Clever nurses

All liaison referrals from the acute hospital come to our liaison team. The nurses (who do almost all the work) discuss every patient with a Consultant Psychiatrist (erm, me). This matters to me. The nurses are excellent at mental health assessments. It's what they do. More, they're excellent at sharing with nurses and managers on the acute wards how to manage their patients.

My input is sometimes into the psychiatry, but usually into the medicine. They are, after all, so medically/surgically unwell that they're needing hospital in-patient care in a hospital that never has enough beds. Medical problems often contribute to presentations, medical interventions can contribute to solutions.

So, a mental health nurse and I explore the issues of every referral.

This results in odd side effects. One side effect is that my nursing colleagues know me well enough to know how I think and the sorts of things I think of and what I like to sleuth out.

A patient was referred last week with low mood and onset of mild confusion. I'd not normally accept such a referral but won't disclose the reasons why we did. Suffice to say, my nursing colleague picked it up and sorted it out. We discussed the referral, she saw the patient, she met with me to discuss it and explained her thinking. The patient was weary and low because they were in hospital (and didn't want to be), were in severe renal failure (and didn't used to be) and critically was digitoxic.

Her high digoxin levels, presumably either caused by changed renal function, or by staff administering it to her regularly (when she'd been less compliant at home) had resulted in dangerously high blood digoxin levels, which explained her symptoms she was referred with along with other symptoms which she had. A previous patient, on digoxin, had resulted in me checking their levels (which were normal) so my nursing colleague had learnt from this and considered the digoxin in this case. The medical team hadn't noted that. They'd not even requested digoxin levels, my nursing colleague had.

A good pick up.

I think my nursing colleagues are very clever :-)

Perfection

Do you like speaking to an answering machine, to leave a message? It seems that most people don't. And yet talking down the 'phone to leave dialogue on a machine that reproduces what you say, perfectly, should be seen as a good and reliable way to communicate. Better than the alternative of leaving a message through just a few words of text, surely? But no, most of us choose to text a few words (despite how fiddly it might be) rather than leave a voice message, just talking, which should be a more natural and effortless and familiar way to be.

Machines, even those which are perfect at what they do, don't always deliver sweeping changes and aren't always warmly embraced.

How desirable is perfection?

Common sense says it's got to be a good thing, right?

Clinically, in mental health we often strive for "good enough" or "as good as can be" rather than perfection.

Our machines have loftier aspirations.

It seems that every ECG machine now wants a perfect reading. Anything less than perfect is flagged as abnormal. Indeed, it's printed out, "Abnormal ECG," along with conjecture as to why. Almost always it is normal. Or normal enough. Not something that a doctor would document as "abnormal" anyway. But unless it's perfect, the ECG machine chews out paper documenting "abnormality" which causes no end of stress and nuisance.

I really do want to do something quite gratuitous to it's rusty innards.

Sometimes I don't want perfection, I want normal.

Teaching Hospitals

Where's the best place to get care? Where's the best place to work? Both are related questions; if you have a happy, motivated, enthusiastic, valued workforce then you're much more likely to have a better quality service and receive good care as a patient.

I've worked in many hospitals, through medical school training, then 2 more as a House Officer, then more whilst I trained as a GP, then more as I trained as a psychiatrist. Many different hospitals in different counties.

It's something that usually you come almost come across by mistake rather than by conscious design . . . do you favour working in a local district general hospital, or a big teaching hospital? At least as a professional I've the choice. For patients, especially if needing involved and ongoing care, we all invariably have to go with what the local service is. You might be referred to foreign parts for your specialist heart surgery or spinal cord stimulator or infectious diseases opinion, but if you're after a community mental health nurse, support worker, social worker, psychiatrist, pharmacist and psychologists' input a few times a week with ongoing contact over months/years, you're invariably not in a position to get that from far away. Private medicine doesn't do it well, either. You get to see a Consultant Psychiatrist (if not fobbed off) but how do you get input from the other disciplines? When a team contributes to care, so half a dozen folk add to it each week, it's a fearsome bill to generate each week in Private Practice. Having a menu from private companies and picking off just one bit (like a Consultant Psychiatrist or a CBT therapist) will work for some people some of the time, but isn't a sensible or coherent way to generate a service.

I don't do any private work so for me it's not an issue, but the point remains . . . for mental health care, usually it's only practical to have an NHS team involved and for this team to be local to you.

