Work

After I just posted about referrals, the Jobbing Doctor posted about how referrals are then managed by teams, writing about it here.

His account is familiar to me, I've trained in teams that function in this manner. Many of them did. Well, in truth, almost all of them did.

There're comments on the Jobbing Doctor's blog that are critical. This is appropriate, blogs are a place to vent grim experiences of what really happens and tell it like it is. As regular readers will know, although I can moan and whine with the best of 'em, and my working world is immersed in the misery and despair that my patients grapple with, being down and negative about it all isn't my style. If we're not hopeful, if we can't think how we can do it all a little bit better, we've kind of missed the point. Sure, there's lots we can't change. But equally, there's lots we can.

In mental health, it's not like much of health care provision where we need machines that go "bing" or bits of kit with sharp spiky bits or infusion pumps/theatre time/guided ultrasound/spirometry/whatever so if we want to do things differently it's much easier to do so.

We've shifted services a few times over the last few years, which really hasn't been that hard to do. We've an active patient forum who tell us what could be done better. We've two active carer forums who're very active within our Trust, locally and politically. Our staff on the shop floor all know what's going well and what could be improved. So we said what we wanted to change (had to have meetings with GPs and commissioners and our Trust managers which did take some time) but then changed it for the better.

I'm bemused by what people think Consultant Psychiatrists do. I suppose I shouldn't be. Our timetables are varied and often diverse. Working age adult services tend to have psychiatrists with pretty fixed and full timetables (although this can change, if there's a will to do so) but other disciplines already often have changed.

What do Consultant Psychiatrists do? Really! How does a Consultant Psychiatrist fill their working week? The short answer is patient contact and meetings. The longer answer is the detail to this.

Other than ward round and clinics, most Consultants have few fixed clinical sessions. Even a full day of both only eats up 2 days of a week. For most Consultants, they've half the week free to do whatever.

For me, although I've a full sector that's a higher patient population than the Royal College of Psychiatry guidance for one Consultant Psychiatrist, and there's no Staff Grade and no ST4-ST7 specialist registrar or any senior medical support at all, I tend to average one in-patient at any one time so my in-patient work takes literally just about 2 hours a week. My out-patient clinic is one morning for 3 hours, once a week. That's 5 hours a week. What do I do with the rest of my time?

Quite a lot - my formal timetable (my Job Plan) goes on over 6 pages, with no sentences or explanation at all, just lists of what I do and where I do them and how much time it takes on direct clinical care or supporting activities. But with just 5 hours a week of fixed activity, it's easy to do other stuff with flexibility.

So I can meet the team every morning and discuss what work they're going to do, that day, and whether there're any medical dimensions I want them to explore when they see their patients. I've no fixed committments in the afternoons so we meet every afetrnoon too, to discuss every patient seen, with discussion on any medical management in care that we need to progress. With no fixed sessions in the afternoons, most of my afternoons are spent in liaison work, in care homes or on joint visits with CPNs or social workers.

My Job Plan's so long because of other stuff we do. Clinical audit, research, clinical effectiveness. Case Conferences. Supervising junior doctors and filling out assessments for them. Preparing interview questions and model answers. Statements of testamentary capacity. Strategy discussions with police. Meeting GPs. Meeting carers every month. Journal Clubs. Safeguarding meetings. Work with the health promotion and neurologists on district wide vascular dementia pathways. Several hours a month spent in supporting nurses in their training. Teaching ward nurses in the acute Trust. s136 assessments. Generating references. Teaching the Consultant physicians and surgeons in the acute Trust in their formal lunchtime training sessions. Joint work with neurology. Mandatory child safeguarding training. Meeting patient reps every month. Discussing care options with PCT commissioners. Work with staff in the hospice. Monthly Consultant meetings. Supervising nurses in non-medical prescribing. Peer group CPD meetings. Letters to the DVLA. Working with community matrons/district nurses/health visitors. Management nonsense. Input into the local APC meetings. Training Primary Care teams. DOLS meetings. Mandatory CPR training. Interviewing nursing, OT and medical candidates for posts in our teams. Medical student seminars. Court of Protection letters. Helping secretaries, nurses and STR workers get the right A4C band. Adding common sense into governance meetings. There's more, but it starts getting a bit specific. Equally, a lot could be expanded upon (the amount of time I spend reading journals, extracting bits for teaching in different forums or taking to different management meeting, is very significant).

