Wednesday 30 January 2008

New Ways of Working

"Noctors." I'm grateful to Dr Rant for this rather splendid neologism, used to mean a non-doctor doing a doctor's role.

This is a recurring theme that's deliberated 'pon Dr Crippen's comments forums by patients and GPs and NHS staff as well as by the good Dr Crippen himself.

"New Ways of Working" (NWW) is a movement that happily arose from psychiatrists, doctors working on the shop floor, who wanted to be able to do the psychiatry bit more and lose the non-doctory bits of work they'd got by mistake. Psychiatrists were a bit like rubbish bins, everything could get tossed their way when it got hard for someone else, they were the default container for all stress, risk and woes so accumulated roles and tasks that were nonmedical and nonsensical. Doctors felt they'd so much of this gubbins that they couldn't crack on and see their patients so dreamt up the NWW proposals. This makes NWW appealing 'cause it's medics driving it, not the Department of Health or whoever.

Dr Crippen commented that, "I have never seen a psychiatrist with a stethoscope but fortunately this one has one."

I find this worrying! If Old Age Psychiatrists aren't looking at physical comorbidity then :
- who will?
- why are they psychiatrists if they're not acting in a medical role?
- won't patients miss out through nobody else having the time to do so?
- won't medical care be poor?

Who will?

If psychiatrists don't consider their patient's physical health and undertake physical examinations then a "noctor" will. This would be A Bad Thing for patient care.

Medical Role

If psychiatrists aren't working as doctors, why have them? Prescribing guidance can be proffered by pharmacists, holistic care is the remit of nursing staff, optomising function falls to physios and occupational therapists, talking therapies go to CBT practitioners and psychologists . . . what do you need a psychiatrist for?
If we're not working as medics then rather than CSIPs helpful views of New Ways of Working in mental health (which has doctors doing doctor things and non-doctors doing non-doctor things and never the twain shall meet) we move to the unhealthy model of doctors doing less and "noctors" doing the doctors' work principally 'cause it's cheaper.

I like the notion CSIP advance of a psychiatrist being able to be a psychiatrist all the time and not do work that others can do just as capably/better, but that a psychiatrist is key to doing what psychiatrists do best.

Part of this is sleuthing out relevant physical comorbidity either causing or arising as a consequence of the patient's mental health problems. Part is looking at complex drug regimens. Part is looking at the biopsychosocial elements and formulating care balancing risk/benefit in all domains. Part is the diagnosis.

Nobody but nobody is trained to elicit symptoms of psychopathology, cluster these and ascribe significance to them except a psychiatrist. On this basis alone, a "noctor" can't replace what medics do.


When my GP colleagues see a patient with a new problem they've about 12 minutes to sort it all out. When I see a new patient, I've an hour at a minimum, if seen at home I can spend longer.

It's simply not possible for a GP to go through a history in the sort of detail I can, then undertake relevant physical examination, so psychiatrists surely should be examining patients since we've the resources (in terms of being medically trained and having the time) to do so.

Medical Care

If I examine a patient I find things. This is good. 1 in 12 causes of dementia are reversible. Unless I look for them, who will? I'd see looking for physical (treatable) conditions with neuropsychiatric sequelae as our remit, and if psychiatrists don't address these then it doesn't get done. Patient care would be the worse for that.

Delirium kills people. Crack your hip, go to hospital, get it fixed, all is well. If on the otherhand you have an episode of delirium (an acute confusional state) whilst having your hip sorted, your chance of death in the next 12 months is 40%. Which is high. 40% mortality is hard to ignore, especially given that delirium is commonly caused by treatable elements but orthopaedic wards miss it (failing to spot most or almost all of it, depending which study you believe). It's better to have psychiatrists addressing problems like delirium, since if we don't hordes of folk die. A "noctor" can't consider the breadth of conditions impacting on a confused patient simply because they've not been trained to do so.