Is a teaching hospital a better place to be, then?

This issue is in my mind because, curiously, a family moved last month from their current city (and teaching hospital) 30 minutes up the road to my corner, specifically to have mental health care from our Trust. One relative needed appropriate dementia care (which they didn't think they were getting in the teaching hospital), one younger adult needed ongoing care in the management of a mood disorder. It's not uncommon that patients have strong views about their GP and seek to remain with good ones they trust (much as the Government seems to believe otherwise).

As well as a patient relocating to be under my care, I also had a supranumerary flexible trainee wish to work here. That surprised me anyway - how many bright young things are zealous to work in old age psychiatry?! But her rationale was seemingly sound. As an older graduate who was more reflective of her training scheme than most, she found that a teaching hospital usually wasn't.

She found that a teaching hospital, in striving to be a centre of excellence, had lots of people trying to gain experience so she was often displaced. More importantly, she'd found that a teaching hospital was driven by research, not by teaching. Teaching added nothing to the researchers' day, and indeed detracted from their research time. Jobbing clinicians were the poorer brothers to the Senior Lecturers and Professorial teams so had disproportionately larger workloads and couldn't find hours a week to teach. It's a valid point. Teaching hospitals usually are research hospitals and are not necessarily at all good at teaching.

Got me pondering.

Is a teaching hospital automatically a desirable place to train (when teaching can be scare), work (where publishing research competes with investing time in teaching/clinical care) or receive care?

Quackery

There are many flaws in the NHS. Oh so very many. But to my mind, both the ideology and delivery of care are better than other models I've seen (which are even more flawed).

If you (or your health insurance company) pay for you to be referred and see and receive care from a Consultant Psychiatrist, what do you get from that?

One lady got not a Consultant Psychiatrist, but an hour for a new patient assessment by a member of the Consultant's team, then 15 to 20 minutes with the Consultant Psychiatrist at the end of this.

You can argue the toss over whether this is good practice or not.

What I find hard to argue is the choice of individual initially seeing this new patient (instead of the Consultant Psychiatrist), the patient being a 38 year old lady with significant past psychiatric needs, necessitating ongoing psychiatric care.

The lady was assessed through her new patient referral to a Consultant Psychiatrist by . . . an Energy Healer.

You couldn't make it up. Read about it here.

Quack quack quack.

Medicines Management

I had an email request from Xavier asking a number of questions about medicines management. The main theme was, "how do you, as a
practitioner who commonly works with geriatric patients requiring various psychotropic medications, work to prevent ADEs in your everyday work?"

ADEs is, I presume, adverse drug events, or what we'd call side effects or treatment emergent adverse events.

The short answer is that I don't prescribe medication unless there's clear, rational grounds to do so. Local audit showed I prescribe at substantially higher doses than peers, but prescribe a lot less often. This doesn't surprise me - either medication shouldn't be used (and homeopathic doses to placate folk is not just an easy option/a con, it's a potential cause of harm) or it should be used at a therapeutic dose and evaluated.

The commonest intervention is to reduce medication. Many patients were started on medication, appropriately, but as time's moved on the "need" for such medication diminishes, if considering a risk:benefit ratio or NNT (Number of patients Needed to be Treated to get one patient to respond beneficially to that treatment). If on a betablocker, say, at age 87, what is the NNT to avoid one serious adverse event over the next year? What's the NNH (Number Needed to Harm) and is it comparable to the NNT? If the chance of beneficial treatment is comparable to the chance of harm, should the drug be used? Sometimes yes, since the issues are so significant, but often the benefit is modest and the utility of the drug can be contested (which is a polite way of saying it can be reviewed and stopped).

As well as often seeing a list of medication that's grown over years and can be reduced, there's also the dose regimen. Taking medication twice a day is much better than taking it four times a day, in terms both of concordance with prescribed use and in delivering care (with carers supporting this through monitored dosage systems). Muddled folk taking extra meds or missing meds can then be optimised which matters for side effects profiles of many drugs but is vital (in the true sense of the word) in the safety of others (like digoxin, warfarin, lithium).

