Services

There's a lot of pressure for mental health Trusts to modernise.

It's understood that there's a lot of activity that isn't seen to be useful. Quite reasonably, it's seen that this needs changing.

Is it helpful to see a practice nurse for blood tests for lithium monitoring every 3 months, in Primary Care. And then see a Consultant Psychiatrist every 3 months in out-patient clinic. And then see a mental health nurse every 3 months in lithium clinic.

Unnecessary clinical contacts are in part historical, from a time when counselling and IAPT and Primary Care's mental health work was thin, so mental health services delivered almost all support, for mental wellbeing. Ongoing support, vists for "tea and cake" were seen as useful, because they were valued.

Now lower level support's delivered (notionally) through Primary Care and specialist mental health services, in this "tiered model" of care, only see the "properly ill patients" with "complex needs."

Except by and large we don't. Mostly we get the same referrals as we did years ago. Changing practice of Consultant Psychiatrists is not a quick or simple task. Having large out-patient clinics one day then saying let's not have large out-patient clinics the next is a tricky proposition to sell, let alone manage. So practice overall has shifted a touch, some clinicians have shifted dramatically, but by and large there's not the "modernisation" that the great and the good wish to see.

The consequence of this is that change is foisted upon us, rather than change being locally and clinically driven.

Managerial change, rather than change from folk on the shop floor seeing what's going on, has the advantage that it happens. It has the potential disadvantage of being divorced from patient need, clinical practice and professional requirements.

I'm uneasy about this.

In my corner we're being left alone. We changed our services and they work pretty well, older adult services nationally aren't targetted for being dismantled at present. It's general adult psychiatry that's being shaken up. Previously a team with a Consultant Psychiatrist was responsible for care of a patient. If additional input was needed, they referred to that source (GP, psychologist, local authority social services, acute Trust's dietician/physio/SALT, neurologist) and that bit of unmet need was met. The team and Consultant Psychiatrist continued delivery of core mental health care. All could work nicely.

Nationally this is changing. In major cities it already has. My colleagues relate how this has resulted from indifferent to horrific service delivery. The change involves a shift from a core team and Consultant Psychiatrist looking after a geographical patch/a number of GPs surgeries (a sector model) to having a number of specialist teams (a functional model).

You're referred by your GP to mental health services. You're seen by Team 1, the gatekeeping and access team. They work out, after one visit, what's wrong with you and what care you'll need. Geeenius. After baring your soul and explaining it all to Team 1, you never see them again (and they never see you again, they never see the consequences of their actions, the clinicians never see anyone recover or improve or get better, ever again). They pass you on to, say, Team 2, the Early Intervention team. They help you for a while but, if you're not cured, they pass you on to Team 3. Team 2 never see you again, either. Having bared your soul and gone over everything, again, to team 2, you now do that with Team 3. Team 3 feel you're making progress but when it gets fraught they think you need more help. They pass you over to Team 4, the home treatment team. They've never seen you before either, so in your acute state of distress you go through it all, again. They try but then reckon you need admission. There's a dedicated in-patient team who only see in-patients now, so you're passed over to Team 5, in-patients. They've never seen you well or in the community but will deliver all your mental health care whlist you're an in-patient, after (of course) you've gone through your tale with yet another team.

Say one team sees your low mood and poor coping as an understandable reaction to social stresses you're having, through relationship problems and money worries and being physically unwell. Say another team sees your low mood and poor coping (with changes in how you're managing relationships and money and stress) as a result of major mood disorder, arising through chemical brain imbalance and psychiatric disorder. One team has a care plan involving support and psychological work. The other team has a care plan involving antidepressant drugs, probably lithium, maybe ECT. Your care changes radically as you pass through from psychosocial to biomedical Consultants.

Not only is there no continuity, but patients at vulnerable times have to develop therapeutic relationships over and over again.

In what way is this better?

Delirium

I was going to muse over the management of acute confusional states (that nowadays seems to be called delirium, again).

