t'interweb

Hassle with 'net access means blogging's a touch trickier. At work we've new software that's overly protective and won't allow access to personal pages, like blogs. Grrrr. So having a thought and spending a few minutes offering it up to t'interweb ain't an option any more.

Ho hum.

I shall just have to slope off early and work at home :-)

Big Brother

We had a letter about a patient.

Nothing too unusual about that.

The patient was on a ward, having been there for a goodly length of time, detained under the Mental Health Act 1983 for treatment of delusions and hallucinations and passivity. It was the patient's first psychotic episode, the delusions had been managed in the community with the patient's family providing rich support, but the effects on work and relationships and health and risk to self resulted in police bringing him to hospital for assessment and care.

The patient felt that a secret military experiment with satellites was affecting her. She wrote to civil servants, her Member of Parliament and the Prime Minister. She was convinced that her experiences were through technological processes the military were developing and she wanted the experiment on her to stop.

We had a letter from FTAC.

Have you heard of them? I hadn't. The Fixated Threat Assessment Centre (FTAC) was apparently set up in October 2006, according to The Times, and consists of police and mental health workers who "identify suspects." Our patient came to light from their 2 or 3 letters to politicians.

Did you know police screened mail to "identify suspects" and then direct mental health services to intervene? Parliamentary questions have been posed, apparently Mr McNulty had "security, counter terrorism and police" within his portfolio, yet he was the chap explaining FTAC to parliament.

Hmmm. It seems that Big Brother is indeed watching us. And Big Brother's mate is a mental health worker . . .

Legal matters

No sooner had I posted on laws on Friday, then Dr Grumble posted about legal matters on Saturday. Odd how themes pop up.

It got me thinking.

How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.

The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.

Laws

The political parties have had their get togethers and rattled sabres muchly. They've talked of "vision" and "character" and "challenge" with little detail of content. Except the Conservatives, to their enormous credit, who've shared specific policy details. Having endured Thatcher's Britain I'd never have imagined I'd see anything the Conservatives did as laudable; plus ca change.

I still think that the likes of the UK Libertarian Party have the right notion.

Government govern through making laws. We have lots of laws. About time someone, instead of just generating loads of edicts, starting doing away with 'em and pulling back to what's necessary.

In this notion of laws, and the desire to be explicit about laws (rather than just posture and waffle) and to have the minimum amount of law that's necessary, how does that translate to mental health? Well, I'm glad you asked. In 1978 we gratefully received the work of Shem, The House of God, a book dressed with humour as a vehicle for the grim themes explored, which sadly resonates with an awful lot of truth in it. The tale is of a keen junior doctor, who's first year as a doctor is damaging to both him and his colleagues and his patients. Having finished medical school and entered hospital practice, his up beat mentor schools his to survive in the really real world through breaking rules and instead using his own rules.

The House of God gave us 13 laws.

In his sequel, Shem offers us insight into progress as a trainee in psychiatry. With the book come new laws. The 13 laws of psychiatry in Mount Misery are as follows :
I. There are no laws in psychiatry.
II. Psychiatrists specialise in their own defects.
III. At a psychiatric emergency, the first procedure is to check your own mental status.
IV. The patient is not the only one with the disease, or without it.
V. In psychiatry, first comes treatment, then comes diagnosis.
VI. The worst psychiatrists charge the most, and world experts are the worst.
VII. Medical school is a liability in becoming a psycho therapist.
VIII. Your colleagues will hurt you more than your patients.
IX. You can learn everything about a person by the way he or she plays a sport.
X. Medical patients don't take their medication fifty percent of the time, and psychiatric patients don't take their medication much at all.
XI. Therapy is part of life, and vice versa.
XII. Healing in psychotherapy has nothing to do with psychology; connection, not self, heals.
XIII. The delivery of psychiatric care is to know as little as possible, and to understand as much as possible, about living through sorrows with others.

What do you think of these laws? Better than HMG suggest, worse than the opposition are proposing, relevant to mental health work? Discuss.

Cash

I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.

The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.

The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.

We gave our views to her medical team. She went in to permanent care.

It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.

Her family visit daily and are very happy with things, too.

She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.

A dismal consequence of the MCA 2005, methinks.

Doctors' work

I find myself increasingly reliant on good nursing colleagues, with investment in our service over the last 5 years involving reducing medical staff numbers whilst increasing nursing staff, OT and social work staff numbers substantially. Still fretting that I don't have enough pharmacy time, but that's a battle for another day.

My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.

Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.

The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.

As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.

It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.

As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.

The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.

At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.

I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.

I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.

A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.

I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.

I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.

Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.

Benzodiazepines

I've differing views on the use of lorazepam and other benzodiazepines (here and here).

The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.

Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.

The outcomes were rather heartening.

Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.

One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.

Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.

Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.

I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.

But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?

Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.

On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.

A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.

Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.

Medication

I work full time. If patients problems through the working week, I am keen to sort them out with them. Sometimes, problems can be around the use of medication. Maybe it isn't working. Last week I had a patient 'phone because they'd been prescribed something else and wanted to know if she could take both tablets together. Maybe it's side effects (a patient last week had his rivastigmine patches stopped and a yellow card filled out after they caused ghastly rashes beneath each patch). Often it's because something destabilised the otherwise manageable situation (such as a patient last week with a chest infection who's otherwise manageable confusion/dementia became unmanageable and another lady who's daughter was going on holiday so couldn't give mum her tablets for that week).

My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.

Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.

Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.

Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.

The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.

He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.

The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.

The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."

No ECG was done for this gentleman before starting haloperidol or during it's use.

Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).

Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).

The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.

Grrr.

Time for more thought on how to solve that one.

Absence

We're not absent, a lot.

I've not had a day off sick, this year. Or last year, come to that. On working through an annual appraisal with one of my Consultant colleagues, we pulled his sickness record for the last 16 years. He'd had just one day off sick.

I know some colleagues who don't use all their annual leave entitlement. Instead of going on holiday or having time off at home or whatever, they stay at work instead.

Gets you thinking.

No, it's not that all my Consultant colleagues are workaholics and passionately addicted to saving lives and making the world a better place. No, it's not that there's any financial advantage to working more (indeed, none of the extra hours or overtime or worked leave is paid). No, it's not that they've dysfunctional lives or grim home settings so would rather be at work.

The issue that one of my Consultants shared at appraisal was this. A holiday was less relaxing and more stressful than being at work. When we're away from work, nobody does our job. Our teams have discussed this. CPNs cover for each other. Ward staff cover shifts. Our OTs and social workers cross cover. Even our secretaries cover each other. This cover is substantial, involving sorting out work, doing depots, reviewing patients, typing letters, getting the work done.

With Consultant Psychiatrist cover, it's just cover for emergencies and specific problems. Nobody does my clinics whilst I'm away. Nobody does my home visits. Nobody does my reports. Nobody does my CPA reviews. Nobody sorts all the GP and solicitors' queries.

