Extremes

When articulating a point of view, increasingly I find myself being more extreme. Usually I'm seeking a view somewhere in the middle ground, but to shake the inertia in the system and effect any substantial change that's sufficient, invariably I'm having to shift from this tempered position to one of a more extreme position, to illustrate dramatically a striking comparison or extreme position in order to make a point/have a point understood and appreciated.

When I recently read a quote, it very much resonated with me.

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan, 1953

Within the NHS, which is brilliant at what it does well, management process seems increasingly to benefit from more extreme views that help clarify the need/importance/consequences. Those staying in the middle of the road are steam rollered over. Sadly, more balanced and moderate views simply seem to be lost in the drone of organisational noise and chaos and process.

Ho hum.

Medicine

We go in to a vocational career, such as medicine, for many reasons.

Here are 10 reasons why we fair well in a job.

Sometimes I read articles that are unwelcome, I sigh, but I let it go and move on. This pernicious utterance is one such lamentable article. Would you give medication to/stick needles in a woman who's just walked off the street?

She writes that she said, "But this is an emergency." There seems to be little unmet clinical needs that are urgent/immediate that need attention. Oh I'm not unsympathetic, I'm also mindful that health is a state of physical, social and mental wellbeing. Getting to work and crack on with global journalism is important to her. What piques me is her contention that NHS resources should be deployed to assuage her inconvenience, rather than prioritising resources according to clinical need. If both can be done (and often they can) then you can generate a responsive, patient centred service that meets clinical needs well. But to strop 'cause a GP you're not registered with won't instantly attend to non-urgent care aggrieves me, it's perhaps a desired expectation but it simply not reasonable to demand this.

For her to then generalise this and contend in her headline, "The caring professions? They just don't seem to care at all," well that's just provocative and vexatious. She didn't get what she wanted and is having a strop, unwelcome though this is I shan't lose sleep over this since medical care wasn't poor, it simply was her organisation was and her expectations were unreasonable.

Professor Sir Bruce Keogh, on the other hand, has worried me more. I've been in a couple of conferences with him and each time he's spoken of innovation and quality and laudable evolution of NHS services, but the medical role in this has been scant. By scant, I mean absent. As the Medical Director for the NHS, this dismays me.

The GMC revalidation plans will have massive impact on medical workforce. CQUINS, QUIPP, CRES, SHA Clinical Pathways and Foundation Trusts all impact on us a lot already, the amount of data collection and form filling is vast. I was incredulous to find the computer entry on seeing a patient is now 3 hours in our Trust, it takes one hour to see a patient. We spend three times as long doing form filling as clinical care. That's all patient contact stuff, that's excluding meetings and policy generation and supporting activities. The NHS informatics systems are not supporting clinical care, they're dominating. Did nurses become nurses to spend an hour seeing a patient then a whole afternoon tippity tapping away at a computer? And they say it's my patients who are mad . . .

Then we've NICE guidance, DOH guidance, Royal College guidance, Trust strategies and policies and protocols and standard operating procedures, Monitor, CQC standards, NHS LA standards and we've to evidence we're compliant with such.

Now our local commissioning consortia wants data on what we do (not activity data, which we already give the PCT each month, but new data on what outcomes we achieve, too). The APC and Medicines Management Committee want data on pharmacological interventions, in great detail. Who gets the drugs, who doesn't, how are patients assessed, how is consent considered, what reviews are in place, how is local Shared Care used, can we demonstrate adherence to care pathways.

So many sources add so much administrative procedural activity to our day. For really rather dubious benefit, much of the time. It's planned that the GMC revalidation will need doctors to evidence their outcomes, mapped on to the 12 Good Medical Practice domains. Their outcomes. Not the team's, or Trust's or GP Surgery's performance/outcomes, but the individual doctor's practice. Needless to say, we don't currently collect data on an individual doctor's performance and outcomes in all 12 domains. We do it, but we look at teams and systems.

The NHS managment costs have escalated stratospherically from about 5% to about 25% with more managers generating more management activity which necessitates more infrastructure and support, so it's a self perpetuating beast that grows and grows. A bit like a neoplasm.

What I'd hoped for from our NHS Medical Director was a bit of sanity, common sense, perspective. A bit of hope that some of the 10 helpful factors I linked to previously of Little hassles, Perception of fair pay, Achievement, Feedback, Complexity and variety, Control, Organisational support, Work-home overflow, Honeymoons and hangovers and being Easily pleased could have been touched on.

More, when talking of quality and innovation and modernisation and change, I wanted to hear that we'd be liberated with greater freedom and less constraint, we'd not be on our knees with yet more process.

Ho hum.

Patient Safety

We have been told (by the General Medical Council) how doctors' revalidation will improve patient safety, back in October 2010.

The sagely Jobbing Doctor muses over whether nurses' revalidation/governance will tighten up, querying what the fallout will be, here.

It truly isn't a cynical comment, it's simply an observation, that I really can't see how revalidation will make any difference to patient safety. Post-Shipman we've had rigorous annual appraisals, taking literally days to do each time. And Consultant peers looking at our cases for Case Based Discussions. And Peer Groups (which should have happened anyway) actually happening, looking at our learning objectives and what we're doing/what we've done. I really can't say patient safety's any different.

