Health and Social Care

What is the role of health care? To indulge me in this musing, consider health care in its broadest sense. The World Health Organisation defined health in 1946 and formally adopted it in 1948 within their constitution as, "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."

Their take on mental health remains broad and holistic, specifically stating that mental health is more than the absence of mental disorder.

So let's consider mental health across the health and social care communities, across primary and secondary care, across voluntary and statutory organisations. What should we all be doing to optomise mental wellbeing?

Mental Nurse postulates that care should be given to those being responsible. In comments last week, E mischievously said that payments for sex should be entertained.

Increasingly I find myself generating management plans for community patients that are broad, varied and comprehensive but are less "doctory" and biomedical. But there has to be a limit here. If I've a patient who doesn't thrive at home but would do better living in the Hilton for weeks on end, all expenses paid, this doesn't seem to be the right way to spend tax payers money despite it reducing risk, optomising physical, social and mental wellbeing and consuming very little staff time and cost.

What should be done to effect optimal mental wellbeing whilst operating an equitable and financially viable system?

Maybe it's the small things. As Linus to Charlie Brown, "The way I see it, every baby born should be issued a banjo."

Free Care

The NHS, notionally, is free at the point of contact.

Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.

Excellent.

Health care is delivered without charge.

But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.

If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.

But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.

The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.

Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.

The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?

Illumination

2008 will hopefully be a fine year in the blogsphere.

Although sadly Maple Leaf Medic has stopped blogging, Dr Brown has returned with patient experiences and keen insight in equal measure, Mousethinks waxes lyrical with thought provoking clinical contacts, Cal's accounts remain as stimulating and entertaining as ever, Milk & 2 Sugars is back from her soujourn after exams and thankfully continues to deliver her antipodean perspective and humour as does Polly with The Girl giving more medical student perspectives.

It's a shame that The Psychiatrist Blog remains silent since even those not enthusiastic 'bout it would say it generated stimulating and animated discussion. Shiny Happy Person continues to write 'bout psychiatry far better than I ever could, succinctly conveying what I'd spend pages waffling over, giving a pithy and somehow more real account of both postgraduate medical training and of psychiatric clinical practice that's always engaging to read.

What with retired nurses and the vibrant Mental Nurse site keeping me both pondering and entertained, there's a lot to look forward to reading through 2008.

What I'm really looking forward to is the illuminating discourse from Zarathustra (gah, the link's old, he's not still a student) 'bout the text Al Azif penned by Abdul Alhazred. A true treatise on sanity, hmmm! ;-)

Preparation

Just 365 sleeps to go then we get to do it all again :-)

Antipsychotics

I work with older adults 'cept when I'm on call.

A couple weeks ago, when on call and covering everything, I had to deal with "a problem" that an acute admission ward was having with a chap in his 20's who was psychotic. He'd no past episodes. He was a non-smoker. Deluded, grandiose, assertive, thought disordered and at risk (having driven his van in to a neighbour's house) and drug/alcohol free, the nursing staff were perturbed that he was awake at night, shouting and resisting personal care (like a bath, earler that evening). When one nurse forced him back in to his bedroom, and the bloke swung at the nurse, they called me to review things.

When I saw him he was pretty calm with me over the hour I talked with him, and pretty reasonable and accepting of options explored.

He felt awake, he wasn't sleepy, he never went to be at 11.00pm normally even when well, he didn't want to lie down when he wasn't remotely tired.

The admitting team had him on 20mg olanzapine (the maximum dose), 4mg lorazepam (the maximum dose) and 7.5mg zopiclone (the maximum dose).

Maximum BNF doses make me ponder. Is it that the drugs are the wrong answer? Is it that drugs are the right answer but we've chosen the wrong drugs? Is it that the drugs aren't being given? Is it that the pharmacodynamics require more than one drug to be given? Is it that patient factors (how their body handles medication) means higher doses need to be given? Is it something that patient's doing (e.g. smoking cigarettes affects olanzapine's dose a lot, effectively halving it) that affects the dose?

