Thursday 30 October 2008


After a run of poor communication on my part 'pon various blogs, it's got me rattled.

T'interweb is a great resource but happen my banter on mental health matters, without explanation or context, is too easily misconstrued. Or maybe it's just that I'm better at talking things through rather than writing things down.

Happy to chatter through emails with folk who've got my address.

Anyways, time for a blogging break and a bit of reflective practice.

Safe roads, one and all!


Over the last few months I've had a rather significant number of folk who've had insight but haven't wanted it.

Several people with dementia have been on treatment for this which has maintained their thinking, memory, concentration and function for a goodly length of time.

As time's marched on, their deficits have progressed. They know they're losing their memory. They know they're losing their attention span. They know they're losing their orientation. They know they're losing their organisational skills. They know their decisions are less considered. They know their function is deteriorating (e.g. no longer being able to dress themselves since they can't manage shirt/blouse buttons). They know they're losing weight since they don't appreciate feelings of hunger/satiety so much now. They know their mood's got worse, being pretty glum and anxious. They know they can't recognise friends they see less frequently now.

Their dementia is progressing. They know.

This insight causes feelings of disquiet, of anxiety, of frustration, of dismay.

This has resulted in a slew of folk wishing to stop their medication, since it was holding them in an unhelpful place, where they had memory problems yet had insight and couldn't forget the woe. The burden was unpleasant. They sought to be relieved of that, to be allowed to forget.

To a one, they've all faired better from stopping their medication. Of course, their cognition and Mini Mental State Examination scores are significantly worse, but they're all, all much more relaxed and less distraught. The knowing is less.

Just sometimes, the loss of memory can be a blessing.

Tuesday 21 October 2008

The tail wags the dog?

Having established that all those doctors are evil, wicked, tyrannical baby eating terrorists who drop gum, talk loudly in cinemas, fail to prevent earthquakes, park in disabled spaces, caused global warming and, through their salaries, have caused a global financial disaster and credit crunch, I set out to see just how ghastly these 'orrible medical folk are.

In November 2006 the BMJ published details of a MORI poll showing what 2000 random adults thought of different professions :
- 92 per cent of the public trust doctors to tell the truth. This is higher than the rating for any other professional group included in the poll.
- teachers 88 per cent
- professors 80 per cent
- judges 75 per cent
- clergymen/priests 75 per cent
- politicians and government ministers 20 per cent

"Doctors will be incredibly heartened to hear that they continue to earn their patients’ trust. These figures once again demonstrate the importance of the doctor-patient relationship and patients will find this trust of enormous value when they attempt to navigate the many changes affecting their health care."

Hats off to the BBC who reported this, but also reported the bottom of the poll which before today I'd not been aware of :
- Business leaders, 31% of the public trust the, they're actively not trusted by 56%
- Politicians Trust, 20% of the public trust the, they're actively not trusted by 72%
- Journalists Trust, 19% of the public trust the, they're actively not trusted by 72%


MORI do the poll every year and the BMA share results this year, which are good :
- Doctors, 90% of the public said they trusted them to tell the truth
- Teachers, 86% of the public said they trusted them to tell the truth
- Professors, 78% of the public said they trusted them to tell the truth
- Judges, 78% of the public said they trusted them to tell the truth
- Clergymen/priests, 73% of the public said they trusted them to tell the truth
- Politicians, 18% of the public said they trusted them to tell the truth

In 2003 MORI conducted a separate survey of politicians’ attitudes to doctors. It found that three quarters of MPs (74 per cent) believe doctors are patient-focused, as opposed to self-centred (18 per cent). Most MPs have a positive view of doctors working in the NHS. They see them as committed (92 per cent), hard-working (87 per cent), and vocationally driven (74 per cent). As well as believing they work effectively (82 per cent) the majority view doctors as helpful (83 per cent). Almost as many MPs as members of the public trust doctors to tell the truth (89 per cent compared to 92 per cent).


Right then. Doctors think they're concientious and have their patients' best interests at heart and know what's best for their patients. MPs agree. Lord Darzi and the DoH reckon we should have a "clinically driven" service. The public reckon politicians and business and journalists can't be trusted but doctors can.
Pretty clear to me who should be deciding how health care's implemented and delivered then, isn't it?

Friday 17 October 2008


My nursing colleagues are underpaid. I know this. I don't see medical colleagues as over paid. Compared to peers, some psychologists seem overpaid for the work they do. OTs seem better paid than nurses, for what they do (since nurses do more, see more patients, put in more hours, carry more responsibility and have more to achieve). But this kind of "they get too much money" isn't a helpful position to hold.

I don't often read The Times, but after clicking a link on Jobbing Doctor's site I started rummaging around The Times online, by mistake.

