogenous/chemical, that's a more involved assessment. Worse, if only the last group generally profit from an antidepressant, we're then having to help people with ghastly low mood, suicidality and feelings of not coping through support that doesn't typically include antidepressants. We have to do more than just offer a prescription and refer to a psytchologist.

Harder work, both in assessment and interventions, but to my mind increasingly it's looking untenable to work in any other way.

Being Left Alone

2011-01-12T15:51:00.003Z

I work with a number of senior, experienced specialist practitioners who, in addition to the perk of getting to pay the NMC a little more each year, also are non-medical prescribers.

Like every Trust, we have a large number of policies, strategies, frameworks, pathways and protocols that are seen as telling staff what to do. Who likes this? I know of no clinical colleague who embraces such policy documentation with joy and enthusiasm. Some colleagues vociferously oppose it as curtailing clinical freedom and, in maveric piques, go against it all.

People don't generally like being told what to do, how to do it, when to do it and what format they have to use.

There's no policy documentation on how non-medical prescribers have to document their prescribing activity. As part of medicines management within our corner, I reviewed it. All of it. There was rather a lot of it. They'd extensive documentation of their Continuing Professional Development, tidily presented in a folder, with the activity and supervision and time taken. They'd evidenced letters to the GP and referrer for all prescriptions, with copies of all of these. They'd detailed the discussions before prescribing, with every case I picked up specifically detailing what had been discussed between them, the patient/carer and a Consultant Psychiatrist. Letters had details of all prescribing, including the specific prescription number of the script. They'd a photocopy of all prescriptions.

I thought it'd be a lot of work for them. It looked fantastic. It wasn't a lot of work, or time, they'd been incredibly efficiant. They simply detailed a one line record of CPD in their folder as it happened. They succinctly summarised prescribing in a couple paragraphs to the GP for each script. They used the copier in the office to keep a copy of all prescriptions, so it was just a few moments to do that. There was little time invested in to it, yet their audit trail of non-medical prescribing activity wasn't just okay, it was flawless.

It's good to see.

It supports what I believe, so is something that stuck in my mind. If folk are told what to do, it's oft times seen as a nuisance and hassle. Leave a nurse (all the non-medical prescribers were nurses) to just crack on and do it herself, without any direction, without any manager, without any Modern Matron, and they're utterly brilliant at sorting stuff themselves.

Now, if I can just persuade folk to leave clinicians alone more of the time . . .

Quote

2011-01-11T16:54:00.003Z

I took my children to see Megamind recently. Great fun it was, too. One line from it made me laugh out loud at the time then resonated again with me when I saw someone today.

After making a mistake, but both wanting to save face and keep a positive sense of self, Megamind 'apologised' by saying, "You were right. I was . . . less right."

Brilliant :P

Liaison Work

2011-01-08T12:47:00.004Z

Acute hospital wards often stuggle with psychiatric problems. Medical and surgical colleagues frequently refer patients with depression who are miserable but not clincially depressed and are not ill. I used to think it odd, doctors (who all trained in some psychiatry as undergraduates) can't usually suss out if someone's ill or not.

I used to think that colleagues should be able to undertake a decent history, examination, ask about informant/contextual history and put together some sort of formulation. Partly through training, partly through prejudice, partly through not being their core business/not routine, and mostly because working on acute wards is now described as beyond grim, even competent colleagues with a will to do so struggle to make sense of psychiatric dimensions to their medical/surgical patients.

If history, assessment and formulation aren't undertaken in a systematic, thoughtful, involved manner then how can care planning be person centred and be effective? Largely it can't.

This generates more difficulties because the culture forced on clinicians through current pressures precludes better ways of working. Nurses know that is someone is wandering around or shouting or pulling drips out or pushing buttons on other patients' syringe drivers that usually drugs makes it worse.

Of course they do. We have no "anti wandering" or "anti shouting" or "anti fiddling" drugs, those are behaviours they're not illnesses. What's sought is abolishing symptoms, without attending to the primary cause of these presentations.

It's ingrained, though, so nursing staff are disempowered/under resourced in managing one to one patient care, call medical staff since it's unsafe and problematic, medics feel they can't do anything but prescribe. What do they prescribe? Usually they prescribe the drugs that don't work/make it worse. If used correctly, as well as usually doing little beneficial and lots that's harmful, the appropriate use of the drug also needs extensive ECG and blood monitoring that ties up even more nursing time, which could otherwise have been used in direct patient care to manage the behavioural disturbance.

There's a bit of an inconsistency, though. On the one hand the acute hospitals generally want a chemical solution, and nothing else, to manage behavioural disturbance. On the other hand, their care pathways for this are very different from most any other care pathway they'd generate.

The Dobbing Doctor explained his hospital has a "Rapid Tranquillisation Protocol" and asked what drug would be better.

A protocol on the administration of a drug to treat a behaviour. Is there an "Inhaled Breathing Protocol" giving the procedure for nebulised n-saline in obstructive airways disease or RSV/croup and the like? Is there a "Bolus Steroid Protocol" for injection of steroids in COPD? No, there's no "Bolus Steroid" protocol but there is a "Rapid Tranquillisation" protocol. Why? Why have a protocol for one class of drugs, major tranquillisers, but for most every other protocol it's about the disease state/care pathway? They have Stroke Pathways, COPD pathways, MI pathways but no delirium/acute confusional state pathway. Instead there's a drug protocol for "rapid tranquillisation."

This is less than ideal since we know medication has a tiny role to play, so if it's the only role your hospital offers in such patients' care then, frankly, patients aren't going to get the right care. Last September's update on National Dementia Strategy outcomes and Banerjee's Time for Action report reiterate the best practice guidance that non-pharmacological approaches must be tried first.

The reality is, they work.

I work with older adults. All my in-patients are ill, with major mental health problems. Almost all of them have physical comorbidity too, such as infections, contributing to their acute deterioration necessitating hospital in-patient care. Most are pretty elderly and pretty frail. Despite being confused, ill, unsettled and presenting with challenging behaviour, use of medication is modest. My last patient with hypomanic features arising through stroke damage was managed and discharged on no psychiatric medication. I've never used our equivallent of the "Rapid Tranquillisation" policy on any of my in-patients patients, ever.

If the frail, elderly, ill, most mentally and behaviourally challening in-patients can be managed with little/no psychiatric medication, it suggests that less mentally ill patients within acute hospitals also should be manegeable without drugs. Which is what best practice guidance, Royal Colleges, patient advocate groups and DoH reports say.

The crunch, of course, is that the environment and nursing ratios need to be fit for purpose. Nurse Anne reckons, ". . . that years of intense research have shown that the maximum number even the best nurse can take and not make mistakes is 4-6 on a general floor." She described how when things went well, "I worked a late shift on a 25 bed ward and there was 4 of us staff nurses and 2 care assistants for the ward." Our wards do have such staffing levels, with one qualified nurse per 4 to 6 patients, plus support workers, plus ward physio time and OT time and ward social worker time.

Rationally, if they're not psychotic, or having abnormal dopamine excess needing pharmacological treatment, why is an antipsychotic indicated?

The right environment and the right staffing obviates the need for antipsychotic medication, most of the time. I reckon that's one for the Ghost of Christmas Future to sort out . . .

Haloperidol

2011-01-07T18:08:00.003Z

A post from my liaison psychiatry work, with musings on haloperidol. I'm not a huge fan of haloperidol.

It has been used by different countries as a drug of torture. Even in both low and moderate therapeutic doses it can cause akathisia.

But quite apart from being a drug with rather unpleasant side effects, more than unpleasant symptoms it can be quite harmful. In older adults with dementia, use of haloperidol is associated with increased risk of death, ramping up risk over the 10 weeks or so on average it was used for by about 60% to 70%. That's less than ideal.
It also explains how it triples your risks of strokes. Nice.

It's a drug with unpleasant side effect profile, it's dangerous, but what about practicalities of its use? Unfortunately it's a tricky drug to use correctly.

The Summary of Product Characteristics (SPC) reminds us that, "Cases of sudden death have been reported . . ." and that it has significant risks if you've heart problems. By significant risks, it's not that the drug has cautions and careful considerations to weigh up, no, it's that it's contra-indicated and should not be used. When is it explicitly contra-indicated, in black and white? When you have :
- clinically significant cardiac disorders
- recent acute myocardial infarction (heart attack)
- uncompensated heart failure
- arrhythmias treated with class IA and III antiarrhythmic medicinal products
- QTc interval prolongation
- history of ventricular arrhythmia
- history of torsades de pointes
- clinically significant bradycardia
- second or third degree heart block
- uncorrected hypokalaemia

Quite a list with pretty common problems, like heart attacks and heart failure, precluding the use of haloperidol.

If a physician is going to prescribe, what do they need to evidence in their records? The SPC directs that, "The risk-benefit of haloperidol treatment should be fully assessed before treatment is commenced," detailing how, including heart monitoring with 12 lead ECGs.

ECGs "particularly during the initial phase of treatment."
"Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . . during therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed on an individual basis."

"Periodic electrolyte monitoring is recommended, especially for patients taking diuretics, or during intercurrent illness," so older adults on water tablets or who are ill should have electrolyte monitoring, which by definition is pretty much all patients in acute general hospital beds (because they'll have intercurrent illness).

What does this mean? It means you've a drug with significant side effects, significant risks, marked increase in strokes and death, that shouldn't be used in patients with many common cardiac problems, it needs frequent blood monitoring for electrolytes, an ECG before starting and repeating an ECG on changing dose.

Odd, then, that on medical and surgical wards in the acute Trust it's widely used. Used on acute hospital wards, I can't say it's an intervention I'd wish for myself, or for my nearest and dearest . . .

Decision making

2011-01-06T17:48:00.003Z

Towards the end of last year I generated a number of letters purely explaining decision making.

One was to a patient's wife, one to a GP and one to a clinical team on a general hospital's orthopaedic ward.

In all 3 cases the patient had been jointly seen by a CPN and me, investigations done, a diagnosis made, explanations given and appropriate management put in to place. But in all 3 cases there was a desire by another party, not the patient, to have more information. The theme was "why" with a desire to know why management was suggested as it was.

Now in all 3 cases the request for more information was polite and inquistive, rather than a forthright demand for explanations, so I'm more than happy to oblige. Sharing reasoning can only be a good thing. The original assessments and letters were extensive; typed up they were a minimum of 5 pages each. The management plans at the end were explicit and numbered, with from 7 to 11 action points in each case. With so much information, it's no surprise that folk want to know a little more about details of specific bits of this.

The wife sought to know why her husband's dementia medication was being withdrawn. The severity of his dementia, the side effects he was experiencing, the risks he'd shown (with ECG changes and collapses), the changes over time on the medication with no benefit seen by us or his wife, the diagnosis (he came to me on medication for Alzheimer's dementia but clearly has vascular dementia, which kind of accounts for why the drugs haven't worked) made decisions on the use of the medication pretty clear cut. Since he's off it he's fantastically better, his mood's settled/undistraught, his thinking's better with less preoccupation and his presentation's better with more successful acceptance of interventions, support and reassurance from his wife. But on stopping his medication his wife, not unreasonably, worried about this and sought more information. She explained how I'd spent an hour reviewing her husband with her, but only 10 minutes talking about medication. She's right, that's pretty much how time was spent. "Only" 10 minutes on why medication's not helpful is to my mind a reasonable amount of time to spend on sharing reasons and understanding, but a carer's mind is a whirl when a Consultant's questioning and investigating and formulating and changing stuff, so it's no surprise she mulled it over then wanted more information. It was no trouble to write to her, my secretary copying and pasting from the GP letter on file, detailing the 11 factors we'd considered that concluded in withdrawl of medication being appropriate. On subsequent review she's been very happy with it all.

The GP and surgical team both sought to know why his patient wasn't getting antidementia medication. It's a GP I know well and with her patient this had been explained but the patient's husband had turned up to the GP with lots of stuff clipped from papers and printed from the internet. The GP wasn't clear on how it all fitted with the current best practice and whether we'd considered relevant factors. On going through the notes it was clear we had, with over half a dozen specific statements about prescribing decisions in one letter alone and almost a dozen factors specified that influenced decisions on the patient's needs and consequent care planning. I liked this one, it was a chance to share with a colleague the reasoning behind prescribing decisions, the evidence base supporting this and the patient factors that impacted upon this. The GP gained understanding around how developing abnormal heart rhythm impacts on risk of medication causing serious harm. Similarly with the ward team.

I guess that like most clinicians, I favour spending most of my time speaking with patients and improving things with them. But sometimes it's also satisfying to have gentle challenge, stirring thoughts on decision making, to organise a response that articulates the contexts and evidence and findings and formulations and risks and degree of benefits and consequences, then share how these have been weighed up and how conclusions have been made.

All 3 times it was joint work with a CPN and others so the responses had effectively a case conference before responses were generated and this open discussion of how we worked and what we did is healthy for our team, reflecting on how we've worked.

So although I favour clinican contact and wouldn't want to navel gaze all the time, having gentle challenge/inquisitiveness to stir reflection of decision making is welcome and, to my mind, keeps us sharp in looking at how we work.

Blimey!

2010-12-31T15:51:00.007Z

I'm surprised!

The readers of Mental Nurse have voted for favourite mental health blogs and have voted for this as their favourite Psychiatrist's blog.

Given the number of popular psychiatrist blogs, more established ones, more frequently updated ones, newer ones, more evidence based ones and almost all of them look nicer/are better presented, and more popular blogs (with me tumbling through 2010 from number 2 to number 15 now) I'm very surpised (and of course pleased) that folk rated my musings.

So, a big thank you for being so kind!

Now, get on to Mental Nurse and rummage around some really good top quality blogs!

Liaison Psychiatry

2010-12-31T15:01:00.002Z

It's stopped.

Bank Holidays must have something to do with it. I can't really fathom it, since that local acute Trust has a massive pressure on beds and is keen as mustard to move patients on.

Yet despite having hundreds of patients within their hospitals who've dementia, delirium and major mental illness, spread over a number of sites, with difficulty in managing and effecting safe discharge for these patients, I've not been swamped by liaison referrals. They've literally hundereds of patients with mental health problems on their wards. Often they find them very very difficult to manage on the ward and to plan discharge for. What with capacity assessments, Best Interest Meetings, Continuing Care needs there's usually process they want support with, before we even get to advice on clinical care.

With pressure on beds you'd expect there's be squillions of referrals to my door, trying to speed up the assessment, diagnosis, management or discharge planning for these patients.

Over 5 consecutive days I had 0 referrals. Not one. We usually have referrals every day. It's utterly unheard of.

Long 4 day Bank Holiday weekends. My fear is that no routine or important work gets done, only urgent/emergency work's attended to. These patients with physical and mental health needs, within the acute Trust, have unusually had no Liaison Psychiatry input in to their care for almost a week. Junior doctors and on-call staff haven't been considering their mental health needs and referring for specialist input.

Bank Holidays seem dangerous. This surely can't be good for patient care . . .

Mental Capacity Act 2005

2010-12-21T23:59:00.002Z

I'm blessed with fantastic colleagues. It's really the only reason I'm working where I am. The staff really are fantastic.

Colleagues outside of the NHS are more variable in their competence. Some social workers are fantastic. I've a lot of time for social workers, they do a hard job with little meaningful support/team work. One disadvantage of this culture is that social workers are pretty idiosyncratic animals. They all work differently, with sometimes very different attitudes and consequently very different interventions (or lack of interventions).

This variability in social work bemused me . . . shouldn't it be a needs led service? Shouldn't what the patient (erm, client, to them) needs define what activities the social worker undertakes/the content of their care schedule? No, it all falls down to the quirks of the individual social worker (or assessment officer) in my corner, and the attitude/whim/habits they possess. Patients get very different responses and outcomes depending which area team social worker picks up their case.

What's more muddling is their response to change, including legislative changes such as the Mental Capacity Act 2005.