It struck me that high dose antipsychotics didn't seem justified even though it's what the nursing staff sought. I'm not one to leave nursing staff to get battered, but I really believed that this chap could be managed with skilled nursing care and the medication he was on. We got an extra nurse on to the ward (she wanted the extra shift for cash before Christmas anyway ;-) ) and helped with reality orientation, distraction and de-escalating arousal/distress better than more antipsychotics could. There were no more assaults and no documented episodes of hostility or aggression.

A week later and the team say he's doing well. His sleep pattern is normal. His psychosis is resolving. Thank goodness he's not established on hefty doses of more drugs (since invariably that's then seen as what's cured him, so that's evidence to stay on them all for ages).

Happen it's because I'm an old age psychiatrist (and often am at BNF limits but seldom exceed BNF limits), but ramping up doses of high dose antipsychotics increasingly fills me with ill ease. When discussed at a case conference I was struck that I was in the minority, most colleagues taking a different view. It's a funny old world.

Social Care

It's not often that I recommend that a patient is detained under the Mental Health Act 1983, but this week I had cause to do just that. That makes 3 patients detained this year, not bad for a full time Consultant Psychiatrist and less than my colleagues, but I'm still conscious that it's loss of liberty and choice for 3 people at a distressing time in their lives.

This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.

I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.

I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.

Much badness.

Care

Again I shamelessly take themes that you, gentle readers, generate yourselves rather than having creativity myself. Again I'm caught by Disillusioned's comments about differences in service provision arising within the same Trust.

So I had a rummage around the stats and, what do you know, Disillusioned is right.

Within our Trust the General Adult services are pretty hit and miss. Some folk get a decent service, many don't. I could wax lyrical about why this is, but it'd be futile and consume me with despair which really isn't in the spirit of the Christmas season!

Within my own corner, Older Adults, my sector is seen to be working well. I've had my annual appraisal last week with a Director from another hospital and he reckoned All Was Good. I've presented at conferences how our team works, since it's seen as A Good Thing. Our Trust likes it and has had me doing teaching and roped in to meetings 'bout it all. In truth, it's all about the team (not me) so it's curious that I get to say my spiel when it's the team as a whole doing the work.

But it got me comparing my team with others. And there is indeed a lack of parity. My team has less qualified and less unqualified staff than any other team. It's the smallest. Other teams, that are larger, have broadly the same amount of work to do (referral rates and sector populations being comparable). In all teams no new patient has to wait more than 10 days to be seen, in our team referrals are all usually seen within the week. Access time aside, from referral with memory problems to receiving your first prescription for a cognitive enhancer, my team gives fastest access, a couple teams are similar but somewhat longer, one team has a delay of almost 2 months longer.

Interesting to see that folk in the same patch with more staff and the same amount of work have a less responsive service.

Now how the heck is this tactfully taken forward?

No work

Disillusioned kindly posted comments 'bout Day Hospital but then interestingly mentioned how staff sickness meant that the work didn't get done.

This got me thinking.

If a Consultant Psychiatrist is off sick for a short time (a few day), any routine work isn't done but any urgent work is covered by colleagues, being absorbed in to their working week. If off for any length of time, a locum is brought in to fill the post and do the work. Although I've not had a day off sick this year, nor have others I work with, I think that it's understandable that if I am off sick, 'phoning in that morning to say I'm on my death bed, then the clinic list for that day would have to be cancelled. Given that the work isn't done by anyone else then has to be done when I return to work, on top of everything else, it's usually easier to soldier on and do the work rather than take time out one week then have 2 weeks' work to do the next. But anyway, short term sickness will occasionally occur and will occasionally impact on appointments.

