Laws

I met with the manager from a care home.

The manager claimed to be in a state of amazement, knowing naught of the unacceptable practice within her home. Ignorance that is impacting 'pon dozens of folks care. Not good.

We discussed care plans and implementation of care. Because they're out of hospital, local GPs will need to be involved in discussing medication protocols. This will take many months. So it goes.

Given her self confessed ignorance of malign care in her establishment, it became clear that we were correct in our assumption that she wasn't clued up on her statutory obligations to provide care under the Mental Capacity Act 2005.

In particular, she wasn't familiar with section 44 and the prospect of her, and staff, spending up to 5 years in prison.

Care

I feel vexed.

This is A Bad Thing because, although I don't get cross often, when I do I'm not always wholly reasonable. No no no, not in a "red mist" kind of way. More in a didactic, assertive, "I know best" kind of way which surprises folks 'cause it's typically alien for them to see this, coming from me. But, when vexed, I am wont to be classically Consultoid and Have Things My Way and assertively progress this state of affairs.

By chance, a social worker commented on assessing capacity. Her rather splendid blog should be known to you, if not, shame on you. Nip on over to here and rummage around.

What perturbed my calm mien was after a member of our CMHT visited a care home for a meeting around a patient's care, returned to the office and discussed things with me. Let's call the care home Limbo. Most care homes in my area were woeful, most are now decent, two are excellent (and I would happily have them care for my kith and kin). This care home she visited is a curious place. The environment is spot on. A modern, purpose built home with structure and content that's pretty much without fault. The staffing is uncertain. Really uncertain. Sometimes I speak with a nurse who's got oodles of common sense, is very patient centred and utterly devoted to those in her care. Popping in to Limbo when she's on shift is a joy. Every other RMN has less enthusiasm, motivation, common sense or interest in residents than my daughter's goldfish. This is not a slur against nurses, it's a comment on the dichotomy 'tween great nurses and those undertaking poor nursing practice.

This makes for curious states of affairs. One care home in our area that's poor (an in, CSCI are involved and they's an embargo sort of poor) had a resident moved to Limbo where care could be better. It was a transfer made from one home to another with the same registration, notionally providing the same level of care. A gentleman who wasn't being cared for by staff was moved to Limbo to receive appropriate care, which he wasn't getting in his previous placement. In Limbo he had exceptional care.

Seeing him in his old home, he was a state. Wild hair, soiled clothes, smelling rank (from not bathing for many months, from incontinence that wasn't attended to, faeces matting up in his pubic hair), he had food that had drippled on to him, his clothes, his beard, had dried and become adherent to him, his beard. Not good.

He was moved to Limbo, the next day I didn't recognise him. No, not an idle comment, I really did walk past him in the entrance foyer, failing to clock who he was. He'd been bathed, shaved, cared for. The nurse (who's exceptional) gave a rich account of how he'd been, despite only having known him for a two shifts.

She had spoken to him and his family. She knew what he liked, what irritated him, what relaxed him, what topics/hobbies interested him, she'd sought an understanding of him even down to what flavours of food he liked and didn't. Person centred care. Superb.

Limbo has other nurses and, sadly, to a one they're not as good. Not even in the same league. Their unqualified carers are, rightly, directed by the nurses. They're a mixed crowd but, typically, have time and interest and common sense in their delivery of care. But if nurses aren't directing them to undertake appropriate care, then appropriate care's not undertaken. Less superb.

Back to a different patient, stuck in Limbo, and a different experience. My CMHT colleague (a social worker) returned from Limbo where they'd had a meeting with 3 nursing staff. Three, on one shift, for one meeting?! The home's not that well staffed. Folk had axes to grind and had come in to make themselves clear. The social worker was concerned that no medication had been given for weeks. The nurses explained that the patient had declined medication offered. The social worker explained that, indeed, this was known and expected, because the patient was severely demented and didn't appreciate their illnesses, the impact of their illnesses, the consequent effects of this on their health and wellbeing, and the desire/need for medication to help manage this. My social worker described how the nurses in Limbo shook their heads and tutted a lot, saying they could only give medication to the patient, including his insulin, when he was unconscious.

