Friday 31 December 2010


I'm surprised!

The readers of Mental Nurse have voted for favourite mental health blogs and have voted for this as their favourite Psychiatrist's blog.

Given the number of popular psychiatrist blogs, more established ones, more frequently updated ones, newer ones, more evidence based ones and almost all of them look nicer/are better presented, and more popular blogs (with me tumbling through 2010 from number 2 to number 15 now) I'm very surpised (and of course pleased) that folk rated my musings.

So, a big thank you for being so kind!

Now, get on to Mental Nurse and rummage around some really good top quality blogs!

Liaison Psychiatry

It's stopped.

Bank Holidays must have something to do with it. I can't really fathom it, since that local acute Trust has a massive pressure on beds and is keen as mustard to move patients on.

Yet despite having hundreds of patients within their hospitals who've dementia, delirium and major mental illness, spread over a number of sites, with difficulty in managing and effecting safe discharge for these patients, I've not been swamped by liaison referrals. They've literally hundereds of patients with mental health problems on their wards. Often they find them very very difficult to manage on the ward and to plan discharge for. What with capacity assessments, Best Interest Meetings, Continuing Care needs there's usually process they want support with, before we even get to advice on clinical care.

With pressure on beds you'd expect there's be squillions of referrals to my door, trying to speed up the assessment, diagnosis, management or discharge planning for these patients.

Over 5 consecutive days I had 0 referrals. Not one. We usually have referrals every day. It's utterly unheard of.

Long 4 day Bank Holiday weekends. My fear is that no routine or important work gets done, only urgent/emergency work's attended to. These patients with physical and mental health needs, within the acute Trust, have unusually had no Liaison Psychiatry input in to their care for almost a week. Junior doctors and on-call staff haven't been considering their mental health needs and referring for specialist input.

Bank Holidays seem dangerous. This surely can't be good for patient care . . .

Tuesday 21 December 2010

Mental Capacity Act 2005

I'm blessed with fantastic colleagues. It's really the only reason I'm working where I am. The staff really are fantastic.

Colleagues outside of the NHS are more variable in their competence. Some social workers are fantastic. I've a lot of time for social workers, they do a hard job with little meaningful support/team work. One disadvantage of this culture is that social workers are pretty idiosyncratic animals. They all work differently, with sometimes very different attitudes and consequently very different interventions (or lack of interventions).

This variability in social work bemused me . . . shouldn't it be a needs led service? Shouldn't what the patient (erm, client, to them) needs define what activities the social worker undertakes/the content of their care schedule? No, it all falls down to the quirks of the individual social worker (or assessment officer) in my corner, and the attitude/whim/habits they possess. Patients get very different responses and outcomes depending which area team social worker picks up their case.

What's more muddling is their response to change, including legislative changes such as the Mental Capacity Act 2005.

A social worker today said they didn't know it, she hadn't had what she thought was enough training on it, she didn't use it and it was "still new" so it didn't matter. 3 of her colleagues thought similarly. New? Still new?! It was drafted in 2005 and implemented in 2007, we've been using it for years!

Good grief.

But those individuals ignore it, don't do formal capacity assessments or Best Interest meetings/decisions or the like. Instead they refer such nonsense to their Team Leader (who has to do it all) because when she says they have to do it, and it's the law, they just tell her she's, "going off on one, again," and shrug and move on.

I'm not sure we've the ideal system, locally, for embedding current best practice within Local Authority social work teams . . .

Tuesday 9 November 2010


Another rant, I'm afraid.

First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.

The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.

The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.

I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.

They weren't.

On face value, with the problem in front of us, it was all very simple indeed.

It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.

Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.

Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).

I was perplexed.

Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.

We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.

They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.

Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.

Wednesday 3 November 2010


Is it wrong to want to slap someone? There's a dark cloud.

There's an irrational, unwanted, non EBM collusion that in older adults you prescribe medication by, "starting low and going slow."

No, I don't really know what that means, either. It was never taught to me in pharmacology lectures at medical school. Nobody in conferences speaks of subtherapeutic prescribing, unless you're in a homeopathy class, presumably. And then, well, frankly it's just water so dose becomes singularly uninteresting to me.

But for proper drugs, doesn't an effective dose matter?

Really, in all the pharamcological and therapeutics conferences, CPD events, reading and training I don't hear folk saying, "Take the patient research, the evidence based medicine, the product SPC and of course just ignore it all . . . halve the starting dose to well below what the BNF has as a minimum, keep 'em on that subtherapetic dose for ages and then maybe titrate up to the minimum dose months later . . . since boy and girls, we much start low and go slow."


Older adults with mental health problems are vulnerable adults. I'd absolutely advocate minimum therapeutic doses, if medication's indicated at all. Most of the time medication's not got a major role to play. When it is used, it's therefore important that it's used effectively and that it works.

Depression is serious. An older adult, being depressed, is harmful. Evidence shows permanent neuronal cell death arising from depression, so each day depressed is a day that a little bit more brain dies.

We know that a metaanalysis of antidepressants confirmed that the drugs aren't any more effective than placebo in mild, moderate or severe depression, with benefits only being realised in very severe depression (as described here). If an older adult is clinically depressed, either it's mild/moderate/severe and arguably medication's seldom used, or it's very severe and medication's used effectively. It's hard to argue to use medication ineffectively.

Why do some folk, who are otherwise sensible and rational and effective doctors, therefore prescribe subtherapeutic doses of antidepressants which don't work (surprise, surprise) then refer them, perplexed, to my door, time and time again? I know why it is, because I asked them. It's because they're harrowed by drug reps whittering on about "start low and go slow" in older adults. Bastards. It means my patients are getting shabby care for no good reason, what so ever, but Big Pharma has lots of FP10s which have to be dished out for months "because you have to go slow" before then the meaningful prescribing can start.

Why should anyone with depression, which is severe enough to need medication, be on citalopram 10mg once a day? The BNF has the minimum starting dose as 20mg once a day. It kindly guides us into evaluating at 3-4 weeks to titrate up to 40mg and kindly specifies that in folk over 65, 40mg is the maximum dose. Brilliant. Crystal clear. For folk over 65, you're on 20mg od and if after 3 to 4 weeks you need more, you're on 40mg od. Why oh why are 10mg or 30mg prescribed, then? Drug rep waffle seems to be cited as the only cause, and worryingly is more powerful in effecting change in practice than the crystal clear/precise BNF is in directing appropriate prescribing.


Olanzapine also is used in timid doses. I don't want high dose presribing, this year my appraisal portfolio evidences just 2 patients under my care received above BNF doses of medication at any time. I'm not after high dose use. I just don't want subtherapeutic or irrational use. Olanzapine's blood level is roughly halved in smokers, with many of my older adults in the deprived areas I cover being smokers. Yet there's a zeal for homeopathic starting doses, which are continued ineffectively for months, to "start low and go slow."

Whoever it is, in 2010, that's going around and poisoning doctors' minds away from evidence based medicine, pharmaokinetics/pharmacodynamics, product testing and the licence/Summary of Product Characteristics and BNF prescribing details, they're harming patient care. Those folk whittering on about this "start low go slow" notion, I want their evidence base or I want to slap them. Or reporting them to APBI may placate me and rid us of such pernicious counsel. There's a dark cloud, but there's a silver lining.

Monday 1 November 2010


Walking through the hospital grounds this morning, beneath bright sunshine, the grounds are a riot of colour. Trees shifting through golds, browns, yellows and vibrant reds.

I love Autumn.

Friday 15 October 2010


I read of people with bipolar affective disorder disorder who see it as a gift. It's part of their chemistry, it's who and how they are, it's something that gives changes and makes things different, with difference from the herd not always being bad. I've yet to meet such folk, my patients tend to see bipolar disorder as a wretched nuisance.

One bloke, though, quite appreciates it. He'd rather not have it, hating the periods of low mood when he describes how melancholia descends and remorselessly harrows him for months on end, but he does like the rest of it. Most of the time he's a naturally cheerful disposition, our team's unclear if this is because we're holding him on average a little on the high side, or if he's one of life's cheery souls.

In any case, he's normally buoyant and optimistic and outgoing. He has no family but has a good number of good friends.

Dr Zorro talked of music. The Jobbing Doctor spoke of music, too.

