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?