Wednesday 10 February 2010


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?


Unknown said...

That sounds shite.

I'm quite happy with the same consultant seeing me regardless of the state of my health. Actually, I'm now just seeing my GP and getting lithium blood tests done by the practice nurse, beacuse I'm un-crazy enough to not need to see CMHT.

They are pretty good round where I live, actually.

XE said...

Oh dear. Can't imagine how distressing that system must be for the patients. I thought everyone understood the importance of continuity of care, and would take that into account when planning a new system... *sigh*

Kelly said...

In what way is this better?
It isn't. It sucks and baring your soul to complete strangers over and over is as detrimental to the person's wellbeing as the underlying illness is. Harmful, not helpful, is the "new, improved" system.

Cat said...

As I'm sure you'll be unsurprised to hear, we are having exactly the same processes happening where we are (unsurprised because it is a national move and change). In my own insular way, I'm glad our services are being preserved as an older adults service (which was by no means guaranteed initially). I am not at all sure it's a way I'd want to work and seems to be intricately connected to Payment by Results which frightens me a little bit. Possibly because I don't know as much about it as my managers might want me to.
But there is such a thing as change fatigue. The amounts of reconfigurations are really disheartening although this time, our consultant assures us it will be REALLY dramatic.
I'm not sure that comforts me too much. Some of my frustrations seem to be about the ways that the supposedly integrated health and social care are being polarised somewhat. There was even some talk about sending all social workers back to the local authorities and taking them out of CMHTs altogether. I think that has now been discounted.. but still, it's nice to know how much we are valued!

Unknown said...

Worth noting that NHS Scotland are not doing this.