My patient speaks of music. He loves to play, plays a few instruments, and is decent at this. Friends think he's okay, he describes how folk amiably listen whilst chatting or sharing wine or whatever on an evening. All pleasant enough. I can't play any instrument competently so envy his aptitude, to pick something up and create melody and rhythm and emotion in instruments he plays. He sounds good to me, too, when he's played for me.

What's different is when he's high. When he's high he plays music and it's divine. His friends enthusiastically agree. He has insight into this too, reckoning that his music, when he's high, is genius. He's not that grandiose either, it really is in a wholly different league. Home visits when he's high are a source of both dismay (finding seeing him manic) and raturous joy, as he enthusiastically plays the most incomparable music I've heard.

Monday 11 October 2010

Paternalistic Healthcare

I started to think this through previously, but derailed into a post about my experiences of GP training and reflection on how clinical focus shifts at different stages of our training and our careers.

My thoughts were on training, particularly my GP training, because one of the teams I work with has recently had animated debate on the topic of paternalistic healthcare. As in, telling patients what they should do.

I work in a world where mostly there're shades of grey. Most folk working in mental illness suss out there's not a magical dichotomy between mentally well and mentally ill, but there's a continuum. No matter how biomedical or psychosocial in their outlook, most folk I work with see medication as not the only treatment/panacea for everything or as useless to all patients all of the time. Whether it's diagnosis or treatment, we're comfortable with managing uncertainty within accepted frameworks. We do shades of grey quite well.

Apart from on this one, it seems.

How paternalistic should we be? It was argued that it's also a continuum and we should be more paternalistic or less paternalistic, taking into account patient factors. Some felt no, we shouldn't be paternalistic at all and that family or IMCAs should take on this role.

If someone's bewildered and all at sea, it was argued that the least restrictive/most proportionate response, acting in their best interests, would be to offer choices to them and if they were unable to make a choice to steer them to what's a good idea. A nurse had an example of a patient they'd seen who was clinically depressed (unable to think, thought they'd been back from their daughter's house 3 days when it had been 9 days, unable and unwilling to eat or drink, demotivated and not leaving the house for weeks, seeing no hope for the future and wanting to be dead).

Depression had caused marked cognitive distortions. After the nurse and I saw him one day, the nurse saw him the next day and again talked through ways of helping him. The patient couldn't make a choice, the nurse met me and arranged for an orodispersible antidepressant so the only choice the patient had to make was whether to take it or not. 2 weeks later things had improved a lot, 4 weeks later he's almost back to normal. The response to medication was unusually good but that wasn't the point, it was that the patient was started on medication through being jollied along into this by his nurse (and indirectly by me, from discussing medication the day before then providing a prescription for him).

A lady with dementia, she's now in respite care, a lot. When at home our support worker takes her out at least once a week. This gives her husband a break but also gives her opportunity for stimulation and lets us get the measure of her functional level/what she can or can't readily do any more. The support worker can get her to do anything. She'll get into her car, pop to the shops, sit and have coffee or something to eat, play a game of bingo or dominoes or snap, have a bath, anything. With respite care or home care or the sitting service we're told she's a "challenging lady" who won't do anything and "is resistive to care."

The support worker and a nurse went to the care home and watched how they treated her. Usually we'd not send two staff but there was a need for a nurse to do some formal Dementia Care Mapping as part of future teaching with that care home anyway. The staff feedback and documentation was interesting. It was clear that carers were offering the lady lots of choices and open comments.

"Do you want to play a game of card?"
"What would you like for lunch?"
"Do you want a drink of tea?"
"You okay there, love?"
"Do you fancy joining the [activities] group this afternoon?"

She sat in the care home, declining everything, "No, I'm alright love, leave me be."
Things were offered and she'd either decline to opt in, or care home staff would see her as not keen to engage so would pass over her. Mostly she was ignored.

Why was she fine with the support worker but not with care home staff? It was a difference of approach. Our support worker would, in her bright and cheery way, suggest, "Come and . . . " or "Come on, let's . . ." and she'd go with the flow and join in.

Rather than choices, to offer direction was helpful. Not for all things, all the time, but there seemed to be a place for directive comments. The lady would never opt in to play a game, but if you said, "Come and have a game of snap with Betty and me," she'd happily walk over and sit down and talk and play. Without being "told" to come and do it, if just offered "Do you want to play snap?" she'd always decline, as she would almost any choice offered to her.

Some of our team illustrated compelling cases where being paternalistic, with some people, some of the time, is a good thing.

Managers will be having a fit.

Friday 8 October 2010

Dementia Care

I'm sure everyone's been gripped by the NICE review and preliminary guidance on the NICE Technology Appraisal (TA 111), released yesterday. It goes on, at length, here. Reading the runes, it's likely to be refreshed from preliminary guidance into national NICE guidance in February 2011 which then has significant implications. Implementation and use of Technology Appraisals in clinical care has to be funded and can't be denied solely on cost grounds.

I'm rather relieved, therefore, that in my corner it isn't going to make a significant difference. Does the review of TA 111 matter, than? It was released in September 2007, updated in August 2009, now refreshed in October 2010 for update in February 2011. Does this document have any use or meaning? It will, helpfully, to a lot of other Trusts.

Microsoft Word tells me the preliminary guidance is 21 824 words. There's a lot of it.

I like it.

It's at variance with some folks' wishes who aren't keen on early diagnosis, since the guidance now invites treatment of mild dementia, rather than waiting 'til you're moderately demented before starting medication. This makes sense to me. The medication typically holds a person at their level of cognition for couple of years. Is is better to be held at a level where MMSE is 24/30 or where MMSE is 14/30? There're exceptions (where insight is a curse and distress blessedly diminishes as the ability to forget becomes more intense) but usually it's desirable (and desired by patients/carers) to keep someone at their best, rather than wait for a decline then keep them at that level.

This is what my colleagues and I've done for years. Our local Alzheimer's Society, PCT, Area Prescribing Committee, GPs and Trust Medicines Management Committee uncharacteristiclaly all agreed a care pwathway and funding such that folk with dementia access treatment on diagnosis, irrespective of severity/MMSE. All my patients with mild dementia have been having the drugs for years.

No changes there, then. Speaking with colleagues in other Trusts, it will open up a huge amount of work for them, with literally hundreds of people who've mild dementia who will be entitled to medication and aren't currently on it needing review and discussion and (often) medication initiated, titrated, reviewed then continued under Shared Care.

I don't prescribe a lot of memantine, using it with just a few patients, so the guidance there won't change my world. Opening up memantine so it can be used in the NHS (outside of clinical trials) isn't a change for me, since I am prescribing it already.

Over 20 000 words saying I can practice as I am.

That's the sort of guidance I can stand to receive!

Tuesday 5 October 2010

Vitamin B

Folks with memory problems have some B vitamins checked before ever reaching my door. Vitamin B12 (and folic acid, and LFTs showing albumin levels) evidence nutrition, or lack of nutrition.

If patients have evidence of vitamin deficiency, it's usually treated by their GP before I assess the patient, so assessment of mood and cognition is looking at contributing mental health problems, not nutritional deficits impacting on their wellbeing.

Recently patients' carers have been asking me about vitamin B preventing/slowing Alzheimer's disease. It's not something I know a lot about. I know a lot about Alzheimer's disease, the risk factors, the pathology that develops within the brain, the evidence of psychological interventions and the evidence of medication's efficacy and effectiveness. I know that about 8% of patients referred to me with dementia have something else instead, so routinely find physical health problems presenting with cognitive impairment.

In all this thinking and sleuthing stuff out, I was perturbed that vitamins could have great benefit to my patients but none of my colleagues knew of this, no current teaching articulated this, no past training covered this and no journal articles and updating continuing professional development taught this. My pharmacist colleagues knew naught of this, either. Perplexing.

I spent a few hours finding what I could. A pharmacist did the same. We met up and compared notes. We'd not found anything illuminating.

I chanced upon another blog today for the first time, which helpfully fisks the rubbish being tossed around in some main stream media. It's heartening that it's not just me and my clinical team that's not wondrously excited by vitamin B.

When patients ask about it, I'm indifferent. It's cheap, it's water soluble (so, unless really really trying hard, if you take too much it is dissolved in our urine and we just wee it out) but it's also not convincingly beneficial. If it's taken with minerals (like iron) then it's not that hard for folk with dementia to poison themselves.

It's not crystal therapy or colour healing. Not quite. It could have some sensible contribution beyond placebo effect. If people want to take vitamin B, all well and good. But it's not something my GPs or I'm prescribing for folk with dementia, yet.