A social worker today said they didn't know it, she hadn't had what she thought was enough training on it, she didn't use it and it was "still new" so it didn't matter. 3 of her colleagues thought similarly. New? Still new?! It was drafted in 2005 and implemented in 2007, we've been using it for years!

Good grief.

But those individuals ignore it, don't do formal capacity assessments or Best Interest meetings/decisions or the like. Instead they refer such nonsense to their Team Leader (who has to do it all) because when she says they have to do it, and it's the law, they just tell her she's, "going off on one, again," and shrug and move on.

I'm not sure we've the ideal system, locally, for embedding current best practice within Local Authority social work teams . . .

Complicated

2010-11-09T12:52:00.004Z

Another rant, I'm afraid.

First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.

The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.

The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.

I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.

They weren't.

On face value, with the problem in front of us, it was all very simple indeed.

It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.

Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.

Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).

I was perplexed.

Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.

We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.

They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.

Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.

Slap

2010-11-03T16:01:00.003Z

Is it wrong to want to slap someone? There's a dark cloud.

There's an irrational, unwanted, non EBM collusion that in older adults you prescribe medication by, "starting low and going slow."

No, I don't really know what that means, either. It was never taught to me in pharmacology lectures at medical school. Nobody in conferences speaks of subtherapeutic prescribing, unless you're in a homeopathy class, presumably. And then, well, frankly it's just water so dose becomes singularly uninteresting to me.

But for proper drugs, doesn't an effective dose matter?

Really, in all the pharamcological and therapeutics conferences, CPD events, reading and training I don't hear folk saying, "Take the patient research, the evidence based medicine, the product SPC and of course just ignore it all . . . halve the starting dose to well below what the BNF has as a minimum, keep 'em on that subtherapetic dose for ages and then maybe titrate up to the minimum dose months later . . . since boy and girls, we much start low and go slow."

Nonsense.

Older adults with mental health problems are vulnerable adults. I'd absolutely advocate minimum therapeutic doses, if medication's indicated at all. Most of the time medication's not got a major role to play. When it is used, it's therefore important that it's used effectively and that it works.

Depression is serious. An older adult, being depressed, is harmful. Evidence shows permanent neuronal cell death arising from depression, so each day depressed is a day that a little bit more brain dies.

We know that a metaanalysis of antidepressants confirmed that the drugs aren't any more effective than placebo in mild, moderate or severe depression, with benefits only being realised in very severe depression (as described here). If an older adult is clinically depressed, either it's mild/moderate/severe and arguably medication's seldom used, or it's very severe and medication's used effectively. It's hard to argue to use medication ineffectively.

Why do some folk, who are otherwise sensible and rational and effective doctors, therefore prescribe subtherapeutic doses of antidepressants which don't work (surprise, surprise) then refer them, perplexed, to my door, time and time again? I know why it is, because I asked them. It's because they're harrowed by drug reps whittering on about "start low and go slow" in older adults. Bastards. It means my patients are getting shabby care for no good reason, what so ever, but Big Pharma has lots of FP10s which have to be dished out for months "because you have to go slow" before then the meaningful prescribing can start.

Why should anyone with depression, which is severe enough to need medication, be on citalopram 10mg once a day? The BNF has the minimum starting dose as 20mg once a day. It kindly guides us into evaluating at 3-4 weeks to titrate up to 40mg and kindly specifies that in folk over 65, 40mg is the maximum dose. Brilliant. Crystal clear. For folk over 65, you're on 20mg od and if after 3 to 4 weeks you need more, you're on 40mg od. Why oh why are 10mg or 30mg prescribed, then? Drug rep waffle seems to be cited as the only cause, and worryingly is more powerful in effecting change in practice than the crystal clear/precise BNF is in directing appropriate prescribing.

Gah.

Olanzapine also is used in timid doses. I don't want high dose presribing, this year my appraisal portfolio evidences just 2 patients under my care received above BNF doses of medication at any time. I'm not after high dose use. I just don't want subtherapeutic or irrational use. Olanzapine's blood level is roughly halved in smokers, with many of my older adults in the deprived areas I cover being smokers. Yet there's a zeal for homeopathic starting doses, which are continued ineffectively for months, to "start low and go slow."

Whoever it is, in 2010, that's going around and poisoning doctors' minds away from evidence based medicine, pharmaokinetics/pharmacodynamics, product testing and the licence/Summary of Product Characteristics and BNF prescribing details, they're harming patient care. Those folk whittering on about this "start low go slow" notion, I want their evidence base or I want to slap them. Or reporting them to APBI may placate me and rid us of such pernicious counsel. There's a dark cloud, but there's a silver lining.

Weather

2010-11-01T09:46:00.001Z

Walking through the hospital grounds this morning, beneath bright sunshine, the grounds are a riot of colour. Trees shifting through golds, browns, yellows and vibrant reds.

I love Autumn.

Music

2010-10-15T10:38:00.002+01:00

I read of people with bipolar affective disorder disorder who see it as a gift. It's part of their chemistry, it's who and how they are, it's something that gives changes and makes things different, with difference from the herd not always being bad. I've yet to meet such folk, my patients tend to see bipolar disorder as a wretched nuisance.

One bloke, though, quite appreciates it. He'd rather not have it, hating the periods of low mood when he describes how melancholia descends and remorselessly harrows him for months on end, but he does like the rest of it. Most of the time he's a naturally cheerful disposition, our team's unclear if this is because we're holding him on average a little on the high side, or if he's one of life's cheery souls.

In any case, he's normally buoyant and optimistic and outgoing. He has no family but has a good number of good friends.

Dr Zorro talked of music. The Jobbing Doctor spoke of music, too.

My patient speaks of music. He loves to play, plays a few instruments, and is decent at this. Friends think he's okay, he describes how folk amiably listen whilst chatting or sharing wine or whatever on an evening. All pleasant enough. I can't play any instrument competently so envy his aptitude, to pick something up and create melody and rhythm and emotion in instruments he plays. He sounds good to me, too, when he's played for me.

What's different is when he's high. When he's high he plays music and it's divine. His friends enthusiastically agree. He has insight into this too, reckoning that his music, when he's high, is genius. He's not that grandiose either, it really is in a wholly different league. Home visits when he's high are a source of both dismay (finding seeing him manic) and raturous joy, as he enthusiastically plays the most incomparable music I've heard.

Paternalistic Healthcare

2010-10-11T12:06:00.003+01:00

I started to think this through previously, but derailed into a post about my experiences of GP training and reflection on how clinical focus shifts at different stages of our training and our careers.

My thoughts were on training, particularly my GP training, because one of the teams I work with has recently had animated debate on the topic of paternalistic healthcare. As in, telling patients what they should do.

I work in a world where mostly there're shades of grey. Most folk working in mental illness suss out there's not a magical dichotomy between mentally well and mentally ill, but there's a continuum. No matter how biomedical or psychosocial in their outlook, most folk I work with see medication as not the only treatment/panacea for everything or as useless to all patients all of the time. Whether it's diagnosis or treatment, we're comfortable with managing uncertainty within accepted frameworks. We do shades of grey quite well.

Apart from on this one, it seems.

How paternalistic should we be? It was argued that it's also a continuum and we should be more paternalistic or less paternalistic, taking into account patient factors. Some felt no, we shouldn't be paternalistic at all and that family or IMCAs should take on this role.

If someone's bewildered and all at sea, it was argued that the least restrictive/most proportionate response, acting in their best interests, would be to offer choices to them and if they were unable to make a choice to steer them to what's a good idea. A nurse had an example of a patient they'd seen who was clinically depressed (unable to think, thought they'd been back from their daughter's house 3 days when it had been 9 days, unable and unwilling to eat or drink, demotivated and not leaving the house for weeks, seeing no hope for the future and wanting to be dead).

Depression had caused marked cognitive distortions. After the nurse and I saw him one day, the nurse saw him the next day and again talked through ways of helping him. The patient couldn't make a choice, the nurse met me and arranged for an orodispersible antidepressant so the only choice the patient had to make was whether to take it or not. 2 weeks later things had improved a lot, 4 weeks later he's almost back to normal. The response to medication was unusually good but that wasn't the point, it was that the patient was started on medication through being jollied along into this by his nurse (and indirectly by me, from discussing medication the day before then providing a prescription for him).

A lady with dementia, she's now in respite care, a lot. When at home our support worker takes her out at least once a week. This gives her husband a break but also gives her opportunity for stimulation and lets us get the measure of her functional level/what she can or can't readily do any more. The support worker can get her to do anything. She'll get into her car, pop to the shops, sit and have coffee or something to eat, play a game of bingo or dominoes or snap, have a bath, anything. With respite care or home care or the sitting service we're told she's a "challenging lady" who won't do anything and "is resistive to care."

The support worker and a nurse went to the care home and watched how they treated her. Usually we'd not send two staff but there was a need for a nurse to do some formal Dementia Care Mapping as part of future teaching with that care home anyway. The staff feedback and documentation was interesting. It was clear that carers were offering the lady lots of choices and open comments.

"Do you want to play a game of card?"
"What would you like for lunch?"
"Do you want a drink of tea?"
"You okay there, love?"
"Do you fancy joining the [activities] group this afternoon?"

She sat in the care home, declining everything, "No, I'm alright love, leave me be."
Things were offered and she'd either decline to opt in, or care home staff would see her as not keen to engage so would pass over her. Mostly she was ignored.

Why was she fine with the support worker but not with care home staff? It was a difference of approach. Our support worker would, in her bright and cheery way, suggest, "Come and . . . " or "Come on, let's . . ." and she'd go with the flow and join in.

Rather than choices, to offer direction was helpful. Not for all things, all the time, but there seemed to be a place for directive comments. The lady would never opt in to play a game, but if you said, "Come and have a game of snap with Betty and me," she'd happily walk over and sit down and talk and play. Without being "told" to come and do it, if just offered "Do you want to play snap?" she'd always decline, as she would almost any choice offered to her.

Some of our team illustrated compelling cases where being paternalistic, with some people, some of the time, is a good thing.

Managers will be having a fit.

Dementia Care

2010-10-08T10:35:00.003+01:00

I'm sure everyone's been gripped by the NICE review and preliminary guidance on the NICE Technology Appraisal (TA 111), released yesterday. It goes on, at length, here. Reading the runes, it's likely to be refreshed from preliminary guidance into national NICE guidance in February 2011 which then has significant implications. Implementation and use of Technology Appraisals in clinical care has to be funded and can't be denied solely on cost grounds.

I'm rather relieved, therefore, that in my corner it isn't going to make a significant difference. Does the review of TA 111 matter, than? It was released in September 2007, updated in August 2009, now refreshed in October 2010 for update in February 2011. Does this document have any use or meaning? It will, helpfully, to a lot of other Trusts.

Microsoft Word tells me the preliminary guidance is 21 824 words. There's a lot of it.

I like it.

It's at variance with some folks' wishes who aren't keen on early diagnosis, since the guidance now invites treatment of mild dementia, rather than waiting 'til you're moderately demented before starting medication. This makes sense to me. The medication typically holds a person at their level of cognition for couple of years. Is is better to be held at a level where MMSE is 24/30 or where MMSE is 14/30? There're exceptions (where insight is a curse and distress blessedly diminishes as the ability to forget becomes more intense) but usually it's desirable (and desired by patients/carers) to keep someone at their best, rather than wait for a decline then keep them at that level.

This is what my colleagues and I've done for years. Our local Alzheimer's Society, PCT, Area Prescribing Committee, GPs and Trust Medicines Management Committee uncharacteristiclaly all agreed a care pwathway and funding such that folk with dementia access treatment on diagnosis, irrespective of severity/MMSE. All my patients with mild dementia have been having the drugs for years.

No changes there, then. Speaking with colleagues in other Trusts, it will open up a huge amount of work for them, with literally hundreds of people who've mild dementia who will be entitled to medication and aren't currently on it needing review and discussion and (often) medication initiated, titrated, reviewed then continued under Shared Care.

I don't prescribe a lot of memantine, using it with just a few patients, so the guidance there won't change my world. Opening up memantine so it can be used in the NHS (outside of clinical trials) isn't a change for me, since I am prescribing it already.

Over 20 000 words saying I can practice as I am.

That's the sort of guidance I can stand to receive!

Vitamin B

2010-10-05T14:33:00.003+01:00

Folks with memory problems have some B vitamins checked before ever reaching my door. Vitamin B12 (and folic acid, and LFTs showing albumin levels) evidence nutrition, or lack of nutrition.

If patients have evidence of vitamin deficiency, it's usually treated by their GP before I assess the patient, so assessment of mood and cognition is looking at contributing mental health problems, not nutritional deficits impacting on their wellbeing.

Recently patients' carers have been asking me about vitamin B preventing/slowing Alzheimer's disease. It's not something I know a lot about. I know a lot about Alzheimer's disease, the risk factors, the pathology that develops within the brain, the evidence of psychological interventions and the evidence of medication's efficacy and effectiveness. I know that about 8% of patients referred to me with dementia have something else instead, so routinely find physical health problems presenting with cognitive impairment.

In all this thinking and sleuthing stuff out, I was perturbed that vitamins could have great benefit to my patients but none of my colleagues knew of this, no current teaching articulated this, no past training covered this and no journal articles and updating continuing professional development taught this. My pharmacist colleagues knew naught of this, either. Perplexing.

I spent a few hours finding what I could. A pharmacist did the same. We met up and compared notes. We'd not found anything illuminating.

I chanced upon another blog today for the first time, which helpfully fisks the rubbish being tossed around in some main stream media. It's heartening that it's not just me and my clinical team that's not wondrously excited by vitamin B.

When patients ask about it, I'm indifferent. It's cheap, it's water soluble (so, unless really really trying hard, if you take too much it is dissolved in our urine and we just wee it out) but it's also not convincingly beneficial. If it's taken with minerals (like iron) then it's not that hard for folk with dementia to poison themselves.

It's not crystal therapy or colour healing. Not quite. It could have some sensible contribution beyond placebo effect. If people want to take vitamin B, all well and good. But it's not something my GPs or I'm prescribing for folk with dementia, yet.

The past

2010-10-04T10:59:00.004+01:00

When I trained as a GP there was consistent recognition of the book "The Doctor, his Patient and the Illness" by Michael Balint. Given that Balint's work involved GPs and psychiatrists meeting up and chewing over discussions of patients the GPs had been seeing, the themes and processes were right up my street. Although I enjoyed working in GP land, having swapped to psychiatry I still find the work equally appealing.

Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.

A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.

As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.

On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.

"The past is a foreign country; they do things differently there."
- L P Hartley

Surprise

2010-10-01T13:42:00.002+01:00

I was surprised.

When the National Dementia Strategy was published in February 2009, although it wasn't a vision of perfection, it had good content and importantly also had cash attached to it. Strategic Health Authorities were given millions to implement the strategy. Not just "these are good ideas" or "do more, and now start doing it right" but instead a sensible strategy with sensible amounts of cash to resource it.

I was pleased.

Okay, okay, in my corner our Trust didn't get a penny more, but had (and still have) to deliver on objectives, so are being asked to do more and mroe without anything extra. But across Primary Care and the Local Authority and care homes, new money has been thrown at it and has helped patients. Mostly with Continuing Care funding, it seems.

I am still pleased.

That was February 2009. Time moves on. 1 year 8 months on and it's all gone quiet, with no enthusiasm to tackle dementia and the focus has moved elsewhere. No no no. This week the Department of Health published another document, following on from the National Dementia Strategy, called Quality outcomes for people with dementia : Builing on the work of the National Dementia Strategy. Okay, it's not the snappiest title for a document, but what's the document about? Read it on the DoH website, here.