We've less Consultant Psychiatrist time than the Royal College say we should have, for our population. We've markedly less Staff Grade and junior doctor time than any other mental health unit I know. We've no Associate Specialist of Hospital Practitioner sessions. We don't have capacity to do the work of anyone else whilst they're on leave.

Through this, when we come back after leave, we've that week's work to do, plus the work of the last week when we were away. All the letters, emails, 'phone call messages, supervision, care home reviews, meetings, teaching, out-patient clinics, home visits you didn't do last week you somehow have to fit in to the week or two when you return, on top of everything else.

The stress some colleagues feel from this is such that they simply feel they can't be off for more than a week, or would give up their holiday entitlement and not go on leave at all.

Can't be healthy.

Must think on how to manage this differently . . .

Private Psychiatry

People dabble in private practice, within the mental health arena. Patients seek solutions outside of NHS care, especially if care's shabby in their corner. Practitioners ply their trades, cross their palm with silver to receive whatever benedicition you desire.

Mostly it's innocuous stuff. A nurse charmingly nailed it when she said it's all a bit like internet porn, everyone knows it's going on and is somewhat unwholesome, it's pervasive and there in the background, but it doesn't change day to day life that much.

I don't do any private work. Partly it's because I simply don't have the time to do so. Mostly it's because the NHS can do it better.

A lady with a bereavement had input from us a few weeks ago. I saw her 3 times in one week, my nursing colleague saw her every day, for an hour, doing CBT. A support worker's since got her out, shopping and swimming and baking and doing again. She had a few days as an in-patient, under my care, when things were bleak. For 5 years she's been housebound. She's had a fair investment of care, over a couple of months.
- I got the referral from a GP on a Friday afternoon, rightly worried she was suicidal. She was seen by me, a Consultant Psychiatrist, at home, that afternoon.
- I saw her twice the next week, visiting to talk with her and her husband, whilst fiddling with tablets, formulating with them and looking at what she wanted to do to cope better
- She's been seen by an OT, looking at getting out to do more, in a purposeful and meaningful and pleasureable way, rather than just doing more
- She's been seen by our support worker who takes her out and goes with her to tea rooms, filled out forms with her, got her back to feeling okay in practical day to day tasks
- She's had input from a Consultant Psychologist who's not seen her but has given advice on her care and CBT that's undertaken
- She's had indirect input from our pharmacist too, discussing her medication with me
- She's seen by a CPN a lot, from subsequent joint visits with me to daily input for CBT to weekly input

Two months on she's strikingly better, will it last? Time will tell.

Could she have received better care, privately? No. Could she have received comparable care within the private sector? Not within my patch, or within the adjacent cities or counties. Episodic input titrated to need, indirect care contributing to the team working, flexible care across in-patients/community, care in clinics/at home (depending on what she wanted her family to hear), joint working, daily input from different qualified/unqualified professionals, rich and meaningfuly input from numerous individuals all effecting change in her care, collaborative working without a medical or nursing or psychological model dominating.

Community Mental Health Teams get a lot of stick. Sometimes rightly so, I'd not want to be a working age adult in receipt of our Trust's services. But when they get it right, it's in incomparable.

The NHS then far outstrips other provision of care.

It's good.

Work

The Girl asked about managing someone with suicidal risk.

It's a contentious area because how ever you deliver care for these patients, you get it wrong.

If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?

If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.

So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.

Clearly, not everyone's going to be happy all the time.

It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.

I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.

My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.

My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.

As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).

That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.

Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.

Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.

Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.

That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .

Shotguns

To get a shotgun in my corner (I don't know if it's a national requirement), a doctor's statement is needed.

This asserts that the person's sane and isn't going to go around killing lots of people.

Tricky one, that.

How can such an assessment of future risks be undertaken robustly? Locally, one GP practice solves this with a simple question to anyone asking for a shotgun. "Do you want a gun?" Anyone saying, "Yes!" doesn't get one. Most people don't want more guns in our society and think they're scary, so they'll assume that anyone who asks for one shouldn't have one. Their take is that they never offer a statement of support.

It's not NHS work, so my Trust obviously won't suffer me seeing folks in clinics or using patients' NHS time for private fee paying work, so it ain't something I do.

But as someone aligned to more libertarian views, it doesn't sit wholly comfortably with me. Shouldn't folk be able to have latitude to do what they want to do, but with that freedom accept the responsibility of consequences? Yet, with guns and the heightened risks to others this generates, it somehow has a different complexion to debates on drugs or other issues.

Police

Jess raised the point of police accessing private places, to bring people to a place of safety for assessment.

In theory, this is covered under section 135 of the Mental Health Act 1983.

Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.

Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.

In practice, it's hardly ever used. I've seen it used once.

If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.

Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.

So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.

Section 136

I get called to a lot of section 136 assessments, out of hours. In fact, it's pretty much all that out of hours work typically involves. Section 136 of the Mental Health Act 1983 allows a police constable to stop and manage, ". . . a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control . . ." to, ". . . remove that person to a place of safety . . ."

Locally, that's a 136 suite in our hospital.

Police find someone acting "a bit odd" and have a choice. They can arrest them, with all the attendant paper work, take them to the cells, wrangle with the custody sergeant why the person needs locking up, do that paperwork . . . or they can fill out a paragraph on one of our forms and drop them at our doors.

No surprise, use of section 136 is increasing massively in my corner.

In fairness, much of the time the police get it right. It's just that sometimes it's clear that the alcohol and social situtation has generated the volatile presentation, so taking them to my door for a psychiatric assessment isn't going to generate hospital in-patient or acute psychiatric care since we've simply not been asked to (and therefore aren't resourced to) deal with this. If you're drunk and feisty, it's not a psychiatric problem.

I concede that having mental illness at the same time can ramp up risks of problems, but if the presentation at that point in time, in that place, in that situation, is because of getting roaringly drunk, I don't have an instant cure for that.

Section 136 is an interesting section of the MHA 1983. You can be picked up anywhere the public have access to. You are thought to need care. You're picked up by police. You have no choice. You're taken to a place of safety. You have no choice. You're held in this locked environment. You have no choice. You're detained there for assessment for as long as it takes, up to 72 hours (that's right, 3 whole days). You have no choice.

What rights do you have, how do you appeal, who do you appeal to? Can you get a First Tier Tribunal to discharge your section 136? No. You can't appeal. You're there for the duration. You have no choice.

Quite scary, really. Anyone acting "a bit odd" can be locked up for 3 days with no rights of appeal or redress.

In fairness, section 136 assessments usually are undertaken pretty sharpish. I always do them straight away, attending immediately. It only seems fair. I need to do the assessment anyway, so why wait? Also it's just a stress to me, knowing I've work to do but not doing it. So when a section 136 is 'phoned through, I'm skipping off to see the patient as soon as an Approved Mental Health Professional (AMHP) can get there (which in my corner still means a band 7 social worker).