Realistically, how would you spot someone like Shipman? We frequently have very different outcomes with different clinicians. A real example from my training : one surgeon wants low mortality rates and only operates on those who will have good outcomes, leaving most to no active treatment/palliative care, so those with moderately advanced cancer are denied surgery and go on to die. But those he operates on do very well and his perioperative death rate was incredibly low, since he only operated on those with early cancers and decent health. Another surgeon would try his hand at even the most desparate cases, figuring that death was inevitable and pretty immediate if he didn't. Many (indeed most) of his patients did very well, but some of course died soon after surgery. His perisurgical death rate was stratospherically higher. But understandaly so. He was still the better surgeon (and arguably the better clinician). Mortality rates alone are just numbers, we need context and understanding of the patient population, the interventions, others involved in care, comparative data with others, understanding of norms and bell curves and variability, it's not simple to speak with a doctor and dichotomously allocate them in to a "safe" box or "murdering" box.

What it boils down to is, usually, over a coffee, hoping to trip up the bad apples through slipping in a question such as, "Well Bob that about covers things. Oh, by the way, d'you have any urges or are you planning on murdering large cohorts of your patient population, within the next year?"

It's as good as governance systems would seem to be . . .

NHS Review

I was reading the weekend papers with Mrs Shrink. Whilst she was musing over a lass who's gone all gaga, I was taken by the front page news, "NHS review chief: health reforms are unworkable."

Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.

The final report's due out at the end of the month.

The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .

. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.

Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.

Hurrah!

Leave

I'm back after a bit of a holiday. Lots of people have enjoyed a break through the glorious sunshine we've been enjoying. I'm mindful when emails bounced back with "Out of office" messages, or when trying to sort out meetings, just how many people are away at the moment.

With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.

At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.

What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.

What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.

I wonder how many people noticed . . .

Care Pathways

I've been throwing in my 2p worth to discussions 'bout how care pathways could be constructed. I was invited on whim. Folk thought I may know what was happening, what best practice guidance is and what could work. All that is true. They also thought that the discussions could then generate a care pathway so patients could receive services according to their oft repeated mantra of, "the right care, in the right place, at the right time, by the right person."

Mmmm.

One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.

Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.

The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.

Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.

Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.

Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.

Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.

The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.

Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .

Crisis Team

I've had to work with a Crisis Team nurse, who was not Charlie Fairhead.

She was, in point of fact, a singularly unhelpful soul who would neither see a patient, nor give them advice, nor arrange any support what so ever.

Time for me to take deep breaths. Count to 10. Self medicate with alcohol, stat.

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 . . .

Advice

One of my patients with dementia has a son in a low secure forensic unit. I met the son to share news on how his mother's faring, wanting to maintain the family involvement in mum's care now she's becoming increasingly confused. The son's Consultant Psychiatrist felt I should share the news episodically (rather than other family members talking with him) so it could be done sensitively without de-stabilising the son's mental wellbeing.

I've mixed views on that.

Okay, I'm used to breaking bad news. Telling someone they have dementia, and what that will do to them, is hardly a cheery act. I share news and discussion and seek input into formulation and decision making from patients and families every day. Speaking with a son about his monther's deterioration, about current options, about future considerations, without causing excessive upset, that I'm happy to do.

But don't his brothers and sister know him far better, aren't they just as capable/more capable to talk with him about their mother and from the options currently considered to then collectively form a coherent family concensus on suggestions of how care could be?

Anyway, I talk with the family and all's affably agreed, on this occasion, with fairly clear views of what's the best way medication options and residence and care package for their mother.

Whilst talking this through with the son, we discussed antipsychotic medication and how this had been tried but was unhelpful in his mother's care, so had been withdrawn. The side effects were significant, the benefit slight, so the decision was simple enough. The son, though, was ineterested. He was on similar medication, being given antipsychotic medication daily, which he felt was causing adverse side effects.

He wanted to discuss his medication, his experiences of how it felt, his side effects, his options for other drugs. I'm not his psychiatrist, I really can't do that. But I can't just ignore him. I ended up sharing my views on what some people find the benefits to be, what side effects could be related to medication, but ultimately it's between him and his own psychiatrist to make sense of how medication supports his care. I wrote to his Consultant Psychiatrist about what we'd discussed (both of his family and incidentally the concerns he'd disclosed on his medication) so hopefully everyone's informed on all issues.

Although there to support his mother's care, it seems fair for a Consultant Psychiatrist not to direct care/give an opinion but to proffer a little information, when asked to do so. Odd that boundaries of care are so explicit that it feels a little racy to do so!

Liaison Work

Acute hospital wards often stuggle with psychiatric problems. Medical and surgical colleagues frequently refer patients with depression who are miserable but not clincially depressed and are not ill. I used to think it odd, doctors (who all trained in some psychiatry as undergraduates) can't usually suss out if someone's ill or not.

I used to think that colleagues should be able to undertake a decent history, examination, ask about informant/contextual history and put together some sort of formulation. Partly through training, partly through prejudice, partly through not being their core business/not routine, and mostly because working on acute wards is now described as beyond grim, even competent colleagues with a will to do so struggle to make sense of psychiatric dimensions to their medical/surgical patients.

If history, assessment and formulation aren't undertaken in a systematic, thoughtful, involved manner then how can care planning be person centred and be effective? Largely it can't.

