Equality

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.

Why?

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.