The last assessment was relatively brief. A gentleman was brought, by police, after saying over many hours in a pub that he was feeling suicidal. He wasn't. It took just an hour to go through history, mental state and formulation. Discharge options were then discussed and off he was, on his merry way. He's been seen subsequently when both he and staff felt he was in fine form, consistently cheerful, with no mental illness evident.

Another gentleman. Another assertion of suicidality. Another assessment over the course of an hour, with no evidence of mental health problems (meaning neither psychological problems nor psychiatric illness) but social upsets (rows with two girlfriends, thrown out by one of them, feeling skint yet owed friends cash, hated his poorly paid sporadic monotonous work). He was told the good news by the AMHP that he wasn't that ill, he didn't need hospital in-patient care and was no longer detained. A free man. He became angry, smashing his fists on walls and kicking doors and screaming like a banshee. He wanted to be in hospital, but wanted to be detained, to show his girlfriend what she had done, what she caused. Police don't like patients being angry and violent aronud NHS staff. Thankfully they take it seriously, here. They arrested him and he had a night in the cells.

A recent section 136 assessment was different.

The gentleman was brought in mid week. He had a curious account of overdose and suicidal thoughts and actions which was inconsistent. Police didn't find his presentation was in keeping with having taken the materials he said he'd taken. When he presented it was clear he was pretty well, physically, when if he'd taken all he said he had, he'd be flat. Odd. Assessing lethality of overdose and ongoing suicidality perplexed the AMHP who sought more information. The section 136 continued after we saw him, so more information could be gleaned, to inform the assessment (and need for discharge or detention). Blood tests were undertaken and showed he'd not taken what he'd asserted. The next day the AMHP tracked down the clinical team in another county that had been looking after him, prior to his drive to my corner and subsequent overdose here. They gave details of two other counties he'd had contact in. More information was gleaned from them. It was on day 3 that he was discharged from his section 136. Only then did the AMHP feel she had sufficient information of psychosocial history, support available, past behaviour, risk, how he'd managed problems historically (with what escalated risks and what reduced risks) and what sensible discharge planning could helpfully and realistically effect support and change. Months on, he's back in his own locality but I heard that he's coping well and is much, much improved. The assessment and care planning and initial local support was of merit, did effect change and this has been sustained back in his own corner.

Maybe then sometimes, just sometimes, detaining someone for 3 days is in their best interests after all.

I still favour getting it all done and dusted in an hour, though . . .

Dignity

Let's try and keep it dignified.

Please, no wailing and gnashing of teeth at this news.

Bwah ha ha ha ha ha haar!

Sorry.

I'm composed again, now. A clinician stops meddling in GP processes and making ill informed decisions on health systems he isn't informed about and returns to clinical practice. Huzzah!

Narcissism

I've good GPs in my corner. Sensible folk, with too much to do and not enough time to do it in, genuinely devoting themselves to their patients' care. I know this because not only do I write to them, a lot, and receive letters from them, a lot, but patients talk about them.

When we meet I habitually explain who I am and why we're meeting, which invariably involves a comment that Dr X felt Blah was going on and we could meet up to think that through, is that a fair comment, what's the truth of it, what're your thoughts on what's going on? The patient then can chatter about either the matter they've been referred with, or the GPs framing of it.

Sometimes it's helpful because they can talk through a another person, such as "The GP says I'm losing my memory, but I'm not, I'm fine," which then can lead on to why would the GP/spouse/daughter reckon your memory's not so good, and so on.

The last way I know anything of the GPs is through meeting them. Rarely I meet them formally, in monthly training they do, if I'm doing teaching with them. Sometimes I meet them in their surgery, popping in after I've seen one of their patients, just to talk it through with them. More frequently I see them in practice meetings when a nurse and I'll meet with the GPs, practice manager and their nursing staff to talk through both operational/service stuff as well as clinical stuff (such as updates on management of different conditions, since without that patients were sometimes getting inaccurate and unhelpful details).

The written contact, formal contact, informal popping in, episodic practice visits and patient dialogue means I get a fair feel for different GPs in my corner. Mostly, they're very good indeed. Some are fantastic.

But it gets me thinking. Who are the good doctors? Which GP would I want for my kith and kin?

And that's where I come a little unstuck. I want a good doctor to generate a service that is accessible. To have no waiting list, at all. I want them to see folk where ever they may be, that's appropriate. I want them to have a motivated, passionate team of relevant disciplines working with them, to work with the doctor to orchestrate exceptional care (synergy, not parallel working). I want few prescriptive protocols since I want care for each patient to be person centred, individual, appropriate care. I want the doctor to have capacity in their service, so all health needs they determine can then be met by their service. I want the doctors/their team to be friendly and work helpfully and collaboratively with others in Primary and Secondary Care. I want the doctor to temper policy and guidance with huge doses of common sense.

And at that stage it kind of struck me, what I want in a good doctor is really what I'd be wanting from myself. Burst my bubble there, as it really is an act of supreme narcissism to think like that. Which helpfully has got me looking at colleagues who work differently, or construct a different service, to try and see the positive in what they're doing.

Plenty of ways to skin a cat, eh?

Cause and Effect

There's been a scheme of late, in an adjacent county, to promote breast feeding. It's been praised as a success. This is because the PCT and midwives and health visitors all have seen that more people have attended or had contact with breast feeding promotion, so more women have had the right information and support. More, patient feedback forms were used. They’re not ill, they’re not even under health services, but they’re still patients and not service users. Hmmm, odd, that. Ho hum.

Anyway, the patient feedback was embarrassingly good. Gushing praise ‘bout dedicated, passionate, informed breast feeding counsellors and peer support counselling and breast feeding cafes and baby bistros where mums could meet for advice and support from other mums and from informed/expert resources too. Mums love it, see it all as a great success and really value it.

Everyone wins.

The PCT wins, they commission a great community programme for young mums and babies, ticking the box for a national agenda (promoting breast feeding) in a locality where breastfeeding rates are low, at under 1/3 of the national average.

The acute Trust wins, saying they’re generating a great patient centred valuable service, through investing in staff and developing projects to invest in mums and babies, getting young babies off to the best start in life.

The local community/patient population wins, with mums saying it’s all great and generating oodles of feedback forms saying so.

A year on, a keen midwife and health visitor evaluated the impact of this combination of successful projects. Everyone was still optimistic, dedicated, enthused and happy. All was as popular as ever. Everyone saying what a fantastic development it is. The midwife and health visitor looked at breast feeding rates now, compared to the years gone by.

They’re no different.

A good idea is had. Good, passionate, competent staff develop the idea. Managers in the PCT fund the idea. The idea’s delivered and the patient love the service. Ticks lots of boxes ‘bout addressing a local failing in low breastfeeding rates, improving patient choice and community services and peer support and Local Extension of Services and whatnots.

But the service isn’t effective.

