Saturday 19 March 2011


I've been seeing a patient for some time, withdrawing their benzodiazepines with them. Mentally well all his life, the patient had felt anxious and when he retired, then widowed, had declined talking therapies and sought medication to help. His GP is a sensible soul but over time and by accident and through locums whilst on holiday ended up with a patient being prescribed and taking very hefty doses of two benzodiazepines and wanting more.

The drugs weren't working any more. On mornings and after coming down off the drugs' peak effects, he was restless and irritable and more anxious. He'd started falling. Alcohol intake was modest (a couple glasses of wine a week) with normal liver function.

I had never seen the patient before being involved this time. I had not started the benzodiazepines. Our PCT has commissioned neither drug and alcohol services nor my corner to manage iatrogenic addiction (ie the doctor caused it), feeling if one doctor's caused dependence through their prescribing, they need to sort it out. I'm no expert at substance misuse at all. The patient had no wish to see me to reduce benzodiazepines, quite the opposite, he wanted more.

I've massive sympathy for the patient and for the GP. Both were trying to do their best at the original point in time, managing the few poor choices they felt were laid out before them. The GP wrote an excellent detailed helpful referral letter to me, asking if I could sort it all out. She's a good GP. She's helpful. We both collude in working to do what's best for her patients despite the local policies and care pathways and frameworks and shared care arrangements; she's sensible in ignorning most of the bureaucracy and instead we just crack on with what's best. I might prescribe when it should sit within her budget. She might prescribe when it hasn't been the exact blah months needed for a shared care to start. She's a good clinician and she works hard, very hard, to support her patients as best she can.

When she wrote saying she'd messed up and got herself into a tricky position, she knew I wasn't a drug and alcohol expert, but she felt stuck and uneasy, well as said within Jerry Maguire she had me at "hello" and I couldn't leave her to flounder.

The patient loves his GP, thinks his GP is ace. I've been involved for many months and soon will be discharging the patient, benzodiazepine free. The patient suffers my visits and has a less than favourable view of what I've done. He understands why, but it's not what he wanted. But as he 'fesses up, he was addicted. I won't need to see him again, hopefully. His GP hopefully will be seeing him for many years.

Even if it's not my mess, not my work, not my problem, sometimes it's better for the GP to be the good guy and me to be the bad guy.

I wonder if the new NHS commissioning and structures will facilitate helpful working arrangement . . .

Monday 14 March 2011


A banker, a Daily Mail reader and a Benefit Claimant are sat round a table, and there are 12 biscuits.

The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."

Wednesday 9 March 2011

Policy is a direction and framework we consider (and should strongly consider) in deciding our clinical practice.

But policy supports clinical practice. Clinical practice doesn't support policy. We do what's right, we don't do what's written down. That's why qualified staff take clinical decisions instead of unqualified staff delivering what the policy says with no decison making at all.

Pyjamas in Bananas has pointed out the flaws of trying to support and use policy documents.

Part of me, rather impishly, wonders how much I should follow policy guidance. NICE guidance should apply to about 3/4 of the population the guidance is generated for. The routine, standard care should typically be in accord with NICE guidance, but for 1/4 of patients specific bespoke custom care is likely to be more appropriate.

As a specialist within Secondary Care services, I'm seeing a patient population that almost by definition don't fit typical routine care pathways that GP and non-medical mental health colleagues progress. When something's unusual or complex, that's typically when it's brought to my door.

On that basis, if NICE guidance applies to 75% of patients, and over 75% are managed in Primary Care or within NICE guidance by nurse lead services in Secondary Care, I'm seeing a portion of all the remaining 25% who sit outside NICE guidance.

Shouldn't 100% of my workload by complex/atypical stuff meaning I'm never adhering to standard policy or guidance or protocol? As I said, it's an impish thought, but I have shared with my Chief Exec that I fear I'm far too compliant with guidance and need to be more maveric and eschew such constraints on my clinical freedom, nigh on 100% of the time. Food for thought . . .

Thursday 3 March 2011

Case Based Discussion

We tell patients the truth. How much is valid consent, how much is coercion?

This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.

One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.

The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.

Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.

Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?

I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.

Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.

I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.

A pleasant surprise.