Monday 4 October 2010

The past

When I trained as a GP there was consistent recognition of the book "The Doctor, his Patient and the Illness" by Michael Balint. Given that Balint's work involved GPs and psychiatrists meeting up and chewing over discussions of patients the GPs had been seeing, the themes and processes were right up my street. Although I enjoyed working in GP land, having swapped to psychiatry I still find the work equally appealing.

Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.

A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.

As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.

On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.

"The past is a foreign country; they do things differently there."
- L P Hartley

Friday 1 October 2010


I was surprised.

When the National Dementia Strategy was published in February 2009, although it wasn't a vision of perfection, it had good content and importantly also had cash attached to it. Strategic Health Authorities were given millions to implement the strategy. Not just "these are good ideas" or "do more, and now start doing it right" but instead a sensible strategy with sensible amounts of cash to resource it.

I was pleased.

Okay, okay, in my corner our Trust didn't get a penny more, but had (and still have) to deliver on objectives, so are being asked to do more and mroe without anything extra. But across Primary Care and the Local Authority and care homes, new money has been thrown at it and has helped patients. Mostly with Continuing Care funding, it seems.

I am still pleased.

That was February 2009. Time moves on. 1 year 8 months on and it's all gone quiet, with no enthusiasm to tackle dementia and the focus has moved elsewhere. No no no. This week the Department of Health published another document, following on from the National Dementia Strategy, called Quality outcomes for people with dementia : Builing on the work of the National Dementia Strategy. Okay, it's not the snappiest title for a document, but what's the document about? Read it on the DoH website, here.

It only came out this week, on the 28th September, so I've only just got around to reading it, thinking about it and forming a view. It contains 9 desired outcomes for people with dementia, which are clear and meaningful and realistic. It gives explanation of how theese outcomes can be delivered without oodles of prescriptive mandates and This Is What Thou Shalt Do edicts. Even the appendix, Annex 1, gives genuinely helpful descriptors for what the 9 outcomes/improvements for patients with dementia mean, in a nutshell.

First there's a National Dementia Strategy with a clear, over arching vision for health and social welfare that had millions attached to it, that we got. Then there's a follow up document a year and a half on, maintaining focus and contributing useful outcomes.

I remain pleased. Pleased and very pleasantly surprised.

Thursday 30 September 2010


I use the internet a lot.

I don't think I use it excessively. At work I rummage around blogs and web sites when I can. On evenings I browse through medical/mental health sites that interest me. A few times a week I'll pop on to Facebook but I don't use it a lot. I'll email* at work several times a day, mostly to managers.

I've a 'puter at home we use for online gaming on evenings, but rarely use it through holidays or weekends.

My mobile 'phone can do email and Facebook and stuff but I've not configured it to do so. I'm quite happy using it to call or text or occasionally take photos.

If I want to communicate then I still like face to face contact. At work I walk to offices to meet folk, I hardly ever use my 'phone. At home I drive to friends and family and hardly chatter by 'phone or texts or Skype or emails. One friend texts* loads, which works fine, since we meet up throughout the week too. To have a real relationship, where you can relate to people, supported by texts/emails works for me.

I'm aware that I'm practically prehistoric in how I interact with the big wide world, though. My wife, who loves gadgets, thinks that although my mobile 'phone can do loads and I use it for just texts/calls/photos, the only reason I have a modern 'phone is because they don't do rotary telephones any more so I was forced to move on.

I recently was reading through work by Kruger (2005) on computer mediated communication. Apparently we're all not very good at it.

Published work shows authors believe they're understood much better than they really are. Folks communicating face to face accurately assessed how often their meanings would be understood. Folks communicating electronically incorrectly thought meaning would be understood about 80% of the time, when it was just a little over half the time. 44% of the time the important meaning (such as sarcasm) simply wasn't got.

Contextual meanings such as sombre or sadness or humour were poorly conveyed. What of smilies and emoticons? They were used and didn't help improve the outcomes. Even with such cues, anything (other than facts) such as sarcasm or emotion or attitude or irony or humour aren't meaningfully conveyed almost half the time.

This comforts me, knowing electronic communication is but a small part of my world. But, gentle reader, just in case you read anything I generate within this blog or comments on other blogs and take issue, can I play the "it's through using t'interweb" card and claim it was meant sarcastically, ironically or humorously? :-)

* email, electronic mail, is it just a noun or is it fair to use is as a verb? Texts, text messages, is it just a noun or is it fair to use is as a verb too?

Wednesday 29 September 2010


An older lady with a diagnosis of schizoaffective disorder was admitted to our acute district general hospital down the road. She lives just out of area and was brought to our local acute hospital through the vagaries of chance. She was maintained on depot flupentixol decanoate (depixol) which had kept her well for a number of years.

She was having this injection every 2 weeks, without any side effects or problems, sought to continue it and both the patient and her psychiatrist/mental health team wished for it to continue. Her mental health team were remarkably helpful, faxing over depot cards and loads of relevant material for me. Continuity of care can work.

On the ward, her mental health was stable. Not a surprise. She'd been stable in the community for a few years, now.

She was referred because the nurses couldn't give her the depot injection. The ward nurses (RGNs) within the district general hospital are trained and competent to give injections, of course. But apparently the technique and administration of oily depot antipsychotic medication is something that mental health nurses (RMNs) are trained to do, but RGNs are not. So the acute hospital referred the lady to my door, for one of my nurses to drive over just to give the lady her injection. She did, shes a helpful soul and wanted the patient to get the right care.

But it struck me as odd. As a doctor, my training in procedures was p'raps more cavalier than it is now, being of the see one/do one/teach one school of practice, so I just assumed if you can give an injection, and you know the drug, you're fine to do it. I vaguely recall discussion about what the differences in practive between an RGN and RMN are, but since both nurses do injections, I'd not appreciated that the nurses can each only do certain types of injections.

Friday 24 September 2010


A nurse and I were in a patient's house, talking with a widowed gentleman who'd apparently not been faring brilliantly.

He has diabetes and hypertension and hyperlipidaemia, presumably these have contributed to his vascular dementia. Mostly he manages pretty well, with support. He is keen to stay in his own home and his social worker's sorted out care for him 3 times a day (he was unable to manage his medicines, so needs home care to prompt with that, as well as support meals and drinks), he attends a day centre once a week where he gets a bath and has some new fangled telecare that means if he leaves his home at night and doesn't come back after a few minutes, his daughter's automatically 'phoned. He's never yet wandered at night, but it's a sensible precaution.

Having vascular dementia there's not a lot that I can personally do. The GP has sorted his physical health and the risk factors. His social worker has sorted practical care. A nurse went through information with him and his family, over a few weeks.

We found ourselves in his home because a new home carer had alerted her manager that he was unwell, confused and "had it in" for his brothers. Homicidal thoughts. High risk. A 'phone call to us sought an urgent review. We knew it wasn't urgent, but we were in the area so popped in to see him.

It was clear he had no new psychiatric problems (in particular there were no mood changes and no persecutory beliefs) and no new physical health symptoms. He was stable and much the same as I'd seen him a year or so ago, when I first saw him for initial assessment and diagnosis. The nurse, who's seen him too, was talking through with him what home care had said of him thinking badly of his brothers.

"Aye," he said, "the both of 'em have been having it away with a lass, she's only 18!" He was mortified that they'd got her pregnant. The nurse looked at him and without even blinking said, "Let's have a look at that, shall we? Your brothers, are they still alive?" We knew his history.

The man paused for a fraction of a second, confusion then surprise then a smile shifting across his face. "No, they're both dead, been dead for years, love. Why'd that daft thought come into my head, then?!"

The nurse had sorted it. There was no homicidal risk. There was no psychiatric illness for me to fiddle with, nothing specific for me to do. But it was still an oddly satisfying visit.

Tuesday 21 September 2010


What is "clinical governance" about? I mean, really? What does it tangibly change in my patients' world?

There's a pervasive assumption that it's always right, always good, always clear, always happening and always helpful to patients.

Wrong, wrong, wrong, wrong, wrong.

But this is heresy and I shall be burnt. So it goes.

Friday 17 September 2010


Aripiprazole (trade name abilify) is an antipsychotic drug, licensed to market itself as indicated in the treatment of schizophrenia, mania and the control of agitation and disturbed behaviour in schizophrenia.