This generates more difficulties because the culture forced on clinicians through current pressures precludes better ways of working. Nurses know that is someone is wandering around or shouting or pulling drips out or pushing buttons on other patients' syringe drivers that usually drugs makes it worse.

Of course they do. We have no "anti wandering" or "anti shouting" or "anti fiddling" drugs, those are behaviours they're not illnesses. What's sought is abolishing symptoms, without attending to the primary cause of these presentations.

It's ingrained, though, so nursing staff are disempowered/under resourced in managing one to one patient care, call medical staff since it's unsafe and problematic, medics feel they can't do anything but prescribe. What do they prescribe? Usually they prescribe the drugs that don't work/make it worse. If used correctly, as well as usually doing little beneficial and lots that's harmful, the appropriate use of the drug also needs extensive ECG and blood monitoring that ties up even more nursing time, which could otherwise have been used in direct patient care to manage the behavioural disturbance.

There's a bit of an inconsistency, though. On the one hand the acute hospitals generally want a chemical solution, and nothing else, to manage behavioural disturbance. On the other hand, their care pathways for this are very different from most any other care pathway they'd generate.

The Dobbing Doctor explained his hospital has a "Rapid Tranquillisation Protocol" and asked what drug would be better.

A protocol on the administration of a drug to treat a behaviour. Is there an "Inhaled Breathing Protocol" giving the procedure for nebulised n-saline in obstructive airways disease or RSV/croup and the like? Is there a "Bolus Steroid Protocol" for injection of steroids in COPD? No, there's no "Bolus Steroid" protocol but there is a "Rapid Tranquillisation" protocol. Why? Why have a protocol for one class of drugs, major tranquillisers, but for most every other protocol it's about the disease state/care pathway? They have Stroke Pathways, COPD pathways, MI pathways but no delirium/acute confusional state pathway. Instead there's a drug protocol for "rapid tranquillisation."

This is less than ideal since we know medication has a tiny role to play, so if it's the only role your hospital offers in such patients' care then, frankly, patients aren't going to get the right care. Last September's update on National Dementia Strategy outcomes and Banerjee's Time for Action report reiterate the best practice guidance that non-pharmacological approaches must be tried first.

The reality is, they work.

I work with older adults. All my in-patients are ill, with major mental health problems. Almost all of them have physical comorbidity too, such as infections, contributing to their acute deterioration necessitating hospital in-patient care. Most are pretty elderly and pretty frail. Despite being confused, ill, unsettled and presenting with challenging behaviour, use of medication is modest. My last patient with hypomanic features arising through stroke damage was managed and discharged on no psychiatric medication. I've never used our equivallent of the "Rapid Tranquillisation" policy on any of my in-patients patients, ever.

If the frail, elderly, ill, most mentally and behaviourally challening in-patients can be managed with little/no psychiatric medication, it suggests that less mentally ill patients within acute hospitals also should be manegeable without drugs. Which is what best practice guidance, Royal Colleges, patient advocate groups and DoH reports say.

The crunch, of course, is that the environment and nursing ratios need to be fit for purpose. Nurse Anne reckons, ". . . that years of intense research have shown that the maximum number even the best nurse can take and not make mistakes is 4-6 on a general floor." She described how when things went well, "I worked a late shift on a 25 bed ward and there was 4 of us staff nurses and 2 care assistants for the ward." Our wards do have such staffing levels, with one qualified nurse per 4 to 6 patients, plus support workers, plus ward physio time and OT time and ward social worker time.

Rationally, if they're not psychotic, or having abnormal dopamine excess needing pharmacological treatment, why is an antipsychotic indicated?

The right environment and the right staffing obviates the need for antipsychotic medication, most of the time. I reckon that's one for the Ghost of Christmas Future to sort out . . .

Decision making

Towards the end of last year I generated a number of letters purely explaining decision making.

One was to a patient's wife, one to a GP and one to a clinical team on a general hospital's orthopaedic ward.

In all 3 cases the patient had been jointly seen by a CPN and me, investigations done, a diagnosis made, explanations given and appropriate management put in to place. But in all 3 cases there was a desire by another party, not the patient, to have more information. The theme was "why" with a desire to know why management was suggested as it was.

Now in all 3 cases the request for more information was polite and inquistive, rather than a forthright demand for explanations, so I'm more than happy to oblige. Sharing reasoning can only be a good thing. The original assessments and letters were extensive; typed up they were a minimum of 5 pages each. The management plans at the end were explicit and numbered, with from 7 to 11 action points in each case. With so much information, it's no surprise that folk want to know a little more about details of specific bits of this.