But what I'm seeking to convey is that a Consultant Psychiatrist can have some fixed time seeing patients some mornings, can also spend most afternoons seeing patients, but there's flexibility to support teams so referral pathways and input into clinical care always involves a Consultant Psychiatrist, even if I don't always see the patient.

We've not that much fixed sessional activity. We've no expensive kit or resources that limit how we can work. We invariably know what's going well and what isn't. So I really can't see why we can't change things, for the better.

Referrals

I met with PCT commissioners and we talked through our services' activity levels.

We were congratulated on over performing, with an invitation to bring 2 presentations to next month's meeting to progress bids for additional funding for 2 bits of the service. All is good.

But . . . there were questions raised about the number of referrals to our service of younger adults who're assessed for dementia, but found not to have dementia. It's the majority. I reckon we know of 74% of those with young onset dementia in our district so there aren't loads and loads of folk left to find. Most referrals to this service don't result in a diagnosis of dementia. PCT sensibly asked about our referral process and care pathway and if, instead of more resourcing, we should tighten up on referral details and primary/secondary care work up before referral to specialist tertiary services.

Tricky.

The commissioners don't appreciate just how poorly psychiatry's seen or respected in medicine, thus how motivated (or not) folk are to put effort into psychiatric care.

Let's contrast two common referrals to two Consultants. One referral is to a Consultant Psychiatrist with depression. One is to a Consultant Cardiologist with heart failure.

A letter to the Consultant Cardiologist saying, "Please review this person's physical health" would be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health" is commonplace.

What if the referral is more specific? A letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest" would still be laughed at and binned.
A letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood" is commonplace.

Even more specific. The letter to the Consultant Cardiologist saying, "Please review this person's physical health, I think there's a problem with his chest, I think it's his heart and needs sorting out" is still be laughed at and binned.
The letter to the Consultant Psychiatrist saying, "Please review this person's mental health, I think there's a problem with his mood, which is low and needs sorting out" is commonplace.

The Cardiologist would expect examination (with pulse rate and BP at a minimum), conceding that cyanosis, clubbing, signs of biventricular failure, JVP etc although desirable are unlikely to be detailed.
The Psychiatrist gets no examination. Ever. Although psychiatry is a medical speciality, no medic ever refers with details of appearance, behaviour, speech, mood, thoughts, perceptions, cognition or insight of a mental state examination.

Having had a richer referral history and examination, the Cardiologist also gets a minimum work up of an ECG and sometimes structural imaging, to then progress further appropriate diagnostic investigation.
The Psychiatrist has had a scant and inadequate history with no examination and invariably no use of instruments or investigation.

Energy isn't invested in trying to progress salient history disclosed (symptoms), objective elements of presentation (signs), testing (investigations) and formulation (diagnosis). Yet symptoms, signs, investigation and diagnosis are ubiquitous to other disciplines in medicine.

I can't see how it will change.

I tried to explain to the PCT, who commission services from other medical specialities, that in mental health we just don't get sophisticated assessments in referrals that allow us to filter those with a high index of clinical suspicion for dementia vs those with cognitive deficits arising through mood disorder/neuropsychiatric sequelae of physical comorbidity/medication. We just have to accept all referrals then 'phone the referrer and patient and family and GP to get enough information to progress the right care. The PCT at first just didn't believe me. Then they believed me and thought medical colleagues should be doing great psychiatric referrals and if they can't it's a matter of poor training and poor practice.

Some days I just don't feel understood.

Complaints

Becca asked about how to complain about a poor care home, or effect a change for the better.

A number of possibilities exist.


1) Talk to the Care Home manager

In my corner, it works out at less than 2% of care home managers want to be left alone. I've no authority or statutory powers to enter care homes or direct how things should be in care homes. Even so, all but one care home manager I've worked with has welcomed me in to work with the NHS to improve care. Most reasonable managers will listen to opinions, especially valid opinions of people who've been through their home. They may listen and take your views on board. They may listen politely but ignore everything. But the first port of call should be the manager since they're in a position to improve things markedly and turn a poor care home into a great care home.