The BNF shows that a month's supply of aripiprazole 30mg has a reference cost of £191.47

Now, a drug cost of £2297.64 a year isn't actually that huge. Compare it to the cost of an admission to hospital and it's clear that keeping someone with manic/schizophrenia well for that amount is great for the patient and great for the NHS. Sure, there're medical costs of assessment and prescribing, pharmacist costs in dispensing, but actually it's still much better for the patient not to relapse and much more cost effective to spend staff/drug costs on this, than have an admission to hospital.

Haloperidol also is licenced for schizophrenia and mania. Top dose haloperidol is also 30mg a day (although I can't recall prescribing an older adult even 1/4 of that dose) at a reference cost of £52.28 a month and haloperidol is, usually, a drug causing a lot more side effects.

Olanzapine, in the treatment of schizophrenia and mania, has a top dose of 20mg a day, at a base cost of £158.90 a month.

I am happy to prescribe olanzapine. It seems well tolerated. It seems to work well. Aripiprazole is a newer and more expensive drug. It's a topic of conversation. It was discussed with Consultant Psychiatrists across 4 mental health hospitals. Working age and old age pschiatrists curiously formed the same view, with nobody seeming to think that aripiprazole seemed to work as well as other drugs. Some vociferously argued it didn't work at all.

Spending a few thousand a year on a drug that works and prevents admission both improves my patient's life and saves the NHS money.

Prescribing a drug that's of dubious effectiveness, hmmm.

Has anyone had decent results from this drug? I've yet to hear of it . . .

Thursday 16 September 2010


This week I've spent hours in meetings, mostly management meetings, striving to keep our service ticking along nicely through basically asking simply for us to be left alone. Investing time in meetings to do nothing and change nothing is necessary, to stop well meaning folk make unhelpful changes, but there's little joy to this. The endless hours can be a bit of a dark cloud on your working week.

I've a gentleman who's just had his 6 week review by his social worker, having been placed in a care home from intermediate care. He's staying in the care home since he's immobile, episodically confused and falling.

He's got severe osteoarthritis, with the wear and tear on his joints causing severe pain, limiting mobility striking. From being independent a year ago, he's no sedentary and almost immobile. When he does try and walk he's in pain and falls, often.

He's an older gentleman and has prostatism, drippling urine and having continence problems.

He was made known to me by the care home, rather than from medics in Primary or Secondary care, with concern that he'd developed pressure areas and was this causing infection making him more confused, causing him to shout out at night now? A fair question for a regular residential home to ask. I pulled medical notes from the acute Trust, spoke with the GP, pulled off his blood results and scans and found a different picture.

His poor gait and falls wasn't put down to arthritis and pain. His incontinence wasn't put down to prostatism. His episodic confusion and decline in function over a year wasn't put down to dementia. He'd been investigated and found to have normal pressure hydrocephalus and placed in permanent residential care to support his consequent deficits.

The care home simply sought sensible advice on whether there was a treatable cause for his new behaviour (of feeling anxious and shouting out at night) or whether as they phrased it, it was part of the progression of his swollen brain.


Good initial GP assessment, then good medical work up by a physician, then good neurosurgical assessment and then good care in a care home.

My dark cloud this week has a silver lining.

Wednesday 15 September 2010


Cancers grow, uncontrollably. It's kind of their definition. This inexorable genesis has side effects.

Perhaps the most curious one, to my mind, is death.

Folks develop a cancer that grows, generating a tumour, a lump, a mass. This often isn't enormous. Our bodies cope with lumps pretty well. People have parasites forming walled off spheres inside us (like hydatid disease). People have inflammatory process generating fluid filled cysts inside us. People have infections generating cavitating lesions or pus filled tissues inside us. Heck, people have babies, with the extra mass of fluid and placenta and baby.

Our bodies can cope with extra lumps inside us, so having a cancer the size of an apple or grapefruit isn't understandable as a cause of death. Sure, if it eats through something important, like an artery, and you bleed to death, that's evidently a clear cause of death. But most people with cancer thankfully don't pass away so dramatically, bleeding catastophically. So why's a lump, just sitting inside you, being a lump, fatal?

One of the common consequences of cancer I see is the paraneoplastic syndrome. This is when cancer causes problems through growing, endlessly, but instead of the mass causing direct symptoms the growth throws out gunge. The tumour churns out lots of chemicals. Hormones and the like. Or things that drive the body to do something/stop doing something. This explains why a tumour causes lots of symptoms (and accounts for why just having a lump that's hardly pushing on anything doesn't directly cause symptoms).

Unfortunately many effects of this can be pretty common. Tiredness. Weight loss. Temperature. Joint pain. Nausea. Mood changes. Confusion.

The last couple months have resulted in several patients being referred to me with ?dementia and history, examination and investigation's found a previously unknown adenocarcinoma causing their presenting symptoms. None had cerebral metastases. None had neurodegenerative dementia. Their symptom burden was part of the neuropsychiatric sequelae of cancer.

The cancer is active, endlessly growing and making and actively synthesising, with the unhappy byproduct of churning out a lot of gunge which makes people feel hellishly unwell. And I can't fix that.

Much badness.

Monday 13 September 2010

Liaison Psychiatry

Nurse Anne has a point. She usually does. Working on an acute ward, delivering hands on nursing care, she's insight into what works well on wards, what's necessary and what works badly.

It's frustrating and bewildering that both cogent, articulate views and intuitively sensible cathartic rants, whilst all true and meaningful, seem to be ignored. A manager who I've a lot of time for was lamentting how intellectual explanation or common sense experiences are all too often brushed aside by management structures if the views aren't, "aligned with the corporate direction of the organisation." She then went to talk about EBITDA and cost pressures and totally lost me. But the message was clear that if you say what managers like, you're listened to. Say what managers don't like and you're not listened to. Oh, you're heard, it's noise that is sometimes attended to, but then discounted. Not every good idea can be progressed, so this managerial self selection of what to attend to is the best that consultation/clinical engagement can feign to date.


In mental health, we're usually more fortunate. I work with a number of managers, but actually have a decent relationship with them. I don't get what I want all the time, obviously, but I get good enough resources to deliver an excellent service, which really is what I want managers to deliver for me. Just give me the tools and then pretty much leave us alone, then we can deliver.

In Nurse Anne's world it's much, much worse. Outside of mental health, acute Trusts have pressures and tend to cut costs through removing/not replacing frontline qualified staff. Our local Trust has a lot more HCAs and a lot less nurses (on the wards) than it did 10 years ago. Oh, it has more nurses in management (as matrons, Champions and project managers in a whole slew of initiatives) but lamentably the clinical areas have fewer clinicians, despite increased activity, increased process and increased technical interventions compared to a decade ago. If you're doing more work, and more complex work, and dealing with iller people, and need folk to deliver technical/complex care, wouldn't you want more nurses? Before you even look at the triage, surveillance, assessments and formulations ward nurses undertake, the documentation and process has increased in volume and complexity with MUST nutritional screening, Waterlow scores, falls assessments, Abbey Pain Scale ratings, medicines reconcilliation and so on, much more than just the TPR that used to be done. What of extended roles, Non-Medical Prescribing, First Contact Practitioner, Nurse led Clinics, Nurse Consultants running wards (in Cumbria, even running mental health wards in place of medical Consultants).

Undeniably, nurses now have more to do. In greater detail. With more patients. With more complicated kit and interventions. We've more nurses in management (so statistics show we still have fair numbers of nurses) but invariably in acute hospitals I visit we've substantially less on wards than wards need and patients deserve.

Much badness.

Nurse Anne very reasonably asks why patients with primary psychiatric problems are admitted onto an acute medical ward. Sadly, she's also given the answer in the sentence questioning, "Why the hell are the medical consultants getting this dumped on them?" Because it does seem that the medics are simply being dumped on. It's really impossible to defend this.

Nurse Anne also has the workings of a solution. "We have no RMN's on staff so basically we are up shit's creek." Indeed. We've got RMNs working in the acute Trust in my corner, who've made a big difference. The nurses and I've persuaded the acute Trust and PCT, through what we've delivered on, that RMNs and Psychiatrist time can improve quality, reduce length of stay and save squillions.