The wife sought to know why her husband's dementia medication was being withdrawn. The severity of his dementia, the side effects he was experiencing, the risks he'd shown (with ECG changes and collapses), the changes over time on the medication with no benefit seen by us or his wife, the diagnosis (he came to me on medication for Alzheimer's dementia but clearly has vascular dementia, which kind of accounts for why the drugs haven't worked) made decisions on the use of the medication pretty clear cut. Since he's off it he's fantastically better, his mood's settled/undistraught, his thinking's better with less preoccupation and his presentation's better with more successful acceptance of interventions, support and reassurance from his wife. But on stopping his medication his wife, not unreasonably, worried about this and sought more information. She explained how I'd spent an hour reviewing her husband with her, but only 10 minutes talking about medication. She's right, that's pretty much how time was spent. "Only" 10 minutes on why medication's not helpful is to my mind a reasonable amount of time to spend on sharing reasons and understanding, but a carer's mind is a whirl when a Consultant's questioning and investigating and formulating and changing stuff, so it's no surprise she mulled it over then wanted more information. It was no trouble to write to her, my secretary copying and pasting from the GP letter on file, detailing the 11 factors we'd considered that concluded in withdrawl of medication being appropriate. On subsequent review she's been very happy with it all.

The GP and surgical team both sought to know why his patient wasn't getting antidementia medication. It's a GP I know well and with her patient this had been explained but the patient's husband had turned up to the GP with lots of stuff clipped from papers and printed from the internet. The GP wasn't clear on how it all fitted with the current best practice and whether we'd considered relevant factors. On going through the notes it was clear we had, with over half a dozen specific statements about prescribing decisions in one letter alone and almost a dozen factors specified that influenced decisions on the patient's needs and consequent care planning. I liked this one, it was a chance to share with a colleague the reasoning behind prescribing decisions, the evidence base supporting this and the patient factors that impacted upon this. The GP gained understanding around how developing abnormal heart rhythm impacts on risk of medication causing serious harm. Similarly with the ward team.

I guess that like most clinicians, I favour spending most of my time speaking with patients and improving things with them. But sometimes it's also satisfying to have gentle challenge, stirring thoughts on decision making, to organise a response that articulates the contexts and evidence and findings and formulations and risks and degree of benefits and consequences, then share how these have been weighed up and how conclusions have been made.

All 3 times it was joint work with a CPN and others so the responses had effectively a case conference before responses were generated and this open discussion of how we worked and what we did is healthy for our team, reflecting on how we've worked.

So although I favour clinican contact and wouldn't want to navel gaze all the time, having gentle challenge/inquisitiveness to stir reflection of decision making is welcome and, to my mind, keeps us sharp in looking at how we work.

Complaints

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?

Occupational wellbeing

Work can be emotionally damaging. This doesn't look good . . .

Consultant Time

A couple days a week I start at 8.30am which I still reckon's an ungodly hour. Although I'm often in at this time, on just 2 days do I start work at 8.30am, on all other days clinical activity (like an out-patient clinic) starts at 9.30am. A much more civilised hour.

Why the early starts, why just some days?

It suits the nurses. It makes no odds to me really when I start, I can organise time as I wish. Home visits, MDT meetings, writing reports, care home reviews and such can all be juggled around and don't have to be at a specific hour.

Nurses though have a lot to do. Too much. They've so much clinical activity to do, now, more than 5 years ago. It's good and interesting and they're very good at it, but it means they're genuinely busier. Audit evidences this increase in direct patient care and increase in complexity of work. It's been formally looked at since it's resulted in job matching and regrading under A4C through nurses' roles shifting. As well as being more involved with more patients doing more work more of the time, they've also got to do more nonsense. Falls and nutritional and other risk assessments. A form for every patient on risks to children/childrens' needs. Screening tools. Repeats of carer assessments. Suicide assessment tools that don't apply to older adults but still must be done. They have to collect lots of demographic data that already exists (ethnicity, marital status, occupation/retired, where they live etc) and enter it into the computer system. They have stupid, stupid amounts of paperwork. The paperwork is only the start, since as well as ward/community paper notes, psychiatric medical notes, letters to GPs/referrers, social work/other referrals, there's also electronic stuff. Our "paperless" notes on the computer with squillions of fields to fill in. Some are always left empty and months later nurses are bullied/harrassed to complete the data set. Assessment forms. Diagnostic/clustering tools. CPA fields. Care plans (plural, since every intervention has to be entered as a separate care plan, with lots of fields on each one). Safeguarding referrals and meetings. Mental Capacity Act assessments, best interest meetings. Doing what only an RMN can do (such as administering oily depot medication). Generating statistics, results, activity levels, outcomes or other information that managers, commissioners, service leads or other parties want (usually straight away). Attending more management meetings than I care to count as more and more is added in without anything being reviewed and stopped. Attending mandatory training, often in things of dubiuous relevance. Carer support (a quarter of their clinical time is spent with carers, not patients). Coordinating multiagency working so patient care actually happens, and happens right. De-escalating challenging behaviour (such as stopping them battering folk). Feeding them. And then there's the direct therapeutic work undertaken with patients, effecting change.

Sometimes, just sometimes, they also need to work with doctors.

It's for this reason that I work when I work. My ward round is on a day and time when no other Consultant is on the ward, my team meetings start at 8.30am since it suits the nurses to do it then, so they can crack on and do everything else from 9.30am onwards when everything kicks off.

I've huge sympathy for poor Militant Medical Nurse who seems to work with medical colleagues who instead of adding helpfully to their process are seen to be unhelpful. I appreciate that in psychiatry Consultants can have much more latitude to shift clinical activity around and generate flexibility, whilst a surgeon has to operate when they've theatre time and that's that, so it's not possible to be as flexible in other disciplines. Yet somehow Militant Medical Nurse's account leaves me frowning and feeling a little ashamed at how my medical colleagues are felt to be adding to, rather than helping with, the stresses that nursing colleagues are grappling with.