It costs a lot of money. The staff time (daytime and evenings), the ongoing staff training, the cost of the use of the properties it’s delivered in, all adds up. Adds up to quite a lot, actually. Massive investment (in time and money) to improve breast feeding, for no improvement in breast feeding uptake or mums maintaining breast feeding.

Should the health service continue to fund this?

We’ve an identical scenario in mental health services locally, that’s popular and well received and highly valued by patients, but doesn’t deliver any beneficial outcomes that patients or staff can see. But it’s just as hard to say that we’ll stop that and use the money in a different and better way, to be more useful. Both commissioners in both situations and flapping about “patient choice” and saying they like the “service” even though it isn’t an effective service.

Is seeing something and liking it and believing it’s doing something else a valid use of taxpayers’ money? Or a valid use of NHS staff and patients’ time? It’s a bit like reckoning that, statistically speaking, those people who have more birthdays live longer, thus I must eat more cake with candles on top. It’s all gone a bit peculiar.

Girl on Girl Action

We reviewed a lady in a care home. She was, "causing a disturbance."

She was holding hands with other ladies, talking suggestively, then at times cuddling, stroking and kissing them. She and the other ladies all have advanced dementia.

The care home sought advice on how to manage this.

Knowing my foibles, they'd already looked for delirium, considered diet and fluids and constipation, arranged for a district nurse to do bloods to exclude infection and common physical causes for acute on chronic confusion and sussed out and documented what the circumstances of this behaviour were.

A life long heterosexual woman, with an active libido throughout her life, she sought companionship and intimacy with accessible men.

Her dementia cued her in to selecting men through one principle determinant, which of a fashion makes sense. She'd progress amorous overtures to anyone in trousers.

I don't have a pill to stop that one.

Continuity of Care

Do patients like continuity of care? Or is it that folk favour a fresh pair of eyes and a new team looking at things?

There's been an irritating practice of late, in my corner, that as soon as someone turns 65 years old, they're referred from their existing working age adult mental health services, to mental health services for older people, and to me. It's flagrantly outwith our Trust's graduation policy, they're all read, shredded and filed carefully in the bin with a succinct letter back to the referrer, but it got me thinking.

Locally, patients we asked favour staying within existing services and didn't want to move on the basis of age alone.

Happily, 2 local audits of working age adult patients (well, they were called audits, but they were surveys) found that patients feel the same way that I do. If they've clinical reasons for being under my care, with stuff that I can do better, I'm keen to snaffle them on over to my corner. If they've no reason to transfer care, I'm keen for them to stay with their existing team.

Surely transfer of care on basis of age alone, not clinical need, is flirting dangerously with age discrimination, no?

Complementary Therapy

I work as a psychiatrist. Having trained as a GP and delivering all liaison psychiatry, I've a bent towards folk presenting with physical comorbidity. In my patch if you're physically unwell and have mental health problems, it's common that someone refers you to my door, or invites me to a case conference to throw in my 2p worth.

It was at just such a fortnightly meeting at the local district general hospital that I was delighted by the succinct, acerbic quip 'bout local independent practitioners.

A young lady had long term back pain, with a degree of sacroiliac and hip pain. Practical treatment had been of some benefit, but the crunch was that she'd knackered joints and a frenetic lifestyle/busy family so couldn't pace herself at a comfortable level. She'd seen a someone about her back between appointments (a chiropracter) who I'd not known, so when the Consultant was describing her care over the last month and mentioned this name, and I asked who this clinician was, it was with great candor that a physio chirped up, "Oh, he's the local quack. Rub you anywhere if you cross his palm with silver."
The lady was no better from seeing him. Apparently, few folk ever are. Ho hum.

The very next patient had problems after a below knee amputation after trauma. Again, discussion on practical and psychosocial and pharmacological management of his care. Young bloke, bad motor bike accident, loss of job and self esteem and social life, not doing too well. He'd also seen someone to help him, an osteopath to, "get him moving again" and sort out, "back spasm" that was, "stopping him walking." The name of the osteopath was not known to me. I asked who he was. It went quiet as medical collegaues tried to think how to frame it, but a physio who knew him well interjected helpfully that he was, "A charlatan."

Clarity of information, I love it. One of the perks of working in old pit villages, people call a spade a spade. As one old man said to me today, when I was asking about diagnosis and how much he sought to know of his dementia, "Tell it like it is, lad. Just tell it like it is." Complementary therapy better deliver meaningful outcomes, because if it doesn't, local folk sure get the measure of it pretty sharpish. And to date, results in my corner are woefully shabby . . .

Fiddling

I trained as a GP, after going to med school. I sought the continuity of care, of looking after folk over the long haul, rather than fiddling for a day then passing them on. I sought the clinical freedom to work as I felt best within my own practice, rather than as I was told to do by hospital managers. I sought work that was biomedical and psychosocial, that was complex and meaningful.

Through this, I found myself spending rather a lot of time in care homes. Most lunch times, in fact. I liked it. Meant I rarely got lunch (a habit that persists to this day) but meant that I could while away time with elderly folk, talking through what was meaningful to them (notionally the "patient agenda") and what was meaningful to me (reviewing their chronic health problems and drug regimens) whilst passing the time of day with what was invariably engaging conversation with interesting folk.

I knew I wanted to work with older adults early on.

Oh, the child health surveillance clinics were good enough. I enjoyed my paediatric SHO job, and obsterics as an SHO and in Primary Care. But rather than kids or young adults, it's always been the older adults I've gravitated towards. So often they ask for nothing, you want to give them everything.

I knew I wanted to be a psychiatrist before I'd even finished my VTS. Somehow I managed to get through all my psychiatry training with just 12 weeks of pure General Adult psychiatry (of which hospital induction, annual leave and study leave wiped out over half of it). I've nothing against General Adult psych, it's just not for me, I knew it never would be, so I didn't want to do it as an SHO. I didn't do any, after being an SHO. I knew I sought to work with Older Adults, so for me it was old age psychiatry all the way. Oh, I did my CAMHS and forensic and rehab and a few specialist posts as an SHO, but thought I may as well focus on what was useful to me rather than fiddle with working age adult psychiatry when I knew my enthusiasm lay elsewhere.

Overall I'm very grateful for all the training posts I've had. Life in A&E and in Primary Care teaches you a lot about triage, consultations, decision making and safety netting. Every post I've had has given me useful training that's shaped me into the clinician I now am. Even though I'm not a physician, there're translatable skills gleaned from that post.

I'm in the habit of visiting all GPs in my patch. Some don't want to meet and over years the only contact we've had is through letters. Some want to but are too busy to. Mostly, though, meeting GPs is a good thing that's welcomed. Firstly so we can wrangle over how we can collectively iron out any wrangles. Secondly so we can share news on patient care (what the guidance released in March 2009 says about schizophrenia, how we should manage vascular dementia vs what stroke outreach do, how acetylcholinesterase inhibitors and memantine's used locally). Thirdy so we can form better relationships, with fewer barriers and more common sense.

