Coffee

Are any medical students needing to gain experience in siting a central line? I'm having a week where I really feel that having venous access to mainline coffee would be a quicker method of maintaining my habit than necking down endless espressos. Oh those naughty Arabica beans, how they tease me!

Percepts

We see what we expect to see, which is informed by what we want to see. Although you'd think we see what we see, our processing filters out what is likely to be extraneous detail as we walk along the street (oooh, number 32 has new curtains) and focuses on what's relevant (that Ford Escort is going to run over that 4 year old playing football) but there're plenty of examples to read. I like the examples of text that's gobbledegook because letters are mixed up but it's stlll instantly readable. Or those "tests" where you count the number of letter "f" in a sentence and find you miss out half of them. I love that the moon on the horizon of a city looks huge, but then same moon up high in the middle of the sky in a forest looks tiny. Or that my mind tells me that as I get closer to my car it should double in size as I halve the distance to it, but it doesn't - it looks big when I see it in the car park and doesn't get much bigger as I walk to it - because my brain thinks cars are big so makes them seem so. What we see isn't real.

Perceiving involves seeing something but then our brain processing the image, where it gets complicated and changes the objective detail into a perception, with the perceived image being different from reality.

This means that perception and disorders of perception interest me. Which is probably why this interests me. We see what we expect to see, so don't expect cheating/things not to be where we feel they rightly should be. But mostly I like this because, to me, it look very, very cool :

the ARTIST (gambling demo) from Grecu Andrew on Vimeo.

Hospitals

There's concern, rightly, that the Mid Staffordshire NHS Trust let people down spectacularly.

The inquiry has released a lengthy report on this, with evidence from over 900 patients/carers as well as staff from the hospital.

His headline message is, dishearteningly, not surprising. It is that, "The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care."

The grim care described is not that different from some of the patients I've seen in our local hospital. Some of the ignored dementia patients rolling around in faeces, and patients left with food out of reach, is exactly the same as poor care that I have seen in our acute Trust, up the road. Therefore the Health Secretary's assertion that, "This was ultimately a local failure," does not ring true. Sadly, I'm more convinced that the president of the Patients Association comment has it nailed with, "The scale of problems at Stafford might have been unique but failures in essential nursing care are not."

If you don't have enough staff, you can't deliver quality care, but heck you can't even deliver acceptable care. How viable is it for ward staff to close the doors and refuse admissions because they feel it's unsafe to do so? Notionally they're obliged to, since the NMC and GMC require nurses and doctors to provide safe care. We've been that bold in community teams, refusing referrals because we can't provide safe care. You wouldn't believe the trouble that got me in to (being summoned to explain this to the great and the good, which was incredibly illuminating for them!) but I still do it (and have done so twice this week already - we deliver good care and can't accept work then deliver substandard care) but it's only working because the team's convinced it's the right thing to do.

Managers have had to accept this. Managers can direct systems, they can't manage direct clinical care. A manager can't say that I have to see Mr Smith and tell him blah and prescribe drug X for him at this dose. Sure, they can generate a framework for me to see patients and can force a Job Plan on me determining where I am and when I'm there, but qualified staff are professionals. Rather than technicians, undertaking what we're tasked to do, that means we're responsible for making decisions on the specific clinical care of the patient in front of us. Managers can't meddle with that. This empowers clinicians, enabling significant leverage in service delivery. We can do what's right for our patients, which can mean suggesting referral to another provider since we aren't in a position to provide appropriate care.

The NMC Code requires nurses to advocate for their patients. Do nurses advocate that admission to Ward X is unsafe? Do nurses allow admissions when they feel the ward's inadequately staffed/resourced to provide appropriate clinical care? They do so usually because nursing hierarchy is notoriously hierarchical and it's seen as unthinkable to say, "No!" to a boss. But when the whole team says, "No!" and it's the Consultant writing the letter saying we'd love to provide care but we're not in a position to do so since such care would be unsafe (and we can't accept then deliver unsafe care), shifting it from a managerial to a clinical decision changes the problem (and solutions) significantly.

Team work. It has to be the way forward.

Deprivation of Liberty Safeguards

The Bournewood case generated legal inconsistencies that notionally have been solved through the Deprivation of Liberty Safeguards (DOLS).

If someone's liberty is "restricted," this can lawfully happen within the Mental Capacity Act 2005 framework, if it's in the person's best interests. An example would be someone saying they wish to leave a care home and return home, but they're guided to have a cup of tea and moments later they're happy and chatting with other residents.

If the resident was hammering at the door, 'phoning for taxis to take them away all the time, sneaking out at every opportunity and adamantly refused to stay, that crosses from "restriction" to "deprivation" of liberty and the DOLS framework kicks in.