There're the causes of it.

There's the assessment of it, through history and examination and investigations.

There're the interventions (both pharmacological and non-pharmacological).

But on balance I truthfully could not put it better, or more succinctly, that Nurse Anne who undeniably has the truth of it, here.

She's absolutely right.

Acute care

Dr Kirsten posed a sensible question, here, asking how could a patient with delirium be managed better.

I'll post on that, later.

It did get me wondering though, why the question wasn't reversed. Why wasn't an old age psychiatrist asking Dr Kirsten for the advice. No, really, think about it. Our psychiatric hospital has less than a dozen patients with dementia on the wards. Our neighbouring acute hospital Trust has, across it's medical and surgical wards, a lot more. Statistically, I'd expect them to have 334 patients who are older adults with dementia in their beds, today.

334.

That's a lot.

That's common place, that's who they have to look after, each and every day, on their wards. We have less than a dozen on ours.

In-patient care of older adults with dementia; who should the experts be?

Ward doctors

Ward nurses are busy. Medical and surgical wards I visit don't have the staff to do the work that's needed. It's manifestly evident to everyone, but since it costs to pay for more nurses, wards are chronically under-resourced. Our mental health wards are not, thankfully, with a 2:1 patient:staff ratio at the moment.

We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.

Our neighbouring acute Trust seems to enjoy collecting data from their medical and surgical directorates. Almost as much as it enjoys documenting events, or non-events. Curiously, it thinks the best people to do this aren't clerical staff or IT staff or medical informatics folk, they reckon it's best to get the nurses to do it. One perk of having nurses on the wards is that they can provide nursing care. On the acute hospital site, I don't see nurses doing a whole heap of nursing now ('cept for the neuro rehab site where they're delightfully anarchic and simply crack on and sort patients, huzzah!) since they're mired in process and paperwork. The Productive Ward has sought to reduce this, but largely hasn't worked on their wards, instead it's generated more process. Ho hum. Maybe it'll get better. They've got less front line nurses and even more Modern Matron managers to sort this out.

Yesterday I saw a lady presenting with confusion, on a medical ward. She had a chest infection, against a background of worsening chronic obstructive pulmonary disease. She had dementia. She had no idea where she was, who was around her, why she was there, how long she'd been there, what was happening, what the different kit around her and the other 3 ladies in her bay was. She had no notion of what day it was, or what time of day.

Ward staff found her difficult to manage, since every 15 to 20 minutes or so she'd anxiously walk to the nursing station, loiter until a nurse passed by, then ask them what she should be doing. It took them time to talk with her. Time they did not have, since their Trust mires them with process that's seemingly more valued than the direct clinical care. They wanted to, but were rushed, they knew they weren't giving her the time she needed and deserved. Much frustration.

But when I saw her, she was settled. She wasn't wandering around the ward, seeking reassaurance any more. She wasn't even sat out in her chair, she was still in her bed. Because the nursing staff had been frazzled, so moaned to the junior doctor. The ward doctor is very young and very inexperienced and has no notion of person centred dementia care. The ward doctor is a doctor and she can prescribe. Haloperidol 10mg had been given, which had flattened her. Spectacularly. Well it would, being about x10 the dose we'd normally give, but ho hum. She was then lying in bed, keeping her nasal cannula on, causing no problems what so ever.

The junior doctor knows no better and can't. She's still too junior.

I get that the junior doctor has to support her nursing colleagues when they're fraught and frazzled. Yet, treating the staff's agenda to the detriment of the patient seems a step too far.

BNF Drugs

I do not have a tablet to stop someone shouting.

t'interweb

Hassle with 'net access means blogging's a touch trickier. At work we've new software that's overly protective and won't allow access to personal pages, like blogs. Grrrr. So having a thought and spending a few minutes offering it up to t'interweb ain't an option any more.

Ho hum.