Having looked at rationalising the drug regimen then optimising appropriate concordance with the prescribed regimen and support the next consideration is non-drug strategies. Can the clinical issue be managed without medication? Or can it be managed with medication but with other whatnots too, reducing the prominence of medication (and thus hopefully reducing the polypharmacy/dose)? This is often the case. We don't have tablets to stop people shouting or stop them wandering; management of behavioural problems invariably profits from behavioural solutions. Medication is, at best, usually just an adjunct.

Really, this is a major issue. The DoH have published the National Dementia Strategy and Prof Sube Banerjee's report highlight the need to prescribe seldom, but prescribe in an evidenced manner, in dementia care. The NHS also touts this view. So do the Alzheimer's Society. The National Institute for Health and Clinical Excellence offer support in dementia care through the NICE Clinical Guideline, CG 42.

Politics, the NHS, voluntary/patient advocate groups and expert bodies all saying the same thing. Amazing! Continued routine use of antipsychotics is grabbing headlines and, validly, is seen as poor practice. The evidence that such drugs cause strokes and death mean we really need good evidence to countenance their use, in our patient's best interests.

What about antidepressants? In mainstream psychiatry we've known they're mostly used as snake oil linament, a trifle to offer folk to take whilst nature takes it's course and things get better. What's big news is that arguably the world's biggest mainstream (not mental health) medical journal published a paper this year, a meta-analysis of antidepressant use, that shows how antidepressants in clinical depression of mild, moderate and severe depression are as effective as placebo. Only in very severe depression was their statistical difference between antidepressants and placebo.
Antidepressants arguably have a tiny or no role in Primary Care, which is why non-directive counselling and IAPT and CBT blossomed.

Obviously, I do prescribe antipsychotics and antidepressants. But invariably I want to see evidence of what the problems are before prescribing, then start drugs at a decent dose and ramp them up to a very decent dose for a decent duration, then evidence if there's improvement. And if not, the drug's stopped.

Really, drugs often don't help. We know that. We see it in clinical practice. We know it from theoretical models (if you've structural brain changes from dementia, why should fiddling with brain chemistry fix anything?!). But although evidence on effectiveness in clinical practice (rather than drug companies' research on efficacy) shows effectiveness of drugs, generally, to be pretty much approaching zero. So statistically they don't often do a whole hill of beans. But for individual patients you can get stunningly good results.

Part of the approach is offering something. It's not as if you get drugs or you get nothing. Our team supports staff/carers working with our patients, offering other solutions. This may be seeing a patient in day hospital every week over a month to see how they interact with others and respond when being encouraged to complete a task, to better inform their spouse how to manage with tasks in company like when they go around a supermarket or journey on a bus. It may be our staff going in to a care home at 7.00am to show the carers how to get someone out of bed and washed and dressed, successfully. It's sitting down with someone and showing them how to facilitate engagement with meals, so the patient won't wander off after 5 minutes or start throwing food or fiddle with other peoples' plates. Our team does teaching at 9.00pm to support night staff in optimal care. These interventions when successful often save staff time. Not using drugs can only viably be part of a care plan if there're other successful, meaningful options being offered instead.

The subsequent use of medication needs to be considered over time. Although it may be that psychotropic medication's used reasonably, with evidenced benefit, it then needs review at a later date to ensure it's continued use remains appropriate. whether it's a mental health team or community pharmacist or GP/Primary Care that do it, there needs to be a system for medication review. Being obsessive, I go through every MARS sheet in every care home in my patch, doing medication clinics, so review all medication that anyone's prescribed (GPs or out of hours or people moving into the area) of everyone, to minimise medication use. I can't see how we can undertake effective medicines management without regular review.

So there we have it, the themes I'd suggest to minimising medication use and thus reducing adverse drug events are :
- Stopping medication that's no longer necessary/of significant benefit
- Ensuring concordance is supported through reduction of number of doses
- Ensuring concordance is supported through Monitored Dosage Systems, if relevant, reducing medication errors/accidental overdose
- Use non-pharmacological strategies with practical support of staff showing people what to do
- Documented objective evidence of problems to address, then introduction of medication, then documented objective evidence of effectiveness (and withdrawl of the drug of it's not proven to be useful)
- Medication review

Work

After I just posted about referrals, the Jobbing Doctor posted about how referrals are then managed by teams, writing about it here.

His account is familiar to me, I've trained in teams that function in this manner. Many of them did. Well, in truth, almost all of them did.