It only came out this week, on the 28th September, so I've only just got around to reading it, thinking about it and forming a view. It contains 9 desired outcomes for people with dementia, which are clear and meaningful and realistic. It gives explanation of how theese outcomes can be delivered without oodles of prescriptive mandates and This Is What Thou Shalt Do edicts. Even the appendix, Annex 1, gives genuinely helpful descriptors for what the 9 outcomes/improvements for patients with dementia mean, in a nutshell.

First there's a National Dementia Strategy with a clear, over arching vision for health and social welfare that had millions attached to it, that we got. Then there's a follow up document a year and a half on, maintaining focus and contributing useful outcomes.

I remain pleased. Pleased and very pleasantly surprised.

t'interweb

2010-09-30T13:05:00.003+01:00

I use the internet a lot.

I don't think I use it excessively. At work I rummage around blogs and web sites when I can. On evenings I browse through medical/mental health sites that interest me. A few times a week I'll pop on to Facebook but I don't use it a lot. I'll email* at work several times a day, mostly to managers.

I've a 'puter at home we use for online gaming on evenings, but rarely use it through holidays or weekends.

My mobile 'phone can do email and Facebook and stuff but I've not configured it to do so. I'm quite happy using it to call or text or occasionally take photos.

If I want to communicate then I still like face to face contact. At work I walk to offices to meet folk, I hardly ever use my 'phone. At home I drive to friends and family and hardly chatter by 'phone or texts or Skype or emails. One friend texts* loads, which works fine, since we meet up throughout the week too. To have a real relationship, where you can relate to people, supported by texts/emails works for me.

I'm aware that I'm practically prehistoric in how I interact with the big wide world, though. My wife, who loves gadgets, thinks that although my mobile 'phone can do loads and I use it for just texts/calls/photos, the only reason I have a modern 'phone is because they don't do rotary telephones any more so I was forced to move on.

I recently was reading through work by Kruger (2005) on computer mediated communication. Apparently we're all not very good at it.

Published work shows authors believe they're understood much better than they really are. Folks communicating face to face accurately assessed how often their meanings would be understood. Folks communicating electronically incorrectly thought meaning would be understood about 80% of the time, when it was just a little over half the time. 44% of the time the important meaning (such as sarcasm) simply wasn't got.

Contextual meanings such as sombre or sadness or humour were poorly conveyed. What of smilies and emoticons? They were used and didn't help improve the outcomes. Even with such cues, anything (other than facts) such as sarcasm or emotion or attitude or irony or humour aren't meaningfully conveyed almost half the time.

This comforts me, knowing electronic communication is but a small part of my world. But, gentle reader, just in case you read anything I generate within this blog or comments on other blogs and take issue, can I play the "it's through using t'interweb" card and claim it was meant sarcastically, ironically or humorously? :-)

* email, electronic mail, is it just a noun or is it fair to use is as a verb? Texts, text messages, is it just a noun or is it fair to use is as a verb too?

Injections

2010-09-29T09:00:00.004+01:00

An older lady with a diagnosis of schizoaffective disorder was admitted to our acute district general hospital down the road. She lives just out of area and was brought to our local acute hospital through the vagaries of chance. She was maintained on depot flupentixol decanoate (depixol) which had kept her well for a number of years.

She was having this injection every 2 weeks, without any side effects or problems, sought to continue it and both the patient and her psychiatrist/mental health team wished for it to continue. Her mental health team were remarkably helpful, faxing over depot cards and loads of relevant material for me. Continuity of care can work.

On the ward, her mental health was stable. Not a surprise. She'd been stable in the community for a few years, now.

She was referred because the nurses couldn't give her the depot injection. The ward nurses (RGNs) within the district general hospital are trained and competent to give injections, of course. But apparently the technique and administration of oily depot antipsychotic medication is something that mental health nurses (RMNs) are trained to do, but RGNs are not. So the acute hospital referred the lady to my door, for one of my nurses to drive over just to give the lady her injection. She did, shes a helpful soul and wanted the patient to get the right care.

But it struck me as odd. As a doctor, my training in procedures was p'raps more cavalier than it is now, being of the see one/do one/teach one school of practice, so I just assumed if you can give an injection, and you know the drug, you're fine to do it. I vaguely recall discussion about what the differences in practive between an RGN and RMN are, but since both nurses do injections, I'd not appreciated that the nurses can each only do certain types of injections.

Orientation

2010-09-24T12:52:00.004+01:00

A nurse and I were in a patient's house, talking with a widowed gentleman who'd apparently not been faring brilliantly.

He has diabetes and hypertension and hyperlipidaemia, presumably these have contributed to his vascular dementia. Mostly he manages pretty well, with support. He is keen to stay in his own home and his social worker's sorted out care for him 3 times a day (he was unable to manage his medicines, so needs home care to prompt with that, as well as support meals and drinks), he attends a day centre once a week where he gets a bath and has some new fangled telecare that means if he leaves his home at night and doesn't come back after a few minutes, his daughter's automatically 'phoned. He's never yet wandered at night, but it's a sensible precaution.

Having vascular dementia there's not a lot that I can personally do. The GP has sorted his physical health and the risk factors. His social worker has sorted practical care. A nurse went through information with him and his family, over a few weeks.

We found ourselves in his home because a new home carer had alerted her manager that he was unwell, confused and "had it in" for his brothers. Homicidal thoughts. High risk. A 'phone call to us sought an urgent review. We knew it wasn't urgent, but we were in the area so popped in to see him.

It was clear he had no new psychiatric problems (in particular there were no mood changes and no persecutory beliefs) and no new physical health symptoms. He was stable and much the same as I'd seen him a year or so ago, when I first saw him for initial assessment and diagnosis. The nurse, who's seen him too, was talking through with him what home care had said of him thinking badly of his brothers.

"Aye," he said, "the both of 'em have been having it away with a lass, she's only 18!" He was mortified that they'd got her pregnant. The nurse looked at him and without even blinking said, "Let's have a look at that, shall we? Your brothers, are they still alive?" We knew his history.

The man paused for a fraction of a second, confusion then surprise then a smile shifting across his face. "No, they're both dead, been dead for years, love. Why'd that daft thought come into my head, then?!"

The nurse had sorted it. There was no homicidal risk. There was no psychiatric illness for me to fiddle with, nothing specific for me to do. But it was still an oddly satisfying visit.

Heresy

2010-09-21T13:03:00.003+01:00

What is "clinical governance" about? I mean, really? What does it tangibly change in my patients' world?

There's a pervasive assumption that it's always right, always good, always clear, always happening and always helpful to patients.

Wrong, wrong, wrong, wrong, wrong.

But this is heresy and I shall be burnt. So it goes.

Aripiprazole

2010-09-17T12:14:00.003+01:00

Aripiprazole (trade name abilify) is an antipsychotic drug, licensed to market itself as indicated in the treatment of schizophrenia, mania and the control of agitation and disturbed behaviour in schizophrenia.

The BNF shows that a month's supply of aripiprazole 30mg has a reference cost of £191.47

Now, a drug cost of £2297.64 a year isn't actually that huge. Compare it to the cost of an admission to hospital and it's clear that keeping someone with manic/schizophrenia well for that amount is great for the patient and great for the NHS. Sure, there're medical costs of assessment and prescribing, pharmacist costs in dispensing, but actually it's still much better for the patient not to relapse and much more cost effective to spend staff/drug costs on this, than have an admission to hospital.

Haloperidol also is licenced for schizophrenia and mania. Top dose haloperidol is also 30mg a day (although I can't recall prescribing an older adult even 1/4 of that dose) at a reference cost of £52.28 a month and haloperidol is, usually, a drug causing a lot more side effects.

Olanzapine, in the treatment of schizophrenia and mania, has a top dose of 20mg a day, at a base cost of £158.90 a month.

I am happy to prescribe olanzapine. It seems well tolerated. It seems to work well. Aripiprazole is a newer and more expensive drug. It's a topic of conversation. It was discussed with Consultant Psychiatrists across 4 mental health hospitals. Working age and old age pschiatrists curiously formed the same view, with nobody seeming to think that aripiprazole seemed to work as well as other drugs. Some vociferously argued it didn't work at all.

Spending a few thousand a year on a drug that works and prevents admission both improves my patient's life and saves the NHS money.

Prescribing a drug that's of dubious effectiveness, hmmm.

Has anyone had decent results from this drug? I've yet to hear of it . . .

Falls

2010-09-16T13:26:00.002+01:00

This week I've spent hours in meetings, mostly management meetings, striving to keep our service ticking along nicely through basically asking simply for us to be left alone. Investing time in meetings to do nothing and change nothing is necessary, to stop well meaning folk make unhelpful changes, but there's little joy to this. The endless hours can be a bit of a dark cloud on your working week.

I've a gentleman who's just had his 6 week review by his social worker, having been placed in a care home from intermediate care. He's staying in the care home since he's immobile, episodically confused and falling.

He's got severe osteoarthritis, with the wear and tear on his joints causing severe pain, limiting mobility striking. From being independent a year ago, he's no sedentary and almost immobile. When he does try and walk he's in pain and falls, often.

He's an older gentleman and has prostatism, drippling urine and having continence problems.

He was made known to me by the care home, rather than from medics in Primary or Secondary care, with concern that he'd developed pressure areas and was this causing infection making him more confused, causing him to shout out at night now? A fair question for a regular residential home to ask. I pulled medical notes from the acute Trust, spoke with the GP, pulled off his blood results and scans and found a different picture.

His poor gait and falls wasn't put down to arthritis and pain. His incontinence wasn't put down to prostatism. His episodic confusion and decline in function over a year wasn't put down to dementia. He'd been investigated and found to have normal pressure hydrocephalus and placed in permanent residential care to support his consequent deficits.

The care home simply sought sensible advice on whether there was a treatable cause for his new behaviour (of feeling anxious and shouting out at night) or whether as they phrased it, it was part of the progression of his swollen brain.

Excellent.

Good initial GP assessment, then good medical work up by a physician, then good neurosurgical assessment and then good care in a care home.

My dark cloud this week has a silver lining.

Gunge

2010-09-15T21:50:00.003+01:00

Cancers grow, uncontrollably. It's kind of their definition. This inexorable genesis has side effects.

Perhaps the most curious one, to my mind, is death.

Folks develop a cancer that grows, generating a tumour, a lump, a mass. This often isn't enormous. Our bodies cope with lumps pretty well. People have parasites forming walled off spheres inside us (like hydatid disease). People have inflammatory process generating fluid filled cysts inside us. People have infections generating cavitating lesions or pus filled tissues inside us. Heck, people have babies, with the extra mass of fluid and placenta and baby.

Our bodies can cope with extra lumps inside us, so having a cancer the size of an apple or grapefruit isn't understandable as a cause of death. Sure, if it eats through something important, like an artery, and you bleed to death, that's evidently a clear cause of death. But most people with cancer thankfully don't pass away so dramatically, bleeding catastophically. So why's a lump, just sitting inside you, being a lump, fatal?

One of the common consequences of cancer I see is the paraneoplastic syndrome. This is when cancer causes problems through growing, endlessly, but instead of the mass causing direct symptoms the growth throws out gunge. The tumour churns out lots of chemicals. Hormones and the like. Or things that drive the body to do something/stop doing something. This explains why a tumour causes lots of symptoms (and accounts for why just having a lump that's hardly pushing on anything doesn't directly cause symptoms).

Unfortunately many effects of this can be pretty common. Tiredness. Weight loss. Temperature. Joint pain. Nausea. Mood changes. Confusion.

The last couple months have resulted in several patients being referred to me with ?dementia and history, examination and investigation's found a previously unknown adenocarcinoma causing their presenting symptoms. None had cerebral metastases. None had neurodegenerative dementia. Their symptom burden was part of the neuropsychiatric sequelae of cancer.

The cancer is active, endlessly growing and making and actively synthesising, with the unhappy byproduct of churning out a lot of gunge which makes people feel hellishly unwell. And I can't fix that.

Much badness.

Liaison Psychiatry

2010-09-13T19:09:00.003+01:00

Nurse Anne has a point. She usually does. Working on an acute ward, delivering hands on nursing care, she's insight into what works well on wards, what's necessary and what works badly.

It's frustrating and bewildering that both cogent, articulate views and intuitively sensible cathartic rants, whilst all true and meaningful, seem to be ignored. A manager who I've a lot of time for was lamentting how intellectual explanation or common sense experiences are all too often brushed aside by management structures if the views aren't, "aligned with the corporate direction of the organisation." She then went to talk about EBITDA and cost pressures and totally lost me. But the message was clear that if you say what managers like, you're listened to. Say what managers don't like and you're not listened to. Oh, you're heard, it's noise that is sometimes attended to, but then discounted. Not every good idea can be progressed, so this managerial self selection of what to attend to is the best that consultation/clinical engagement can feign to date.

Disheartening.

In mental health, we're usually more fortunate. I work with a number of managers, but actually have a decent relationship with them. I don't get what I want all the time, obviously, but I get good enough resources to deliver an excellent service, which really is what I want managers to deliver for me. Just give me the tools and then pretty much leave us alone, then we can deliver.

In Nurse Anne's world it's much, much worse. Outside of mental health, acute Trusts have pressures and tend to cut costs through removing/not replacing frontline qualified staff. Our local Trust has a lot more HCAs and a lot less nurses (on the wards) than it did 10 years ago. Oh, it has more nurses in management (as matrons, Champions and project managers in a whole slew of initiatives) but lamentably the clinical areas have fewer clinicians, despite increased activity, increased process and increased technical interventions compared to a decade ago. If you're doing more work, and more complex work, and dealing with iller people, and need folk to deliver technical/complex care, wouldn't you want more nurses? Before you even look at the triage, surveillance, assessments and formulations ward nurses undertake, the documentation and process has increased in volume and complexity with MUST nutritional screening, Waterlow scores, falls assessments, Abbey Pain Scale ratings, medicines reconcilliation and so on, much more than just the TPR that used to be done. What of extended roles, Non-Medical Prescribing, First Contact Practitioner, Nurse led Clinics, Nurse Consultants running wards (in Cumbria, even running mental health wards in place of medical Consultants).

Undeniably, nurses now have more to do. In greater detail. With more patients. With more complicated kit and interventions. We've more nurses in management (so statistics show we still have fair numbers of nurses) but invariably in acute hospitals I visit we've substantially less on wards than wards need and patients deserve.

Much badness.

Nurse Anne very reasonably asks why patients with primary psychiatric problems are admitted onto an acute medical ward. Sadly, she's also given the answer in the sentence questioning, "Why the hell are the medical consultants getting this dumped on them?" Because it does seem that the medics are simply being dumped on. It's really impossible to defend this.

Nurse Anne also has the workings of a solution. "We have no RMN's on staff so basically we are up shit's creek." Indeed. We've got RMNs working in the acute Trust in my corner, who've made a big difference. The nurses and I've persuaded the acute Trust and PCT, through what we've delivered on, that RMNs and Psychiatrist time can improve quality, reduce length of stay and save squillions.

Liaison Psychiatry done well works brilliantly, with patients, acute staff and mental health staff all feeling happy (and having shorter admissions and saving cash, incidentally). Liaison Psychiatry done badly is ghastly. Utterly ghastly. I've no answers for Nurse Anne, no explanations, but inwardly cringe at the shabby service it seems my mental health colleagues provide in her corner. Ouch.

Complaints

2010-09-08T16:09:00.004+01:00

It was recently reported that the number of NHS complaints has gone up, rather a lot.

The details are unfortunately numbers, giving us data, rather than information. I was taken, for example, by the increase in complaints across Primary Care that increased by 4.4%. Does this mean anything? In my corner there's been a LES that's increased a lot of clinical activity in Primary Care. They've also started undertaking a slew of activities that the acute Trust used to provide. A number of exercises in partnership working with the voluntary sector (eg in promoting breastfeeding with baby bistros, in dementia cafes, in osteoporosis prevention) ramped up health visitor and midwifery and GP activity. Activity in Primary Care has increased. Is an increase in complaints of 4.4% in keeping with an increase in activity of 4.4% and therefore of no real interest? Is it less than the increased activity, therefore the proportion of patients complaining is actually going down?