This patient is an incapacitated adult, unable to either give or to withhold consent. The nurses just couldn't (or wouldn't) get that.

My social worker sadly didn't know the NMC guidance on covert medication so had to accept the 3 nurses telling him that they couldn't provide appropriate medication for the patient. He quoted the relevant bits of the Mental Capacity Act 2005 to them. They were having none of it. If that patient says no, the patient gets no treatment. All this is becoming much less than superb.

Worse, on review, the patient was in a state. Sitting in urine sodden clothes. Not moist, but apparently soaked. The social worker was astonished, since the urine was even dripping down the chair. He backed out of the room so staff could attend to the patient with dignity, undressing and attending to him without the social worker present. The staff left the room too. They left the patient. They wouldn't change him. He told them he'd not been incontinent and didn't need to change his clothes. The social worker questioned if, being diabetic, leaving him sat in urine was okay for his skin. Nurses said it was his choice. If that's how he wanted to live, they wouldn't and couldn't force anything on him.

Nothing polite can convey what I was thinking, feeling and expressing to my social worker at this point. Suffice to say, I was animated and more than a little vexed.

A nurse and I'm meeting with their manager tomorrow.

Advocacy

I am sure, of course, that all commissioners have ensured that robust, effective advocacy services are in place for next week. Because they have had to do so. They got the cash last November, but it wasn't ring fenced, so I'm a little uneasy about how much has been used to commission front line staff to do this work.

Why does it matter?

Because every patient in my corner detained under section 2, 3, 7, 37, a Supervised Community Treatment order (SCT) or conditionally discharged will, from next week, be a "qualifying patient" and entitled, nay obliged to have offered to them, an Independent Mental Health Advocate (IMHA). Why? The Mental Health Act 1983 was ammended in 2007 and from next week advocacy is a statutory requirement.

Does it matter? Well, quite probably. There are very few patients detained, in my corner. Although I've a typical (according to the Royal College) size of patient population in my patch, who I'm responsible for, my team and I don't use the Mental Health Act 1983 very often, at all. In case my memory failed me, and in the interests of determining how often SCTs may be considered, my Mental Health Act office kindly let me know how often I've had patients under my care detained under section 3. Since 2003, there have been 3 of them. Not many, then. What can I say, I'm blessed to work with exceptional staff. Nationally, it's a different story. The total number of people detained under the Mental Health Act 1983 is about 42000 in a year. That's a lot of pink forms.

Quite how we'll suddenly, from next week, be awash with advocacy services (that are qualified or will have the national level 4 City & Guilds IMHA qualification within a year), to manage the advocacy needs of 42000 people perplexes me. Every detention, every meeting, every Hospital Managers hearing, every Tribunal, an IMHA should be offered.

The IMHAs have powers. They have a right to see the patient in private. They have a right to interview clinical staff (nurses, psychiatrists, whoever). With the patient's consent, or without if they're incapacitated and it's in their best interests, the IMHA has a right to access the patient's medical records. Good luck to them accessing the electronic medical records in my corner. And even more luck in deciphering the meaning of what's documented. Interesting times.

Okay, I've no patients detained under the MHA 1983 and haven't had any for an age. But in forensic and LD corners, I can see April being a very, very busy month . . .

Cured!

Happy days.

I was referred a gentleman with memory problems, over a couple of years, who had a daughter who, "wanted something doing about it." Unlike Dr Crippen's locale, I read each and every referral letter, even if they're addressed to a CPN or psychologist or social worker. We work as a team, not as individuals in the same building, so I've no qualms in contributing to each and every referral made. Likewise, letters addressed to me are shared with the team every day. People have good ideas. Thoughts are stirred.