There're comments on the Jobbing Doctor's blog that are critical. This is appropriate, blogs are a place to vent grim experiences of what really happens and tell it like it is. As regular readers will know, although I can moan and whine with the best of 'em, and my working world is immersed in the misery and despair that my patients grapple with, being down and negative about it all isn't my style. If we're not hopeful, if we can't think how we can do it all a little bit better, we've kind of missed the point. Sure, there's lots we can't change. But equally, there's lots we can.

In mental health, it's not like much of health care provision where we need machines that go "bing" or bits of kit with sharp spiky bits or infusion pumps/theatre time/guided ultrasound/spirometry/whatever so if we want to do things differently it's much easier to do so.

We've shifted services a few times over the last few years, which really hasn't been that hard to do. We've an active patient forum who tell us what could be done better. We've two active carer forums who're very active within our Trust, locally and politically. Our staff on the shop floor all know what's going well and what could be improved. So we said what we wanted to change (had to have meetings with GPs and commissioners and our Trust managers which did take some time) but then changed it for the better.

I'm bemused by what people think Consultant Psychiatrists do. I suppose I shouldn't be. Our timetables are varied and often diverse. Working age adult services tend to have psychiatrists with pretty fixed and full timetables (although this can change, if there's a will to do so) but other disciplines already often have changed.

What do Consultant Psychiatrists do? Really! How does a Consultant Psychiatrist fill their working week? The short answer is patient contact and meetings. The longer answer is the detail to this.

Other than ward round and clinics, most Consultants have few fixed clinical sessions. Even a full day of both only eats up 2 days of a week. For most Consultants, they've half the week free to do whatever.

For me, although I've a full sector that's a higher patient population than the Royal College of Psychiatry guidance for one Consultant Psychiatrist, and there's no Staff Grade and no ST4-ST7 specialist registrar or any senior medical support at all, I tend to average one in-patient at any one time so my in-patient work takes literally just about 2 hours a week. My out-patient clinic is one morning for 3 hours, once a week. That's 5 hours a week. What do I do with the rest of my time?

Quite a lot - my formal timetable (my Job Plan) goes on over 6 pages, with no sentences or explanation at all, just lists of what I do and where I do them and how much time it takes on direct clinical care or supporting activities. But with just 5 hours a week of fixed activity, it's easy to do other stuff with flexibility.

So I can meet the team every morning and discuss what work they're going to do, that day, and whether there're any medical dimensions I want them to explore when they see their patients. I've no fixed committments in the afternoons so we meet every afetrnoon too, to discuss every patient seen, with discussion on any medical management in care that we need to progress. With no fixed sessions in the afternoons, most of my afternoons are spent in liaison work, in care homes or on joint visits with CPNs or social workers.

My Job Plan's so long because of other stuff we do. Clinical audit, research, clinical effectiveness. Case Conferences. Supervising junior doctors and filling out assessments for them. Preparing interview questions and model answers. Statements of testamentary capacity. Strategy discussions with police. Meeting GPs. Meeting carers every month. Journal Clubs. Safeguarding meetings. Work with the health promotion and neurologists on district wide vascular dementia pathways. Several hours a month spent in supporting nurses in their training. Teaching ward nurses in the acute Trust. s136 assessments. Generating references. Teaching the Consultant physicians and surgeons in the acute Trust in their formal lunchtime training sessions. Joint work with neurology. Mandatory child safeguarding training. Meeting patient reps every month. Discussing care options with PCT commissioners. Work with staff in the hospice. Monthly Consultant meetings. Supervising nurses in non-medical prescribing. Peer group CPD meetings. Letters to the DVLA. Working with community matrons/district nurses/health visitors. Management nonsense. Input into the local APC meetings. Training Primary Care teams. DOLS meetings. Mandatory CPR training. Interviewing nursing, OT and medical candidates for posts in our teams. Medical student seminars. Court of Protection letters. Helping secretaries, nurses and STR workers get the right A4C band. Adding common sense into governance meetings. There's more, but it starts getting a bit specific. Equally, a lot could be expanded upon (the amount of time I spend reading journals, extracting bits for teaching in different forums or taking to different management meeting, is very significant).

But what I'm seeking to convey is that a Consultant Psychiatrist can have some fixed time seeing patients some mornings, can also spend most afternoons seeing patients, but there's flexibility to support teams so referral pathways and input into clinical care always involves a Consultant Psychiatrist, even if I don't always see the patient.