Mental health work

The Girl asked two questions here, sensibly querying the stigma against psychiatry and how to manage without burnout.

General Practice is different from specialist care because it's harder. It's a specialist area in it's own right, but is mostly unidisciplincary in approach (you see a doctor, or a practice nurse, or a midwife, but you don't usually see several clinicians who've all discussed your care as a team) making it a harder area as a clinician (to my mind). And you never get to discharge anyone. And you get all problems/symptoms and have to divine what's of medical significance and what isn't. Which is often difficult, because if the patient has a symptom (e.g. of being knackered all the time) but it's investigated and not caused by any clinically significant illness or process, so medicine has little to offer, the patient's still usually keen for resolution of their target symptom. An explanation that it's not serious, not due to major disease or anything significant, placates so far but doesn't solve the patient's symptom burden. Before even managing patient agenda, governance frameworks, central DoH/NICE mandates, local PCT/APC/LMC direction, just thriving in a world of clinical uncertainty is trouble enough. Especially when you just have 10 minutes or so with each patient. Having trained and worked in Primary Care I know it's a challenging speciality and not one I've the stamina for.

With that caveat aside, that Primary Care is a separate complex speciality, what are my thoughts on Secondary Care specialities and mental health in particular?

Clinical practice within psychiatry is a very mixed field indeed. Most areas of Secondary Care medicine have diversity in approach but, by and large, the majority of doctors have similar approaches to care. Management of MI, childhood atopy, pre-eclampsia, lateral epicondylitis, angina, COPD or whatever is variable. But not that variable. Maybe one clinician would favour a NSAID over a moderate opiate, but by and large the care pathway is similar. Maybe one medic would do X first then Y, another would do Y then X, but over time most of their patients end up with mostly the same treatment.

Not so in psychiatry.

You may have a very biomedical psychiatrist who's interested in genes and biology and neurochemistry. Process is very medical, with complex imaging and serum rhubarb tests. Management is very pharmacological, or neurological (magnetic stimulation, ECT, whatever) to effect chemical change within what's seen to be a chemically imbalanced brain. When things don't work, you need more drugs. Or heroic doses. Or complicated drug augmentation strategies. Or specialist referral to centres who do psychosurgery or treatment with rare drugs. Got to fix the chemistry.

You may have a very psychosocial psychiatrist who's interested in a patient's current experience and life events and past experiential learning and ongoing maintaining factors. Process is very psychological, or practical (such as diary keeping) to gain understanding of why things are as they are. Management is very pragmatic or behavioural. Psychological therapy to aid acceptance. Behavioural therapy to effect meaningful change in the here and now. Got to either accept how things are, or make changes.

You may have a very community oriented psychiatrist. Problems arise in the patient's real world. The patient's going to return and live and thrive there. Why bring them in to what's been shown to be a "toxic environment" of a ward, where activities have little that's real for the patient's world, the situation's dislocating the patient from their problems and, when it comes down to their clinical needs, what can happen in a psychiatric hospital that can't happen in the community? Okay, often ECT is started/done in hospital (but even this can be done in the community), psychosurgery is certainly an in-patient procedure. But what else? Really, why have lots of hospital beds at all? Nobody gets admitted.

You may have a very hospital oriented psychiatrist. Problems arise in the community, if the patient could fix them they would have. Who'd choose to be miserable and not coping? They need time out, some solace and sanctuary and space to reflect or make sense of things. Or somewhere for rich assessment and investigation and and fiddling with drugs day to day. Really, if they've become unwell in the community and can't cope, how can they realistically be expected to recover and be cured there, in a timely manner? Everybody gets admitted.

You may have a liberal psychiatrist who accepts and supports everything. You may not. Someone with schizophrenia assaults a member of the public in a supermarket. One psychiatrist says they were hearing voices but just as if they heard you say to punch someone they could say no, they had control and chose not to exercise it, they made an elective choice to punch the victim. Charge them and go down the criminal justice system route. Another psychiatrist says they were hearing voices so not in control of their actions, there's no criminal intent and the person's unwell, needing disposal through health with hospital admission and in-patient care. Same patient, same action, sometimes it goes to police, sometimes it goes to health services.

Other disciplines look at psychiatry and shake their heads. It's all a bit of a mess, isn't it? It's not sensible. It's not seen to be about patients or clinical needs. It looks random and chaotic. It can be seen to be ineffective. Why would any doctor want to work in that world, as a career, when other options of proper medicine exist?

Worse, a lot of mental health services are poor. In particular, working age adults can get pretty shoddy care. Services often are under valued, under commissioned, under resourced and not fit for purpose. So sometimes there's bad care. So sometimes medical colleagues look at psychiatry and think, it's all a bit rubbish, really, isn't it.

But when it's done well, it's just brilliant. Everything works. It's fantastic for patients, getting help and improvement and appropriate care and feeling better for our input. It's fantastic for staff, feeling they're part of an effective, ace service. It's fantastic for families and carers, getting support and help and time to assist in how they can cope. It's fantastic for colleagues, GPs in particular, who know everyone is seen promptly (within days if routine, hours if urgent), everyone has nurses and social workers and pharmacist and psychiatrist inputting into every single patient (true multidisciplinary care) with all medication clearly sorted out, all care clearly documented and typed/faxed/posted to the GP/referrer, with patient/carer feedback and service evaluation and audit and monthly PCT reporting evidencing outcomes and quality of care, continuously.