One problem GPs have is what's happening in care homes. Out of hours, when struggling, especially if poorly staffed, care homes call the out of hours doctors. The doctors are presented with skewed information by the care home, of an unmanageable patient in profound distress who's generating risk to themselves and to others so needs something doing right away. Dementia typically progresses over months and doesn't typically get worse over minutes/hours - if they were settled at 4.00pm why are they now unsettled at 7.00pm? Their dementia's not warranting hospital in-patient care, suddenly, so what can the on-call doctors do? The deterioration could be delirium, so could be managed medically in Primary or Secondary Care. Usually the care home's just after some medication "to calm them down." The on-call GP has few options. The on-call GP invariably isn't in a position to effect changes in care plans generating person centred dementia care that addresses the causes and consequences of the person's presentation with nonpharmacological strategies. You need to know the staff, the care home, the environment, the patient, the resources and the context before you have a hope of that. The on-call GP is left with the stark choice of effectively do nothing or prescribe a tranquilliser, most often the antipsychotic, haloperidol. The care home reports a need for this to continue so it's added to a repeat prescription at low dose.

A local "audit" by the PCT has shown that invariably it isn't reviewed. The sampling wasn't perfect so I went through all care homes in my patch and reviewed every MARS and it was true - most psychotropics were initiated in Primary Care and most weren't reviewed. Was it audit? What was the gold standard being espoused, what was the GP and Consultant Psychiatrist's variance from this? No, it wasn't formal clinical audit. More a PCT survey, really. But the PCT pharmacist has at least got the discussion going. Scared the willies out of me, for a start.

Lots of elderly incapacitated folk, on psychotropic meds, without review.

Over the last year or two the amount of psychotropic medication used in care homes has plummeted. Care homes know that I'll pop in promptly, as will our CPNs, so there's little excuse for hassling a GP out of hours for mental health problems. Although I regularly go through every care home, it's a time consuming business. Most folk in care homes aren't known to our Trust. To suss out what's going on, why they're on medication, what the effect of the medication is, isn't straightforward. A lot of unpicking to be done. Usually the care home manager sits with a CPN and me as we review all their residents, sometimes it's the RMN if it's a nursing home, but someone has to be there to explain the consequences of medication and presentation of their residents. It's a good learning opportunity for all parties, too. Thus, as well as popping in to sort specific patient problems, we also review the drug regimen and mental health of all residents in care homes, which takes roughly 6 months to do. With current resourcing, that means we review everyone in a care home in my patch twice each year. Could be better, could be worse, I guess.

Usually we stop the medication and review this. Mostly they're better off the drugs.

Milo has suggested that, "I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication!"

Dementia, schizophrenia, depression, anxiety . . . if you're taking medication there should be rational prescribing practice. I'm not judgmental towards someone not taking medication. I think GPs and Consultants simply need to evidence sound, rational prescribing.

Increasingly I'm of the view that Voltaire had the truth of it in saying, "The art of medicine consists in amusing the patient while nature cures the disease." Medication has a place. A very important place. Mental illness can be ghastly and can cause permanent structural damage. Medication therefore matters. Whether palliation, whether prophylaxis, whether effecting a cure, medication can be key in reducing/removing symptom burden and ensuring restoration of decent mental health. But it's often just part of the answer, a way to improve things so that "the proper treatment" can then work. And when the non drug treatment's working, often the medication's withdrawl is then useful.

I guess all this is a long way of saying I'd challenge Milo's view. I think mental health is better at reviewing patient's medication, offering choices and considering rational prescribing practice. I do think we fiddle less.

Therapy

After twelve years of therapy my psychiatrist said something that brought tears to my eyes. He said, ‘No hablo ingles.’

Thirst

I've a lady who has a mood disorder who I've been seeing for a few years, now. As time's ticked by, she's also developed dementia. She recently had an acute admission, onto a medical ward that's busy, rather like this.

Staff are largely well meaning but care's not as you'd wish since the wards don't have enough staff to optimally support the patients' needs.

This was rather brought home when, last week, I was in their hospital seeing other folk but had heard my lady with dementia had been admitted. I popped on to her ward, to see how she was being cared for and to let the ward team know what support we'd be able to put in place on discharge. I saw her, she didn't look good. She was thirsty. She was very thirsty.

Her bedside looked like this. I've not moved a thing, this is exactly as I found it :



This was all well outside of her reach.

5 drinks, if you count them. There was water there from the morning. Orange juice that came with lunch. Then coffee. Then a dietary supplement. Finally, some more water from the afternoon.

5 drinks, all on the tray of a lady with dementia, all still there for hours and not drunk as drink after drink is added.

She was discharged back home that afternoon, on antibiotics for her exacerbation of COPD, where she's getting a couple hours of home care and 2 visits a day from daughters to support her. Tragically, this episodic care 4 to 6 times a day results in far better care for her than being on an in-patient unit where there are staff there continuously, 24 hours a day.

As Nurse Anne says, something's very wrong on our acute medical wards . . .

Care Planning

Yesterday I described a lady who had schizophrenia, but had been managing fairly well.

She had emerging deficits and had historically reacted to command hallucinations and delusional ideation that, to a modest degree, adversely affected her (e.g. in employment opportunities, where to live, who to be around and in personal relationships) but, since she could talk to so many friends psychically, she'd always got by well enough. Effectively, she'd her own support network.

Calling 999 and presenting with breathlessness unsettles me. When I did my time in GP land, before jumping over to mental health, we'd reflect in Balint groups. Oddly, I've no reflective practice or peer support now I'm doing more complex and risky and distressing work in mental health, but that's another story and I digress. Again. When reflecting, one of the recurring questions was, "Why now?"
Most people pitching up in Primary Care weren't there with true emergencies. So the dry, pink, itchy skin rash you've had on and off at times for 6 months or so, why'd you come to see me about it today? Why not yesterday? Why not next week? The headaches you've had and put down to stress, for 2 years or so, what brought you to consult me, "just to get things checked out," right now? That indigestion you've managed for a couple months with over the counter antacids, what brought you to discuss your fears of stomach cancer now, in this moment?

Timing matters. To a degree it's pragmatism. It's about when we can get time off work, when an appointment's available. But more often it's about what we want. We want reassaurance since things haven't settled down as swiftly as we'd wish. We want an intervention early on, just in case we need to stop something getting worse. We're now worried enough to make changes or do something about it, so consult. A friend died with similar symptoms, giving us impetus to act. The media say that a condition we think we might have now has a miraculous treatment. Our family's worried and nags us into going because the symptoms grumble on and they're worried it's something sinister.

We're creatures of purpose. We don't take time out to fret over things, make an active decision to seek help, 'phone for that, take time out of our week, travel, wait, talk, be examined, discuss ideas, consider investigations, weigh treatments, arrange follow up, travel to chemists, wait, pay for pills and do all the other gubbins that seeing a medic involves, just on whim.

