Communication

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

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

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

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

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

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.