Liaison Psychiatry done well works brilliantly, with patients, acute staff and mental health staff all feeling happy (and having shorter admissions and saving cash, incidentally). Liaison Psychiatry done badly is ghastly. Utterly ghastly. I've no answers for Nurse Anne, no explanations, but inwardly cringe at the shabby service it seems my mental health colleagues provide in her corner. Ouch.

Wednesday 8 September 2010


It was recently reported that the number of NHS complaints has gone up, rather a lot.

The details are unfortunately numbers, giving us data, rather than information. I was taken, for example, by the increase in complaints across Primary Care that increased by 4.4%. Does this mean anything? In my corner there's been a LES that's increased a lot of clinical activity in Primary Care. They've also started undertaking a slew of activities that the acute Trust used to provide. A number of exercises in partnership working with the voluntary sector (eg in promoting breastfeeding with baby bistros, in dementia cafes, in osteoporosis prevention) ramped up health visitor and midwifery and GP activity. Activity in Primary Care has increased. Is an increase in complaints of 4.4% in keeping with an increase in activity of 4.4% and therefore of no real interest? Is it less than the increased activity, therefore the proportion of patients complaining is actually going down?

Sadly I do not know, since it was reported without such refined deliberation. Ho hum.

In parts of my service, activity has increased by over 400%, another team is overperforming at 200%, but despite activity increasing strikingly over the last financial year the number of complaints haven't quadrupled/doubled. If our activity goes up by 400% but our rate of complaints in Secondary Care went up by 13.4% in those teams, it'd suggest a profound reduction in total proportion of patients experiencing poor satisfaction and complaining.

The data doesn't really tell me much. It piqued my curiosity, though. Although this year, as fortunately is typically the case, I've had written compliments and no complaints, I pulled all the formal complaints for our directorate that were investigated and our Chief Exec responded to, over the last few years. Interestingly, across the Trust, the majority of complaints are upheld, fully or partially, with the patients' being found to have valid cause for complaint in at least one aspect of their complaint.

In older adults' services, almost no complaints were upheld.

Not only do we have few complaints, but those who do complain have investigation and, unlike other services (so it's not an organisational bias) aren't found to be at fault.

It was noted that written opinion in clinics and visits were frequently sought, with a high rate of return. In-patients are surveyed on discharge too, so there's systematic attempts to solicit patients' opinion.

Locally we've therefore lots more patient feedback, lots more clinical activity, yet few complaints. I wonder if that's in keeping with the national picture. Are the numbers crude data, without the context of activity levels and service redesign and expansion into riskier areas, really showing more complaints? Or is it, as may well be the case, as we're finding locally, that the rate of complaints is actually going down?

Thursday 2 September 2010

Junior Doctors

I've met with my junior doctor, dutifully undertaking an hour's supervision each week, assiduously documenting what we discuss.

What he wants out of supervision is, most meaningfully to him, being equipped to pass his exams. Without that, his career is thwarted and he can't progress his training to become a Consultant Psychiatrist.

What the Royal College wants out of supervision is unrealistic, with a full lever arch file failing to contain all that's meant to be covered, but in essence there's an expectation that all elements of the GMC's Good Medical Practice and all core generic medical competencies and old age psychiatry will be delivered. Most meaningfully to the RCPsych is progress of the curriculum (evidenced in doctor's portfolio and online workplace based assessments).

What the Trust wants is a safe practitioner doing appropriate work so, most meaningful to the Trust, is a supervised practitioner who's learnt and is fully aware and using in their practice the hundreds of Trust policies we have.

What the patients want of him isn't really factored in.

What I want is different and diverse and aspirational. In 3 or 4 years, my junior doctor is likely to be a Consultant Psychiatrist. What should such a junior doctor be mentored, informed or developed in, through ongoing weekly supervision?

Tuesday 24 August 2010

Clinical Depression

I recently saw a gentleman, who has dementia of moderate severity, who was low in mood. His GP had reasonably started an antidepressant. Things were no better. I stopped the antidepressant. I reviewed him. Things were no different.

I recently saw a lady who was tearful all the time, felt hopeless and wasn't doing sociable things with friends at the local tea room and Tuesday evening bingo. Her GP had sensibly started an antidepressant, reviewed her, changed it then referred to me. I stopped the antidepressant, reviewed the lady, things were no different.

It's not easy work. In both cases I saw the patient in their home with a CPN colleague, it took over an hour doing an initial assessment then time following up and reviewing them.

The gentleman's scans showed widespread vascular damage. His limbic system was shot to pieces. If the bits of your brain that regulate your mood no longer exist/are damaged, it's unsurprising that peoples' mood is less than perfect.

The lady had low mood because she'd recently been widowed, her sister had also died this year and she had a blood disorder (which slowly is getting worse) meaning she's knackered all the time. Her mood is low because life's grim. She's not mentally ill, there's no psychiatric disease.

If there's no chemical depression, with no chemical solution, answers aren't in a tablet. This makes it harder. Patients and carers need to do something to get better, to change something if they want things to be different. Professionals can't just gift an FP10 and be done. And, invariably, things can be improved, but they can't be "cured" and less than perfect mood needs to be accepted/endured/dealt with rather than "fixed" or changed.

Management of clinical depression is, to my mind, pretty easy. But management of other low mood is grim.

Wednesday 4 August 2010

Occupational wellbeing

Work can be emotionally damaging. This doesn't look good . . .

Consultant Time

A couple days a week I start at 8.30am which I still reckon's an ungodly hour. Although I'm often in at this time, on just 2 days do I start work at 8.30am, on all other days clinical activity (like an out-patient clinic) starts at 9.30am. A much more civilised hour.

Why the early starts, why just some days?

It suits the nurses. It makes no odds to me really when I start, I can organise time as I wish. Home visits, MDT meetings, writing reports, care home reviews and such can all be juggled around and don't have to be at a specific hour.

Nurses though have a lot to do. Too much. They've so much clinical activity to do, now, more than 5 years ago. It's good and interesting and they're very good at it, but it means they're genuinely busier. Audit evidences this increase in direct patient care and increase in complexity of work. It's been formally looked at since it's resulted in job matching and regrading under A4C through nurses' roles shifting. As well as being more involved with more patients doing more work more of the time, they've also got to do more nonsense. Falls and nutritional and other risk assessments. A form for every patient on risks to children/childrens' needs. Screening tools. Repeats of carer assessments. Suicide assessment tools that don't apply to older adults but still must be done. They have to collect lots of demographic data that already exists (ethnicity, marital status, occupation/retired, where they live etc) and enter it into the computer system. They have stupid, stupid amounts of paperwork. The paperwork is only the start, since as well as ward/community paper notes, psychiatric medical notes, letters to GPs/referrers, social work/other referrals, there's also electronic stuff. Our "paperless" notes on the computer with squillions of fields to fill in. Some are always left empty and months later nurses are bullied/harrassed to complete the data set. Assessment forms. Diagnostic/clustering tools. CPA fields. Care plans (plural, since every intervention has to be entered as a separate care plan, with lots of fields on each one). Safeguarding referrals and meetings. Mental Capacity Act assessments, best interest meetings. Doing what only an RMN can do (such as administering oily depot medication). Generating statistics, results, activity levels, outcomes or other information that managers, commissioners, service leads or other parties want (usually straight away). Attending more management meetings than I care to count as more and more is added in without anything being reviewed and stopped. Attending mandatory training, often in things of dubiuous relevance. Carer support (a quarter of their clinical time is spent with carers, not patients). Coordinating multiagency working so patient care actually happens, and happens right. De-escalating challenging behaviour (such as stopping them battering folk). Feeding them. And then there's the direct therapeutic work undertaken with patients, effecting change.

Sometimes, just sometimes, they also need to work with doctors.

It's for this reason that I work when I work. My ward round is on a day and time when no other Consultant is on the ward, my team meetings start at 8.30am since it suits the nurses to do it then, so they can crack on and do everything else from 9.30am onwards when everything kicks off.

I've huge sympathy for poor Militant Medical Nurse who seems to work with medical colleagues who instead of adding helpfully to their process are seen to be unhelpful. I appreciate that in psychiatry Consultants can have much more latitude to shift clinical activity around and generate flexibility, whilst a surgeon has to operate when they've theatre time and that's that, so it's not possible to be as flexible in other disciplines. Yet somehow Militant Medical Nurse's account leaves me frowning and feeling a little ashamed at how my medical colleagues are felt to be adding to, rather than helping with, the stresses that nursing colleagues are grappling with.