It has annoyed me. The Times says that CEOs typically earn £212,910 and, ". . . are the head of the business . . . will answer to a board of directors."
Useful information, okay. Leadership but accountability, a fair comment to account for their salary and balance this with this comment of the framework they work within.

They move on to City Brokers, average pay is £94,293. "The City broker is usually portrayed by the media as a scary man screaming and gesticulating manically. They are in fact qualified professionals who buy and sell shares on behalf of investors. To become one, a person is required to pass the Certificate in Securities from the Securities and Investment Institute."
Great! Challenging stigma and negative media portrayal, they frame the broker as a qualified and professional responsible soul.

Then they move on to doctors. Average earnings £81,744. A group who've been savaged by the Government for reluctantly accepting the deal the Government imposed upon the profession. So it goes.
What is The Times view on this? Like City Brokers, do they redress this negative portrayal with some sensible perspective or comment?
"The salary of doctors has been high up the political agenda lately after the Government introduced new contracts that many outside observers regarded as overly generous."

Many see it as overly generous.

Maybe I should give up and just join the massed throngs and throw rotten tomatoes too. Bastard doctors.

Tuesday 14 October 2008


One of my nursing colleagues was discussing with me how she'd seen a lady in a care home who was distraught. The lady would often shout out, incoherently. When family were with her, she was settled and fine.

The nurse worked with the home to understand why the behaviour was arising and if there was unmet need.

She worked with the care home to look at if she was hungry or thirsty or needing assistance in mobilising or toileting, addressing practical elements of care.

The nurse sorted out analgesia for her, four times a day, over one week, to see if pain was causing her distress. It wasn't, so she suggest stopping the analgesia and things were neither better nor worse.

She arranged with District Nurses to have blood tests undertaken to exclude common causes of delirium.

She visited when the lady was distraught and told me, "Her blood pressure and respiratory rate and pulse were all normal."

In order to ensure the patient was communicating and not anxious, she'd thought to look for signs of autonomic overactivity consistent with an anxiety state, checking pulse etc.

I'd never have thought of doing that.

Some people are so clever. Very impressed.

Saturday 11 October 2008


The Jobbing Doctor has been musing over 50 folk who've been said to shape the NHS in recent times. I thought I'd share my thoughts of a woman. Fear not, I'm not about to wax lyrical 'bout affairs of the heart. Mental health I do, agony aunt I do not. But to flirt (ha!) with affairs of the heart for one moment, if I wasn't married and Nadine Schofield didn't have a partner, I could whisk her up and hug her.


Well, she says all the right things that get me excited.

She's passionate about older adults getting exceptionally good care. She's not just feeling strongly about it, she's vocal and active in effecting change too, with tangible results for the better. She challenges, without compromising and capitulating at every turn, yet without being stroppy and unreasonable and unrealistic. Over the last couple years we've crossed paths at a number of conferences and I've always been stunningly impressed by her. She speaks enthusiastically and with has real insight . . . a woman who can present well and who's got sensible, salient, contentious and vital content to deliver. Vital in the true sense of the word (i.e. in maintaining vital signs, reducing mortality) rather than in a management "this is what I think is awfully important this month" sort of vital.

She collaboratively developed the Lets Respect campaign which is just starting to gain prominence in some acute Trusts as more of us bang on about it. Particularly those doing a lot of liaison psychiatry for them. John Holmes should also get an honourable mention here, promoting older adults mental health needs within a mental health Foundation Trust that's providing liaison psychiatry input to another Foundation Trust that's historically had a somewhat modest mental health agenda.

What's been pertinent of late are her views that services hould be equal. Fine, that makes sense, is hard to argue against and sounds fair. Nadine's point is that we need to develop services that are appropriate, which means that equal does not mean the same.

To explain, if younger adults have a service to deliver mental health care if they present to A&E, then older adults should, too. If younger adults have services to support them in crisis, then older adults should too. Of note, this doesn't mean that younger and older adults all get the same service.

Why not?

Because just as "equal" does not mean "the same" so "the same" is not "equal."

Say I change my practice such that I could honestly say that I give the same service to all my patients. Every single patient is seen in the same location. Every single patient is given the same amount of time. Every single patient is seen by me. Is this an equal and a fair service? If everyone has to be seen in out-patient clinic and folk can't get there, that's not fair. It's an un-equal service already. Everyone's seen for the same duration, but what of the people who need more time to grasp and explore and understand? I see everyone so there's Consultant input into all care, but I'm British and speak English. So everyone gets an equal, same service, but if managers were to prvocatively say you choose not to speak or understand English then though you're getting the same service regrettably you'll not understand a thing, so is it a fair service? Not good, huh? Giving the same service to everyone isn't patient centred and doesn't address individuals needs.