I shall just have to slope off early and work at home :-)

Big Brother

We had a letter about a patient.

Nothing too unusual about that.

The patient was on a ward, having been there for a goodly length of time, detained under the Mental Health Act 1983 for treatment of delusions and hallucinations and passivity. It was the patient's first psychotic episode, the delusions had been managed in the community with the patient's family providing rich support, but the effects on work and relationships and health and risk to self resulted in police bringing him to hospital for assessment and care.

The patient felt that a secret military experiment with satellites was affecting her. She wrote to civil servants, her Member of Parliament and the Prime Minister. She was convinced that her experiences were through technological processes the military were developing and she wanted the experiment on her to stop.

We had a letter from FTAC.

Have you heard of them? I hadn't. The Fixated Threat Assessment Centre (FTAC) was apparently set up in October 2006, according to The Times, and consists of police and mental health workers who "identify suspects." Our patient came to light from their 2 or 3 letters to politicians.

Did you know police screened mail to "identify suspects" and then direct mental health services to intervene? Parliamentary questions have been posed, apparently Mr McNulty had "security, counter terrorism and police" within his portfolio, yet he was the chap explaining FTAC to parliament.

Hmmm. It seems that Big Brother is indeed watching us. And Big Brother's mate is a mental health worker . . .

Legal matters

No sooner had I posted on laws on Friday, then Dr Grumble posted about legal matters on Saturday. Odd how themes pop up.

It got me thinking.

How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.

The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.

Laws

The political parties have had their get togethers and rattled sabres muchly. They've talked of "vision" and "character" and "challenge" with little detail of content. Except the Conservatives, to their enormous credit, who've shared specific policy details. Having endured Thatcher's Britain I'd never have imagined I'd see anything the Conservatives did as laudable; plus ca change.

I still think that the likes of the UK Libertarian Party have the right notion.

Government govern through making laws. We have lots of laws. About time someone, instead of just generating loads of edicts, starting doing away with 'em and pulling back to what's necessary.

In this notion of laws, and the desire to be explicit about laws (rather than just posture and waffle) and to have the minimum amount of law that's necessary, how does that translate to mental health? Well, I'm glad you asked. In 1978 we gratefully received the work of Shem, The House of God, a book dressed with humour as a vehicle for the grim themes explored, which sadly resonates with an awful lot of truth in it. The tale is of a keen junior doctor, who's first year as a doctor is damaging to both him and his colleagues and his patients. Having finished medical school and entered hospital practice, his up beat mentor schools his to survive in the really real world through breaking rules and instead using his own rules.

The House of God gave us 13 laws.

In his sequel, Shem offers us insight into progress as a trainee in psychiatry. With the book come new laws. The 13 laws of psychiatry in Mount Misery are as follows :
I. There are no laws in psychiatry.
II. Psychiatrists specialise in their own defects.
III. At a psychiatric emergency, the first procedure is to check your own mental status.
IV. The patient is not the only one with the disease, or without it.
V. In psychiatry, first comes treatment, then comes diagnosis.
VI. The worst psychiatrists charge the most, and world experts are the worst.
VII. Medical school is a liability in becoming a psycho therapist.
VIII. Your colleagues will hurt you more than your patients.
IX. You can learn everything about a person by the way he or she plays a sport.
X. Medical patients don't take their medication fifty percent of the time, and psychiatric patients don't take their medication much at all.
XI. Therapy is part of life, and vice versa.
XII. Healing in psychotherapy has nothing to do with psychology; connection, not self, heals.
XIII. The delivery of psychiatric care is to know as little as possible, and to understand as much as possible, about living through sorrows with others.

What do you think of these laws? Better than HMG suggest, worse than the opposition are proposing, relevant to mental health work? Discuss.

Cash

I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.

The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.

The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.

We gave our views to her medical team. She went in to permanent care.

It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.

Her family visit daily and are very happy with things, too.

She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.

A dismal consequence of the MCA 2005, methinks.