Shall I read a novel in the park as the cherry blossom cascades down around me, shall I whimsically whisk my wife off to a fantastic new restaurant, shall I weigh up the merits of a rather splendid 24 year old Port Ellen vs a bottle of Shiraz I've been gifted and partake of the winner, shall I lavish time on my children who're enthused with a new playground, or shall I go to the doctor and discuss indigestion I've had on and off for a few months?

To seek medical advice, even when free at the point of delivery, we need something that's motivated us to do it then, at that point in time, at that moment, rather than do whatever else we'd otherwise wish to do. There's no cash cost, but there's always an opportunity cost.

For a lady to be silent 'bout her mental wellbeing for 30 years then now choose to urgently disclose what's going on, in rich and exhaustive detail, surely is relevant.

The experiences had mostly been positive, now she's having more unpleasant thoughts about conspiracies and her role in surveillance. She's being told what to do more. They're affecting her physically, once causing pain and recently making her breathless.

Symptom burden seems perhaps to be increasing.

She's sought contact with mental health services after so long, having feared psychiatry for decades. There are no high risks. There're no risks that are serious/significant but unlikely or are moderate but likely to arise, to either herself or property or others.

She's adamant she ain't taking tablets, so medication's not an option. We talked through different medication options, considering what could help her feel more in control of her thoughts and feel more resilient, what could help her feel more relaxed and less distraught, affording her more fortitude, but she was firm in her view that medication simply wasn't going to happen.

Diagnostically her symptoms, negative impact (on career, residence, social behaviour, relationships) and mental state undeniably attract a diagnosis of F20.0 paranoid schizophrenia. It's not a diagnosis I often make, but if I could share all details it'd be evident that it's really not contentious.

A nurse (band 6 on an acute medical ward) felt she was mentally ill. The nurse is correct. She has a mental disorder, within the meaning of the Mental Health Act 1983.
The nurse felt she was psychotic. The nurse is correct. She has hallucinations and delusions and lacks insight into the nature of these and, critically, into the impact and consequences of these.
The nurse felt she needed mental health input. The nurse is correct. She has had increased symptoms which recently have been more distressing and wanted to talk to a psychiatrist and wanted to share her narrative at length, at this point in time. She's not known to us so the nurse felt her mental health and risks, "needed monitoring."
The nurse felt she needed medication. I'd say the nurse was wrong, here. Medication might help some symptoms some of the time, but abolishing all psychopathology would surely be a futile and unhelpful endeavour. The amount of medication necessary would no doubt be stratospheric. The fact she's refusing means she'd need detaining under the Mental Health Act 1983 so medication would be undertaken as a depot administered under Part IV of the Act. Not the best way to forge a therapeutic relationship, for certain. Probably not the best way to manage her mental health, either. The nurse disagreed, vehemently. "You're saying she's ill, she's got schizophrenia, she's hallucinating and deluded, she's hearing voices telling her to do stuff, she's got things making her feel pain and become breathless, she's wasting ambulance time and she's been in A&E and a medical bed when she's not ill, so we can't let her go and not treat her!" She went on to state how my lady's mentally ill, we don't know anything about her, she's refusing treatment, so we need to "section" her.

Talking glibly of "section her" was what finally did it for me. Pedantic, I know, but one of my many foibles is we don't "section" people, I make recommendations for detention and treatment. We don't do punishment, we do therapy, we do care. The glib presumption that somehow I can lock folk up on whim and stick needles in 'em as, "a section," always, always riles me. A lot.

I documented the interview at length, since it had been a lengthy consultation and she was such an interesting soul. I concluded that she was psychiatrically fit for discharge. She went home that afternoon.

I'm seeing her next week, at her home, so she doesn't feel threatened and doesn't need to come to a hospital. I'm sure there'll be no change in risk. I'm sure there's little benefit from ongoing surveillance. I'm sure she'll again decline social support, CPN input, out-patient follow up, CBT, day hospital, psychological work, in-patient admission and our functional community group that's just a couple minutes up the road from her. I'm sure she'll want no drug treatment. But maybe Balint had it right. Maybe sometimes the doctor's the drug.

Voices

I recently saw a lady who medics asked me to assess on their ward. She'd been brought in breathless but had been checked out and all was well. That's to say, serious things (like a heart attack) had been excluded, no cause for her breathlessness was found, but since it got better she was medically fit for discharge. She'd nociceptive pain that seemed pleuritic to me and was a touch alkalotic for my liking, but by the time I got to see her I couldn't hear anything odd in her lungs, her CXR was clear, haematological and biochemical indices were all normal (but her ABG hadn't been repeated). It could have been anxiety. It probably was. It could be pleuritic pain and consequent suboptimal ventilation and respiratory alkalosis from rapid short shallow breaths blowing off her CO2 but, in truth, I think the medics had it right and she'd been anxious.

What surprised me was that they sought an urgent consultation because as the discharge facilitator said, "She's mad as a sack of rats." Challenging stigma. Ace.

The lady told me, at length, about her voices. She hadn't told anyone about them for 30 years. Last time she mentioned them they locked her up and gave her ECT. Coercive psychiatry that did her no good. She was rightly wary of mental health services after that less than helpful contact.

I don't know why she said to ward staff she wanted to talk with someone about her voices, or why she opened up to me after 30 years of silence, but she'd clearly a desire to narrate her life story and what changes voices had made. They'd told her who to marry. Where to live. Which countries to go to. They'd hidden behind her eyes, spying for Stalin (which was when she piped up about them and had ECT in England as a young woman).

Mostly the voices talked with her about politics, current affairs and gossip. She really enjoyed them, she didn't believe she was ill and certainly didn't either want help or want the voices to go away. They talked to her, constantly. She said, several times, that they were real people who could talk to her psychically and were her friends. Better still, they could make her feel things. One had made her breathless (causing her admission) but mostly they made her feel good things. Every evening she has an overwhleming feeling of warmth, as if held, and is suffused with a feeling of being loved, "as if you look in to your mother's smiling eyes." It sounded beautiful.

She manages everything at home. She's been living like this for ages. Decades.

She has auditory hallucinations talking to her.
She has auditory hallucinations talking about her.
She has mood incongruent delusions of government conspiracies unfolding through presences utilising surveillance and telepathy within her head.
She has made acts, to touch things.
She has made feelings, usually they're positive.
She has made impulses, usually thoughts of travel.
She has thought insertion.
She has thought withdrawl.
She has thought broadcast.
She has had these for decades, she described hearing voices since she was an 11 year old child.
Maybe you like to consider Schneider's First Rank symptoms. Maybe you like Andrew Sims models of throught disorder (a man I met in my training, and even when he explained it to me I still couldn't get it). I tend to favour Nancy Andreasen's definitions of thought disorder. But however you like to assess, formulate and structure things, it's clear she's psychotic.

She had sufficient symptom and signs to attract a diagnosis F20.0 paranoid schizophrenia.

