Thursday, 18 August 2011


We used to assess and document insight a lot, routinely for every patient. It's become more of a trivial afterthought now (and rightly so) with more appropriate and sophisticated consideration of decision/situation specific capacity replacing the concept of insight being present/absent.

I was musing this over with an AMHP as we discussed what insight means, how it's been mis-used in the past in tribunals as a proxy to not being capacitated, how it's seldom relevant now. She raised this because in all her time in the multidisciplinary team it dawned on her that she's never heard us discuss insight. She saw this as a good thing and I'd agree. Insight as a concept has been of enormous import and done rightly is fine, equally it has historically oft times been a shorthand that's too superficial/medical to have the utility it needs. Patients' formulation of their experiences, understanding of needs, engagement with informal family/friends/support and formal health/social servcies can be framed in terms of insight but invariably is better considered in terms of understanding and capacity.

Having chewed the cud with an AMHP and stirred thoughts on the concept of insight at length, I moved on half an hour later and to my shame, I lacked insight.

I met with our Trust's Chief Executive. I do so fairly often. Our Chief Executive is an agreeable, competent, grounded and incredibly sensible soul. I'll frequently meet the Chief Executive and talk through stuff over coffee. Or email stuff that merits Board level consideration. Or the Chief Executive will come see me, which happened yesterday.

Because our Chief Executive is so approachable and engaged with Consultants, I rather fear I've done them a disservice.

I'd always thought the Chief Executive to be influential. I was naive. The Chief Executive has great influence over a great many things, but it's finite and in some ways is actually quite narrow. I'd not really appreciated the constraints that Monitor and CQC and SHA and DoH and others shackle the Chief Executive with. The Chief Executive has responsibility but Executive Directors have their own portfolios and they, not the Chief Executive, sort those. After deciding how things shall be, the Chief Executive then has tiers of managers whose Chinese whispers distort the detail and implementation of the intentions, horribly. Can the Chief Executive direct me to prescribe Mrs Smith olanzapine 5mg velotab at night? No. That's a clinical not a managerial decision, the Chief Executive has no direct influence on what clinicians do in their work.

National drivers constraining the Chief Executive's options. Local commissioners directing the Chief Executive's choices. Tiers of managers running with the Chief Executive's wishes yet effecting implementation (or not) their own way. Managerial decisions' boundary with clinical decision making (and no direct managerial influence in this). Good grief. I'd not really thought through what a grim position it is to hold, having all the responsibility yet with much less opportunity to effect detailed sophisticated systemic change than I'd considered. Worse, I erroneously presumed that the Chief Executive is boss and can sort everything. Most folk do.

I lacked insight into the situation.

Time to remedy this.


Cockroach Catcher said...

As usual, great insight and great humility. There is much craftiness in this whole reform business and soon it will be too late.

Like they say, if these people are that good why are all the financial institutions in such trouble. If anyone can employ talent, they could afford to.

No top heavy blah, blah, blah!!!

Alias Grace said...

On your first point - my problem with "insight" was always that clinicians said I lacked it when I disagreed with them in what still seems to me now to be a completely reasonable way.

Keep writing. It's interesting.

- Grace

Unknown said...

Great post. A lot of great points. I like it. Thanks for sharing.