When it's done well, nobody else knows. The patient and family are happy, they don't go back to their GP or other Consultant and wax lyrical about psychiatry because, appropriately, subsequent clinical contacts focus on their clincal needs. The system works, GPs get a 3 to 4 page letter when the patient's discharged but won't read all that; the detail isn't needed most of the time by most GPs.

The variability in practice often evens out, particularly if there's clinical supervision. There're plenty of ways to skin a cat. It'd be grim if we got to a day when every patient got the same treatment, in the same place, for the same duration, in the same way, with no personal care, no consideration of variables, no choice. That psychiatry still has latitude to be flexible in models of care is, to my mind, a great strength. Sure, we need to evidence it's effective and not just careless/maveric care, so I'm more than willing to evidence process and outcomes. Helps us improve the services too.

How to reduce emotional burnout is simple. Work in a way that's not stressful. To me, that means a range of things need to be in place.
1) I need to have clinical freedom, so can do what I feel is right for my patients. This is something we still enjoy in psychiatry, with no care pathways or algorithms or edicts directing what we must do. Our Trust has no hospital formulary, I can prescribe what so ever I wish.
2) I need to have colleagues I trust and can work with and share care with. I do. I'm blessed with brilliant teams. It can be hard (had several internal and external applicants for a post and couldn't appoint and none met the standard for the team), so 5 internal candidates were disappointed and we had a team with a vacant post. But it matters too much to me, we need the right people in the team and patients deserve the right people.
3) I need to have a good working relationship with managers. I meet our service manager at least once every fortnight. I meet a member of the Trust Board at least once every couple months. I meet with the Medical Director every month. I meet the Chief Exec too and write on average twice a month. Me talking with managers about how it is, and writing, and emailing, and making time to meet them matters.
4) I need a good relationship with partners. I meet GP colleagues in their surgeries, I meet Consultant colleagues on their ward rounds/meetings/teaching, I meet PCT commissioners every month so can help them with commissioning process/decisions whilst also having confidence in security of core bits of our service. Knowledge and security of the cash flow reduces stress and burnout.
5) I need to be able to blow off. Half the week I'm too busy for a lunch break but usually once a week a colleague and I'll skip off 30/40 minutes for lunch and blow off about what's going well, what's a real bitch, what needs changing, what we just need to grit our teeth over and accept. Being listened to and understood by someone who works in that world whilst you sound off and whitter on and on is awfully cathartic.

Well that's my initial thoughts on reasons for bias 'gainst psychiatry, reasons why that's not always valid, and thoughts on how I manage to remain up beat and optimistic without burnout. But you can always email me if you've specific stuff you want to chew over!

NHS Reform

I have read through the NHS white paper, "Quality and excellence : liberating the NHS" that was published 2 days ago.

It perturbs me.

This is unusual. Usually I can look at things with a "glass half full" kind of take on it, looking for positive opportunity and what it can enable us to do better. Most papers and policies and DoH edicts have not immediately been embraced as wondrously helpful, but on unpicking things I've usually found something that we can use to push commissioning buttons or support change we're making or that strengthens a case to resist dismantling of/meddling in services.

This paper's "vision" is all very positive.

The implementation superficially is neutral but on thinking it through I see it as concerning, with significant opportunity for negative effects. The detail scares me. It's noteworthy that there has been much comment with GPs being less than enthusiastic or critical or pessimistic about the changes to PCTs and commissioning.

What perturbs me is not the ill ease of grappling with uncertainty, which is normal/continuous life in the NHS. Change and uncertainty and wrestling with unknowns is a normal state of affairs. No, what worries me is the implications and explicit intentions of the white paper. I'm worried since it erodes the NHS.

As reported, the intention is for GPs to commission health care. More than an intention, it's forced upon them (since no sane GP would volunteer for this role). It's a poisoned chalice that's offered, and no mistake. GPs are then seen to be responsible for all deficiencies, since they've failed to commission the right services. Rubbish access for paediatric ADHD clinics, no easy access to tattoo removal, no service for aymptomatic varicose vein removal, it's all laid at the GPs door (a door that can't be closed). Rather than government cuts and suboptimal resourcing, it's then poor GP management that results in inadequate healthcare provision. Mmmm.

Worse, how are GPs going to spend the hours and hours necessary to commission care? It takes ages to go through each service. Just to commission older adults' mental health services (with community services, liaison services, early onset dementia care, forensic care, in-patient services, day hospital services, memory clinics, memory therapy day care, Mental Health Act arrangements, psychology services, Cognitive Stimulation Therapy etc) is a lot of detail to think over. Then do it with adults of working age and crisis services. Then with child and adolescent services. Then with forensic services. Then learning difficulty services. Then drug and alcohol services. Then IAPT and community mental health services. The with partners like MIND and Alzheimer's Society and Age Concern and others. Then do that for every other bit of health. There's no way GPs can absorb this activity. Hence the intention that as reported that the money will go, ". . . to private corporations which will buy hospital and community health services on behalf of GPs."