2) Talk to Secondary Care

Some hospitals have specialist services that visit care homes. Care Home teams, Outreach Teams, Liaison Teams, names vary. But it's becoming more common for NHS prividers to have a specialist team that visit private and Council care homes to provide support. Our team knows which care homes are great and which are dreadful. We're involved in all the Safeguarding referrals and all investigations, simply because we can contribute information to the processes but equally can contribute solutions in both staff development/training and direct patient care. Care home teams can therefore take on board comments you have. One of our carer forums gave great feedback to us, resulting in us training a large number of care home staff. The carers were pleased since standards have improved. The care homes are pleased since they've had free specialist training (and forged close working relations for ongoing support).


3) Talk to the company

Care Homes mostly are run by massive companies. There's a tension in them. They want to maximise profits. But they also want good publicity and to be seen to have decent standards of care, holding a decent reputation. Care home managers may compromise too much, eroding care (through poor food, poor staffing, poor environment, poor recreational opportunities) to maximise profits and be seen to succeed for the company. The company likes a good balance sheet. But extra profit at the cost of 21 Safeguarding cases and the home closed for investigation is less attractive to them. Which is what heppened in one of my local care homes. The company had no idea it was so bad. It can be very worthwhile telling the parent organisation what you feel, since you sharing your views affects their reputation, which matters to them.


4) Talk to the Council

What if it's not an independent care home? If it's run by the Local Authority, then get on to the Council. Heck, even if it's a private care home, the Council have major influence.

The Council will have a contracts department for care homes. They will have details of what care homes are registered to provide (although this is changing) but critically they details what the Council, through social care funding, will pay care homes. If a care home is embargoed, no Council funding is given. Nobody's funded to go there. Councils therefore have enormous clout. If you've concerns about a care home, you can talk to the Contracts department and share this concern. They'll not be able to act on their own, usually, but it's healthy for them to have an awareness that all's not well in Home Blah since then they're obliged to do some digging.


5) Talk to the PCT

The PCT fund a lot of care home placements now, through Continuing Care funding. This NHS cash going into care homes is managed by the PCT. If a care home's doing a rubbish job, the PCT can intervene through different systems. They can investigate directly themselves, informally or formally. They can use resources (like PCT pharmacists, Community Matrons, Health Visitors) to provide surveillance or support. They can refuse Continuing Care funding and with with the Local Authority to embargo a care home, effectively closing it down until it sorts itself out.


6) Talk to the Care Quality Commission

The Care Quality Commission (CQC) will take your complaint. They've taken over CSCI and now oversee care homes. They helpfully detail what they'll do. They can direct homes to progress certain actions and have teeth, effectively being able to close them down until they pull their socks up to the CQC's satisfaction.

BNF Indications

The British National Formulary (BNF) details the licensed indications for medications I prescribe.

Much of the time I prescribe outwith the licensed indications. Sometimes it's because the drug's not licensed for older adults. Sometimes it's because it's administed in a specific manner (e.g. crushed up). Usually it's because it's outwith licenced indications.

This shouldn't matter.

The marketting authorisation for a drug is there to ensure that the drug's got proven efficacy (i.e. for the named indications put forward by the drug company that the drug works better than placebo, so is an active drug, rather than some spurious snake oil linement whatnots). This then confines the drug company to marketting their product just for that indication. In theory, when drug reps come to talk to clinicians about their drugs they give us a summary of product characteristics and talk just about that.

They didn't they'd come and talk about all sorts of anecdotal nonsense which infuriated me sufficiently to report one to the ABPI and stopped seeing any more of 'em. I don't often have hissy fits but the Big Pharma nonsense pushed me rather too far. Ho hum.

What's peculiar is that the "Indications" for drugs seems to be taken, in some corners, as an irrelevant nonsense and inconvenient, artless work of fiction.

I have a lot of time for proper nurses and spend time each day sorting out liaison work in the acute hospital and RMNs grappling with difficult residents in EMI Nursing homes. When good nurses have tried everything sensible, medication often can have a role to play in assisting the staff deliver appropriate care.

What I find slightly more frustrating is when nursing colleagues from the acute Trust refer a patient to me so I can, "make them stay in bed," or I could, "prescribe something to stop them shouting," or better still, "give them something to stop them swearing."

The BNF does not do medication with indications to treat with a "stay in bed" pill or a "use the quiet voice" pill or indeed a "nice language only" pill.

