Insight

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

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

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

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

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

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

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

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

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

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.