I thought this elderly gentlemen had symptoms suggesting Alzheimer's disease and may merit treatment, but he'd had a few falls and was on more drugs that I could count, so a CPN saw him at home first to look at his mood, his function, realistic goals we could achieve, his drug regimen and daughter's input and expectations.

The CPN then met with me that afternoon and talked it through. He was woeful with medication. My CPNs are canny, on this occasion she'd asked about his medication and he'd told her, then she'd checked his account out with the daughter who'd corroborated this. She then looked at the dates on the boxes of pills and realised they should have been replaced. She saw each was for 28 days. Over 365 days, that means a little over 13 requests for repeat prescriptions. The GP surgery confirmed he'd had 8 repeat prescriptions issued in the last 12 months. Ah ha! Suboptimal complicance with medication, another relevant factor. I'm so blessed by savvy CPNs.

So she'd sorted out home care, drugs in a Nomad box for home care to prompt, done a lot of information gathering and assessment but felt, "It wasn't quite right." I saw him at home, with the CPN. It all seemed quite right to me. Elderly man, losing his memory for 3 years, steady decline, increasing periods of confusion. On lots of meds for COPD and OA and prostatism and management of hypertension. One fall of late, no head injury sustained, attributed to joint pain (with NSAIDs bd and co-codamol being used qds to manage this). I spent an hour with him. No worrying symptoms. No new problems, other than his prostatism being more of a nuisance so some more nocturia. No recent infections to destabilise things (with normal WCC and CRP). But my CPN is clever. If she doesn't think it stacks up, there's a high index of suspicion that something's afoot.

I organised a CT brain scan. It showed no vascular damage at all, which for a bloke in his 70's with hypertension necessitating 4 tablets, surprised me. It showed modest atrophy, in keeping with a brain that was 70-odd years old. There were no infracts. There were no space occupying lesions. Phew. There was enlargement of ventricles. Normal pressure hydrocephalus (NPH) was suggested.

NPH classically presents with cognitive changes suggesting dementia, urinary incontinence and gait disturbance. I thought his dementia was likely to be through Alzheimer's disease since he had a global, progressive deterioration in all domains consistent with this. I'd put his urinary disturbance down to his prostatism. His gait I'd assumed was antalgic, through his arthritis (and somewhat affected through 240mg codeine a day on top of everything else). I'd not thought of NPH since I'd ascribed other significance to his symptoms.

I referred him on to a neurosurgeon. This happens fairly often. On this occasion the neurosurgeon agreed he had NPH and operated last year. Unusually, things didn't get a fair bit better, they got completely better. His procedural and declarative memory, sequencing, decision making, concentration, praxis, registration and new learning, all ticking along nicely. Fantastic.

I reviewed him. He thanked me enormously for, "being cured."
Okay, I had a small role to play. But really, it was a CPN seeing a pattern that didn't quite fit with Alzheimer's disease progressing over time, then a radiologist seeing atrophic changes but ventricular abnormalities on the CT scan suggesting increased pressure, then a neurosurgeon who fixed it.

But the outcome's excellent. A person's referred with dementia, an incurable condition that'll get worse. They leave, cured. A heartening result, in otherwise chequered times.

Continuity

Yet another post that's not clinical, isn't positive and is about management. Such is my life, at present. Ho hum!

In a previous hospital, when I was training as a psychiatrist, the Chief Executive changed. In my previous job, in the previous hospital, the Chief Exec changed. In my current job, in my current hospital, I asked about management before even entertaining the post. The Medical Director explained that the Chief Exec was a reasonable enough soul and basically let him get on and do what was sensible. He also commented that he'd seen 3 Chief Exec's since he'd been Medical Director. There have been 2 more have since he made that statement, 6 years ago.