This is why I like her awfully compelling argument that services should be equal so whatever your age or ethnicity or social class or gender or whatever you get the right care for your needs. Which through necessity means that services will have to be different in order to optimally meet needs, since different groups will have different clinical needs. Patients I work with typically have very different mental health problems, physical health problems and social adversity compared to child & adolescent or learning difficulty or forensic or general adult or rehabilitation psychiatry patient populations.

Thus, older adult services should be discreet and different from other mental health provision.

The DoH mantra of "cradle to grave" psychiatry and "needs based" services (so if you're depressed at 16, 46 or 86 you get the same team sorting out your mood problems) is flawed.

Thank goodness there're sensible and effective folk like Nadine telling them so.

Friday 10 October 2008

Age concern

Why isn't this publicised more?

Wednesday 8 October 2008


The Girl with the Blue Stethoscope has posed an interesting comment.

"What kind of proportion of your work is made up of patients with dementia and related conditions?"
Probably about a third to a half of my work is dementia related.

"What can you do for them if (as in this case) medications won't help?"
Ah, now that's what is of interest.

My starting point would be that lots can be done by a great many people. What can I do, well that's a much more modest thing.

As a doctor, when medication won't help, and I can't change the underlying process at all, my role is mostly explanation and psychoeducation, with a touch of patient and carer support thrown in too. The biggest thing I do, typically, is to involve the right colleagues.

When someone has dementia they need advice on a lot of things (initial assessment letters often run to over a dozen points for various folk to act on). After this, input is provided according to need.

My stab at the simple answer of what's done could be that, "appropriate patient centred health care and social welfare is provided with dignity and respect."

The complicated answer is that we need to understand the person, we need to understand them very well indeed.

It's easy in mental health to see a behaviour and attribute this to mental illness. Normal behaviour can become pathology all to readily. The way to challenge this is to understand the behaviour. The behaviour may be wrong (e.g. taking food from someone elses plate) or may be unacceptable (e.g. pushing people to the floor when they're in your way) but this isn't about moral judgement it's about understanding. Why did the behaviour arise? Was it the situation that made the event almost destined to happen? Was it the interaction with staff or residents that escalated frustration? Was it that the person had tried to communicate and now couldn't see any other way of behaving? Was it to do with the person's beliefs or experiences that cause a certain reaction? We have to spend a lot of time in care homes and a lot of time with family and carers to then be able to suggest interventions that form appropriate person centred care.

All a bit abstract, so here're two real examples.

One patient with Alzheimer's disease in an EMI residential home was settled almost all the time, but occasionally would wander and occasionally would pack clothes at 4.30am (when he'd always woken up and had to get up all his working life as a miner, to get to the pit on time). None of this was problematic. What was difficult was meal times. In the dining room every breakfast, lunch and dinner he'd throw things. Food, crockery, cutlery, whatever. He'd shout and moan. He was too demented to express himself lucidly when distraught. His wife gave us the answer. He hated sitting with his back to people walking behind him, with him not knowing who they were or what they were doing. All his life in cafes or meals out, he hated being in the middle of a room. When he was seated with his back to a wall, almost all his frustration and challenging behaviour evaporated.
Through knowing him, he got better care.

One lady with Alzheimer's disease was wandering a lot in the corridors and grounds of a large EMI nursing home. She often (twice a day or so) would get upset and sometimes cry but with frustration and anger rather than sorrow. She'd shout repetitively, she'd rail against carers and repeatedly slap furniture and walls. This would last anything up to an hour and a half, with her shouting and tap tap tapping the wall.
Solution : understand what works for her, to help her feel calm and relaxed.

How was this done? We spoke with her and her family and the care staff in the EMI unit. This was documented within a diary, detailing an increasingly richer picture of her and her world.
So from this, should the answer in her care plan be : "When distressed, people around make a difference. This can help de-escalate her distress and associated behaviours."
No. Not good enough. What do people do that makes a difference, is it that she needs one to one time with her hand held and close contact and eye contact and talk and reality orientation? Or is that proximity winding her up, is she best left and given space and encouraged to pace and discharge her emotion through walking, walking, walking around the grounds?
So from this, should the answer in her care plan be : "When distressed, she responds well to having one to one care, through someone being with her."
No. Not good enough. What do they do that makes a difference? We still don't understand what the person does.
So from this, should the answer in her care plan be : "When distressed, a person needs to sit with her for 20 minutes, sitting near to her but not within her immediate personal space."
No. Still not good enough. We understand what the person does, but we still don't understand the quality of the interaction so can't yet understand how to help her.