Sadly I do not know, since it was reported without such refined deliberation. Ho hum.

In parts of my service, activity has increased by over 400%, another team is overperforming at 200%, but despite activity increasing strikingly over the last financial year the number of complaints haven't quadrupled/doubled. If our activity goes up by 400% but our rate of complaints in Secondary Care went up by 13.4% in those teams, it'd suggest a profound reduction in total proportion of patients experiencing poor satisfaction and complaining.

The data doesn't really tell me much. It piqued my curiosity, though. Although this year, as fortunately is typically the case, I've had written compliments and no complaints, I pulled all the formal complaints for our directorate that were investigated and our Chief Exec responded to, over the last few years. Interestingly, across the Trust, the majority of complaints are upheld, fully or partially, with the patients' being found to have valid cause for complaint in at least one aspect of their complaint.

In older adults' services, almost no complaints were upheld.

Not only do we have few complaints, but those who do complain have investigation and, unlike other services (so it's not an organisational bias) aren't found to be at fault.

It was noted that written opinion in clinics and visits were frequently sought, with a high rate of return. In-patients are surveyed on discharge too, so there's systematic attempts to solicit patients' opinion.

Locally we've therefore lots more patient feedback, lots more clinical activity, yet few complaints. I wonder if that's in keeping with the national picture. Are the numbers crude data, without the context of activity levels and service redesign and expansion into riskier areas, really showing more complaints? Or is it, as may well be the case, as we're finding locally, that the rate of complaints is actually going down?

Junior Doctors

2010-09-02T10:56:00.002+01:00

I've met with my junior doctor, dutifully undertaking an hour's supervision each week, assiduously documenting what we discuss.

What he wants out of supervision is, most meaningfully to him, being equipped to pass his exams. Without that, his career is thwarted and he can't progress his training to become a Consultant Psychiatrist.

What the Royal College wants out of supervision is unrealistic, with a full lever arch file failing to contain all that's meant to be covered, but in essence there's an expectation that all elements of the GMC's Good Medical Practice and all core generic medical competencies and old age psychiatry will be delivered. Most meaningfully to the RCPsych is progress of the curriculum (evidenced in doctor's portfolio and online workplace based assessments).

What the Trust wants is a safe practitioner doing appropriate work so, most meaningful to the Trust, is a supervised practitioner who's learnt and is fully aware and using in their practice the hundreds of Trust policies we have.

What the patients want of him isn't really factored in.

What I want is different and diverse and aspirational. In 3 or 4 years, my junior doctor is likely to be a Consultant Psychiatrist. What should such a junior doctor be mentored, informed or developed in, through ongoing weekly supervision?

Clinical Depression

2010-08-24T12:59:00.003+01:00

I recently saw a gentleman, who has dementia of moderate severity, who was low in mood. His GP had reasonably started an antidepressant. Things were no better. I stopped the antidepressant. I reviewed him. Things were no different.

I recently saw a lady who was tearful all the time, felt hopeless and wasn't doing sociable things with friends at the local tea room and Tuesday evening bingo. Her GP had sensibly started an antidepressant, reviewed her, changed it then referred to me. I stopped the antidepressant, reviewed the lady, things were no different.

It's not easy work. In both cases I saw the patient in their home with a CPN colleague, it took over an hour doing an initial assessment then time following up and reviewing them.

The gentleman's scans showed widespread vascular damage. His limbic system was shot to pieces. If the bits of your brain that regulate your mood no longer exist/are damaged, it's unsurprising that peoples' mood is less than perfect.

The lady had low mood because she'd recently been widowed, her sister had also died this year and she had a blood disorder (which slowly is getting worse) meaning she's knackered all the time. Her mood is low because life's grim. She's not mentally ill, there's no psychiatric disease.

If there's no chemical depression, with no chemical solution, answers aren't in a tablet. This makes it harder. Patients and carers need to do something to get better, to change something if they want things to be different. Professionals can't just gift an FP10 and be done. And, invariably, things can be improved, but they can't be "cured" and less than perfect mood needs to be accepted/endured/dealt with rather than "fixed" or changed.

Management of clinical depression is, to my mind, pretty easy. But management of other low mood is grim.

Occupational wellbeing

2010-08-04T21:39:00.001+01:00

Work can be emotionally damaging. This doesn't look good . . .

Consultant Time

2010-08-04T20:45:00.004+01:00

A couple days a week I start at 8.30am which I still reckon's an ungodly hour. Although I'm often in at this time, on just 2 days do I start work at 8.30am, on all other days clinical activity (like an out-patient clinic) starts at 9.30am. A much more civilised hour.

Why the early starts, why just some days?

It suits the nurses. It makes no odds to me really when I start, I can organise time as I wish. Home visits, MDT meetings, writing reports, care home reviews and such can all be juggled around and don't have to be at a specific hour.

Nurses though have a lot to do. Too much. They've so much clinical activity to do, now, more than 5 years ago. It's good and interesting and they're very good at it, but it means they're genuinely busier. Audit evidences this increase in direct patient care and increase in complexity of work. It's been formally looked at since it's resulted in job matching and regrading under A4C through nurses' roles shifting. As well as being more involved with more patients doing more work more of the time, they've also got to do more nonsense. Falls and nutritional and other risk assessments. A form for every patient on risks to children/childrens' needs. Screening tools. Repeats of carer assessments. Suicide assessment tools that don't apply to older adults but still must be done. They have to collect lots of demographic data that already exists (ethnicity, marital status, occupation/retired, where they live etc) and enter it into the computer system. They have stupid, stupid amounts of paperwork. The paperwork is only the start, since as well as ward/community paper notes, psychiatric medical notes, letters to GPs/referrers, social work/other referrals, there's also electronic stuff. Our "paperless" notes on the computer with squillions of fields to fill in. Some are always left empty and months later nurses are bullied/harrassed to complete the data set. Assessment forms. Diagnostic/clustering tools. CPA fields. Care plans (plural, since every intervention has to be entered as a separate care plan, with lots of fields on each one). Safeguarding referrals and meetings. Mental Capacity Act assessments, best interest meetings. Doing what only an RMN can do (such as administering oily depot medication). Generating statistics, results, activity levels, outcomes or other information that managers, commissioners, service leads or other parties want (usually straight away). Attending more management meetings than I care to count as more and more is added in without anything being reviewed and stopped. Attending mandatory training, often in things of dubiuous relevance. Carer support (a quarter of their clinical time is spent with carers, not patients). Coordinating multiagency working so patient care actually happens, and happens right. De-escalating challenging behaviour (such as stopping them battering folk). Feeding them. And then there's the direct therapeutic work undertaken with patients, effecting change.

Sometimes, just sometimes, they also need to work with doctors.

It's for this reason that I work when I work. My ward round is on a day and time when no other Consultant is on the ward, my team meetings start at 8.30am since it suits the nurses to do it then, so they can crack on and do everything else from 9.30am onwards when everything kicks off.

I've huge sympathy for poor Militant Medical Nurse who seems to work with medical colleagues who instead of adding helpfully to their process are seen to be unhelpful. I appreciate that in psychiatry Consultants can have much more latitude to shift clinical activity around and generate flexibility, whilst a surgeon has to operate when they've theatre time and that's that, so it's not possible to be as flexible in other disciplines. Yet somehow Militant Medical Nurse's account leaves me frowning and feeling a little ashamed at how my medical colleagues are felt to be adding to, rather than helping with, the stresses that nursing colleagues are grappling with.

Writing Style

2010-07-30T11:13:00.002+01:00

Dr Shock invites us to consider our writing style. Copy and paste some of your text here and see.

Going through my last few posts, I get results either of David Foster Wallace or of Dan Brown. Curious!

Mental health work

2010-07-27T16:17:00.005+01:00

The Girl asked two questions here, sensibly querying the stigma against psychiatry and how to manage without burnout.

General Practice is different from specialist care because it's harder. It's a specialist area in it's own right, but is mostly unidisciplincary in approach (you see a doctor, or a practice nurse, or a midwife, but you don't usually see several clinicians who've all discussed your care as a team) making it a harder area as a clinician (to my mind). And you never get to discharge anyone. And you get all problems/symptoms and have to divine what's of medical significance and what isn't. Which is often difficult, because if the patient has a symptom (e.g. of being knackered all the time) but it's investigated and not caused by any clinically significant illness or process, so medicine has little to offer, the patient's still usually keen for resolution of their target symptom. An explanation that it's not serious, not due to major disease or anything significant, placates so far but doesn't solve the patient's symptom burden. Before even managing patient agenda, governance frameworks, central DoH/NICE mandates, local PCT/APC/LMC direction, just thriving in a world of clinical uncertainty is trouble enough. Especially when you just have 10 minutes or so with each patient. Having trained and worked in Primary Care I know it's a challenging speciality and not one I've the stamina for.

With that caveat aside, that Primary Care is a separate complex speciality, what are my thoughts on Secondary Care specialities and mental health in particular?

Clinical practice within psychiatry is a very mixed field indeed. Most areas of Secondary Care medicine have diversity in approach but, by and large, the majority of doctors have similar approaches to care. Management of MI, childhood atopy, pre-eclampsia, lateral epicondylitis, angina, COPD or whatever is variable. But not that variable. Maybe one clinician would favour a NSAID over a moderate opiate, but by and large the care pathway is similar. Maybe one medic would do X first then Y, another would do Y then X, but over time most of their patients end up with mostly the same treatment.

Not so in psychiatry.

You may have a very biomedical psychiatrist who's interested in genes and biology and neurochemistry. Process is very medical, with complex imaging and serum rhubarb tests. Management is very pharmacological, or neurological (magnetic stimulation, ECT, whatever) to effect chemical change within what's seen to be a chemically imbalanced brain. When things don't work, you need more drugs. Or heroic doses. Or complicated drug augmentation strategies. Or specialist referral to centres who do psychosurgery or treatment with rare drugs. Got to fix the chemistry.

You may have a very psychosocial psychiatrist who's interested in a patient's current experience and life events and past experiential learning and ongoing maintaining factors. Process is very psychological, or practical (such as diary keeping) to gain understanding of why things are as they are. Management is very pragmatic or behavioural. Psychological therapy to aid acceptance. Behavioural therapy to effect meaningful change in the here and now. Got to either accept how things are, or make changes.

You may have a very community oriented psychiatrist. Problems arise in the patient's real world. The patient's going to return and live and thrive there. Why bring them in to what's been shown to be a "toxic environment" of a ward, where activities have little that's real for the patient's world, the situation's dislocating the patient from their problems and, when it comes down to their clinical needs, what can happen in a psychiatric hospital that can't happen in the community? Okay, often ECT is started/done in hospital (but even this can be done in the community), psychosurgery is certainly an in-patient procedure. But what else? Really, why have lots of hospital beds at all? Nobody gets admitted.

You may have a very hospital oriented psychiatrist. Problems arise in the community, if the patient could fix them they would have. Who'd choose to be miserable and not coping? They need time out, some solace and sanctuary and space to reflect or make sense of things. Or somewhere for rich assessment and investigation and and fiddling with drugs day to day. Really, if they've become unwell in the community and can't cope, how can they realistically be expected to recover and be cured there, in a timely manner? Everybody gets admitted.

You may have a liberal psychiatrist who accepts and supports everything. You may not. Someone with schizophrenia assaults a member of the public in a supermarket. One psychiatrist says they were hearing voices but just as if they heard you say to punch someone they could say no, they had control and chose not to exercise it, they made an elective choice to punch the victim. Charge them and go down the criminal justice system route. Another psychiatrist says they were hearing voices so not in control of their actions, there's no criminal intent and the person's unwell, needing disposal through health with hospital admission and in-patient care. Same patient, same action, sometimes it goes to police, sometimes it goes to health services.

Other disciplines look at psychiatry and shake their heads. It's all a bit of a mess, isn't it? It's not sensible. It's not seen to be about patients or clinical needs. It looks random and chaotic. It can be seen to be ineffective. Why would any doctor want to work in that world, as a career, when other options of proper medicine exist?

Worse, a lot of mental health services are poor. In particular, working age adults can get pretty shoddy care. Services often are under valued, under commissioned, under resourced and not fit for purpose. So sometimes there's bad care. So sometimes medical colleagues look at psychiatry and think, it's all a bit rubbish, really, isn't it.

But when it's done well, it's just brilliant. Everything works. It's fantastic for patients, getting help and improvement and appropriate care and feeling better for our input. It's fantastic for staff, feeling they're part of an effective, ace service. It's fantastic for families and carers, getting support and help and time to assist in how they can cope. It's fantastic for colleagues, GPs in particular, who know everyone is seen promptly (within days if routine, hours if urgent), everyone has nurses and social workers and pharmacist and psychiatrist inputting into every single patient (true multidisciplinary care) with all medication clearly sorted out, all care clearly documented and typed/faxed/posted to the GP/referrer, with patient/carer feedback and service evaluation and audit and monthly PCT reporting evidencing outcomes and quality of care, continuously.

When it's done well, nobody else knows. The patient and family are happy, they don't go back to their GP or other Consultant and wax lyrical about psychiatry because, appropriately, subsequent clinical contacts focus on their clincal needs. The system works, GPs get a 3 to 4 page letter when the patient's discharged but won't read all that; the detail isn't needed most of the time by most GPs.

The variability in practice often evens out, particularly if there's clinical supervision. There're plenty of ways to skin a cat. It'd be grim if we got to a day when every patient got the same treatment, in the same place, for the same duration, in the same way, with no personal care, no consideration of variables, no choice. That psychiatry still has latitude to be flexible in models of care is, to my mind, a great strength. Sure, we need to evidence it's effective and not just careless/maveric care, so I'm more than willing to evidence process and outcomes. Helps us improve the services too.

How to reduce emotional burnout is simple. Work in a way that's not stressful. To me, that means a range of things need to be in place.
1) I need to have clinical freedom, so can do what I feel is right for my patients. This is something we still enjoy in psychiatry, with no care pathways or algorithms or edicts directing what we must do. Our Trust has no hospital formulary, I can prescribe what so ever I wish.
2) I need to have colleagues I trust and can work with and share care with. I do. I'm blessed with brilliant teams. It can be hard (had several internal and external applicants for a post and couldn't appoint and none met the standard for the team), so 5 internal candidates were disappointed and we had a team with a vacant post. But it matters too much to me, we need the right people in the team and patients deserve the right people.
3) I need to have a good working relationship with managers. I meet our service manager at least once every fortnight. I meet a member of the Trust Board at least once every couple months. I meet with the Medical Director every month. I meet the Chief Exec too and write on average twice a month. Me talking with managers about how it is, and writing, and emailing, and making time to meet them matters.
4) I need a good relationship with partners. I meet GP colleagues in their surgeries, I meet Consultant colleagues on their ward rounds/meetings/teaching, I meet PCT commissioners every month so can help them with commissioning process/decisions whilst also having confidence in security of core bits of our service. Knowledge and security of the cash flow reduces stress and burnout.
5) I need to be able to blow off. Half the week I'm too busy for a lunch break but usually once a week a colleague and I'll skip off 30/40 minutes for lunch and blow off about what's going well, what's a real bitch, what needs changing, what we just need to grit our teeth over and accept. Being listened to and understood by someone who works in that world whilst you sound off and whitter on and on is awfully cathartic.

Well that's my initial thoughts on reasons for bias 'gainst psychiatry, reasons why that's not always valid, and thoughts on how I manage to remain up beat and optimistic without burnout. But you can always email me if you've specific stuff you want to chew over!

Holistic healthcare

2010-07-17T09:03:00.003+01:00

Not all medical specialities look holistically at all elements of a patient's presentation :

NHS Reform

2010-07-14T11:27:00.003+01:00

I have read through the NHS white paper, "Quality and excellence : liberating the NHS" that was published 2 days ago.