We've not that much fixed sessional activity. We've no expensive kit or resources that limit how we can work. We invariably know what's going well and what isn't. So I really can't see why we can't change things, for the better.

Referrals

I met with PCT commissioners and we talked through our services' activity levels.

We were congratulated on over performing, with an invitation to bring 2 presentations to next month's meeting to progress bids for additional funding for 2 bits of the service. All is good.

But . . . there were questions raised about the number of referrals to our service of younger adults who're assessed for dementia, but found not to have dementia. It's the majority. I reckon we know of 74% of those with young onset dementia in our district so there aren't loads and loads of folk left to find. Most referrals to this service don't result in a diagnosis of dementia. PCT sensibly asked about our referral process and care pathway and if, instead of more resourcing, we should tighten up on referral details and primary/secondary care work up before referral to specialist tertiary services.

Tricky.

The commissioners don't appreciate just how poorly psychiatry's seen or respected in medicine, thus how motivated (or not) folk are to put effort into psychiatric care.

Let's contrast two common referrals to two Consultants. One referral is to a Consultant Psychiatrist with depression. One is to a Consultant Cardiologist with heart failure.

A letter to the Consultant Cardiologist saying, "Please review this person's physical health" would be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health" is commonplace.

What if the referral is more specific? A letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest" would still be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood" is commonplace.

Even more specific. The letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest, I think it's his heart and needs sorting out" is still be laughed at and binned.
The letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood, which is low and needs sorting out" is commonplace.

The Cardiologist would expect examination (with pulse rate and BP at a minimum), conceding that cyanosis, clubbing, signs of biventricular failure, JVP etc although desirable are unlikely to be detailed.
The Psychiatrist gets no examination. Ever. Although psychiatry is a medical speciality, no medic ever refers with details of appearance, behaviour, speech, mood, thoughts, perceptions, cognition or insight of a mental state examination.

Having had a richer referral history and examination, the Cardiologist also gets a minimum work up of an ECG and sometimes structural imaging, to then progress further appropriate diagnostic investigation.
The Psychiatrist has had a scant and inadequate history with no examination and invariably no use of instruments or investigation.

Energy isn't invested in trying to progress salient history disclosed (symptoms), objective elements of presentation (signs), testing (investigations) and formulation (diagnosis). Yet symptoms, signs, investigation and diagnosis are ubiquitous to other disciplines in medicine.

I can't see how it will change.

I tried to explain to the PCT, who commission services from other medical specialities, that in mental health we just don't get sophisticated assessments in referrals that allow us to filter those with a high index of clinical suspicion for dementia vs those with cognitive deficits arising through mood disorder/neuropsychiatric sequelae of physical comorbidity/medication. We just have to accept all referrals then 'phone the referrer and patient and family and GP to get enough information to progress the right care. The PCT at first just didn't believe me. Then they believed me and thought medical colleagues should be doing great psychiatric referrals and if they can't it's a matter of poor training and poor practice.

Some days I just don't feel understood.

Complaints

Becca asked about how to complain about a poor care home, or effect a change for the better.

A number of possibilities exist.


1) Talk to the Care Home manager

In my corner, it works out at less than 2% of care home managers want to be left alone. I've no authority or statutory powers to enter care homes or direct how things should be in care homes. Even so, all but one care home manager I've worked with has welcomed me in to work with the NHS to improve care. Most reasonable managers will listen to opinions, especially valid opinions of people who've been through their home. They may listen and take your views on board. They may listen politely but ignore everything. But the first port of call should be the manager since they're in a position to improve things markedly and turn a poor care home into a great care home.


2) Talk to Secondary Care

Some hospitals have specialist services that visit care homes. Care Home teams, Outreach Teams, Liaison Teams, names vary. But it's becoming more common for NHS prividers to have a specialist team that visit private and Council care homes to provide support. Our team knows which care homes are great and which are dreadful. We're involved in all the Safeguarding referrals and all investigations, simply because we can contribute information to the processes but equally can contribute solutions in both staff development/training and direct patient care. Care home teams can therefore take on board comments you have. One of our carer forums gave great feedback to us, resulting in us training a large number of care home staff. The carers were pleased since standards have improved. The care homes are pleased since they've had free specialist training (and forged close working relations for ongoing support).