GPs are private businesses already. This paper strengthens and extends this, generating a situation where large companies can pick off small GP practices (then sack the expensive staff, like GPs, and go for First Contact Practitioners) and through block contracts/large consortia can then purchase Secondary Care from hospitals to get what they want. Except what they want, as a business, is a good balance sheet for their share holders.

A company buys/owns/represents all the GPs in my locality. The GPs advise the company on what they want then the company negotiates contracts and commissions services. The private health company, maybe it's BUPA, maybe it's another, then thinks where it wants to spend it's share of the £80 billion pounds. Does it give it to an NHS hospital? Or does it give it to a sister company or to itself, commissioning services from a BUPA hospital?

I'm perturbed since I see this paper as a mechanism for dumbing down healthcare (through eroding quality to save costs), devolving blame (but not power) to GPs and effecting the privatisation of healthcare, to the marked detriment of NHS care.

Much badness.

Booze

Doctors are known to self medicate with alcohol, at least as enthusiastically as the general population. The sterotype is that problematic use of alcohol's an occupational hazard. Personally I drink less than 21 units a week (in fact, it's invariably less than half that).

Although it's not that I partake frequently and regularly, I guess it's fair to say that nursing and medical colleagues can indeed sink a fair bit of drink on nights out. Social workers are a bit more sensible and never seem to drink to excess. Although we're all totally outclassed by secretaries; my they can drink.

After a fraught afternoon yesterday I got home and had a real Withnail moment, "I demand to have some booze!" My wife helpfully obliged. But then, having to read stories and do bathtime and put the kids to bed kind of tempers ones options for sinking into oblivion with drink and rubbish telly. I had to make do with one drink then later crashing out with Ms McCall and her Big Brother.

Gets you thinking.

How do we cope with stress, how do we manage to de-stress? As usual, it wasn't clinical work or patients causing stress, but was management activity (and inactivity) that added woe to my week.

I shall try not to mix my drinks :

Policies

I do not like them in a box.
I do not like them with a fox.
I do not like them in a house.
I do mot like them with a mouse.
I do not like them here or there.
I do not like them anywhere.
- Dr Seuss

It's always good to get a second opinion on contentious and contested issues. As well as frequent consults with Dr Google, it's sometimes good to reflect 'pon the wise counsel of Dr Seuss, too.

My current raison d'etre seems to be to manage policy. It's impossible for front line clinicians to manage policy day to day, so we have team meetings where we agree what policies we're not able to do, reason why we can't, which I then minute and send to managers. Maybe we'll be the next Mid Staffs with managers being informed by clinicians and Consultants what the problems are, but doing modest amounts to effect change. Who knows. We shall see. The important bit of it is that clinical teams are 'fessing up to what we can and can't deliver on, documenting that our practice is at variance with Trust guidance, reasoning why we're not doing it and informing the managament structure of this different clinical care.

It's not ideal, to meet up once a month to have to reflect on how we work, especially since 2 hours is a fair bit of time for a whole team to take out, but it's saved us a lot of time, in the long run. Not doing form filling, when the information's already captured and documented in 3 places already, has saved masses of time. And moved to a more paperless practice. And made everything more legible. And made it easier to print/email information. Clinical and secretarial staff have a lot of clever ways of working smartly.

But the main reason for this is the massive industry of policy generation that's become unhelpful. Excluding corporate/finance policies, our Trust has over 200 policies that apply to clinical staff, seeing patients. In a moment of ennui, I popped onto the web site and looked.

My oh my.

How can that work? A new junior doc or seconded nurse or bank nurse or trainee AMHP social worker or psychologist is in our service. They go to a clinic or DV or ward to see a patient. They have all their clinical process and knowledge and skills in their heads, structuring what they do and how they do it. They have the GMC/NMC/regulatory body directives in their heads, structuring what they do and how they do it. They have national guidance influencing their thinking. Maybe. They have legislative direction (particularly that MCA 2005 and MHA 1983) structuring how they work. There's usually us Consultants with our foibles, meaning certain types of assessment or interventions are "how we like things to be" which influences clinical care. On top of all this professional material, can anyone credibly believe these staff will also read, understand, implement and use over 200 policies in their practice, as well?

My angst is that oft times too much policy is generated by folk who aren't clinicians. Worse, it's done without any consultation with practising coal face clinicians. Even worse, the decision to make something happen is usually to make a policy, then consult on the policy. It's as if any alternative to a policy is never ever even entertained as a possibility. Yet how many clinical teams working in creative, iterative models of care, have working their practice defined clearly within a policy? Even the operational policies of the teams seem to be works of fiction that bear little resemblance to the function and activities of the teams.

How many times has a clinical team said, "Oooh yes, our clinical care in this area is so much better than it was last year, because we've embedded this Trust policy into our working practice and now everything's brilliant!"
Never happened, in my corner. Curious, then, that policy documentation is generated at such a staggering rate when the outcome/utility from it is evidenced as so poor. Hmmm.

People working far away from a specific clinical team will generate a policy that applies to that clinical team. They're working in the dark and generate material that's usually pretty sensible on reading through it, but is oft times unnecessary, overly tortuous and very very rarely impacts on direct clinical care.