Friday 30 July 2010

Writing Style

Dr Shock invites us to consider our writing style. Copy and paste some of your text here and see.

Going through my last few posts, I get results either of David Foster Wallace or of Dan Brown. Curious!

Tuesday 27 July 2010

Mental health work

The Girl asked two questions here, sensibly querying the stigma against psychiatry and how to manage without burnout.

General Practice is different from specialist care because it's harder. It's a specialist area in it's own right, but is mostly unidisciplincary in approach (you see a doctor, or a practice nurse, or a midwife, but you don't usually see several clinicians who've all discussed your care as a team) making it a harder area as a clinician (to my mind). And you never get to discharge anyone. And you get all problems/symptoms and have to divine what's of medical significance and what isn't. Which is often difficult, because if the patient has a symptom (e.g. of being knackered all the time) but it's investigated and not caused by any clinically significant illness or process, so medicine has little to offer, the patient's still usually keen for resolution of their target symptom. An explanation that it's not serious, not due to major disease or anything significant, placates so far but doesn't solve the patient's symptom burden. Before even managing patient agenda, governance frameworks, central DoH/NICE mandates, local PCT/APC/LMC direction, just thriving in a world of clinical uncertainty is trouble enough. Especially when you just have 10 minutes or so with each patient. Having trained and worked in Primary Care I know it's a challenging speciality and not one I've the stamina for.

With that caveat aside, that Primary Care is a separate complex speciality, what are my thoughts on Secondary Care specialities and mental health in particular?

Clinical practice within psychiatry is a very mixed field indeed. Most areas of Secondary Care medicine have diversity in approach but, by and large, the majority of doctors have similar approaches to care. Management of MI, childhood atopy, pre-eclampsia, lateral epicondylitis, angina, COPD or whatever is variable. But not that variable. Maybe one clinician would favour a NSAID over a moderate opiate, but by and large the care pathway is similar. Maybe one medic would do X first then Y, another would do Y then X, but over time most of their patients end up with mostly the same treatment.

Not so in psychiatry.

You may have a very biomedical psychiatrist who's interested in genes and biology and neurochemistry. Process is very medical, with complex imaging and serum rhubarb tests. Management is very pharmacological, or neurological (magnetic stimulation, ECT, whatever) to effect chemical change within what's seen to be a chemically imbalanced brain. When things don't work, you need more drugs. Or heroic doses. Or complicated drug augmentation strategies. Or specialist referral to centres who do psychosurgery or treatment with rare drugs. Got to fix the chemistry.

You may have a very psychosocial psychiatrist who's interested in a patient's current experience and life events and past experiential learning and ongoing maintaining factors. Process is very psychological, or practical (such as diary keeping) to gain understanding of why things are as they are. Management is very pragmatic or behavioural. Psychological therapy to aid acceptance. Behavioural therapy to effect meaningful change in the here and now. Got to either accept how things are, or make changes.

You may have a very community oriented psychiatrist. Problems arise in the patient's real world. The patient's going to return and live and thrive there. Why bring them in to what's been shown to be a "toxic environment" of a ward, where activities have little that's real for the patient's world, the situation's dislocating the patient from their problems and, when it comes down to their clinical needs, what can happen in a psychiatric hospital that can't happen in the community? Okay, often ECT is started/done in hospital (but even this can be done in the community), psychosurgery is certainly an in-patient procedure. But what else? Really, why have lots of hospital beds at all? Nobody gets admitted.

You may have a very hospital oriented psychiatrist. Problems arise in the community, if the patient could fix them they would have. Who'd choose to be miserable and not coping? They need time out, some solace and sanctuary and space to reflect or make sense of things. Or somewhere for rich assessment and investigation and and fiddling with drugs day to day. Really, if they've become unwell in the community and can't cope, how can they realistically be expected to recover and be cured there, in a timely manner? Everybody gets admitted.

You may have a liberal psychiatrist who accepts and supports everything. You may not. Someone with schizophrenia assaults a member of the public in a supermarket. One psychiatrist says they were hearing voices but just as if they heard you say to punch someone they could say no, they had control and chose not to exercise it, they made an elective choice to punch the victim. Charge them and go down the criminal justice system route. Another psychiatrist says they were hearing voices so not in control of their actions, there's no criminal intent and the person's unwell, needing disposal through health with hospital admission and in-patient care. Same patient, same action, sometimes it goes to police, sometimes it goes to health services.

Other disciplines look at psychiatry and shake their heads. It's all a bit of a mess, isn't it? It's not sensible. It's not seen to be about patients or clinical needs. It looks random and chaotic. It can be seen to be ineffective. Why would any doctor want to work in that world, as a career, when other options of proper medicine exist?

Worse, a lot of mental health services are poor. In particular, working age adults can get pretty shoddy care. Services often are under valued, under commissioned, under resourced and not fit for purpose. So sometimes there's bad care. So sometimes medical colleagues look at psychiatry and think, it's all a bit rubbish, really, isn't it.

But when it's done well, it's just brilliant. Everything works. It's fantastic for patients, getting help and improvement and appropriate care and feeling better for our input. It's fantastic for staff, feeling they're part of an effective, ace service. It's fantastic for families and carers, getting support and help and time to assist in how they can cope. It's fantastic for colleagues, GPs in particular, who know everyone is seen promptly (within days if routine, hours if urgent), everyone has nurses and social workers and pharmacist and psychiatrist inputting into every single patient (true multidisciplinary care) with all medication clearly sorted out, all care clearly documented and typed/faxed/posted to the GP/referrer, with patient/carer feedback and service evaluation and audit and monthly PCT reporting evidencing outcomes and quality of care, continuously.

When it's done well, nobody else knows. The patient and family are happy, they don't go back to their GP or other Consultant and wax lyrical about psychiatry because, appropriately, subsequent clinical contacts focus on their clincal needs. The system works, GPs get a 3 to 4 page letter when the patient's discharged but won't read all that; the detail isn't needed most of the time by most GPs.

The variability in practice often evens out, particularly if there's clinical supervision. There're plenty of ways to skin a cat. It'd be grim if we got to a day when every patient got the same treatment, in the same place, for the same duration, in the same way, with no personal care, no consideration of variables, no choice. That psychiatry still has latitude to be flexible in models of care is, to my mind, a great strength. Sure, we need to evidence it's effective and not just careless/maveric care, so I'm more than willing to evidence process and outcomes. Helps us improve the services too.

How to reduce emotional burnout is simple. Work in a way that's not stressful. To me, that means a range of things need to be in place.
1) I need to have clinical freedom, so can do what I feel is right for my patients. This is something we still enjoy in psychiatry, with no care pathways or algorithms or edicts directing what we must do. Our Trust has no hospital formulary, I can prescribe what so ever I wish.
2) I need to have colleagues I trust and can work with and share care with. I do. I'm blessed with brilliant teams. It can be hard (had several internal and external applicants for a post and couldn't appoint and none met the standard for the team), so 5 internal candidates were disappointed and we had a team with a vacant post. But it matters too much to me, we need the right people in the team and patients deserve the right people.
3) I need to have a good working relationship with managers. I meet our service manager at least once every fortnight. I meet a member of the Trust Board at least once every couple months. I meet with the Medical Director every month. I meet the Chief Exec too and write on average twice a month. Me talking with managers about how it is, and writing, and emailing, and making time to meet them matters.
4) I need a good relationship with partners. I meet GP colleagues in their surgeries, I meet Consultant colleagues on their ward rounds/meetings/teaching, I meet PCT commissioners every month so can help them with commissioning process/decisions whilst also having confidence in security of core bits of our service. Knowledge and security of the cash flow reduces stress and burnout.
5) I need to be able to blow off. Half the week I'm too busy for a lunch break but usually once a week a colleague and I'll skip off 30/40 minutes for lunch and blow off about what's going well, what's a real bitch, what needs changing, what we just need to grit our teeth over and accept. Being listened to and understood by someone who works in that world whilst you sound off and whitter on and on is awfully cathartic.

Well that's my initial thoughts on reasons for bias 'gainst psychiatry, reasons why that's not always valid, and thoughts on how I manage to remain up beat and optimistic without burnout. But you can always email me if you've specific stuff you want to chew over!

Saturday 17 July 2010

Holistic healthcare

Not all medical specialities look holistically at all elements of a patient's presentation :

Wednesday 14 July 2010

NHS Reform

I have read through the NHS white paper, "Quality and excellence : liberating the NHS" that was published 2 days ago.

