Friday 24 April 2009


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.

Thursday 23 April 2009


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?

Tuesday 14 April 2009


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.


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.

Friday 10 April 2009


Well this all sounds less than ideal . . .

Thursday 9 April 2009

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.

Sunday 5 April 2009

What matters?

I've been to a number of meetings and conferences committees that have left me thoughtfully confused. As I've said before, I invest time in this malarky because if someone doesn't we'll get sold down the river, so it's best to at least chip in to have a voice in the process.

I think the GMC expect us to, aren't they about protecting patients? Ah no, their tag line now summaries that they too now are focussed on, "Regulating doctors, ensuring good medical practce." Well, they used to care about protecting patients. I'm sure as a doctor we're still obliged to protect patients from malign care. Thus, if managers are having a brainstorming session and generate what I would charitably call "idiosyncratic ideas" that will affect clinical practice unhelpfully, I like to be able to interject a bit of common sense and pragmatism in to the deliberations.

Mostly this works, which is why I keep doing it. I'm over stating it a bit, since in my corner the managers are actually pretty sensible and clever and helpful folk. The problems mostly involve evidencing something or doing something that we all know is nonsense but, for mind numbingly frustratingly incomprehensible and labyrinthine reasons just, "has to be done." So we get around a table and mull over how we do something we mostly agree doesn't truly need doing, and think of how it can have the least hassle for staff and least nuisance for patients.

Meetings with the SHA and PCT and partner organisations have been more . . . curious.

There's an enthusiasm to measure things. Evidence things. Prove things. Monitor things. Manage things.

This has lead to me knowing far too much about "things" which no sane man should know. Things like "quality metrics" which I won't sully your pure and beautiful minds with; enjoy the innocence, unfettered with such nonsense.

The notion proposed in my corner is that "quality" and "outcomes" are measured. Along with the work done (the content of a service line, i.e. the staff and resources). And the activity undertaken. And, for this work, the cost to our Trust for this. Anyone flirting with management will recognise this unholity trinity of Service Line Reporting (SLR) there, which is then fused with quality and outcomes and Payment By Results (PbR) and Quality Outcomes into some hideously ghastly abomination.

Zarathustra will love this. H P Lovecraft couldn't craft a finer tale of complexity, understated malevolence, despair and of something slumbering, quiescent, about to errupt causing "much badness." Reality is indeed more curious than fiction.

For now, within our corner, we're having to report to the SHA on quality. And report on Service Line Reporting to entertain Monitor.

So, over to you. What do you think will be looked at, when considering quality? For a patient, going through our service, what things matter? What is quality, what things should be recorded and reported and publically shared, to reflect whether we're doing well or not? I've my views, which I'll whitter on about another time, but for now, have a blank bit of paper. Add what so ever you will. If you're interested in a quality mental health care from our Trust, what would you be wanting to know about? What's on your list? What matters?