Nurses come and go. It's necessary for their career progression. In my corner they tend to start at band 5 on the wards, then progress to a band 5 post in the community, then band 6 in a CMHT or specialist team, then band 7 as a team leader or ward manager, then they're stuck. Band 8a Modern Matrons are managers. Band 8b Nurse Consultants are managers. So it goes. To progress from band 5 to a senior role, nurses need to move around and gain experience in different arenas, so often there's turnover of staff, in a good way.

It does mean, though, that managers and nurses are coming and going at a fair rate of knots. The stability, both within the organisation and with patient care, is through the medical workforce. Senior doctors (GP partners and hospital Consultants) tend to stick around for the long haul. It's been suggested in mental health that all that's good from New Ways of Working is jettisoned and, instead, a "modular" approach is used. A care coordinator (who's re-written as some sort of journies facilitator in new CPA speak) will stick with a patient as they move through Single Point of Access, Assessment teams, Early Intervention teams, Crisis Resolution teams, Home Treatment teams, In-patient care, Rehabilitation Teams, Severe Enduring teams and so on. The fact that a patient's bounced from team to team doesn't matter - the care coordinator will remain a stable point of contact. The fact they've squillions of people to tell their tale to and no continuity doesn't matter - their care coordinator will be that continuity. The fact that each team will have a different doctor (somewhere, that's accessible some of the time, to some people) won't matter - the care coordinator will magically ensure that biomedical and psychosocial psychiatrists and GPs seemlessly deliver the same consistent care.

It's an epic work of contemporary fiction that I fully expected to see shortlisted for the Man Booker Prize. I've been disappointed. Ho hum.

The crux of it is that care coordinators come and go at frequent intervals. A band 5 CPN will be after a band 6 post. A band 6 CPN will need some experience teaching student nurses or doing CBT or undertaking nurse prescribing or managing acute care or supervising colleagues or developing management expertise so will move through posts to gain the requisite skills to then apply for a team manager or more specialist role at band 7. After time at band 7, many will look to band 8. Care coordinators are set up to fail, "navigating" the various teams and services, but equally they sure ain't providing the continuity over the long term.

Doctors can. Doctors do.

The notion of polyclinics worries many folk. Jobbing Doctor has, astutely and succinctly, narrated the zeitgeist within ivory towers and how choice is eschewed in favour of didactic This Is How It Shalt Be. Today he posts on how there will be self evident bad consequences.

It's obvious.

This perturbs me. Private healthcare can (and often is) riskier than NHS care. When my wife needed to see a Consultant, we waited a year rather than going to a private specialist. Private hospitals concern me, because I know just how scary a place they are outside of the working week. Friends work in them. The NHS does out of hours care better. The NHS has flaws, which are magnified by managers (at all levels, up to the DoH) making wholly unhelpful changes. Well, it's their job. They've got to do something.

Doctors need to be in the thick of it. We know what systems work. Folk have already said, we can sort it out on the back of an envelope over coffee in 20 minutes. Patients talk to us, day in day out. We're at the coal face. More, we're there for the long haul. For our patients, for our teams, for our organisations, doctors provide stability and continuity. It'll be a tragic day if that's lost.

Motivation

I've had to spend a lot of time of late mixing with managers. This used to be seen as fraternising with the enemy but increasingly I do see it as A Good Thing because there's then the opportunity for managers to appreciate what life's like for clinicians at the coal face (so make more valid and helpful decisions for us) and for clinicians to interject in to decision making to minimise how unhelpful decisions are implemented.

Part of the managers' agenda is "clinical engagement" and motivating clinical staff to improve things, as managers desire/are tasked to do/are required to evidence.

Some things really are about just showing that we do what we do. Our PCT knows what we do. The commissioner for our services was a senior manager within our Directorate and knows exactly what we deliver on. A request for information on what clinical activity we're undertaking is purely a tick box exercise to evidence a target's been met. Staff take time to record the activity explicitly for no additional benefits, no change in patient care, but it's done for the direct benefit of managers.