It perturbs me.

This is unusual. Usually I can look at things with a "glass half full" kind of take on it, looking for positive opportunity and what it can enable us to do better. Most papers and policies and DoH edicts have not immediately been embraced as wondrously helpful, but on unpicking things I've usually found something that we can use to push commissioning buttons or support change we're making or that strengthens a case to resist dismantling of/meddling in services.

This paper's "vision" is all very positive.

The implementation superficially is neutral but on thinking it through I see it as concerning, with significant opportunity for negative effects. The detail scares me. It's noteworthy that there has been much comment with GPs being less than enthusiastic or critical or pessimistic about the changes to PCTs and commissioning.

What perturbs me is not the ill ease of grappling with uncertainty, which is normal/continuous life in the NHS. Change and uncertainty and wrestling with unknowns is a normal state of affairs. No, what worries me is the implications and explicit intentions of the white paper. I'm worried since it erodes the NHS.

As reported, the intention is for GPs to commission health care. More than an intention, it's forced upon them (since no sane GP would volunteer for this role). It's a poisoned chalice that's offered, and no mistake. GPs are then seen to be responsible for all deficiencies, since they've failed to commission the right services. Rubbish access for paediatric ADHD clinics, no easy access to tattoo removal, no service for aymptomatic varicose vein removal, it's all laid at the GPs door (a door that can't be closed). Rather than government cuts and suboptimal resourcing, it's then poor GP management that results in inadequate healthcare provision. Mmmm.

Worse, how are GPs going to spend the hours and hours necessary to commission care? It takes ages to go through each service. Just to commission older adults' mental health services (with community services, liaison services, early onset dementia care, forensic care, in-patient services, day hospital services, memory clinics, memory therapy day care, Mental Health Act arrangements, psychology services, Cognitive Stimulation Therapy etc) is a lot of detail to think over. Then do it with adults of working age and crisis services. Then with child and adolescent services. Then with forensic services. Then learning difficulty services. Then drug and alcohol services. Then IAPT and community mental health services. The with partners like MIND and Alzheimer's Society and Age Concern and others. Then do that for every other bit of health. There's no way GPs can absorb this activity. Hence the intention that as reported that the money will go, ". . . to private corporations which will buy hospital and community health services on behalf of GPs."

GPs are private businesses already. This paper strengthens and extends this, generating a situation where large companies can pick off small GP practices (then sack the expensive staff, like GPs, and go for First Contact Practitioners) and through block contracts/large consortia can then purchase Secondary Care from hospitals to get what they want. Except what they want, as a business, is a good balance sheet for their share holders.

A company buys/owns/represents all the GPs in my locality. The GPs advise the company on what they want then the company negotiates contracts and commissions services. The private health company, maybe it's BUPA, maybe it's another, then thinks where it wants to spend it's share of the £80 billion pounds. Does it give it to an NHS hospital? Or does it give it to a sister company or to itself, commissioning services from a BUPA hospital?

I'm perturbed since I see this paper as a mechanism for dumbing down healthcare (through eroding quality to save costs), devolving blame (but not power) to GPs and effecting the privatisation of healthcare, to the marked detriment of NHS care.

Much badness.

Saturday 10 July 2010


I was rummaging around the BBC News, this afternoon. Initially it was to see Acting Chief Constable Sue Simm, since she's great to see on telly. Not only has she eschewed the whole "I'm going to be glam and gorgeous" thing, she's opted straight for the Ashes to Ashes look, appearing as though she should be sitting next to Gene Hunt. It was female friends in the police who first drew my attention to her "special" hair style and how she seems locked in that error, erm, I mean era.

But hats off to the lass. Or hats on, my friends in blue suggest she sticks a PSU riot helmet on her head, whatever one of those may be. But really, it is great that the woman sits infront of the nation's media, without a care that her appearance isn't sculpted and classically elegant. Very laudable. It's her substance, her actions, that matter.

Whilst on the BBCs site and looking through the video news, the top editor's choice was an article on Donald McGill and his saucy postcards.

He even drew pictures of nurses. I fear that Unison would not approve. But truly I don't care what they think. I'm invariably interested in what a proper RMN or RGN who works with patients has to say. Those who used to be clinicians are like those who used to do PE at school . . . everyone did it, it's not impressive, it doesn't qualify you to talk about it or claim to be an expert in it still. An ex-nurse (or ex-doctor) lacks credibility.

Therefore I'm happy to ignore the view of pompous folk telling me nurses should wear sacks and look beige, so we see their actions and not their looks. Many RMNs are of the Jo Brand school, or male, with an average age in my corner that's within a decade of retirement. The demographics mean that NHS nurses in older adult's mental health really have very little in common with the Benny Hill/Donald McGill images of nurses.

I'm not sure how nurses should be portrayed by main stream media.

Still, on seeing Donald McGill postcards, I could stand to see my nurses in more traditional atire :

Sexy nurse


Doctors are known to self medicate with alcohol, at least as enthusiastically as the general population. The sterotype is that problematic use of alcohol's an occupational hazard. Personally I drink less than 21 units a week (in fact, it's invariably less than half that).

Although it's not that I partake frequently and regularly, I guess it's fair to say that nursing and medical colleagues can indeed sink a fair bit of drink on nights out. Social workers are a bit more sensible and never seem to drink to excess. Although we're all totally outclassed by secretaries; my they can drink.

After a fraught afternoon yesterday I got home and had a real Withnail moment, "I demand to have some booze!" My wife helpfully obliged. But then, having to read stories and do bathtime and put the kids to bed kind of tempers ones options for sinking into oblivion with drink and rubbish telly. I had to make do with one drink then later crashing out with Ms McCall and her Big Brother.

Gets you thinking.

How do we cope with stress, how do we manage to de-stress? As usual, it wasn't clinical work or patients causing stress, but was management activity (and inactivity) that added woe to my week.

I shall try not to mix my drinks :

Thursday 8 July 2010


I do not like them in a box.
I do not like them with a fox.
I do not like them in a house.
I do mot like them with a mouse.
I do not like them here or there.
I do not like them anywhere.

- Dr Seuss

It's always good to get a second opinion on contentious and contested issues. As well as frequent consults with Dr Google, it's sometimes good to reflect 'pon the wise counsel of Dr Seuss, too.

My current raison d'etre seems to be to manage policy. It's impossible for front line clinicians to manage policy day to day, so we have team meetings where we agree what policies we're not able to do, reason why we can't, which I then minute and send to managers. Maybe we'll be the next Mid Staffs with managers being informed by clinicians and Consultants what the problems are, but doing modest amounts to effect change. Who knows. We shall see. The important bit of it is that clinical teams are 'fessing up to what we can and can't deliver on, documenting that our practice is at variance with Trust guidance, reasoning why we're not doing it and informing the managament structure of this different clinical care.

It's not ideal, to meet up once a month to have to reflect on how we work, especially since 2 hours is a fair bit of time for a whole team to take out, but it's saved us a lot of time, in the long run. Not doing form filling, when the information's already captured and documented in 3 places already, has saved masses of time. And moved to a more paperless practice. And made everything more legible. And made it easier to print/email information. Clinical and secretarial staff have a lot of clever ways of working smartly.

But the main reason for this is the massive industry of policy generation that's become unhelpful. Excluding corporate/finance policies, our Trust has over 200 policies that apply to clinical staff, seeing patients. In a moment of ennui, I popped onto the web site and looked.

My oh my.

How can that work? A new junior doc or seconded nurse or bank nurse or trainee AMHP social worker or psychologist is in our service. They go to a clinic or DV or ward to see a patient. They have all their clinical process and knowledge and skills in their heads, structuring what they do and how they do it. They have the GMC/NMC/regulatory body directives in their heads, structuring what they do and how they do it. They have national guidance influencing their thinking. Maybe. They have legislative direction (particularly that MCA 2005 and MHA 1983) structuring how they work. There's usually us Consultants with our foibles, meaning certain types of assessment or interventions are "how we like things to be" which influences clinical care. On top of all this professional material, can anyone credibly believe these staff will also read, understand, implement and use over 200 policies in their practice, as well?