It perturbs me.

This is unusual. Usually I can look at things with a "glass half full" kind of take on it, looking for positive opportunity and what it can enable us to do better. Most papers and policies and DoH edicts have not immediately been embraced as wondrously helpful, but on unpicking things I've usually found something that we can use to push commissioning buttons or support change we're making or that strengthens a case to resist dismantling of/meddling in services.

This paper's "vision" is all very positive.

The implementation superficially is neutral but on thinking it through I see it as concerning, with significant opportunity for negative effects. The detail scares me. It's noteworthy that there has been much comment with GPs being less than enthusiastic or critical or pessimistic about the changes to PCTs and commissioning.

What perturbs me is not the ill ease of grappling with uncertainty, which is normal/continuous life in the NHS. Change and uncertainty and wrestling with unknowns is a normal state of affairs. No, what worries me is the implications and explicit intentions of the white paper. I'm worried since it erodes the NHS.

As reported, the intention is for GPs to commission health care. More than an intention, it's forced upon them (since no sane GP would volunteer for this role). It's a poisoned chalice that's offered, and no mistake. GPs are then seen to be responsible for all deficiencies, since they've failed to commission the right services. Rubbish access for paediatric ADHD clinics, no easy access to tattoo removal, no service for aymptomatic varicose vein removal, it's all laid at the GPs door (a door that can't be closed). Rather than government cuts and suboptimal resourcing, it's then poor GP management that results in inadequate healthcare provision. Mmmm.

Worse, how are GPs going to spend the hours and hours necessary to commission care? It takes ages to go through each service. Just to commission older adults' mental health services (with community services, liaison services, early onset dementia care, forensic care, in-patient services, day hospital services, memory clinics, memory therapy day care, Mental Health Act arrangements, psychology services, Cognitive Stimulation Therapy etc) is a lot of detail to think over. Then do it with adults of working age and crisis services. Then with child and adolescent services. Then with forensic services. Then learning difficulty services. Then drug and alcohol services. Then IAPT and community mental health services. The with partners like MIND and Alzheimer's Society and Age Concern and others. Then do that for every other bit of health. There's no way GPs can absorb this activity. Hence the intention that as reported that the money will go, ". . . to private corporations which will buy hospital and community health services on behalf of GPs."

GPs are private businesses already. This paper strengthens and extends this, generating a situation where large companies can pick off small GP practices (then sack the expensive staff, like GPs, and go for First Contact Practitioners) and through block contracts/large consortia can then purchase Secondary Care from hospitals to get what they want. Except what they want, as a business, is a good balance sheet for their share holders.

A company buys/owns/represents all the GPs in my locality. The GPs advise the company on what they want then the company negotiates contracts and commissions services. The private health company, maybe it's BUPA, maybe it's another, then thinks where it wants to spend it's share of the £80 billion pounds. Does it give it to an NHS hospital? Or does it give it to a sister company or to itself, commissioning services from a BUPA hospital?

I'm perturbed since I see this paper as a mechanism for dumbing down healthcare (through eroding quality to save costs), devolving blame (but not power) to GPs and effecting the privatisation of healthcare, to the marked detriment of NHS care.

Much badness.

Nurses

2010-07-10T17:46:00.003+01:00

I was rummaging around the BBC News, this afternoon. Initially it was to see Acting Chief Constable Sue Simm, since she's great to see on telly. Not only has she eschewed the whole "I'm going to be glam and gorgeous" thing, she's opted straight for the Ashes to Ashes look, appearing as though she should be sitting next to Gene Hunt. It was female friends in the police who first drew my attention to her "special" hair style and how she seems locked in that error, erm, I mean era.

But hats off to the lass. Or hats on, my friends in blue suggest she sticks a PSU riot helmet on her head, whatever one of those may be. But really, it is great that the woman sits infront of the nation's media, without a care that her appearance isn't sculpted and classically elegant. Very laudable. It's her substance, her actions, that matter.

Whilst on the BBCs site and looking through the video news, the top editor's choice was an article on Donald McGill and his saucy postcards.

He even drew pictures of nurses. I fear that Unison would not approve. But truly I don't care what they think. I'm invariably interested in what a proper RMN or RGN who works with patients has to say. Those who used to be clinicians are like those who used to do PE at school . . . everyone did it, it's not impressive, it doesn't qualify you to talk about it or claim to be an expert in it still. An ex-nurse (or ex-doctor) lacks credibility.

Therefore I'm happy to ignore the view of pompous folk telling me nurses should wear sacks and look beige, so we see their actions and not their looks. Many RMNs are of the Jo Brand school, or male, with an average age in my corner that's within a decade of retirement. The demographics mean that NHS nurses in older adult's mental health really have very little in common with the Benny Hill/Donald McGill images of nurses.

I'm not sure how nurses should be portrayed by main stream media.

Still, on seeing Donald McGill postcards, I could stand to see my nurses in more traditional atire :

Booze

2010-07-10T16:18:00.007+01:00

Doctors are known to self medicate with alcohol, at least as enthusiastically as the general population. The sterotype is that problematic use of alcohol's an occupational hazard. Personally I drink less than 21 units a week (in fact, it's invariably less than half that).

Although it's not that I partake frequently and regularly, I guess it's fair to say that nursing and medical colleagues can indeed sink a fair bit of drink on nights out. Social workers are a bit more sensible and never seem to drink to excess. Although we're all totally outclassed by secretaries; my they can drink.

After a fraught afternoon yesterday I got home and had a real Withnail moment, "I demand to have some booze!" My wife helpfully obliged. But then, having to read stories and do bathtime and put the kids to bed kind of tempers ones options for sinking into oblivion with drink and rubbish telly. I had to make do with one drink then later crashing out with Ms McCall and her Big Brother.

Gets you thinking.

How do we cope with stress, how do we manage to de-stress? As usual, it wasn't clinical work or patients causing stress, but was management activity (and inactivity) that added woe to my week.

I shall try not to mix my drinks :

Policies

2010-07-08T18:29:00.004+01:00

I do not like them in a box.
I do not like them with a fox.
I do not like them in a house.
I do mot like them with a mouse.
I do not like them here or there.
I do not like them anywhere.
- Dr Seuss

It's always good to get a second opinion on contentious and contested issues. As well as frequent consults with Dr Google, it's sometimes good to reflect 'pon the wise counsel of Dr Seuss, too.

My current raison d'etre seems to be to manage policy. It's impossible for front line clinicians to manage policy day to day, so we have team meetings where we agree what policies we're not able to do, reason why we can't, which I then minute and send to managers. Maybe we'll be the next Mid Staffs with managers being informed by clinicians and Consultants what the problems are, but doing modest amounts to effect change. Who knows. We shall see. The important bit of it is that clinical teams are 'fessing up to what we can and can't deliver on, documenting that our practice is at variance with Trust guidance, reasoning why we're not doing it and informing the managament structure of this different clinical care.

It's not ideal, to meet up once a month to have to reflect on how we work, especially since 2 hours is a fair bit of time for a whole team to take out, but it's saved us a lot of time, in the long run. Not doing form filling, when the information's already captured and documented in 3 places already, has saved masses of time. And moved to a more paperless practice. And made everything more legible. And made it easier to print/email information. Clinical and secretarial staff have a lot of clever ways of working smartly.

But the main reason for this is the massive industry of policy generation that's become unhelpful. Excluding corporate/finance policies, our Trust has over 200 policies that apply to clinical staff, seeing patients. In a moment of ennui, I popped onto the web site and looked.

My oh my.

How can that work? A new junior doc or seconded nurse or bank nurse or trainee AMHP social worker or psychologist is in our service. They go to a clinic or DV or ward to see a patient. They have all their clinical process and knowledge and skills in their heads, structuring what they do and how they do it. They have the GMC/NMC/regulatory body directives in their heads, structuring what they do and how they do it. They have national guidance influencing their thinking. Maybe. They have legislative direction (particularly that MCA 2005 and MHA 1983) structuring how they work. There's usually us Consultants with our foibles, meaning certain types of assessment or interventions are "how we like things to be" which influences clinical care. On top of all this professional material, can anyone credibly believe these staff will also read, understand, implement and use over 200 policies in their practice, as well?

My angst is that oft times too much policy is generated by folk who aren't clinicians. Worse, it's done without any consultation with practising coal face clinicians. Even worse, the decision to make something happen is usually to make a policy, then consult on the policy. It's as if any alternative to a policy is never ever even entertained as a possibility. Yet how many clinical teams working in creative, iterative models of care, have working their practice defined clearly within a policy? Even the operational policies of the teams seem to be works of fiction that bear little resemblance to the function and activities of the teams.

How many times has a clinical team said, "Oooh yes, our clinical care in this area is so much better than it was last year, because we've embedded this Trust policy into our working practice and now everything's brilliant!"
Never happened, in my corner. Curious, then, that policy documentation is generated at such a staggering rate when the outcome/utility from it is evidenced as so poor. Hmmm.

People working far away from a specific clinical team will generate a policy that applies to that clinical team. They're working in the dark and generate material that's usually pretty sensible on reading through it, but is oft times unnecessary, overly tortuous and very very rarely impacts on direct clinical care.

I'll leave the final words, once again, to my colleague Dr Seuss :

Say! In the dark?
Here in the dark!
Would you, could you, in the dark?
I would not, could not, in the dark.

Overheard

2010-07-05T23:08:00.002+01:00

A colourful lady in her 80's now, with paranoid schizophrenia that's well controlled, but leaves her with delightfully eccentric foibles.

"No, I don't suffer with madness . . . I enjoy every day of it!"

Passion

2010-07-03T12:32:00.004+01:00

I was told by a couple of different managers last week that I was obviously "passionate" about my work.

It's a word I struggle with. You can be passionate about a woman. Catholic friends have talked long into the night, over far too much drink, about, "the passion of Christ." It's a word that is often over used.

Some words that had a strong meaning are hijacked and over used, to somehow increase the weak meaning of a point. Politicians, they're often doing it. Politicians are presented with a statement of how they cocked up. How do they respond?
"Erm, yeah, bit of a mess I made, wasn't it?" Nope, never.
"Hey, it wasn't my fault!" Sometimes, but then politicians in power have responsibility so it's their fault or their bosses, so it's not a response we see so often now.
"I deny that!" This used to be a common response. Whatever some half arsed journo dreamt up as a claim, it's just dismissed and brushed aside. Doesn't sound convincing or drawing a line under it, though.
"I refute that!"
My.
It's refuted.
A refutation, what is that? It's much stronger than a denial. It sounds clever and impressive and definitive, how can the conversation possibly continue once the debater has refuted the argument you've contended? Your argument, by definition, has been proven false.

Of course, they say they refute the charge, but they don't offer the evidence that then goes beyond explaining and suggesting and incontestably provides the necessary proof that they're right.

But still, politicians continue to say they "refute" a claim instead of saying they "deny" or "don't like" a claim, despite this being more accurate. Refute is carelessly used by politicians and is becoming a weaker word through such use, soon to lose it's definitive meaning of proof and simply be a posh way of saying deny.

I like a range of words, with subtly different meanings.

So is it right to claim to be passionate about work? I love David Mitchell's rant about passion because it's exactly how I think. Passion is a word that's vastly over used.

But then I saw a video about an astrophyscist who's the Director of the Hayden Planetarium in New York. The clip is here, the site is here, click When I Look Up. Okay, maybe some people are passionate about their job, their speciality, their field, their work . . .

Offence

2010-06-26T10:05:00.001+01:00

'It's now very common to hear people say, "I'm rather offended by that", as if that gives them certain rights. It's no more than a whine. It has no meaning, it has no purpose, it has no reason to be respected as a phrase. "I'm offended by that." Well, so fucking what?'
- Stephen Fry

Genius.

Nursing levels

2010-06-24T11:40:00.004+01:00

There has been a lot of discussion about inadequate staffing levels. It's abundantly clear that having too few qualified nursing staff on wards compromises patient care and results in more deaths. The evidence consistently shows this. Accounts within clinical practice consistently illustrates this. Patients admitted (and their course, with some unnecessary deaths) consistently experience this.

It's therefore not surprising to me that when the Healthcare Commission investigated shabby care in hospitals, they found ward staff to be good, but management systems not supporting them (through cutting costs and not staffing wards with adequate numbers/adequate qualified staff). Subsequently the Care Quality Commission (CQC) have done the same. The CQC regulates hospitals, challenging them on quality and services. How deeply have their investigations and reports rocked managers worlds?

Has it changed anything in practice?

We learnt of the woeful outcomes at Mid Staffordshire NHS Foundation Trust with the report stating :
"It appears that some staff from whom we heard were often demotivated, undervalued and working in an understaffed and stressful environment"
"The staff who worked on these wards all agreed that there was a shortage of nursing staff."
"We heard these wards were significantly short of nurses, especially at nights and weekends."
"Some staff expressed the view that there were insufficient nurses before the reorganisation and that there were fewer after."
"Many witnesses noted that there were too few nurses and that those that were there were doing their best in difficult circumstances."

The Mid Staffs report described good nurses doing the best they could. To my knowledge, nobody was reported to the NMC for poor professional practice. Nor should they be. They worked as well as they could within the environment that managers generated for them. Indeed, the independent and detailed investigation found and documented that the nurses worked inordinately hard and beyond their duties, putting in huge effort to care for their patients.

The issue wasn't poor nursing, the hospital was fortunate and had great nurses. The issue was the the hospital, to save cash, didn't staff the wards with enough nurses (i.e. qualified staff) to keep patients safe. How huge is that. Not that there weren't enough nurses for gold standard care. Not that there weren't enough nurses for reasonable quality care. There weren't enough staff for safe care. Patients needlessly died.

But time's moved on.

Things surely have improved. Lessons learned. Erm, sadly it seems not. Scarborough looks to be operating in a scarily similar manner to Mid Staffs.

So it goes.

This week I read a new report by the CQC. This is dear to me, since it's about older adult mental health services, within a Trust providing mental health services. Not mine, I may add. The CQC are positive about the Trust. "The Trust has cooperated fully with us during the course of our enquiry . . . the Trust has not waited for the publication of our report. It has proactively started a process to improve its mental health service for older people."

One unit was terrible (and closed), the other units were fine.

So it's a decent Trust, with decent units, providing decent care. The management structure quickly made management changes and 'fessed up to shoddy care, investigating things themselves and reporting themselves to the CQC and making changes themselves. All genuinely poisitve stuff, the way the Trust behaved really does seem sound.

Most of the problem seems to have been one unit which was doing quirky things which nobody knew about. Things like using strong opiate analgesics inappropriately and hooking folk with dementia up to syringe drivers to control agitation. This was a huge error in governance which the Trust raised it's hand up and sorted out. Grand.

So the Trust, a decent Trust, find an area of rubbish care, sort it out and 'fess up to the CQC they've been rubbish, they're investigated and all's seen to now be okay.

Apart from one area.

Page 30 : "We looked at the relative costs of nursing staff against the trust’s spend on senior managers and managers for the years 2005/06 to 2008/09. Our analysis showed that while the spending costs for qualified nurses had dropped over that period from £26.1 million to £25.4 million and for unqualified nurses from £14 million to £12.5 million, the costs for senior managers and managers had risen from £4.5 million to £6.8 million"

"Our impression as we visited the older people’s mental health inpatient units was of highly dedicated ward managers, nurses and nursing assistants working under constant pressure. On more than one occasion, we came across ward managers who were trying to do their best for their patients with too little resource and fearful that they had not covered every aspect of patient care and the management of their ward."

Page 52 : "We found that members of staff working in these clinical effectiveness and risk roles in the trust appeared to have a good grasp of what needed to be done but were frustrated by the lack of effective systems to enable them to feel as confident as they should around overall clinical governance and compliance."

The CQC evidence that the wards were understaffed and staff knew what needed doing. And the Trust board spent a lot on management and moved from generating loss to generating surpluss. What have the Trust done to support nursing colleagues on the ward?