But, she's well. She's had no contact with mental health services for decades, she sees herself as well, she's scared witless of hospitals and psychiatrists (no idea why she spoke to me for an age), she's adamant that she will accept no medication (having had ghastly experiences of it, and since she sees herself as well) and avoids seeing her GP unless she feels she absolutely has to.

What should I have done?

A&E

I was in A&E this week to see a gentleman in his early 50's who was confused. The A&E nurse had triaged the patient and determined he had dementia. Since he was just over 50 she sought input from my team. It was an "urgent" referral not because the clinical presentation necessitated prompt medical input, but because the nurse wanted it all sorted out within 4 hours. At least she was honest enough to 'fess up to that, which improved my humour so off I went.

I wasn't really expecting him to have dementia. I look after everyone in the district who develops dementia at at early age (defined simply as under 65, in my corner) and know from the demographics that there should be 43 people in my service who aren't in it, yet. Somewhere in my patch there are 43 people under the age of 65 with dementia who I don't know about. Knowing this, I've a low threshhold for reviewing potential cases of early onset dementia, which A&E and the acute Trust shamelessly play on.

I visit the gentleman. He's had "baseline investigation" in A&E and assessment. The nurse tells me he's confused and can't go home and they can't access hospital social workers so I need to sort it all out.

He's a patient within a different Foundation Trust, under a different clinical team, and it's now my job to sort it all out and make your problems go away? There's no SLA for liaison work. I'm here in your A&E as a favour. It took me half an hour to drive here, half an hour to drive back, and the time in your wretched department. 2 hours, minimum, which I've taken out of my day for no good reason but to be helpful. And you then tell me what I have to do. When I have to do it. And what must happen. My bonhomie evaporates.

I talk to the gentleman and his wife. He'd been well, cognitively intact that morning. I look at the gentleman. He looks ill. He's grey and sweaty. He's distraught. He's conscious, but confused. I look at the blood tests undertaken. His creatinine kinase is elevated. The nurse nods, saying it's through his confusion and sitting/lying for hours and having muscle breakdown. I ask for an ECG. She glowers, as if I've asked for the blood of her first born child. I smile. She glowers more, then arranges it. It shows an inferior MI. She doesn't accept this, requiring that we have more blood tests for Troponin T (a test that wasn't done when I did my A&E job or worked in cardiology and on CCU) since apparently the history, clinical presentation, CK and ECG aren't good enough.

Why? He had no chest pain.

I spoke to the nurse about this. I remember this well, since as a medical student I was harrowed in a cardiology clinic by Dr Twattington Puffball hollering at me that, "A quarter, 25%, ONE IN FOUR MIs are silent with no symptoms at all!!"

Although I love my RMN nursing colleagues, it irked me that this nurse was managing this gentleman's care since she couldn't diagnose an atypical MI without a Troponin T test (which delayed his care) and she was insistent that he had dementia until that came back.

I had an utterly childish moment, wishing to enact something along the lines of this. But I didn't. I just documented that he'd an acute inferior MI and needed appropriate care, now, and if he'd ischaemic damage to refer to me when he was stable. And I left, consumed with despair.

Sex

Can people have sex?

Well, yes. Obviously. Or we'd not be here and the world'd be an emptier place. But, if there weren't people then there wouldn't be Pot Noodle, so it wouldn't be all bad.

I chanced upon an article in Slate Magazine today, because I was looking for information on sex. It's with hindsight that it dawned on me that Googling (is that a verb?) for "sex" at work may raise a few eyebrows when the IT server guys see what I came up with. My, human creativity really does know no bounds. I'm so glad I did it all on someone else's computer.

The rationale for finding oh so many sites of oh so many obliging women? Because I don't know enough about sex and older people. Always one to value CPD and a thirst for knowledge and self directed learning, I assiduously studied all I could, online.

Better still, the whole team poured over it all. We didn't learn a lot. I did learn that some of my colleagues know far too much about obscure specialist subjects.

Back to the reason for our diligent search. Sex. Can older people do it?

Really, can they?

No no no, not in a sweaty, physical, swinging from the chandaliers sort of way. In a legal, "Are they allowed to?" sort of way. A tricky matter to disentangle. Googling found far more sites of scantily clad ladies of a certain age than it did of learned legal discourse. There were of course some sites dedicated to lusty, obliging women. And sites dedicated to lawyers. All from the same search. I guess lawyers and prostitutes have more in common than one may first imagine, seeking to use their skills to satisfy their clients for significant amounts of cash.

We've a lady in a care home. She holds hands with a man. They kiss and cuddle. They're both widowed, so single. They're both demented, and are incapacitated adults (within the meaning of the Mental Capacity Act 2005, with respect to the decision of an intimate relationship). They like to sleep together. They've sought to have a sexual relationship together.

It's a bit like this.

MCA 2005 directs what can and can't happen, about a great many things (e.g. marriage) but not specifically about sex. Neither does the European Convention of Human Rights, that we could find. Nor did any guidance we rummaged around, on such sites that weren't gloriously lurid.

So, the question remains unanswered. And care homes in my corner take very different views on it "meddling" as they feel wont to do. A definitive answer 'pon desire is desirable. Do older adults have a right to sex?

DOLS

You've perhaps read the Deprivation of Liberty Safeguards, and Code of Practice.

Because I'm a tad neurotic and obsessive 'bout these things, I've read it all rather thoroughly, more than once, and been to various awareness and training days. I feel pretty clued up about it all.

We've a lady in a care home. She has dementia. Her daughter thinks she needs to be in a care home since she can't manage on her own. Heck, she can't even walk on her own. She has no notion of what problems she has, what she can't do, what help she needs. She's evidently an incapacitated adult, within the meaning of the Mental Capacity Act 2005. She's no donee or deputy or advance decision. Management is therefore manifestly straightforward. We have a duty to provide appropriate care, within the Best Interests framework of the MCA 2005.

Care home staff reckon she's best in the care home. Her daughter thinks she's best placed in the care home. Nursing staff reckon she's best placed there. I think it's the only place for her. Best Interest meeting evidences her deficits and what needs to be put in place to address her health and social welfare needs (both optimally and at an acceptable minimum) and it's clear that 24 hour care within a care home's necessary. Everyone agrees.

She keeps saying she wants to go home.

She's no way out. She's not detained under any law or process (such as Guardianship, or SCT) that allows scrutiny or review or challenge. Technically she could go to the Court of Protection for a Declaration to determine if her placement in care's lawful or unlawful but, clearly, she's not in a position to instruct solicitors and progress such a course, even if it was reasonable to do so.

Enter the Deprivation of Liberty Safeguards (DOLS) that came in to force 14 days ago. The PCT or Council considser the issues if this deprivation of liberty is appropriate they issue "authorisation." After 6 assessments and enough paperwork to fell a small rainforest.

I speak with a social worker and we consider DOLS. I'm advised that we can document sufficient details in her care plan to "restrict" rather than "deprive" her of her liberty. Which then, under the MCA 2005, is lawful. Resitriction's fine. We can game on and place her and deliver necessary care under section 5, all's good.