As regular readers know, I'm slavishly devoted to multidisciplinary team working, I love my nursing colleagues, I'd not be able to do my job as I do without them and patient care would be worse. How I see it, though, is that medics and nurses both work differently through NWW. Nurses (or others) never take on the role of a doctor and doctors don't take on roles they don't need to.

Monday 28 January 2008

New Ideas

I've been spending a lot of time with therapists of late.

No no no, I've not been going under quite yet, it's simply that we've had to generate business cases for more therapists, then job plans for them, then job descriptions and adverts, then interview questions and model answers, then the interviews.

Through this process it's been evident that Cognitive Behavioural Therapists (CBT) and Cognitive Analytical Therapists (CAT) have, for a good while, been preoccupied with (mindful of?) the concept of Mindfulness.

Since about 2000 it's been described in terms such as, "Mindfulness is a technique in which a person becomes intentionally aware of their thoughts and actions in the present moment, non-judgmentally."

It's a sort of acceptance (and mindfulness is at the foundation of Acceptance and Commitment Therapy).

It's been enthusiastically embraced by many clinicians and patient groups because intuitively it makes sense and because its roots are old (thousands of years old, linked to Buddhism and Sufism) so it's neither someone's new fangled get-rich-quick fad, nor a Government edict to change and try this for the sake of being seen to do things differently. Plenty of evidence supports its theory, application and outcomes.

Still, you've got to wonder, although it's been in vogue for 7 or 8 years now, it's not a new idea at all. Is it seen in EastEnders or Corrie this year? No, not yet, but it was foisted 'pon the masses over 400 years ago :

". . . for there is nothing either good or bad, but thinking makes it so."
- Hamlet, Act II, scene 2

Thursday 24 January 2008

Criminal Conduct

I've spent the last few months working with criminals.

No, not the patients. Us, the staff. My colleagues, and me.

We receive referrals from our neighbouring acute hospital Trust. They've an endless stream of delirium, dementia, depression (and placement issues and capacity assessments) to sort out, frequently with disturbed patients battering their staff. We accept the appropriate referrals, we go to their hospital, we can't park, we return home. But sometimes, just sometimes, we get to see their patients. We speak with the ward staff, read the notes, meet the patient then document our contact contemporaneously in their medical records in keeping with the GMC's direction, "Good Medical Practice" document, Good Clinical Care, "In providing care you must . . . make records at the same time as the events you are recording or as soon as possible afterwards."

I heard today from a Caldicott Guardian (the chap responsible for protecting patient information) from another Trust that the Data Protection Act makes this unlawful. We can't read or see or use their notes at all. Clinical details of their Trust's patients (including referral details) are protected by the Data Protection Act. It's unlawful to rummage around in them.


Wednesday 23 January 2008


A patient became unwell. She was admitted with F31.20 Bipolar affective disorder, current episode manic with mood-congruent psychotic symptoms.

Her manic episode had left a swathe of destruction behind her. Her house was trashed. Her and her neighbours' gardens were trashed. Her car was smashed up and is no longer road worthy. She'd spent slightly over £10000 on goods that were then not wanted and given away. She offended friends, carers, family (including her hypomanic daughter who's also an in-patient) and folk in her locale. When she regains insight and has to face the legacy of her manic phases she's invariably incredulous and ashamed in equal measure.

She ended up under my care by chance. I'd never met her before, she was under the care of general adult psychiatry but when she became manic they felt she was best managed on old age wards (she's in her 70's) than their wards so I took over her care.

One element that's emerged is she's financially exploited by her daughter who'd taken over £100000 from her accounts over the last 5 or 6 years. Her social worker thought this was okay since the daughter, "would get the money when she dies, anyway."

She's now had adult protection meetings (through PoVA) and her finances are, now, protected.

Her daughter will, indeed, gain her entire estate when she dies. But, 'til then, it's hers.