Grand. Folks get appropriate care, within a lawful framework.

On to a conversation I overheard this week :

Community mental health nurse (band 7 CPN) : "The patient's settled, the occasional comments she'd rather be at home can be managed as 'restriction' of liberty, not 'deprivation' in the care you've now structured in the detail within your care plans."

Care home manager : "Great, thank you."

CMHN : "If she progresses and makes persistent, active attempts to leave, we'll need to consider DOLS."

Manager : "Oh yes, we use doll therapy all the time to distract them."

Services

There's a lot of pressure for mental health Trusts to modernise.

It's understood that there's a lot of activity that isn't seen to be useful. Quite reasonably, it's seen that this needs changing.

Is it helpful to see a practice nurse for blood tests for lithium monitoring every 3 months, in Primary Care. And then see a Consultant Psychiatrist every 3 months in out-patient clinic. And then see a mental health nurse every 3 months in lithium clinic.

Unnecessary clinical contacts are in part historical, from a time when counselling and IAPT and Primary Care's mental health work was thin, so mental health services delivered almost all support, for mental wellbeing. Ongoing support, vists for "tea and cake" were seen as useful, because they were valued.

Now lower level support's delivered (notionally) through Primary Care and specialist mental health services, in this "tiered model" of care, only see the "properly ill patients" with "complex needs."

Except by and large we don't. Mostly we get the same referrals as we did years ago. Changing practice of Consultant Psychiatrists is not a quick or simple task. Having large out-patient clinics one day then saying let's not have large out-patient clinics the next is a tricky proposition to sell, let alone manage. So practice overall has shifted a touch, some clinicians have shifted dramatically, but by and large there's not the "modernisation" that the great and the good wish to see.

The consequence of this is that change is foisted upon us, rather than change being locally and clinically driven.

Managerial change, rather than change from folk on the shop floor seeing what's going on, has the advantage that it happens. It has the potential disadvantage of being divorced from patient need, clinical practice and professional requirements.

I'm uneasy about this.

In my corner we're being left alone. We changed our services and they work pretty well, older adult services nationally aren't targetted for being dismantled at present. It's general adult psychiatry that's being shaken up. Previously a team with a Consultant Psychiatrist was responsible for care of a patient. If additional input was needed, they referred to that source (GP, psychologist, local authority social services, acute Trust's dietician/physio/SALT, neurologist) and that bit of unmet need was met. The team and Consultant Psychiatrist continued delivery of core mental health care. All could work nicely.

Nationally this is changing. In major cities it already has. My colleagues relate how this has resulted from indifferent to horrific service delivery. The change involves a shift from a core team and Consultant Psychiatrist looking after a geographical patch/a number of GPs surgeries (a sector model) to having a number of specialist teams (a functional model).

You're referred by your GP to mental health services. You're seen by Team 1, the gatekeeping and access team. They work out, after one visit, what's wrong with you and what care you'll need. Geeenius. After baring your soul and explaining it all to Team 1, you never see them again (and they never see you again, they never see the consequences of their actions, the clinicians never see anyone recover or improve or get better, ever again). They pass you on to, say, Team 2, the Early Intervention team. They help you for a while but, if you're not cured, they pass you on to Team 3. Team 2 never see you again, either. Having bared your soul and gone over everything, again, to team 2, you now do that with Team 3. Team 3 feel you're making progress but when it gets fraught they think you need more help. They pass you over to Team 4, the home treatment team. They've never seen you before either, so in your acute state of distress you go through it all, again. They try but then reckon you need admission. There's a dedicated in-patient team who only see in-patients now, so you're passed over to Team 5, in-patients. They've never seen you well or in the community but will deliver all your mental health care whlist you're an in-patient, after (of course) you've gone through your tale with yet another team.

Say one team sees your low mood and poor coping as an understandable reaction to social stresses you're having, through relationship problems and money worries and being physically unwell. Say another team sees your low mood and poor coping (with changes in how you're managing relationships and money and stress) as a result of major mood disorder, arising through chemical brain imbalance and psychiatric disorder. One team has a care plan involving support and psychological work. The other team has a care plan involving antidepressant drugs, probably lithium, maybe ECT. Your care changes radically as you pass through from psychosocial to biomedical Consultants.

Not only is there no continuity, but patients at vulnerable times have to develop therapeutic relationships over and over again.

In what way is this better?

Delirium

I was going to muse over the management of acute confusional states (that nowadays seems to be called delirium, again).

There're the causes of it.

There's the assessment of it, through history and examination and investigations.

There're the interventions (both pharmacological and non-pharmacological).

But on balance I truthfully could not put it better, or more succinctly, that Nurse Anne who undeniably has the truth of it, here.

She's absolutely right.