My angst is that oft times too much policy is generated by folk who aren't clinicians. Worse, it's done without any consultation with practising coal face clinicians. Even worse, the decision to make something happen is usually to make a policy, then consult on the policy. It's as if any alternative to a policy is never ever even entertained as a possibility. Yet how many clinical teams working in creative, iterative models of care, have working their practice defined clearly within a policy? Even the operational policies of the teams seem to be works of fiction that bear little resemblance to the function and activities of the teams.

How many times has a clinical team said, "Oooh yes, our clinical care in this area is so much better than it was last year, because we've embedded this Trust policy into our working practice and now everything's brilliant!"
Never happened, in my corner. Curious, then, that policy documentation is generated at such a staggering rate when the outcome/utility from it is evidenced as so poor. Hmmm.

People working far away from a specific clinical team will generate a policy that applies to that clinical team. They're working in the dark and generate material that's usually pretty sensible on reading through it, but is oft times unnecessary, overly tortuous and very very rarely impacts on direct clinical care.

I'll leave the final words, once again, to my colleague Dr Seuss :

Say! In the dark?
Here in the dark!
Would you, could you, in the dark?
I would not, could not, in the dark.

Monday 5 July 2010


A colourful lady in her 80's now, with paranoid schizophrenia that's well controlled, but leaves her with delightfully eccentric foibles.

"No, I don't suffer with madness . . . I enjoy every day of it!"

Saturday 3 July 2010


I was told by a couple of different managers last week that I was obviously "passionate" about my work.

It's a word I struggle with. You can be passionate about a woman. Catholic friends have talked long into the night, over far too much drink, about, "the passion of Christ." It's a word that is often over used.

Some words that had a strong meaning are hijacked and over used, to somehow increase the weak meaning of a point. Politicians, they're often doing it. Politicians are presented with a statement of how they cocked up. How do they respond?
"Erm, yeah, bit of a mess I made, wasn't it?" Nope, never.
"Hey, it wasn't my fault!" Sometimes, but then politicians in power have responsibility so it's their fault or their bosses, so it's not a response we see so often now.
"I deny that!" This used to be a common response. Whatever some half arsed journo dreamt up as a claim, it's just dismissed and brushed aside. Doesn't sound convincing or drawing a line under it, though.
"I refute that!"
It's refuted.
A refutation, what is that? It's much stronger than a denial. It sounds clever and impressive and definitive, how can the conversation possibly continue once the debater has refuted the argument you've contended? Your argument, by definition, has been proven false.

Of course, they say they refute the charge, but they don't offer the evidence that then goes beyond explaining and suggesting and incontestably provides the necessary proof that they're right.

But still, politicians continue to say they "refute" a claim instead of saying they "deny" or "don't like" a claim, despite this being more accurate. Refute is carelessly used by politicians and is becoming a weaker word through such use, soon to lose it's definitive meaning of proof and simply be a posh way of saying deny.

I like a range of words, with subtly different meanings.

So is it right to claim to be passionate about work? I love David Mitchell's rant about passion because it's exactly how I think. Passion is a word that's vastly over used.

But then I saw a video about an astrophyscist who's the Director of the Hayden Planetarium in New York. The clip is here, the site is here, click When I Look Up. Okay, maybe some people are passionate about their job, their speciality, their field, their work . . .

Saturday 26 June 2010


'It's now very common to hear people say, "I'm rather offended by that", as if that gives them certain rights. It's no more than a whine. It has no meaning, it has no purpose, it has no reason to be respected as a phrase. "I'm offended by that." Well, so fucking what?'
- Stephen Fry


Thursday 24 June 2010

Nursing levels

There has been a lot of discussion about inadequate staffing levels. It's abundantly clear that having too few qualified nursing staff on wards compromises patient care and results in more deaths. The evidence consistently shows this. Accounts within clinical practice consistently illustrates this. Patients admitted (and their course, with some unnecessary deaths) consistently experience this.

It's therefore not surprising to me that when the Healthcare Commission investigated shabby care in hospitals, they found ward staff to be good, but management systems not supporting them (through cutting costs and not staffing wards with adequate numbers/adequate qualified staff). Subsequently the Care Quality Commission (CQC) have done the same. The CQC regulates hospitals, challenging them on quality and services. How deeply have their investigations and reports rocked managers worlds?

Has it changed anything in practice?

We learnt of the woeful outcomes at Mid Staffordshire NHS Foundation Trust with the report stating :
"It appears that some staff from whom we heard were often demotivated, undervalued and working in an understaffed and stressful environment"
"The staff who worked on these wards all agreed that there was a shortage of nursing staff."
"We heard these wards were significantly short of nurses, especially at nights and weekends."
"Some staff expressed the view that there were insufficient nurses before the reorganisation and that there were fewer after."
"Many witnesses noted that there were too few nurses and that those that were there were doing their best in difficult circumstances."

The Mid Staffs report described good nurses doing the best they could. To my knowledge, nobody was reported to the NMC for poor professional practice. Nor should they be. They worked as well as they could within the environment that managers generated for them. Indeed, the independent and detailed investigation found and documented that the nurses worked inordinately hard and beyond their duties, putting in huge effort to care for their patients.

The issue wasn't poor nursing, the hospital was fortunate and had great nurses. The issue was the the hospital, to save cash, didn't staff the wards with enough nurses (i.e. qualified staff) to keep patients safe. How huge is that. Not that there weren't enough nurses for gold standard care. Not that there weren't enough nurses for reasonable quality care. There weren't enough staff for safe care. Patients needlessly died.

But time's moved on.

Things surely have improved. Lessons learned. Erm, sadly it seems not. Scarborough looks to be operating in a scarily similar manner to Mid Staffs.

So it goes.

This week I read a new report by the CQC. This is dear to me, since it's about older adult mental health services, within a Trust providing mental health services. Not mine, I may add. The CQC are positive about the Trust. "The Trust has cooperated fully with us during the course of our enquiry . . . the Trust has not waited for the publication of our report. It has proactively started a process to improve its mental health service for older people."

One unit was terrible (and closed), the other units were fine.

So it's a decent Trust, with decent units, providing decent care. The management structure quickly made management changes and 'fessed up to shoddy care, investigating things themselves and reporting themselves to the CQC and making changes themselves. All genuinely poisitve stuff, the way the Trust behaved really does seem sound.

Most of the problem seems to have been one unit which was doing quirky things which nobody knew about. Things like using strong opiate analgesics inappropriately and hooking folk with dementia up to syringe drivers to control agitation. This was a huge error in governance which the Trust raised it's hand up and sorted out. Grand.

So the Trust, a decent Trust, find an area of rubbish care, sort it out and 'fess up to the CQC they've been rubbish, they're investigated and all's seen to now be okay.

Apart from one area.

Page 30 : "We looked at the relative costs of nursing staff against the trust’s spend on senior managers and managers for the years 2005/06 to 2008/09. Our analysis showed that while the spending costs for qualified nurses had dropped over that period from £26.1 million to £25.4 million and for unqualified nurses from £14 million to £12.5 million, the costs for senior managers and managers had risen from £4.5 million to £6.8 million"

"Our impression as we visited the older people’s mental health inpatient units was of highly dedicated ward managers, nurses and nursing assistants working under constant pressure. On more than one occasion, we came across ward managers who were trying to do their best for their patients with too little resource and fearful that they had not covered every aspect of patient care and the management of their ward."

Page 52 : "We found that members of staff working in these clinical effectiveness and risk roles in the trust appeared to have a good grasp of what needed to be done but were frustrated by the lack of effective systems to enable them to feel as confident as they should around overall clinical governance and compliance."

The CQC evidence that the wards were understaffed and staff knew what needed doing. And the Trust board spent a lot on management and moved from generating loss to generating surpluss. What have the Trust done to support nursing colleagues on the ward?

They closed the ward. They appointed a lot of Modern Matrons. They appointed a Director of Nursing.

Okay, I'm sold that they need the Director of Nursing but the Board minutes reporting ". . . outstanding concerns against overspending on in-patient wards and [the Director of Finance] pointed out the need to ensure optimum ward rotas," leaves me cold. More nurse management, less ward nurses.

The pages on community staff levels, case loads of 27.2 cases/staff is a whole post in itself, with community resources and practice meritting discussion. But to stay vaguely on topic, suffice to say that governance of ward process and staffing on the in-patient ward lead to grim patient care.

How many Trusts are staffing in-patient units well? How many Trusts are staffing in-patient units, if not well, at least adequately? Gah. So it goes.

Read the report from the CQC and see what you make of it.