They closed the ward. They appointed a lot of Modern Matrons. They appointed a Director of Nursing.

Okay, I'm sold that they need the Director of Nursing but the Board minutes reporting ". . . outstanding concerns against overspending on in-patient wards and [the Director of Finance] pointed out the need to ensure optimum ward rotas," leaves me cold. More nurse management, less ward nurses.

The pages on community staff levels, case loads of 27.2 cases/staff is a whole post in itself, with community resources and practice meritting discussion. But to stay vaguely on topic, suffice to say that governance of ward process and staffing on the in-patient ward lead to grim patient care.

How many Trusts are staffing in-patient units well? How many Trusts are staffing in-patient units, if not well, at least adequately? Gah. So it goes.

Read the report from the CQC and see what you make of it.

NHS Costs

2010-06-23T17:31:00.004+01:00

There's been much discussion on the blue/gold government's health policies. Rightly so. It's serious, it really really matters and it's possible to cock it up, spectacularly, if they get it wrong.

Some areas, such as qualified nursing staffing levels, have been poorly resourced in most in-patient and many community teams, for years. What will the new "austerity measures" mean? For our Trust we're already uneasy, with no uplift from any of our PCT commissioners this year, so we're having to do more with the same amount of cash (but inflation means we of course have less). And, of course, we're still obliged to make cost reduction efficiency savings each and every year, trimming off literally millions from what invariably are our staff costs.

Local and regional "stretch targets" mean we lose millions if we don't meet the quality targets (and evidence that we meet them). We won't. We can't meet some of them. Others, if we did meet them, it'd cost more to do that than we'd get paid. So we're destined to lose cash that historically has been part of our base income. Even less cash to pay our staff with. Not good.

Although it looks ugly in Secondary Care, in fairness it looks uglier elsewhere. My poor colleagues in Primary Care are being pushed into a corner. Instead of seeing patients and providing clinical care, they're going to be expected to commission services from providers. With the best will in the world, how could 30 consortia get different services from our Trust? Would providers tender for activity from a single practice if that GP practice wanted services that couldn't be easily provided? Will a Trust provide "loss leading" services? Our Trust has declined work from a PCT that's invited us to undertake activity, but won't pay us enough to consistently break even, so even with large amounts of cash from a PCT we're saying no; what influence will a group practice have? I do not know. But the GPs I know are not enthusiastic about having to sort out all this commissioning nonsense for all their patients for all clinical community and hospital and acute and mental health activities. At the moment, GPs are independent. Unlike a PCT, or SHA, they're not directly accountable to the Department of Health. If they commission quirky services, is there any accountablity? Not at the moment. Will GPs be brought into an accountability framework?

It doesn't look fun to be be sitting in GP land, right now.

The government quite rightly is looking at management costs within the NHS and thinks too much cash is spent on management. They're right. It is.

Slimming down Whitehall to do less and tell us to do less, such as disbanding oodles of targets, has to be a good thing.

Slimming down the regional Strategic Health Authorities (SHAs) seems a fair plan. Less intrusion and more cash saved.

Slimming down (or almost getting rid of) local Primary Care Trusts (PCTs) has left my PCT colleagues in a state of anxiety. Sadly, in all honesty, I'd not miss much of the PCT if they went. I'd miss the PCT pharmacists who are dynamic, sensible, pro-active, helpful and clinically focussed. But much of the managers and their committees and generated paperwork doesn't make quite as much impact on the district's health provision as some might imagine. Certainly the cash thrown at the buildings and staff and operation of the PCT doesn't seem to deliver wondrous value for money. But I concede I don't see all they do.

So the central DoH, the regional SHAs and local PCTs are all in the firing line. None of this seems bad, to me.

GPs are to have more duties, responsibilities (and accountability).
This does concern me, since most GPs I know aren't keen on this and aren't equipped to do this.

Secondary Care providers continue to provide secondary care.
Phew.

Could have been a whole heap worse, dismantling front line services. But to be hitting the tiers of management actually is a positive intervention that can save money, reduce intrusion and improve how GPs and hospitals deliver care.

I remain optimistic.

Death

2010-06-15T09:24:00.004+01:00

I saw a lady who'd tried to kill herself, pretty seriously, with paracetamol and strong opiates and alcohol.

After being ventilated and coming out of intensive care, it was clear she wasn't clinically depressed. She'd had low mood through relationship changes, chronic pain, changes in health, her GP'd started an antidepressant last year but it hadn't helped. A sensible thought to try one, but not surprising it did nothing, given she was low in mood through reacting to grim life situations, not through endogenous clinical depression.

We talked for an hour and a half. She wasn't mentally ill. She was psychiatrically fit for discharge. She went home to her husband with numbers of our crisis team (which she'll never call) and an appointment with our psychologist, which hopefully will afford her changes in perspective, acceptance and alternative ways of coping that're useful, enabling her to feel she is equipped to manage.

I stopped her antidepressant. Sometimes suicide isn't about clinical depression. Sometimes it's not a mental illness, sometimes it's a choice. But I hope she'll choose a different way.

Work

2010-06-14T11:50:00.004+01:00

I've a wife and children so am not a workaholic, I arrive at 8.20am or a bit earlier and leave when I can, which usually is before 6.00pm. At home I do end up doing a fair bit of work on nights, usually generating presentations or reviewing/ammending policy documentation or teaching materials or interview questions and model answers or Continuing Professional Development, so there're many extra hours of work there, too. I guess that's almost 10 hours a day at work, plus an hour or two most nights at home, making for a reasonable investment in time whilst trying to keep a decent work/life balance.

On top of this there is on call work, out of hours. As a doctor approved under section 12 (2) of the MHA 1983, that means all Mental Health Act work comes to me, out of hours. Since junior doctors can't do liaison psychiatry now, all hospital queries come to me, too. A&E and police seem to like to have my point of view, too. Our in-patient wards have junior doctor support, but these doctors have to discuss pretty much everything with me (eg they're not allowed to prescribe anything off licence . . . which pretty much makes up all out of hours prescribing decisions).

Whilst on call I'm just waiting to be hassled by anyone and everyone. It is not restful. There are many calls. Unlike many Consultant colleagues in the acute Trust, I frequently have to go out to see a patient in the middle of the night. Not uncommonly, several patients.

In one recent week on call I had 21 hours sleep over 5 days, averaging a touch over 4 hours a night.

Against the background of working something like 11 or 12 hours a day anyway, the nights on call are a real kicker. Still, I'm paid £3.17 an hour for this (less 40% tax then other deductions), so for £1-something an hour I'm certainly not doing it for the cash.

Investing blood, sweat and tears into a vocation you're passionate about is commonplace amongst my medical colleagues. I could hug Nurse Anne for, in an inadvertent comment lost at the bottom of a thread of much more important themes, reminding folk that doctors invariably work very very hard. Bless her cotton socks. *hugs*

Nonsense

2010-06-11T00:19:00.002+01:00

I had a message left with my secretary from an orthopaedic ward. It was about a post op elderly patient who'd fractured her hip and was profoundly confused, apparently throwing hot tea and drinks at people, pulling out lines and battering the staff.

I 'phoned up the ward, who know me well, and spoke with a staff nurse, saying I'd received some info about a patient causing havoc and could I make arrangements to review her that afternoon. I gave the nurse the patient's name (which was quite common) and asked for identification details (date of birth, NHS number) so I could see if we'd any past details from CMHT, GP, memory therapy or memory clinic contacts.

The nurse said she couldn't give me that information.

"So you're referring a patient to me, but you won't tell me who they are?!"

"Sorry, it's the policy . . . seems a bit silly, doesn't it?"

You couldn't make it up.

Charities and groups

2010-06-09T20:08:00.003+01:00

Do you have much to do with charities and groups?

Odds are you do. Is seems there's been thought about hospitals and charities on blogs for a few years now with some 1530 hospital Trusts having charities. Whether charities should be paying for MRI scanners and the like is a valid question, with different views having been aired.

As well as hospital charities, there're other charitable groups. In my corner that boils down to the Alzheimer's Society, MIND and Age Concern. They tend to contribute an incredibly useful and independent role in offering supporting information, shared perspective and emotional support from peers, which NHS services can't (and shouldn't) compete with.

Local hospital charities. National special interest charities. What of patient groups? I'm enthusiastic about most of them; one of the best conferences I've ever been to was an annual Hearing Voices Network international conference. The patient perspective was so clearly and powerfully and helpfully presented I didn't even blinch at the emphatic liberal use of "survivor" instead if "patient" since it was so congruent with the account. Perspectives shared in presentations and workshops and over pints on an evening changed my views on mental health care more than any training or placements or CPD ever did. I even gleaned more on the consideration and use of therapeutic interventions there than I did in any other conference. I'm uncomfortable with minority patient groups misrepresenting majority patient groups e.g. patient focus groups who insist on being called 'clients' or 'service users' have ingrained this into national dialogue, because a vocal few have demanded this. Yet local consultation with 4 patient groups and 2 carer forums and Alzheimer's Society groups in 3 areas found the prefered term was 'patient' from all parties, which fits with a paper published in the psychiatric bulletin that proactively asked people what they wanted to be called and got 'patient' back too. So a small very vocal minority group have changed things in a way that's at variance with local and national evidence.

That's undue and unfair and unhelpful influence.

But apart from this tiny, tiny issue of vociferous minority groups misrepresenting majority views, I'm all for patient groups and advocacy for change for the better. So if there's independent thinking, helpfully generating constructive challenge or interjecting alternative viewpoints, why am I uneasy about the Kings Fund?

Although founded in 1897 as an independent charity essentially to look at better hospital care in London, it's now a behemoth that asserts that they ensure, ". . . independence and expertise remain at the heart of we do."

What is the heart of what they do, you may ask. They tell us. It's about how they, ". . . play a special role in shaping policy, developing effective practice, and supporting individuals and organisations."

Superb.

Policy with implemented effective practice, independently generated by experts, what's not to like? I met with and spoke with folk from the Kings Fund, their passion and motivation was self evident. Their message and the change they're effecting was crystal clear. Inspired independent change being joyfully and enthusiastically progressed, what's not to like?

Well, it's just that more than a small part of me feels intense disquiet that it's not really that independent. In fact, isn't it all well represented either directly by Department of Health workforce (directly or indirectly through Select Committee or quango appointment), or private health company presidents, or Monitor, or other interest groups. So not independent at all. Indeed, they're placed to advance either government policy or the interests of private healthcare companies, yet overtly state they're independent. Grrrr.

I note that cleverer folk spotted this before me in December last year.

Much badness.

Hospitals

2010-06-03T18:41:00.005+01:00

Times are changing. Allegedly. Although maybe not changing an awful lot, since our PCT 'fessed up today that the money the SHA has given them for the implementation of the National Dementia Strategy, not being ring fenced, has been swallowed up by other stuff and spent on other things. So it goes.

Cash that could have been used to improve dementia care therefore's evaporated and the acute Trust down the road grumbles along, despite the national picture reported by the Alzheimer's Society showing that, well, it's all a bit shabby.

Is there any hope, then? Locally, the acute Trust is working with us and is keen to improve. There's a lot of work to be done, though. For example, the DoH have accepted Prof Banerjee's report and recommendations around antipsychotic prescribing in dementia care. 180 000 patients with dementia on such drugs with only 36 000 getting benefit rightly raises concern that prescribing practice needs to be more robust. How're things to improve? Exceptionally and very hearteningly, there's no requirement for more committees and no desire for more management. The report requires that Medical Directors and existing governance structures deliver on this. Deliver on what? Just one bit of one recommendation is that the Trust has to ensure good practice in initiating medication. And ensure good practice if it's maintained (e.g. a patient comes in on it and the hospital ward continues to administer it to them). And ensure good practice in discontinuing medication. All sensible stuff.

What's intrigues me more is that in addition to the clinical quality improving, there Trust has to ensure this is done. So just bashing out some protocols or care pathways or policies or naming a couple Dementia Champions or Medicines Management Champions or Lead Practitioners or having a standard operating procedure or drafting guidance ain't enough. They need to ensure that the system works. First the clinical care has to improve, then evidence of this meaningful implementation needs to be generated. Without more managers or committees or nonsense.

Having met with PCT and LA and colleagues today, I am hopeful. But the acute Trust having to do this, with no new cash 'cause the PCT snaffled it . . . somehow this seems less than ideal.

Lifestyle

2010-05-28T00:36:00.002+01:00

Care Pathways

2010-05-27T22:37:00.003+01:00

I saw a patient with dementia. He was wandering on evenings, couldn't manage his money any more, couldn't sort food for himself and couldn't maintain his property adequately.

He was seen by a CMHT nurse and myself. Assessment was clear. CT imaging confirmed atrophic change. A diagnosis of a neurodegenerative dementia, almost certainly Alzheimer's disease, was made. He had 16 interventions made on his care plan including Council Tax exemption, advice to sort out two LPAs, getting his will sorted, a monitored dosage system, reducing meds, benefits check, three Home Care visits a day, DVLA notification and selling his car, Social Work follow up to review care schedules, nurse visits to family for carer education and support, telecare for a pendant alarm and to alert family if he's opening doors after 10.00pm, an FP10 for galantamine, ongoing follow up for review, day Memory Therapy Services for CST, follow up with me for titration/review of Rx, advice to him/his family on local Alzheimer's Society resources. Usually we provide decent care for folk with dementia, a regional report has us as a beacon service. All well and good.

I saw a patient with dementia. He was wandering on evenings, couldn't manage his money any more, couldn't sort food for himself and couldn't maintain his property adequately.

He was seen by a CMHT nurse and myself. Assessment was clear. CT imaging confirmed vascular damage. A diagnosis of a vascular damage was made. The care pathway is then refer to Primary Care to manage, who can refer to neurology and stroke outreach if necessary (who have no social work and no community services, at all). He had 2 interventions on his care plan, basic advice given and discharge to Primary Care.

Somehow, for both people to have the same sort of experiences, yielding the same consequent deficits, but profoundly different support, stirs disquiet . . .

Zarathustra's musings

2010-05-27T18:27:00.000+01:00

Well, he has me intrigued!

Being recognised

2010-05-24T21:58:00.002+01:00

I don't live in the locale I work within so don't often see folk out of work. Although last time our team went out and I was rather the worse for drink I did meet a few patients' relatives who came to chatter with me, but they could hardly stand up either, so I don't think much embarrasment was held by either party. Phew.

Got me thinking how some time ago I did meet an elderly patient, when I'd popped out to the shops at lunchtime to buy a sandwich. I was in the shop, in the queue, when a patient marched over and very loudly shouted out, "Ooooh, hello doctor!" and came over to give me a tight hug. I said hello and 'cause we were in a busy place didn't really want to ask her anything personal so simply opened with a polite and genuine enquiry, since she's a friendly chatty woman who the whole team hold a lot of warmth and affection towards, asking whether she was enjoying the great weather we were enjoying, that day.

She then shouted out, she has such an incredibly loud voice, that she wasn't doing too badly at all and had just had her hair done, having to get out of the house 'cause she'd seen childrens' faces in her walls leering at her and voices from her smoke alarms telling her that her (dead) husband's, "A mean fuck who should burn and die."

I stood in silence, aghast, pondering how to respond. Everyone paused, the world stopped. The shop stared at me, waiting for the doctor to deal with the crazy lady.

You could see everyone around her taking a few steps back. For some perverse reason, that really irritated me. She shouted at me, "Ah, but I don't bother with that today." She paused and grinned at me and told me the same thing she tells me each and every time. "It's my schizophrenia!" She's always been a straight talker with me and my, do I love her for that.

I couldn't do anything but laugh, hug her back and loudly say something along the lines of, "Well it's cracking that it's not upsetting you today, you're feeling bright and cheery, and all's well with the world!" Maybe it was the utterly banal chatter we shared and the manifest lack of concern I showed. Probably it was the total lack of worry and the gesture of hugging her. Who knows. The shop let out a collective sigh, folk realised they weren't about to be axed, the world turned again.