3) Talk to the company

Care Homes mostly are run by massive companies. There's a tension in them. They want to maximise profits. But they also want good publicity and to be seen to have decent standards of care, holding a decent reputation. Care home managers may compromise too much, eroding care (through poor food, poor staffing, poor environment, poor recreational opportunities) to maximise profits and be seen to succeed for the company. The company likes a good balance sheet. But extra profit at the cost of 21 Safeguarding cases and the home closed for investigation is less attractive to them. Which is what heppened in one of my local care homes. The company had no idea it was so bad. It can be very worthwhile telling the parent organisation what you feel, since you sharing your views affects their reputation, which matters to them.


4) Talk to the Council

What if it's not an independent care home? If it's run by the Local Authority, then get on to the Council. Heck, even if it's a private care home, the Council have major influence.

The Council will have a contracts department for care homes. They will have details of what care homes are registered to provide (although this is changing) but critically they details what the Council, through social care funding, will pay care homes. If a care home is embargoed, no Council funding is given. Nobody's funded to go there. Councils therefore have enormous clout. If you've concerns about a care home, you can talk to the Contracts department and share this concern. They'll not be able to act on their own, usually, but it's healthy for them to have an awareness that all's not well in Home Blah since then they're obliged to do some digging.


5) Talk to the PCT

The PCT fund a lot of care home placements now, through Continuing Care funding. This NHS cash going into care homes is managed by the PCT. If a care home's doing a rubbish job, the PCT can intervene through different systems. They can investigate directly themselves, informally or formally. They can use resources (like PCT pharmacists, Community Matrons, Health Visitors) to provide surveillance or support. They can refuse Continuing Care funding and with with the Local Authority to embargo a care home, effectively closing it down until it sorts itself out.


6) Talk to the Care Quality Commission

The Care Quality Commission (CQC) will take your complaint. They've taken over CSCI and now oversee care homes. They helpfully detail what they'll do. They can direct homes to progress certain actions and have teeth, effectively being able to close them down until they pull their socks up to the CQC's satisfaction.

BNF Indications

The British National Formulary (BNF) details the licensed indications for medications I prescribe.

Much of the time I prescribe outwith the licensed indications. Sometimes it's because the drug's not licensed for older adults. Sometimes it's because it's administed in a specific manner (e.g. crushed up). Usually it's because it's outwith licenced indications.

This shouldn't matter.

The marketting authorisation for a drug is there to ensure that the drug's got proven efficacy (i.e. for the named indications put forward by the drug company that the drug works better than placebo, so is an active drug, rather than some spurious snake oil linement whatnots). This then confines the drug company to marketting their product just for that indication. In theory, when drug reps come to talk to clinicians about their drugs they give us a summary of product characteristics and talk just about that.

They didn't they'd come and talk about all sorts of anecdotal nonsense which infuriated me sufficiently to report one to the ABPI and stopped seeing any more of 'em. I don't often have hissy fits but the Big Pharma nonsense pushed me rather too far. Ho hum.

What's peculiar is that the "Indications" for drugs seems to be taken, in some corners, as an irrelevant nonsense and inconvenient, artless work of fiction.

I have a lot of time for proper nurses and spend time each day sorting out liaison work in the acute hospital and RMNs grappling with difficult residents in EMI Nursing homes. When good nurses have tried everything sensible, medication often can have a role to play in assisting the staff deliver appropriate care.

What I find slightly more frustrating is when nursing colleagues from the acute Trust refer a patient to me so I can, "make them stay in bed," or I could, "prescribe something to stop them shouting," or better still, "give them something to stop them swearing."

The BNF does not do medication with indications to treat with a "stay in bed" pill or a "use the quiet voice" pill or indeed a "nice language only" pill.

No matter how hard we look, they don't have a licenced indication for, "Stop Mrs Smith ripping out peoples' venflons, biting and scratching nurses and hurling drip stands around the ward!"

Treating a behavioural problem with a chemical solution isn't ideal, but heck, often it won't even work. Not uncommonly it can make things worse. So why do I have oodles of requests for medication to de-escalate behavioural disturbance? Because ward staff feel they've no other viable choice before them. As my nursing colleagues eloquently assert, if wards are understaffed, then caring nurses can't deliver excellent person centred care.