Saturday 29 August 2009


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 . . .

Sunday 23 August 2009

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.