How much clinician time can be eroded in such a way? How many audits, data capture, clinical review, risk management proforma, benchmarking, key performance indicator outcomes, quality metric data and target data can clinicians be asked to complete, on every patient, before really it's compromising their work as clinicians and really should be work a data analyst or clinical governance staff or clinical effectiveness staff or a service manager should be undertaking?

But through habit and good will, clinical staff keep filling in the forms. If their boss tells them to, it's hard to say no.

Hardly the best way to inspire clinicians, to engender "clinical engagement" and improve quality, though.

A clever man shared a moment of insight with me, recently. He was of the opinion that staff motivation and drawing on the good will and expertise of clinical staff is a tricky job for managers because loyalties are divided and diffuse. His thought was that most clinical staff feel principal loyalty to their professional group, identifying themselves primarily in this way. "I'm a doctor. I'm a nurse. I'm an occupational therapist." At work, what I am is defined by my profession. This can be a modest factor or a very strong factor, as animated discourse on Dr Crippen's blog and Mental Nurse have evidenced.

After the professional role comes the discpline. "I'm a surgeon. I'm a GP. I'm an RMN. I'm a forensic psychologist." We identify ourselves by our discpline. I'm a psychiatrist.

Next, we identify ourselves with our service or our team. "I work as a cardiac surgeon within the Aceness on a Stick Unit. I'm a rehab OT in the orthopaedic ward for smashed up motorbike people. I'm a diabetes nurse working within the prison in-reach services." We think of ourselves as in-patient paediatric staff or as ITU staff or as community mental health workers in the CMHT or as palliative care staff in the hospice or whatever.

Then we've affilliation to the place, "I work for the Royal Magnificent Hospital. I work at the Wondrous Care Practice." We identify ourselves with the place and locality we work within.

We've then some understanding of the organisation. "I work for the Best Care Ever NHS Foundation Trust." The organisation tells us how we work, what we do, pays our wage so figures somewhere in our thinking, but is too abstract to be in the fore of our thoughts or loyalties.

Lastly it was suggested we've loyalty, "scattered like magical dust throughout this," to the NHS.

You could tell it was a senior and experienced clinician who'd suggested this, 'cause he's right on the money. When with a patient, our loyalty is to our patient. When thinking more abstractly, our loyalty tends to be to profession, discpline, team, hospital, then organisation.

Our Trust needs to do a lot of work in wooing and rewarding staff if clinicians are to be enamoured with the Trust agenda and do yet ever more for them . . .

Psychiatrists

I've been talking with managers at work about psychiatrists. Rather a lot, of late. I work in the NHS, changes are afoot, changes are always afoot. I talk with endless folk, endlessly, because it allows me protect my corner and be left alone to do what we do best. All that seeing patients and making things better malarky.

Managers have a different agenda. They usually are not thinking about the personal and privileged relationship a doctor or nurse, in a room with a patient, have, and how management can make this work best for one and all. Many years ago, that's what I imagined managers did. Now I remain buoyant and optimistic but I'm not so naive.

As an aside, Professor Sir Bruce Keogh, Medical Director at the Department of Health, does seem to have his finger on the pulse. The Jobbing Doctor feels, as many medics do, that our Chief Medical Officer has much to be contrite over. I am heartened that Bruce Keogh was saying how everything managers do, all systems that are in place, should be to improve the quality of that privileged moment of a therapist and their patient, in a room together, getting help. Superb!

Most weeks I speak with managers in our organisation, in neighboring FTs and with the PCT. The LMC and APC like to shred Consultants in Secondary Care too. The role of psychiatry in undergraduate teaching is modest, discussions I have with the university policy makers as an old age psychiatrist are laughable. But I enter the lions' dens time and time again because if I didn't I'd get sold down the river and life for me, our teams and my patients what be a whole heap worse.

I've also undertaken formal investigation of rubbish psychiatry in a neighbouring area. As well as middle grade doctors who've needed performance management, it got worse than that. Always grim, to see practice by a Consultant that's beyond poor and in to utterly shameful.

