Fridges

How do you practice psychiatry in hospitals, and clinics, as folk in the USA mostly do, with folk who have dementia?

I ask in the spirit of genuine inquiry since I find visiting folk at home to be a core and wholly necessary part of work. The bit that's most useful is, of course, the patient's fridge.

It's always good to look in a fridge, I find.

There's the opportunity to see what food and drink's in it. One once was stacked full (so full you couldn't see the fridge light at the top) of beer. An opportunity to talk about alcohol use and the amount drunk.

One had nothing in it but milk for tea and plasticky cheese slices. An opportunity to talk about diet and opportunistic health promotion.

One today had a mix of things. Greens, mostly. But not in a good way. The fridge was filled with food that was covered in green fur. Or, on some of it, black mould. In addition to the varied diet of mouldy food (the food long since obliterated so I've no idea what it originally was), was what Withnail and I would call, "matter."
Just semi solid stuff, composting down, with dark greenish black fluid seeping out of the bottom.
An opportunity to talk about a suboptimal level of function.

You can look in a fridge and see if food's out of date. "What is the date today, is this in date?" An opportunity to test orientation and decision making, without abstract instruments irrelevant to our patients but instead with tests of ecological validity.

Using fridges works too. "Fancy a cup of tea, doc?" "Why yes, thank you kindly, I rather would." Do they go straight for the tea or hunt around several cupboards for it? Do they sequence with cold water in the kettle, then heat it, then mix hot water with tea, leave it to brew (but not for too short or too long a time), place the hot tea in a cup, add milk, all in the right pace and order? Is there a tremour? Do they get muddled? Is the milk in date? An opportunity to talk about organisation and sequencing.

Seeing someone at home, seeing what's in their fridge and how they use it, beats 20 minutes of questions in clinic any day!

Cause and Effect

There's been a scheme of late, in an adjacent county, to promote breast feeding. It's been praised as a success. This is because the PCT and midwives and health visitors all have seen that more people have attended or had contact with breast feeding promotion, so more women have had the right information and support. More, patient feedback forms were used. They’re not ill, they’re not even under health services, but they’re still patients and not service users. Hmmm, odd, that. Ho hum.

Anyway, the patient feedback was embarrassingly good. Gushing praise ‘bout dedicated, passionate, informed breast feeding counsellors and peer support counselling and breast feeding cafes and baby bistros where mums could meet for advice and support from other mums and from informed/expert resources too. Mums love it, see it all as a great success and really value it.

Everyone wins.

The PCT wins, they commission a great community programme for young mums and babies, ticking the box for a national agenda (promoting breast feeding) in a locality where breastfeeding rates are low, at under 1/3 of the national average.

The acute Trust wins, saying they’re generating a great patient centred valuable service, through investing in staff and developing projects to invest in mums and babies, getting young babies off to the best start in life.

The local community/patient population wins, with mums saying it’s all great and generating oodles of feedback forms saying so.

A year on, a keen midwife and health visitor evaluated the impact of this combination of successful projects. Everyone was still optimistic, dedicated, enthused and happy. All was as popular as ever. Everyone saying what a fantastic development it is. The midwife and health visitor looked at breast feeding rates now, compared to the years gone by.

They’re no different.

A good idea is had. Good, passionate, competent staff develop the idea. Managers in the PCT fund the idea. The idea’s delivered and the patient love the service. Ticks lots of boxes ‘bout addressing a local failing in low breastfeeding rates, improving patient choice and community services and peer support and Local Extension of Services and whatnots.

But the service isn’t effective.

It costs a lot of money. The staff time (daytime and evenings), the ongoing staff training, the cost of the use of the properties it’s delivered in, all adds up. Adds up to quite a lot, actually. Massive investment (in time and money) to improve breast feeding, for no improvement in breast feeding uptake or mums maintaining breast feeding.

Should the health service continue to fund this?

We’ve an identical scenario in mental health services locally, that’s popular and well received and highly valued by patients, but doesn’t deliver any beneficial outcomes that patients or staff can see. But it’s just as hard to say that we’ll stop that and use the money in a different and better way, to be more useful. Both commissioners in both situations and flapping about “patient choice” and saying they like the “service” even though it isn’t an effective service.

Is seeing something and liking it and believing it’s doing something else a valid use of taxpayers’ money? Or a valid use of NHS staff and patients’ time? It’s a bit like reckoning that, statistically speaking, those people who have more birthdays live longer, thus I must eat more cake with candles on top. It’s all gone a bit peculiar.

