Friday 31 July 2009


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 . . .

Thursday 30 July 2009


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.

Wednesday 29 July 2009


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.

Tuesday 28 July 2009

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 . . .

Friday 17 July 2009


Let's try and keep it dignified.

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

Bwah ha ha ha ha ha haar!


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!

Thursday 16 July 2009


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?

Tuesday 14 July 2009

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.