For nursing staff, the story's the same for short term sickness too. If colleagues are off for a short time then urgent stuff is dealt with and some it's understood that appointments for that day may need to be cancelled. Going through all activity since April 2008, we've actually not had to do this terribly often, since either other CPNs* or I have done the visits instead. Thus, we can count on one hand the number of patients who've had cancellations through sickness. We don't like to mess patients around so if we can sort it out we rather would do, then we're up to date and the patient's had the input we'd all felt was needed.

Long term sickness is different, though. I've little sympathy or understanding for why long term sickness should affect patient visits and support at all, since it's long term (so plans can be made to address this).

Disillusioned said that staff off long term do have impact on support. Needs identified and planned for within the Care Programme Approach (CPA) should, obviously, be met. The whole point of it is that you're looking at needs and planning medical, social and nursing care to address these needs.

For a service to have folk, with CPA evidencing the service provision nececssary for their health, to then fail to deliver, seems wholly inexcusable. Okay, if through short term sickness I'd concede as above that the odd visit may not happen, but for people to just do nothing is unbelievable. It's embarrassing.

In what other area could someone be off work, have patients in need of support, and still no support is given and no work gets done?


* Apologies to anyone who's a Integrated Developed Independent Outreach Team (IDIOT) nurse and not a CPN, but I can't get my head around new jargon for new jargon's sake ;-)

Clinical Research

Commonly I'm asked to help manage Behavioural and Psychological Symptoms of Dementia (BPSD).

Usually this involves stopping medication that's making things worse and changing the environment to reduce ambiguity and distress then psychoeducation to guide carers on what to expect, how to de-escalate distress and what interventions can be effective to minimise disturbed behavioural repetoires without compromising personal care.

For example, a wife recently struggled to bath her dementing husband because he assertively resisted each time she tried. Removing unnecessary medication made him much more content more of the time anyway, then guidance with her meant she'd cracked it and was able to use a mix of ongoing reality orientation and reassaurance to bath him without any problems.

Still, for some folk, medication for BPSD is useful. I don't like older antipsychotics, I won't sedate anyone to "make things more manageable" and I'll only use medication as part of the process of care (rather than being seen as the solution itself). At best, medication then is something that helps the patient and carers manage behavioural disturbance better, allowing the patient to engage with the carer in the techniques they can use. Medication, then, is just a tiny part of the solution, helping the carer do the high quality dementia care we teach and advocate.

With that in mind, it's not often I find myself using olanzapine or risperidone in the treatment of BPSD. Just a couple times a year, that I can recall. But there's a snag.

The UK Medicines and Healthcare products Regulatory Agency (MHRA) said that they shouldn't be used.

Letters in the British Medical Journal criticised the authority/strength of direction, saying these drugs shouldn't be used, since they're clinically helpful and risks were low.

A more objective observational study didn't find the level of risk and concern the MHRA described concluding, "Perhaps the best we can say is that on the basis of this good observational study, the risk of increased strokes from atypical antipsychotics in dementia is less than the trials indicate."

The MHRA say that background risk of stroke is about 1% a year in this patient group. Patients on olanzapine or risperidone have an annual risk of about 3%. Many of the strokes are small (and arising in people with a degree of vascular dementia already).

The MHRA conceded that it's not likely to be a problem with these specific drugs, it's just that there's evidence about them. So alternatives aren't known to be any safer.

These patients with dementia and behavioural disturbance often can't and don't have capacity to give valid consent to treatment with a difficult risk/benefit ratio to consider. As the medics in the BMJ wrote, who is advocating that they should get the care they need and deserve?

Studies tell us about general risks and trends and effects. They don't tell us about our specific patient in front of us. Curtailing clinical freedom so the individual's care is overly influenecd by "average" statistical trial outcomes is harmful.

Much badness.

Day Hospital

Should we have one?

The case against is compelling.

Our day hospital has oodles of staff treating very few of my patients. Not much bang for our buck. If the staff were in a Community Mental Health Team they'd be seeing about 4 to 5 times as many folk.

What does a Day Hospital do that a CMHT and social service day centres and EMI nursing homes can't do, if NHS staff visit and work within them?