She probably did more there to challenge views of schizophrenia and stigma than I ever could.

Acute Wards

2010-05-19T17:14:00.004+01:00

I do work on medical and surgical wards, covering liaison psychiatry for older adults in the acute hospital.

Things ain't great.

Medication is accidentally omitted (oddly, never reported to the NPSA despite their alert on this issue).

People are left lying in urine.

People are left unfed.

This happens every day.

Rather than plan person centred care, Wellness Recovery Action Plans, sophisticated dementia care and the like, basics need to improve. They're not poor because the wards are poor. The nurses and HCAs aren't turning up to work full of wickedness, intending to do a bad day's work. The crunch is that they're understaffed.

As an outsider seeing this, and not someone they can sack, it's been easy for me to raise this with their management structure. Which I did. They took note of the serious concerns raised, the unacceptable standards of care, care at variance with national guidance and the risk generated for their Trust through suboptimal care. Excellent. So what's happened?

They now have Modern Matrons charged to make it better, but they've no resources (at all, no extra time, no teaching time, no money, no staff, nothing). But because it's such an important issue, the Modern Matrons must ensure that Dementia Champions are trained. They don't have a view on what these Champions will do, but the Trust needs to have some, so staff have to be removed from the ward for training (but there's neither cover nor a training budget for this training). Failure will therefore be a ward level failure, with the managers having given strategic direction and solutions. Hmmm.

How will the Trust be sure that things are in place? Nurses will check. Except the senior nurses, who 2 years ago were seeing patients, now don't. They now "support the governance framework" through checking things on clipboards are ticked off and done. This drives them to distraction, they're band 8 nurses, not band 3 clerical support, but that's what the Trust requires of them. Tick, tick, tick.

So when there's a clinical problem, the solution was remove nursing time from the ward and remove senior nurses to do surveys/tick boxes, compounding the problem of a lack of hands on ward time.

My, how my colleagues in the acute Trust live in interesting times.

More on medication

2010-05-08T09:29:00.003+01:00

Drugs have a really important role to play in mental health care. They can cure people. They can make symptoms disappear. They can keep people well for years, when without them their lives are in bits. I've seen this time and time again, with patients feeling they're doing well on medication and feeling/showing they're doing badly without.

Maybe it's because of this that use and review of drugs matters. It's not a simple "drugs are good" message. Medication is good, for some people, some of the time.

How do we know who it's good for? We don't. We guess. It's an informed guess, but it's still a guess. Sometimes it's pretty clear that medication can have a useful role to play (i.e. it is "indicated") but that's different from knowing it's going to work and should be continued.

How often does a patient continue medication over the long term? It's not meant as a rhetorical question. Really, I'm inviting you to speculate. In the teams that I lead and I'm the only doctor in them, so all prescribing decisions come through me, we have in the ballpark of 5000 direct face to face patient contacts/year. 96 a week. How many patients, each week, have medication put on repeat prescription? Take a moment and have a guess.

We did an audit on oral medication use over the last 3 months and it surprised me. It excluded depot antipsychotic injection, which is long term medication so I'll 'fess up that there are 5 patients on long term depot. But apart from these 5 folk who wish to continue on depot, how many of the 96 contacts/week result in repeat prescriptions of medication?

The thing with drugs is it's not all about just one thing. The indication needs to be right and as the posts below describe, "depression" isn't good enough. Nor's "clinical depression" or even a DSM-IV "Major Depressive Disorder" diagnosis. Because management is guided by accurate formulation. Presence or absence of somatic symptoms has major implications for whether an alerting (help get up from bed, have some energy) or sedating (help stop worrying and get some rest and restorative sleep) and on use of medications over time. Psychological factors and social factors impact on psychological and practical interventions.

Meaningful assessment takes some time. Quite a lot of time.

From this, if medication potentially has a part to play, it's offered and started and doses are fiddled with and it's reviewed. If it's not working it's stopped. If it is working and side effects/risks are absent/tolerable it's continued. It's continued by the GP, so all longer term management is prescribed through Primary Care.

Which takes me back to the audit. Rather than just a short term intervention that our service prescribes and I'm involved with through assessment/medication use/review, the number of patients having repeat prescription from the GP was audited. All activity for 3 months was reviewed. Many, many patients had trials of medication. Often it was stopped. Often it was fiddled with by me, so I kept prescribing since doses and drug combinations were constantly changeing.

So how many did pass back to the GP for longer term prescribing of a stable medication dose regimen?

Of the roughly 96 patient contacts/week, 1.92 patients/week had a repeat prescription. It's not that many. We spend so much time prescribing and fiddling with drugs and reviewing drugs, it's only on review of the big picture that we see that drugs aren't a major longterm feature for most.

That surprised me.

Blood

2010-05-06T12:13:00.003+01:00

I learnt something new today.

I do most days, mostly from nurses, but on this occasion it was after our monthly team CPD (continuing professional development) meeting. We'd rattled through a discussion of recent papers and how they should affect our practice, we noted the bias of one review and chewed over how we were doing with NICE guidance. We discussed depot olanzapine's evidence of what the pharmaceutical company report as a "post injection syndrome" and how everyone else calls it "a coma" and how this seemed bad.

It was noted that I brought a number of abstracts from British and US journals but nursing colleagues didn't. Yet they're very interested in the 10 minute discussion of each paper, grabbing the headline messages and learning points, with their "care pathways" having changed for the better over time through considering new research and reviewing what we do. A number of articles and papers have been published by us over the last year. If nurses embrace new research (in a balanced and critical way) then adopt the good bits, why aren't they sharing lots of papers at our monthly meeting?

It's all down to what's valued. Consultant Psychiatrists have time set aside each week for CPD. Nurses do not. Nurses are told what to adopt and articulate how they're not given time to provide even basic nursing care. I wonder how many nurses have time for CPD in their week? Do any have time to browse web sites, muse over abstracts, download papers and read through NICE, DoH and other advice, guidance and direction? I know of no nurses who do.

So for a hour a month we do it ourselves, rattling through a couple papers (no more than 10 minutes on each, just to distill what the issue was, what the paper shows us, the weaknesses of the paper and how we then could use it in our work) and any new guidance and obstacles to good practice.

At least this means we've a fighting chance of spotting quackery that's increasingly peddled in more mainstream literature. Like this, which I learnt of today. Live Blood Analysis (LBA). You take a spot of patients blood, both you and the patient just look at it on a big screen for 2 hours, you see stuff move and decide what this means. Such as, "Look at those moving, they must be alive, you have parasites in your blood, take this herbal medication that's expensive but look at your blood, it's so worth it."

A Dr Rubin looked at this and found no papers on LBA in the scientific literature. None. Yet there were 2.5 million hits on Google. Interesting. Someone's advertising and making a lot of money from this LBA thingy. So, does LBA work? Is the scientific community elitist and simply ignoring a helpful diagnostic intervention? Actually, no. It's pseudoscience and doesn't work.

That's a helpful paper. I've learnt today of a new entity, Live Blood Analysis, and learnt of rigorous review of LBA which found it to be so much stuff and nonsense. Which is worth knowing.

Should I charitably tag this post as "Complimentary Therapy" or should I generate a new tag of "Fraud" I wonder . . .

Homeopathy

2010-05-01T10:49:00.007+01:00

A number of people, indeed most, will look at options of self management, which is a good thing. Some will be desparate and try things which have little benefit. But hey, what's to lose. Some will be even more desparate and try things that have little benefit but cost money. Hmmm.

Complementary Therapy has had bad press, because much of it that is useful is understated (since it's obvious and now mainstream rather than "complementary" to maintstream practice) so it's the more extreme claims that are pushed. Which invariably aren't valid.

The bottom line is that sensible people try stuff and find it doesn't work very well.

"Herbal medicine has been around for thousands of years, indeed it has, and then we tested it all and then the stuff that worked became 'medicine' and the rest of it is just a nice bowl of soup and some pot pouri."

"Well, science knows it doesn't know everything, otherwise it'd stop."

"I'm sorry if you're into homeopathy; it's water! How often does it need to be said, it's just water!" and, "The great thing about homeopathy is you can't overdose on it. Well you could fucking drown!"

Not very politially correct at all, but pretty darn amusing :

More drugs!

2010-04-28T17:54:00.003+01:00

Although an American publication this year alluded to the message, "Drugs, just say no!" as discussed below, there's new news.

The British Medical Journal last month published a clinical review paper on, "Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants."

What did it show us?

It showed us 3 things.

1) We're prescribing more antidepressants.

They assume this is because people are prescribed them for longer (because that's what they found, so they're right). The assumption is flawed, though. We prescribe more antidepressants in the UK and USA than we did in 1993 because over the last 17 years prescribing practice has changed.

People with generalised anxiety disorder, adjustment disorder, post traumatic stress disorder and somatoform disorders used to get pretty rubbish drugs. If you had such a problem, with "neurotic" and not "psychotic" problems, and weren't clinically depressed, you often didn't get an antidepressant or antipsychotic (since you're not depressed or psychotic) so got an anxiolytic. Diazepam. Or another benzodiazepine of choice. They were liked because they worked and melted away distress well. Then, years on, problems emerged and subsequently "antidepressant" medication is commonly used in the management of anxiety states. Anxiety states often endure, hence such medication's needed for a long, long time.

Use of antidepressant medication's gone up not necessarily through changes in management of depression, but because "neurotic" disorders are managed with such medication now, instead of dishing out nothing or benzodiazepines.

2) If you continue on medication, you do better

Relapse rates are lower. Antidepressants drugs reduce the rate of relapse, significantly. Hurrah!

The drugs also cause side effects which are common (e.g. at best 24% and at worst 80% of people on antidepressants developed sexual dysfunction).

Stay on the drugs, but get side effects most of the time. Hmmmm.

How many do you need to treat to prevent relapse? They looked at that, too. 4. So for every 4 patients you keep on an antidepressant long term, 3 get no benefit and 1 won't experience a relapse they otherwise would. 3 have no benefit but all the side effects, 1 has benefit and side effects. Hmmmm.

3) The title lies

"Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants" is misleading. It suggests that the paper is about people with depression being on antidepressants long term and although most have serious/unpleasant side effects and for 75% it won't help, for 25% it will be beneficial.

Sadly not.

To their enormous credit, the authors do 'fess up to this. This is because the published papers have significant bias. Rather than taking people with depression, half having antidepressants and half having placebo, then seeing how they do over time (a randomised controlled trial), the studies reviewed were "discontinuation trials." This means that the (usually drug company sponsored) research involved getting a group of people with depression and giving them an antidepressant. Any who didn't respond are then excluded. So of your 100 depressed patients, it may well be that half got better anyway and a third didn't benefit from the drug, so only 10 patients progress through to the trial. What the "discontinuation" bit means is that the researchers then discontinue the antidepressant medication in half the people it's helping and swap them onto placebo.

So a more accurate take on this very good and detailed systematic review of 31 trials, mainly/all discontinuation trials, is :

"In patients with depression, who respond well to an antidepressant, continuing the antidepressant over a longer time (e.g. 12 months) can reduce risk of relapse for 1 in 4 patients."

It's not quite as catchy a headline, though.

Meh, maybe the drugs still don't work quite as well as we'd wish, or as pharmaceutical companies would lead us to believe. But at least if I've patients with chemical clinical depression, who respond to an antidepressant, and have a relapse, then this paper supports the ongoing use of an antidepressant over the longer teerm (over years). And that this works well, halving the risk of relapse. That's good news. It's certainly something folk will welcome, who've shown clearly that the antidepressants work well for them, as robust evidence that it's worth continuing and shouldn't be taken off them!

Antidepressants

2010-04-21T11:14:00.004+01:00

Drugs work. They do. They can be very, very helpful indeed.

But as Richard Ashcroft of The Verve penned, regarding the effect of drugs on his father dying of cancer when he was 11 years old, "and I hope you’re thinking of me, as you lay down inside, now the drugs don’t work, they just make you worse, but I know I’ll see your face again."

We think drugs work well. But for an 11 year old boy, reality hit hard, seeing his dad die and drugs fail to change things.

Drugs work, but drugs aren't miraculous.

Having a discussion on this is always contentious. There are two wholly valid reasons for this. Firstly the statistical evidence can be challenged/critiqued/appraised. Secondly experiential learning (of having drugs and being cured/being worse) gives valid and wholly accurate evidence that they're brilliant/harmful. These two sources of information, aggregate trial data of large numbers and single patient therapeutic trials with an n of 1 both give different perspectives and facts, both supporting enthusiastic use/reticence to use antidepressant drugs.

DeeDee's comment stirred my thoughts on this, again.

Like any meaningful, complicated, multifactorial issue, in or out of health care, a dichotomous "this is good" or "this is bad" doesn't really work. Much as it's cozy and comfortable for a newspaper to publish that antidepressants are great and patients are missing out through not being properly treated, or antidepressants aren't wonderful and patients have shabby care through doctors dishing them out inappropriately, the truth is more complicated. Newspaper headlines can't be complicated. Many newspaper articles need to be timely, snappy and simple so can't be complicated. Complicated health issues (with personal and socioeconomic consequences) aren't easily discussed or debated in mainstream media. The issues are left to wither. So it goes.

If I was to be horribly reductionist and come down with a quick and easy message my thoughts'd be that antidepressants can work well as part of a package of care for some people some of the time so the message would be, "Use antidepressants appropriately and get it right!"

Which isn't massively helpful.

The crux of it is that it's incredibly useful for individual patients, as DeeDee describes. Or it's unhelpful/harmful for individual patients, as others describe.

Beyond patient numbers, we get the same pattern. Drug companies have had to evidence efficacy (that the drugs work) to get a marketting authorisation to sell their antidepressants. Clinical trial data shows that the drugs work in clinical trials. Out of clinical trials, in the really real world, a study this year published in the Journal of the American Medical Association showed that antidepressants work no better than placebo in mild, moderate and severe depression (with benefit emerging just through very severe depression).

This means if you're a GP seeing someone with mild, moderate or severe depression you're informed that, statistically, prescribing an antidepressant for the patient sat in front of you will have as much effect as prescribing placebo. Yet, clinically, some patients respond brilliantly.

It's a flaw of evidence based medicine that effects which are uncommon but highly significant for a small number of people get diluted/lost in the trial data. Trials aren't usually sufficiently powered to evidence statistical significance through rare but highly meaningful events. This is even more true in looking at clinical effectiveness of treatments (i.e. how it works in real clinical practice) rather than trials of efficacy (rigid clinical trials with strict patient inclusion/exclusion criteria).

In the really real world, outside clinical trials, people have low mood. A lot. Most people with low mood do not meet ICD-10 diagnostic criteria for clinical depression. Most people with low mood do not have a somatic syndrome, common in chemical (functional, endogenous) mood disorder. For most people, chemical solutions (of antidepressant medication) therefore has little benefit. Which is what patient and trial evidence, and clinical experience, shows us.

Yet, for people with chemical mood disorders, psychosocial interventions have some but modest utility and chemical treatments (or treatments effecting chemical changes in the brain, like ECT) can work brilliantly.

Antidepressants therefore have a very important and very valuable role to play, but in a very defined subgroup of people who have a mood problem. Of all those with mood difficulties, those with endogenous chemical depression do well. Those with reactive depression, feeling depressed because of events, responding (as most of us would) with depressed mood to a depressing situation, are low in mood through their situation not their brain chemistry, so plying medication 'pon them unsurprisingly effects little benefit.

Gets you thinking.

If appropriate and successful drug treatment hinges on accurate diagnosis and subtyping of diagnosis (it's pretty robustly evidenced and understood that chemical functional mental illnessness of ICD-10 recurrent mood disorders and bipolar disorders merit antidepressants) then is it fair to ask GPs to do this?