Now, on the one hand this means there's no assessments and meetings and paperwork and taxpayers' expense for a DOLS authorisation. On the other hand, she's in a care home, saying she want to leave and go back to her house, and has no way to effect this.

14 days in and already DOLS ain't evidencing transparent decision making or external scrutiny to protect liberty in any kind of robust fashion, what so ever. Ho hum.

Teams

I have a good working relationship with folk within our PCT. A few months ago I thought part of our service wasn't good enough and we needed more staff to do the job right. 3 months later and they've given me all the cash I asked for, for 4 more staff and development of the team. Surprisingly, they've given it as recurrent funding, which I reckon's a mistake on their part since new teams and projects tend to be done as a fixed pot of cash to then evidence and evaluate at the end. Still, happy days, it means we can appoint substantively and have more goodly folk join our merry throng.

A Modern Matron was asking me about the team and how having more folk join would affect things, how is it we can ensure that a team functions well? Got me thinking.

Bigger office, for a start. If we've 4 more folk we'll need more room, or people at desks sitting on one another's laps, and whilst a relaxed working environment's laudable I reckon that's taking the notion of "hot desking" one step too far.

Time out to think through how they'll work. Or, less euphemistically, to be guided by the Team Leader and myself on how we wish (or need) things to be. How they deliver it, I'm pretty happy to leave to them. But how the service works, the absence of waiting times, the collaborative work with colleagues, the multidisciplinary input into every case, the letters to GPs generated when the patient's seen, the ethos of support of patients in a least restrictive manner, of advocacy for them, of being relentlessly uncompromising in delivering exceptional care to everyone, all the time.

How do we know when we get there, when the community team is working together well? Part of it's through numbers. Is everyone pulling their weight, with comparable numbers of new patients seen, of follow up visits undertaken, of teaching sessions delivered, of conferences presented, of carer forums facilitated, of night shifts covered, of students allocated. Part of it's through the feedback (which I get a lot of ) from PCT, GPs, care homes, patient/carer forums, families, 360 degree appraisal, Your Opinion Counts forms and so on.

But it boiled down to just a couple of things that highly effective teams seem to have in common. First, there's the coffee. A good team can sort out the tea/coffee money and who makes the drinks (we all do) and who washes up and so on. Got that right and I reckon it's a fantastic correlate with a cohesive and organised team. Second, it's the attitude to one another. Respect that's genuine, so banter can be taken with good humour . . . as well as sorting coffee, in effective teams I've been in we've all been able to tell one another, in good humour, to fuck off, without causing offense.

So there's my plan, for my Modern Matron. Get the new staff appointed, get 'em sorting the tea and coffee with the rest of us, and get 'em confortable speaking their mind with all of us.

Wards

Well this all sounds less than ideal . . .

Being approachable

Milk and Two Sugar, over at Tea at Ten, got me thinking on a comment she made.

It got me thinking about how approachable Consultants are. Or aren't.

I think of myself as approachable, because patients and families are frequently seeking me out, "Just to tell me blah," which was worrying them and on their mind, or "I've not told anyone else, doctor, but . . . " then opening up. All doctors experience this, it was very common in General Practice, too.

Since I joined this Trust none of my patients have sought a second opinion or change of Consultant. Every other sector have had folk wishing to change Consultants and, for whatever reasons, have asked to change to me. I'm no better a clinician than my colleagues, it's got to be something about how people work (not the work that's done).

I cover a wider geographical area than I should, by mistake, which I won't bore you with. Patients live in areas between our hospital and 3 other hospitals. Patients on the borders have choices of where they wish to go, with our PCT paying us to see patients out of our area, recognising in our contract that 6% of activity should be out of area referrals. Locally, our service is well regarded. Patients outside my catchment area know of me and our team, through this rather fluid boundary. Oddly, the Medical Director and service manager at the neighbouring hospital met with me in March and the amount of patients they saw from my patch within their hospital in the last financial year was 0%. Patients have moved home from neighbouring Trusts to be in our catchment area. Clinical care isn't particularly better in my corner than it is in the university teaching hospital they're moving from. People have said they've moved so they can get good care. People do this with GPs often, too, not letting them know of change of addresses or being coy with details so they can see "their doctor" still. Lord Darzi should heed this. It matters. Still, for folk to be so enthusiastic to have care from my team reflects, I think, the approachability and compassionate care provided (rather than us doing anything miraculous, clinically).

We're signed up to 360 degree appraisal. This means I give a list of secretaries, clerical support staff, domestics, physios, OTs, nurses, social workers, Consultant Colleagues, GPs, junior doctors and managers who I work with over 4 hospitals, in-patients and community, from which random folk are anonymously sampled and give feedback on me. My secretary also generates a lengthy list of consecutive patients seen, from which a random sample are anonymously sampled with questionnaires about me. Their results are mailed back to the Royal College of Psychiatrists (so it's independent) to crunch the numbers and give feedback. They give feedback as graphs, showing the average range, top and bottom of the range, where you rate yourself and where staff and patients rate you. Feedback was embarrasingly positive, with scores at the top of the reference range, and some well above it. This can't be, I know I'm no better than most colleagues and certainly am not the best in the country! It has to be about perception of those staff and patients scoring me, of which I reckon approachability's key.

This really can be encapsulated in a conversation I recently had with a senior nurse. It's been busy in our team. I'd been working particularly long hours, which happens from time to time, but there'd been a run of this. She'd been working a couple extra hours a day too, doing far more work than she should. She'd mentioned that I was doing too much work, laughingly chiding me, "I don't like seeing you busy, it's not normal!"
We joke that she does all my work for me, because she does so much. And there's truth there, she does a stunning job that eases my workload big time.

We had a patient referred. It was a patient I'd seen before, a few years ago, with vascular dementia. Strokes had caused widespread damage, particularly affecting word finding and judgement. After a few months of assessment and advice, the patient was picked up by social services and day care and Alzheimer's Society input and was discharged with an open appointment, since there was nothing further at that point that our service could usefully do. She'd been seen by both me (for assessment and diagnosis) and the nurse (for advice/psychoeducation, coordinating social service and other care, and carer support). They were re-referred because the patient's dementia had progressed and the family wanted advice on what the referrals letter suggested amounted to wandering, a reversed sleep/wake pattern and respite care.

The nurse wanted to take the referral, since she knew I was busy and there wasn't any medical work to do, she could pick this re-referral up and discuss it with me. I wanted to take the referral, since I knew she was busy, I'd seen the patient already so could pick it up and easily see them again.

I don't think she finds me unapproachable and difficult to talk with. She jokes I do no work and she does it all, but everyone knows that everyone in our team all pull their weight. It was with kindness that she took the referral, flounced off (she's good at flouncing) telling me, "Oooh, stop being an idiot and fuck off back to your office and go pretend to do some work!"

I love this team.