The pragmatic approach of social workers in the local area teams is presumably a helpful trait for them to function and get things done. I know that the evidence of what we'll see over the next few months for our patient won't be any different now her money's protected (she won't be any iller or healthier, she won't have more or less stress, her activities will be unchanged). I know that the long term outcome for my patient is poor (she's in biventricular heart failure that physicians can't control), she will die and her daughter will get everything.
Despite this, the pragmatic approach of letting her be exploited, even though it had no massive tangible impact, was anathema to me and the rest of the mental health team.

The more I experience of mental health and social care communities working together, the more I see social care doing what they believe is pragmatic and mental health services doing what they believe is right.

Thursday 17 January 2008


I met with a young patient who has dementia (F00.02 Dementia in Alzheimer's disease, early onset, severe) and his wife.

They'd had a chequered course before relocating to be with family, so moving in to my patch. They've input from social services, our local Alzheimer's Society branch, myself, my nursing colleagues and a Support Time and Recovery (STAR) worker. The patient's never been to hospital, we're all pretty community focussed and see them there to give advice (no Council Tax to pay, get Attendance Allowance etc), to give emotional support, to give practical support (our STAR worker visits once a week to care for him so his wife can pop out and get a break), to offer other helpful ways to cope (they're starting day respite with us tomorrow), to answer queries (this week they were wondering why his walking up stairs was worse) and to look at medication.

His MMSE is 2/30, his dementia is severe. Donepezil is being used to treat Behavioural and Psychological Symptoms of Dementia (BPSD) not to maintain cognitive levels any more. When his MMSE dropped from moderate to severe the donepezil was withdrawn. He became upset, irritable, distraught and withdrawn, shouting and resistsing personal care. When re-introduced he became active, animated and appreciative (most of the time) of his wife's input. The donepezil is doing the man good.

Now, with so many people involved, a lot of information was gained before I met with him and his wife. What was embarassing for the senior nurse was that the medication she said our patient was taking, "Just donepezil," wasn't quite true. She and I saw them this week. When I was talking about mood swings, irritability, frustration emerging when attending to ADLs and forgetfulness, his wife chipped in that she gave him an antidepressant they still had lying around, "but only once or twice a month." He also received over the counter medication for coughs, colds, constipation and pain too. The nurse was scarlet, couldn't believe that the history I got was so different from what she's ellicited just a couple days ago after spending 2 hours with them. I'd not see it as a big thing, they spoke at length with her about practical care but spoke at length with me about symptoms, progression and medication.

I remember as a junior doctor the injustice of me taking a lengthy history then my patient saying something different to my Registrar or Consultant. People do, though. It can be that going through things once then raises more thoughts. It can be that stirring thoughts around in that direction leads on to more detail and depth when asked again.

Anyway, one outcome from me spending an hour with them talking through their dementia care was that he regularly wasn't swallowing his medication. I don't feed at the trough at all, I don't take anything from drug companies (not even biros). But credit where it's due, their orodispersible donepezil is A Good Thing. She puts it on his tongue, it instantly melts and dissolves, all is well.

Without medication, he's unwell. With it, life's better for him and his wife. The medication's formulated in a way that folk with severe dementia can take it.

Much goodness.

Monday 14 January 2008

Being ill

I saw a lady at her home who'd taken to her bed and stopped eating. Her GP asked a Community Psychiatric Nurse (CPN) to see her at home because she was depressed. On reading the referral she seemed to have significant infirmity so the nurse and I went to see her together, with her family, to sleuth out what was going on and what we could do to help.

The patient was not well. She'd lost a massive amount of weight. Lying in bed, breathless and gasping, with open leg ulcers and a cough, she looked profoundly unwell. Her mouth was dry and had oral candidiasis (thrush) in it. She was clinically anaemic. She had focal signs in her chest suggesting a left lower lobe infection. Her lungs were over expanded, pushing her liver down. Her abdomen was tender. She was clinically dehydrated.

She was too breathless to talk with me in anything other than two words at a time. She said she was thirsty but was too tired to sit up to drink and had to be helped up.