What is culminated to was that she was relaxed when someone was with her but there was no pressure or expectations placed upon her. She didn't do well when people tried to talk with her, she didn't have the concentration and attention span to engage in a 10 minute conversation so became more frustrated and distraught. Equally she didn't want to be ignored. She wanted human contact and company so did better if people were around her rather than being left on her own. A lot of eye contact and sitting facing her and a lot of questions, especially open questions, were bewildering and threatening to her, making things worse. She didn't want to be asked how she was or how she felt or what she fancied for supper or how she'd like to fill time through the sunny afternoon. This gave us a solution for her.
Her care plan read along the lines of, "When distraught, she benefits from staff input. This needs to be one to one, sitting at the side of her, doing a passive activity shared together. This shared contact should continue for 20 minutes in order to be therapeutic. Her preferred activity at the moment is watching old black and white films, sitting with someone as a shared experience of something familiar to her but in a situation where she doesn't have to respond or react to other people. After 20 minutes of sitting and watching it with her, staff can leave her to continue watching her film alone."

Knowing how a shared human contact impacts upon that lady, so understanding the detail of what key elements need to be in place, that's what my team and I do for folk with dementia when medication's not the answer.

Tuesday 7 October 2008

Low mood

I've a lady with Alzheimer's disease, let's call her Gladys.

She's living on her own but has frequent support from family who live nearby (very near, it's about 2 to 3 minutes walk from their house to hers) so has folk around her much of the time.

Still, they have their own lives so are busy and aren't with Gladys all the time.

Much of the time Gladys is low in mood. She's down, feeling miserable and glum. She doesn't cry, but feels as if she could. She doesn't see much of a future for herself, with nothing to look forward to. She eats what family cook or bring, but doesn't enjoy food, has no interest in it and no appetite. She has no guilt, no initial insomnia, no early morning wakening, no broken sleep, no significant weight loss, no diurnal variation in mood. She's never self harmed and has never had suicidal thoughts or feelings or impulses.

Gladys has tried different antidepressants. She's tried them at the maximum doses, so she's tried them at a therapeutic dose. She's tried them for a minimum of 6 weeks, so she's tried them for a therapeutic duration. She's no better on them. She has no evidence of a chemical mood disorder (endogenous depression) so it's no surprise that fiddling with the chemistry (i.e. taking tablets) has made no difference.

Still, it's hardly a cheery scenario. Alzheimer's disease damages your mood before it damages memory (with changes in the limbic system being the first changes in Alzheimer's disease) so she's structural changes in her brain that mean her mood's likely to be different. Changing or low mood is likely, then.

She sees herself becoming a burden to her family (they already invest huge amounts of time caring for her rather than just being with her), they won't entertain social services home care since they believe they can do it better and are happy to do so.
Gladys is miserable because she has a terminal condition that's getting worse by the month, robbing her of her memory and speech and personality then will kill her.
Unlike cancer, there's no hope of surgery, no hope of chemotherapy, it's destined to march on and take its toll.

She's low in mood because she should be.

Not an easy scenario to manage.

Wednesday 1 October 2008

Deadly doctors

Dr Shipman's actions have had a lasting impact on the medical workforce.

Training, regulation and scrutiny have all explicitly changed as a result of this. I'm sure there are other issues around trust and confidence and probity that have also been challenged through this.

Nowadays I have to go through an annual appraisal with a Medical Director at a neighbouring hospital, once a year. This is a significant and laborious process. I've said before how it ties up a full week of my time and a full week of secretarial/clerical time to do this. Unlike Dr Bacon's spurious website to rate doctors, I'm anonymously rated by patients, doctors, receptionists, clerical staff, nursing staff, physiotherapists, OTs, social workers, healthcare assistants, secretaries and managers in a structured and rigorous fashion, collated by the Royal College who then illustrate my ratings against a national benchmark, to see how I compare.

Masses of time, effort and expense is therefore invested in to annual appraisal. This is a subject dear to my heart at the moment since I've to generate my appraisal folder over the next couple months, a folder that will fill a lever arch file.

By unhappy chance, in the past I have been involved in the investigation of a number of complaints. One was around the practice of a Consultant Psychiatrist in another hospital. Looking at her case notes, standards of care seemed poor. Speaking with staff, standards of care seemed poor. Speaking with patients, standards of care seemed poor. Speaking with carers, standards of care were poor and their fury towards this doctor was palpable. Speaking with the service manager, standards of care, organisation, service delivery and teamwork seemed poor. Lots of complaints had been generated. 360 degree appraisal suggested the doctor was not good. Yet, this Consultant Psychiatrist had signed off annual appraisals.

Annual appraisal can only realistically appraise the evidence that is brought to the meeting. Even with a lever arch file of evidence, it's perfectly possible for a bad doctor to limp through it, presenting their practice as good enough.

I am quite certain that the current systems would not pick up or spot a doctor like Dr Shipman. Clinical audit could. Investing massive effort and confidence in appraisal seems to be missing the point.