With patients, commissioners and staff I find myself increasingly having to justify the role of a Consultant Psychiatrist. In my corner, oddly, Old Age services are well regarded by all parties, so the knives are out for colleagues. Therein lies another post.

Suffice to say, we live in interesting times.

Normally, when a crowd get together and pool decision making, decisions are better. Sources of bias and error are cancelled. Guess the weight of a jar of sweets. You'll guess wrong. So will most folk. But use the crowd's answers and pool the answers, take an average, and you'll likely get close. Still not right, maybe, but better than the guess you'd have made yourself.

It was of interest to me, then, to see that this "wisdom of crowds" effect got worse when you gathered 300 psychiatrists together. Read about it here.

My managers will love this . . .

Clouds

Thanks to Dr Shock for this Wordle thingy, which shows a cloud of what my blog's about :

Clicky.

Well, it amused me :)

Speech

Okay, okay, time to 'fess up. I've been a tad naughty.

On commenting on my favourite Social Worker's blog, here, I used colourful vocabulary. I shouldn't have. Her "Comment Policy" even says :
"4. No swearing/bad language"
Although in fairness I never read it before today. Ooops.
Quite rightly, she's ammended my comment so it's clear what I said, but it's not obviously offensive. I feel suitably chided and won't sully her splendid blog with my base vulgarity again. Sorry, CB.

It did get me thinking, though.

I don't comment on people, often. It's not something I feel comfortable doing. The only people I comment on are folk I know very well. Whether it's to say they're a good person or a caring person or a loyal friend, or whether it's to say they're scatty or self centred or ruthlessly assertive, such comments can only be made on folk we know inside out.

I do comment on behaviour often. Someone may be a good or not so good person, which I can't know so can't comment on. But their behaviour, as Tolkein's Faramir would say, is a chance for a man to, "show his quality."

On this basis, I felt wholly justified and reflexively commented that, on considering a suitable description of Ed Ball I opted for, "I’d try for, “behaving as an utter cunt.”"

I have my quirks and foibles. One of them's language. I'm pretty easy going and am not seeking to change how other folk use language. I've no crusade. My use of language is often far from perfect. My schooling was in a local comp by a massive deprived housing estate; nuances of grammar were eclipsed by teachers' desire for us to simply write in something less troublesome than someone elses blood. So it's simply a personal position that I see careless, sloppy, wildly inaccurate use of language as "bad" language and see colourful/swearing as simply part of vocabulary to use when sought.

It's not often I swear, in truth. But I see such words as helpful interjections. Almost by definition, such interjections are exclamations and inherently have an exclamation mark. Thus they're useful if, like exclamation marks, they're scattered occasionally to succinctly reinforce a point.

My wife chides me over this. Brought up on a diet of Germaine Greer, Naomi Wolfe and the like, she doesn't like me using such words. And I'm not so bold as to frustrate the will of my wife. I curtail my use of colourful language in her good company. When it was in vogue in the '90s, she went to the theatre to see "The Vagina Monologues" with some female friends. She relayed how the audience had been challenged to see female words, like cunt, as positive. A bloke on the street shouts out, "You utter cunt!" The woman's response should be to beam radiantly and visibly cherish this, replying "Oooh, thank you!"

Reclaiming words. This appeals to me. A bit like mental health stigma, I like to believe we can reclaim unfashionable words to use them helpfully.

She's still mortified to hear the word cunt. I shall endeavour to behave better.

Rewards

Mr Edwards went to a cafe in a charming garden centre today, then walked around looking at the bedding plants, enjoying the riot of colour. I know this because a support worker relayed to me how cheery he was, ambling about seemingly aimlessly, chattering away to her with real zeal and passion. Mr Edwards has always been an enthusiastic gardener.

He has Parkinsons Disease (PD) which affects him in three particular ways.