Ker-ching!

I've a patient who's not asking for anything.

I see her every so often, at her home, usually with the CPN who's doing her depot. I've known her for a number of years and find her utterly delightful. Because she's on a depot and now in her late 60's I'm obliged to review her depot medication and consider the risks, benefits, necessity and rationale for it with her, which is a pleasure to do since she's such good company.

She's never had any side effects on her current depot antipsychotic. She sees it as keeping her exceptionally well for a goodly while, now. She absolutely wishes to continue and is, "Very happy indeed, thank you, doctor."
She's had no recent changes to her drug regimen, no new over the counter medication, no substantial change to her physical health (although her osteoarthritis is worse), so all's stable and she continues on her depot antipsychotic unchanged.

A local lass visits. Helps her with shopping, helps her into and out of the bath. Put in about half an hour a day, at most, usually less. My patient gives her money for her help. It amounts to about £6000 a year. £34 an hour. My patient isn't wealthy and resides in a hellishly deprived area.

She has learning difficulties (LD) and bipolar mood disorder. Dunno if she's dementing or not, tricky to tease out the cognitive deficits that are through LD and through just getting older (Primary Ageing) and changes superimposed on this which could suggest a neurodegenerative process too. If she is dementing, it's early, with no compelling clinical evidence yet. But how ever you frame it, she's not sharp at working out details. And she's nice to people, she likes to be helpful.

She worries about money and won't accept elements of social care offered because she reckons that they cost too much (averaging just a few pounds a day).

She doesn't appreciate what the minimum wage is and what a typical wage for home care would be. The carer won't meet with anyone professional to talk about it.

I can't help but think this young carer is taking my patient for a ride.

Staffing Care Homes

I wrote about care homes and how, sometimes, they're the best place for a person to be.

Recently our Trust has been sharing experiences with an area in the USA.

This coincidentally resonated with a comment Pem made about quality of provision of community care. In the USA the best quality of care in hospitals is arguably the best in the world. It's got problems with delivering great care for chunks of the population, but what hospital care does well, it does very well.

Through funding pressures, community services (especially in mental health) are generally much less well developed in the USA than in the UK.

Both health and social welfare provision isn't brilliant in the UK, but it can be pretty good. It struck me that a gentleman of 62 with Parkinson's Disease who's developed PD dementia or Lewy Body Dementia can get very good care in the UK. There are many specialist units to look at younger adults/folk of working age with cognitive impairement. Thus his assessment, diagnosis and care planning can be generated by a dedicated Consultant Psychiatrist and a capable, motivated, enthusiastic multidisciplinary team. Ongoing community support from the team can be frequent (several times a week) with care provided by Health services in centres outside hospital environments. Any medication can be prescribed by the NHS Consultant Psychiatrist, protocols are simply guidelines and the Consultant has clinical latitude to prescribe in their patient's best interests (unlike when care's privately funded and either the hospital or the insurance company can curtail clinical freedom, meaning certain drugs may not be available).

Care can be shared across boundaries more readily in the UK, so this chap with Parkinson's Disease and dementia will be seen by a specialist early onset dementia team but also by a specialist Parkinson's Disease nurse and neurologist.

A real difference is in care homes. Within half an hour of where I'm sitting there are over 60 registered care homes. There's plenty of choice. What if a care home can't undertake the care the man needs and deserves? They've not the staffing levels, or experience? Well, resources can be put in place so they can meet his needs. A community team from the Trust can reach in to the care home, supporting their staff with ongoing training and education as well as modeling practical dementia care (e.g. getting him up and out of bed on a morning then having breakfast) so the care staff can learn good practice. If they don't have staffing levels to continue to attend to this, Continuing Care funding can ensure they do have cash for extra staff to be employed on the shifts so the gentleman can get the time needed. It may be he needs one to one care, if so, we can get it funded and he can get one to one care.

With mental health services providing continuity of his dementia care through a specialist team (which includes a dedicated Consultant Psychiatrist), social services providing funding for a 24 hour specialist care home for him, joint Continuing Care funding for extra staff, a Parkinson's Disease team providing continuity of care of his PD and mental health services having ongoing training for the care homes, the gentleman can receive exceptionally good care.

A work of fiction? An idealistic aspiration? Why, no, not at all. The scenario above describing the NHS and social provision is exactly, exactly what one of my patients (and his care home) is currently receiving.

The NHS can coordinate and deliver community care well. Sometimes we forget that.