In older adults it's even more complicated. Loss of health, role, mobility, opportunity, income, friends and family is common in older adults we see. There's often been a lot of adversity. If life's not peachy, should folk be feeling peachy? Then, as well as loss events, there're cognitive changes. In neurodegenerative dementia like Alzheimer's Disease the limbic system, controlling mood, is always affected before memory is. Everyone with Alzheimer's Disease has brain damage affecting their mood area of the brain so frustration, irritability, low mood and changeable mood is common, before even accounting for the changes in their life that dementia causes. Teasing out if older adults have a mood disorder that's sufficient to attract an ICD-10 diagnosis of clinical depression isn't quick and easy. Determining if medication has a role to play is complex.

Our APC and PCT's been wrestling with this. Clinical care is one consideration. Cost of the drugs is another. So the question last month was, "Is it fair to ask GPs to initiate antidepressant medication, or should this always be undertaken within specialist care?"

I'm sure nobody will be bold enough to answer it.

IAPT

2010-04-16T10:44:00.003+01:00

The Improving Access to Psychological Therapies (IAPT) programme is seen in different ways.

Okay, I chide myself to remember as Billy Shakespeare penned in The Life Everlasting, "There is nothing good or bad, but thinking makes it so," yet I still think of IAPT and think, "Yes, but . . ."

It's a big "but" too. A really big arse of it all. Because IAPT piques me.

I had the fortune to work with pioneers (they really were called pioneers) who pilotted IAPT and wrote up how ace it all was. Of course, it wasn't, but who could present their work as a failure when their career/credibility and national policy and being seen to do something positive was necessary?

Subsequent external criticism and internal comment from IAPT workers 'fessing up that it's a service which is self-selecting the "worried well" generates concern. Why? Because IAPT uses a "step tiered" model and, arguably, uses it in an unhelpful manner.

If you're having mild problems, in theory there's "watchful waiting" but in practice these individuals who have contact with IAPT and then over time get better are evaluated by outcomes which suggests that IAPT have facilitated the recovery of someone who, through waiting, got better anyway. Okay IAPT may have a role in surveillance, but to argue that IAPT have improved this person's wellbeing in a meaningful and cost effective and active manner is rather overstating the case.

With mild and self limiting problems being seen within IAPT and then getting better, in spite of (rather than because of) anything that is done, simply through time passing and people recovering, IAPT claims success. Again I think it's disingenuous to suggest IAPT have major impact here because, of course, mental health services aren't amazingly brilliant at curing folk. Shock, horror, but usually we're good at facilitating improvement, hurrying along restoration of wellbeing as nature takes it's course, giving support to make things more understood whilst processes are unfolding, but by and large interventions aren't as miraculous as people would wish to believe.

People had depression before there were antidepressants. People got better. Effectiveness of antidepressants were reviewed in the Journal of the American Medical Association this year and found to work as well as placebo in mild, moderate and severe depression, with drugs only starting to work better than placebo in very severe depression.

We know that drugs, psychological therapy and ECT can help with depression for some people, some of the time. Some people get stunningly good results. Would paying for a good holiday help people with mild depression feel better? Probably. Would talking with IAPT mean that, 2 months on, things were better for someone with mild problems? Probably. Would not talking with IAPT but talking with friends/having a moan/challenging your boss/getting more sleep, mean 2 months on, things were better for someone with mild problems? Probably.

IAPT is attractive to politicians, it's seen as delivery of psychological therapy to large numbers of people. The presence of such a programme then satisfies the desire to do something, to have something.

But what of the process, what of the content?

The people usually have telephone advice. My patients have not felt listened to and heard and understood. IAPT screens for suicidality every contact. My patients weren't suicidal so felt that asking questions that weren't relevant meant they clearly weren't being listened to, with their agenda/needs not being addressed. This switched them off IAPT so much they disengaged. I asked IAPT what had happened in their care, after their GPs referred them to us. In 3 cases IAPT replied that the patient had worked with IAPT and, having made progress, then no longer needed contact. The patient sees their contact with IAPT as an unresponsive self-serving protocol driven process that's not helping them, with failure, resulting in GP contact and referral to mental health services. IAPT report it as a success with a positive patient outcome. In all 3 cases the patient was going through a normal bereavement and didn't need specialist psychological work or medication, yet IAPT couldn't support peoples' mental wellbeing through a normal but unpleasant time.

IAPT should, in tier 3, deal with "high intensity" need such as severe depression and PTSD delivered by CBT trained therapists but they don't. They say they're complex patients who need specialist services so turf them to us.

Mild, self limiting problems are seen within IAPT and reported to do well. Patients who drop out with bad outcomes are seen by IAPT and reported to do well. High intensity severe problems are part of IAPT's role which they fail to deliver on but since it's their role and they've no failures (referring them all) they report they do well.

IAPT therefore paint themselves as stunningly successful, seeking expansion and resourcing. There's only finite cash. Colleagues have described how psychological therapy that was historically accessed in Primary Care or Secondary Care no longer exists because IAPT has consumed those resources and is seen to meet the need, so alternatives aren't commissioned/delivered.

A cheap and cheerful high volume largely telephone advice protocol driven service, to meet most of the psychological needs of most of the patient population needing help . . . I can't help but think it's all gone spectacularly wrong. But we've an election, so I'm sure since the NHS and spending and return to work and family life are such big issues, parties will be offering us choices, no?

Erm, no.

So it goes.

Fridges

2010-04-15T15:53:00.003+01:00

How do you practice psychiatry in hospitals, and clinics, as folk in the USA mostly do, with folk who have dementia?

I ask in the spirit of genuine inquiry since I find visiting folk at home to be a core and wholly necessary part of work. The bit that's most useful is, of course, the patient's fridge.

It's always good to look in a fridge, I find.

There's the opportunity to see what food and drink's in it. One once was stacked full (so full you couldn't see the fridge light at the top) of beer. An opportunity to talk about alcohol use and the amount drunk.

One had nothing in it but milk for tea and plasticky cheese slices. An opportunity to talk about diet and opportunistic health promotion.

One today had a mix of things. Greens, mostly. But not in a good way. The fridge was filled with food that was covered in green fur. Or, on some of it, black mould. In addition to the varied diet of mouldy food (the food long since obliterated so I've no idea what it originally was), was what Withnail and I would call, "matter."
Just semi solid stuff, composting down, with dark greenish black fluid seeping out of the bottom.
An opportunity to talk about a suboptimal level of function.

You can look in a fridge and see if food's out of date. "What is the date today, is this in date?" An opportunity to test orientation and decision making, without abstract instruments irrelevant to our patients but instead with tests of ecological validity.

Using fridges works too. "Fancy a cup of tea, doc?" "Why yes, thank you kindly, I rather would." Do they go straight for the tea or hunt around several cupboards for it? Do they sequence with cold water in the kettle, then heat it, then mix hot water with tea, leave it to brew (but not for too short or too long a time), place the hot tea in a cup, add milk, all in the right pace and order? Is there a tremour? Do they get muddled? Is the milk in date? An opportunity to talk about organisation and sequencing.

Seeing someone at home, seeing what's in their fridge and how they use it, beats 20 minutes of questions in clinic any day!

Desperation

2010-04-09T19:07:00.003+01:00

A couple of patients a day are seen within the acute Trust down the road by our liaison psychiatry service. I am involved in all of them, managing all referrals and seeing many folk on medical and surgical wards.

All is not good.

Again I've had a week of misery and depression and despair. Mercifully, that's not my patients. Nor my team. Nor myself. The low mood and low morale and consequent, "fuck it all!" attitude is increasingly pervading the acute Trust's wards. Staff are desperate.

This is bad.

If staff truly weren't bothered then they'd not care. They'd turn up, do their 37.5 hours a week, go home and collect their pay cheque and repeat it all next month (or a few days into next month, after taking a few days off sick, 'cause everyone does, right?). But no. They're mostly concientious, frustrated staff who want to do a good job, want to do things better but feel impotent.

As many folk have articulated, Nurse Anne better than most, the bottom line is that the medical and surgical wards simply don't have enough qualified nurses and support staff to deliver clinical and practical care, now. Modern health care needs staff to do a lot and to do it well. You need good staff simply to do the work. What else is our work? Almost all "work" in the NHS is an interaction (direct or indirect) between a patient and a practitioner. Fewer staff, fewer interactions, less meaningful activity and less purposeful healthcare. Quality falls. Care becomes shabby. Not because staff are bad but because there aren't enough staff to do the work asked of them.

Liaison psychiatry used to be about both proactive presence on wards/in A&E to improve how things were done and reactive response to referral requests to sort out specific goals or issues that had to be managed through liaison psychiatry input into in-patient care/couldn't be picked up by mental health services on discharge.

That's changed.

Now ward staff on medical and surgical wards are less interested in what liaison psychiatry assessments are. They're less interested in how formulations can impact on care plans. There's less interest in advice on how care can be more person centred to be more effective in delivering personal care/interventions. There's strikingly less interest in rationalising drug regimens and reducing psychotropic medication use. Ward staff see me on wards now and, with faces filled with desperation and despair, simply wish for me to make patients' problems go away, or take the patients away, or both.

As clinical care is causing me more concern, not because staff are bad but because the Trst doesn't have enough nurses on wards, as the election looms nearer, I find myself thinking more and more of a post I've bookmarked from a year ago by Dr Grumble on NHS spending. It's sobering stuff. It seems that the NHS spent 7 billion quid, in 2008, on Primary Care. In the same year it spent 12.6 billion quid on management of the NHS. That's excluding each hospital's management costs. Grim reading. NHS managers in Strategic Health Authorities or DoH or "support" roles cost much, much more than all we spend on Primary Care in it's entirety.

It's a scandal.

It's a scandal that's affecting patient care.

If as a country we need to save squillions, I know where I'd be making "cost efficiency savings" and I know where I'd be enriching front line care. Too many managers. Too few nurses. Loss of half the managers would only improve things in my world. That's 6.3 billion saved. Let's use just half of that to pay off national debt, since we're altruistic folk in the NHS, and ring fence just 3.15 billion for more ward nurses.

It's a policy I'd vote for.

Clever nurses

2010-03-26T12:02:00.003Z

All liaison referrals from the acute hospital come to our liaison team. The nurses (who do almost all the work) discuss every patient with a Consultant Psychiatrist (erm, me). This matters to me. The nurses are excellent at mental health assessments. It's what they do. More, they're excellent at sharing with nurses and managers on the acute wards how to manage their patients.

My input is sometimes into the psychiatry, but usually into the medicine. They are, after all, so medically/surgically unwell that they're needing hospital in-patient care in a hospital that never has enough beds. Medical problems often contribute to presentations, medical interventions can contribute to solutions.

So, a mental health nurse and I explore the issues of every referral.

This results in odd side effects. One side effect is that my nursing colleagues know me well enough to know how I think and the sorts of things I think of and what I like to sleuth out.

A patient was referred last week with low mood and onset of mild confusion. I'd not normally accept such a referral but won't disclose the reasons why we did. Suffice to say, my nursing colleague picked it up and sorted it out. We discussed the referral, she saw the patient, she met with me to discuss it and explained her thinking. The patient was weary and low because they were in hospital (and didn't want to be), were in severe renal failure (and didn't used to be) and critically was digitoxic.

Her high digoxin levels, presumably either caused by changed renal function, or by staff administering it to her regularly (when she'd been less compliant at home) had resulted in dangerously high blood digoxin levels, which explained her symptoms she was referred with along with other symptoms which she had. A previous patient, on digoxin, had resulted in me checking their levels (which were normal) so my nursing colleague had learnt from this and considered the digoxin in this case. The medical team hadn't noted that. They'd not even requested digoxin levels, my nursing colleague had.

A good pick up.

I think my nursing colleagues are very clever :-)

Perfection

2010-03-25T13:01:00.004Z

Do you like speaking to an answering machine, to leave a message? It seems that most people don't. And yet talking down the 'phone to leave dialogue on a machine that reproduces what you say, perfectly, should be seen as a good and reliable way to communicate. Better than the alternative of leaving a message through just a few words of text, surely? But no, most of us choose to text a few words (despite how fiddly it might be) rather than leave a voice message, just talking, which should be a more natural and effortless and familiar way to be.

Machines, even those which are perfect at what they do, don't always deliver sweeping changes and aren't always warmly embraced.

How desirable is perfection?

Common sense says it's got to be a good thing, right?

Clinically, in mental health we often strive for "good enough" or "as good as can be" rather than perfection.

Our machines have loftier aspirations.

It seems that every ECG machine now wants a perfect reading. Anything less than perfect is flagged as abnormal. Indeed, it's printed out, "Abnormal ECG," along with conjecture as to why. Almost always it is normal. Or normal enough. Not something that a doctor would document as "abnormal" anyway. But unless it's perfect, the ECG machine chews out paper documenting "abnormality" which causes no end of stress and nuisance.

I really do want to do something quite gratuitous to it's rusty innards.

Sometimes I don't want perfection, I want normal.

Teaching Hospitals

2010-03-23T10:32:00.003Z

Where's the best place to get care? Where's the best place to work? Both are related questions; if you have a happy, motivated, enthusiastic, valued workforce then you're much more likely to have a better quality service and receive good care as a patient.

I've worked in many hospitals, through medical school training, then 2 more as a House Officer, then more whilst I trained as a GP, then more as I trained as a psychiatrist. Many different hospitals in different counties.

It's something that usually you come almost come across by mistake rather than by conscious design . . . do you favour working in a local district general hospital, or a big teaching hospital? At least as a professional I've the choice. For patients, especially if needing involved and ongoing care, we all invariably have to go with what the local service is. You might be referred to foreign parts for your specialist heart surgery or spinal cord stimulator or infectious diseases opinion, but if you're after a community mental health nurse, support worker, social worker, psychiatrist, pharmacist and psychologists' input a few times a week with ongoing contact over months/years, you're invariably not in a position to get that from far away. Private medicine doesn't do it well, either. You get to see a Consultant Psychiatrist (if not fobbed off) but how do you get input from the other disciplines? When a team contributes to care, so half a dozen folk add to it each week, it's a fearsome bill to generate each week in Private Practice. Having a menu from private companies and picking off just one bit (like a Consultant Psychiatrist or a CBT therapist) will work for some people some of the time, but isn't a sensible or coherent way to generate a service.

I don't do any private work so for me it's not an issue, but the point remains . . . for mental health care, usually it's only practical to have an NHS team involved and for this team to be local to you.

Is a teaching hospital a better place to be, then?

This issue is in my mind because, curiously, a family moved last month from their current city (and teaching hospital) 30 minutes up the road to my corner, specifically to have mental health care from our Trust. One relative needed appropriate dementia care (which they didn't think they were getting in the teaching hospital), one younger adult needed ongoing care in the management of a mood disorder. It's not uncommon that patients have strong views about their GP and seek to remain with good ones they trust (much as the Government seems to believe otherwise).

As well as a patient relocating to be under my care, I also had a supranumerary flexible trainee wish to work here. That surprised me anyway - how many bright young things are zealous to work in old age psychiatry?! But her rationale was seemingly sound. As an older graduate who was more reflective of her training scheme than most, she found that a teaching hospital usually wasn't.

She found that a teaching hospital, in striving to be a centre of excellence, had lots of people trying to gain experience so she was often displaced. More importantly, she'd found that a teaching hospital was driven by research, not by teaching. Teaching added nothing to the researchers' day, and indeed detracted from their research time. Jobbing clinicians were the poorer brothers to the Senior Lecturers and Professorial teams so had disproportionately larger workloads and couldn't find hours a week to teach. It's a valid point. Teaching hospitals usually are research hospitals and are not necessarily at all good at teaching.

Got me pondering.

Is a teaching hospital automatically a desirable place to train (when teaching can be scare), work (where publishing research competes with investing time in teaching/clinical care) or receive care?