Firstly, his speech sounds slurred. Although he's readily understood he's very self conscious of this because he reckons he doesn't sound like himself but worse, he reckons he sounds drunk. Happen he's right. I don't think his dysarthria sounds like drunken slurred speech, but I'm tuned in to medicalising stuff and in critiquing nuances of speech that means I sift through a number of reasons why he's slurring speech whilst folk in his neighbourhood would instead probably assume he's drunk. He lives in a hellishly deprived area. It's a statement of fact that lots of people are drunk lots of the time. He feels awfully self conscious that, if he speaks, folk will presume he's a drunken sot.

Secondly, his gait is poor. He staggers and sometimes falls. Steps are a nightmare for him. This compounds his belief that folk will see him as drunk. It also concerns him, whilst he's out and about, that he might freeze or fall in an awkward place. Tragically, he's not fearful that he'll come to harm through this, no, he's fearful that someone else will. He's terrified he could collapse in the road and cause someone to swerve and have an accident, all because of him.

Thirdly, as sadly everyone with PD will if they live long enough, he has developed dementia. It's expected and inevitable, PD is a progressive neurodegenerative disease so only goes one way, but for Mr Edwards his dementia's responding well to medication and he's just a little muddled with dates, a little forgetful of times (was it 2 days ago we last met up, or was it a week?) and a little impaired with recent declarative memory. Procedural memory, such as riding his bike to his allotment, is fine. So's managing finances. Orientation in his locale is fine (he's lived there all his life so knows his way around effortlessly). Judgement/decision making is still sound and has improved significantly on galantamine.

An Occupational Therapist sorted some practical changes for him, both in his home and his allotment and with tools. A Social Worker sorted out practical support, with a care package of home carers twice a day. A clever and devoted chap within our local Alzheimers Society branch has sorted out his benefits and finances. Nurses in our memory clinic have done exhaustive memory testing initially (to inform diagnosis) and periodically (to assess efficacy/effects of galantamine). A CPN gave advice to him and to his PD Nurse, several times, over a period of a month or so, with oodles of practical changes made consequent to this. She then did some CBT with him over four months. Yes yes, I know he's got dementia, but that doesn't preclude CBT. Indeed the behavioural stuff and experiential learning over a month or so, with a fortuitous ability to forget the bad things in the months before this, meant Mr Edwards regained significant confidence and competence through the CBT. Underpinning this, a Support Worker has been assisting him in maintaining function (e.g. going to his allotment, going to shops, using a bus for journies he can't cycle, going to his GP and hospital appointments for things that he'd been putting off, visiting friends he'd worked with for decades, getting to church).

I saw him at his home with a CPN (and the results of her initial assessment) and memory clinic assessment, the PD Nurse's referral details, the subsequent GP referral letter and blood results and the results of the CT imaging and ECG I'd requested. We'd considered a DAT scan but it wasn't necessary. I spoke to him at length, assessed his mental state, assessed areas of cognition that had been equivocal on memory clinic testing and reviewed all the results. The diagnosis was obvious. He had PD dementia.

We discuss options. It doesn't take long. My colleagues have already paved the way to this point, with ongoing discussion at each stage, by each person, so my words are simply the concluding confirmation, the distilled summary.

In my corner it's only Consultant Psychiatrists who start acetylcholinesterase inhibitor treatment, so having discussed medication out comes an FP10 and we start galantamine.

I've not seen him since. I hear about him several times a week, through working in the same office as the Support Worker and CPN. In his care I've been involved in over 20 conversations, from dicussions at the point of referral then assessment then intervention. I've consistently directed and influenced his care. But in terms of face to face contact, in truth, it's the support worker and CPN who've effected change and in his words, "Given me my life back."

Yet, this week, he gave the Support Worker a gift wrapped bottle of wine and card to give to me. The unqualified Support Worker has done the most work, yet she didn't get anything. The qualified nurse (a CPN) has done the next most amount of work, yet she didn't get anything.

I have a series of conversations with staff and see him once. I can't claim that's a lot of work.

Doesn't seem quite fair.