I'll leave the final words, once again, to my colleague Dr Seuss :

Say! In the dark?
Here in the dark!
Would you, could you, in the dark?
I would not, could not, in the dark.

Passion

I was told by a couple of different managers last week that I was obviously "passionate" about my work.

It's a word I struggle with. You can be passionate about a woman. Catholic friends have talked long into the night, over far too much drink, about, "the passion of Christ." It's a word that is often over used.

Some words that had a strong meaning are hijacked and over used, to somehow increase the weak meaning of a point. Politicians, they're often doing it. Politicians are presented with a statement of how they cocked up. How do they respond?
"Erm, yeah, bit of a mess I made, wasn't it?" Nope, never.
"Hey, it wasn't my fault!" Sometimes, but then politicians in power have responsibility so it's their fault or their bosses, so it's not a response we see so often now.
"I deny that!" This used to be a common response. Whatever some half arsed journo dreamt up as a claim, it's just dismissed and brushed aside. Doesn't sound convincing or drawing a line under it, though.
"I refute that!"
My.
It's refuted.
A refutation, what is that? It's much stronger than a denial. It sounds clever and impressive and definitive, how can the conversation possibly continue once the debater has refuted the argument you've contended? Your argument, by definition, has been proven false.

Of course, they say they refute the charge, but they don't offer the evidence that then goes beyond explaining and suggesting and incontestably provides the necessary proof that they're right.

But still, politicians continue to say they "refute" a claim instead of saying they "deny" or "don't like" a claim, despite this being more accurate. Refute is carelessly used by politicians and is becoming a weaker word through such use, soon to lose it's definitive meaning of proof and simply be a posh way of saying deny.

I like a range of words, with subtly different meanings.

So is it right to claim to be passionate about work? I love David Mitchell's rant about passion because it's exactly how I think. Passion is a word that's vastly over used.

But then I saw a video about an astrophyscist who's the Director of the Hayden Planetarium in New York. The clip is here, the site is here, click When I Look Up. Okay, maybe some people are passionate about their job, their speciality, their field, their work . . .

NHS Costs

There's been much discussion on the blue/gold government's health policies. Rightly so. It's serious, it really really matters and it's possible to cock it up, spectacularly, if they get it wrong.

Some areas, such as qualified nursing staffing levels, have been poorly resourced in most in-patient and many community teams, for years. What will the new "austerity measures" mean? For our Trust we're already uneasy, with no uplift from any of our PCT commissioners this year, so we're having to do more with the same amount of cash (but inflation means we of course have less). And, of course, we're still obliged to make cost reduction efficiency savings each and every year, trimming off literally millions from what invariably are our staff costs.

Local and regional "stretch targets" mean we lose millions if we don't meet the quality targets (and evidence that we meet them). We won't. We can't meet some of them. Others, if we did meet them, it'd cost more to do that than we'd get paid. So we're destined to lose cash that historically has been part of our base income. Even less cash to pay our staff with. Not good.

Although it looks ugly in Secondary Care, in fairness it looks uglier elsewhere. My poor colleagues in Primary Care are being pushed into a corner. Instead of seeing patients and providing clinical care, they're going to be expected to commission services from providers. With the best will in the world, how could 30 consortia get different services from our Trust? Would providers tender for activity from a single practice if that GP practice wanted services that couldn't be easily provided? Will a Trust provide "loss leading" services? Our Trust has declined work from a PCT that's invited us to undertake activity, but won't pay us enough to consistently break even, so even with large amounts of cash from a PCT we're saying no; what influence will a group practice have? I do not know. But the GPs I know are not enthusiastic about having to sort out all this commissioning nonsense for all their patients for all clinical community and hospital and acute and mental health activities. At the moment, GPs are independent. Unlike a PCT, or SHA, they're not directly accountable to the Department of Health. If they commission quirky services, is there any accountablity? Not at the moment. Will GPs be brought into an accountability framework?

It doesn't look fun to be be sitting in GP land, right now.

The government quite rightly is looking at management costs within the NHS and thinks too much cash is spent on management. They're right. It is.

Slimming down Whitehall to do less and tell us to do less, such as disbanding oodles of targets, has to be a good thing.

Slimming down the regional Strategic Health Authorities (SHAs) seems a fair plan. Less intrusion and more cash saved.

Slimming down (or almost getting rid of) local Primary Care Trusts (PCTs) has left my PCT colleagues in a state of anxiety. Sadly, in all honesty, I'd not miss much of the PCT if they went. I'd miss the PCT pharmacists who are dynamic, sensible, pro-active, helpful and clinically focussed. But much of the managers and their committees and generated paperwork doesn't make quite as much impact on the district's health provision as some might imagine. Certainly the cash thrown at the buildings and staff and operation of the PCT doesn't seem to deliver wondrous value for money. But I concede I don't see all they do.

So the central DoH, the regional SHAs and local PCTs are all in the firing line. None of this seems bad, to me.

GPs are to have more duties, responsibilities (and accountability).
This does concern me, since most GPs I know aren't keen on this and aren't equipped to do this.

Secondary Care providers continue to provide secondary care.
Phew.

Could have been a whole heap worse, dismantling front line services. But to be hitting the tiers of management actually is a positive intervention that can save money, reduce intrusion and improve how GPs and hospitals deliver care.

I remain optimistic.