Her mood wasn't great but, really, it was the last thing her family or the CPN and I were worried about. Her GP had seen her the day before (and then initiated the referral) and had her district nurses visiting daily to dress the leg ulcers and had arranged a mattress to reduce pressure areas.

The CPN and I spoke with the family about depression and how we would treat that where ever the patient was (at home or on a medical ward) but that her physical health was causing us concern and this needed addressing, rather than just treatment or admission under our care.

We left and I 'phoned her GP and explained what we'd found (that she was physically ill and not needing urgent psychiatric input at present, but I'd happily follow her up where ever), the GP arranged admission that afternoon. 3 days later she died on the medical ward.

Wednesday 9 January 2008

Weight Gain

I just saw a chap who's got a diagnosis of F31.7 Bipolar affective disorder, currently in remission.

He's been stable whilst I've been looking after him, over the last few years, but had frequent relapses prior to this (necessitating frequent and lengthy hospital admissions) which caused a wake a devastation through his life each time he became manic. He was handed over to me stable after starting lithium and olanzapine.
Weight gain, how much should we do to address this?

We meet up, despite him being well for years now, simply because he's on lithium and wishes to see me rather than his GP. 6 months ago we had a conversation about weight, he'd been gaining substantial amounts of weight and was asking to stop his olanzapine. He lives with his brother. On talking through why he might be gaining weight, I felt his brother's splendid cooking and the 6 pints of ale a day with no exercise at all may contribute something to his weight gain. He agreed to eat his brother's meat pie just once a week at most but try for once a month and reduced the ale down to 3 pints a night on just 3 nights a week. He walks to the pub, and shops, to get some exercise too. Informant history and support workers corroborate that he's managed these sustained changes successfully over the 6 months, with a commensurate reduction in weight down to normal (for him) once again.

So there we have it. From pie and chips most days, with 84 units of alcohol a week, down to the odd piece of pie once a month and 18 units of alcohol a week, whilst being less sedentary, is successful. And has to be better than fiddling with the chemistry.

Tuesday 8 January 2008

It's all about MEE

Well the new glossy Tooke Report is out, have a read of it here.

Their 2 new recommendations seem to be :

1) Recommendation 46, be aware of the European Working Time Directive and look for a more flexible way to manage this.

2) Recommendation 47. Lose the roles of the Postgraduate Medical Education and Training Board and have a new body (Medical Education England, MEE) that, "interface between policy development and implementation" and "coordinate coherent advice to Government" amongst others. See pages 64, 65 for the details.

I've spent time reading through this (and I'm slightly bitter that I've wasted time that is now gone and I'll never get back again, ever) but have yet to understand the implications or benefits to junior doctor training of having MEE. Can someone clever explain it to me?

Monday 7 January 2008

Health and Social Care

What is the role of health care? To indulge me in this musing, consider health care in its broadest sense. The World Health Organisation defined health in 1946 and formally adopted it in 1948 within their constitution as, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Their take on mental health remains broad and holistic, specifically stating that mental health is more than the absence of mental disorder.

So let's consider mental health across the health and social care communities, across primary and secondary care, across voluntary and statutory organisations. What should we all be doing to optomise mental wellbeing?

Mental Nurse postulates that care should be given to those being responsible. In comments last week, E mischievously said that payments for sex should be entertained.

Increasingly I find myself generating management plans for community patients that are broad, varied and comprehensive but are less "doctory" and biomedical. But there has to be a limit here. If I've a patient who doesn't thrive at home but would do better living in the Hilton for weeks on end, all expenses paid, this doesn't seem to be the right way to spend tax payers money despite it reducing risk, optomising physical, social and mental wellbeing and consuming very little staff time and cost.

What should be done to effect optimal mental wellbeing whilst operating an equitable and financially viable system?

Maybe it's the small things. As Linus to Charlie Brown, "The way I see it, every baby born should be issued a banjo."

Thursday 3 January 2008

Free Care

The NHS, notionally, is free at the point of contact.

Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.


Health care is delivered without charge.

But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.

If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.

But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.

The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.

Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.

The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?