No matter how hard we look, they don't have a licenced indication for, "Stop Mrs Smith ripping out peoples' venflons, biting and scratching nurses and hurling drip stands around the ward!"

Treating a behavioural problem with a chemical solution isn't ideal, but heck, often it won't even work. Not uncommonly it can make things worse. So why do I have oodles of requests for medication to de-escalate behavioural disturbance? Because ward staff feel they've no other viable choice before them. As my nursing colleagues eloquently assert, if wards are understaffed, then caring nurses can't deliver excellent person centred care.

Coffee

Are any medical students needing to gain experience in siting a central line? I'm having a week where I really feel that having venous access to mainline coffee would be a quicker method of maintaining my habit than necking down endless espressos. Oh those naughty Arabica beans, how they tease me!

Percepts

We see what we expect to see, which is informed by what we want to see. Although you'd think we see what we see, our processing filters out what is likely to be extraneous detail as we walk along the street (oooh, number 32 has new curtains) and focuses on what's relevant (that Ford Escort is going to run over that 4 year old playing football) but there're plenty of examples to read. I like the examples of text that's gobbledegook because letters are mixed up but it's stlll instantly readable. Or those "tests" where you count the number of letter "f" in a sentence and find you miss out half of them. I love that the moon on the horizon of a city looks huge, but then same moon up high in the middle of the sky in a forest looks tiny. Or that my mind tells me that as I get closer to my car it should double in size as I halve the distance to it, but it doesn't - it looks big when I see it in the car park and doesn't get much bigger as I walk to it - because my brain thinks cars are big so makes them seem so. What we see isn't real.

Perceiving involves seeing something but then our brain processing the image, where it gets complicated and changes the objective detail into a perception, with the perceived image being different from reality.

This means that perception and disorders of perception interest me. Which is probably why this interests me. We see what we expect to see, so don't expect cheating/things not to be where we feel they rightly should be. But mostly I like this because, to me, it look very, very cool :

the ARTIST (gambling demo) from Grecu Andrew on Vimeo.

Hospitals

There's concern, rightly, that the Mid Staffordshire NHS Trust let people down spectacularly.

The inquiry has released a lengthy report on this, with evidence from over 900 patients/carers as well as staff from the hospital.

His headline message is, dishearteningly, not surprising. It is that, "The Inquiry found that a chronic shortage of staff, particularly nursing staff, was largely responsible for the substandard care."

The grim care described is not that different from some of the patients I've seen in our local hospital. Some of the ignored dementia patients rolling around in faeces, and patients left with food out of reach, is exactly the same as poor care that I have seen in our acute Trust, up the road. Therefore the Health Secretary's assertion that, "This was ultimately a local failure," does not ring true. Sadly, I'm more convinced that the president of the Patients Association comment has it nailed with, "The scale of problems at Stafford might have been unique but failures in essential nursing care are not."

If you don't have enough staff, you can't deliver quality care, but heck you can't even deliver acceptable care. How viable is it for ward staff to close the doors and refuse admissions because they feel it's unsafe to do so? Notionally they're obliged to, since the NMC and GMC require nurses and doctors to provide safe care. We've been that bold in community teams, refusing referrals because we can't provide safe care. You wouldn't believe the trouble that got me in to (being summoned to explain this to the great and the good, which was incredibly illuminating for them!) but I still do it (and have done so twice this week already - we deliver good care and can't accept work then deliver substandard care) but it's only working because the team's convinced it's the right thing to do.

Managers have had to accept this. Managers can direct systems, they can't manage direct clinical care. A manager can't say that I have to see Mr Smith and tell him blah and prescribe drug X for him at this dose. Sure, they can generate a framework for me to see patients and can force a Job Plan on me determining where I am and when I'm there, but qualified staff are professionals. Rather than technicians, undertaking what we're tasked to do, that means we're responsible for making decisions on the specific clinical care of the patient in front of us. Managers can't meddle with that. This empowers clinicians, enabling significant leverage in service delivery. We can do what's right for our patients, which can mean suggesting referral to another provider since we aren't in a position to provide appropriate care.

The NMC Code requires nurses to advocate for their patients. Do nurses advocate that admission to Ward X is unsafe? Do nurses allow admissions when they feel the ward's inadequately staffed/resourced to provide appropriate clinical care? They do so usually because nursing hierarchy is notoriously hierarchical and it's seen as unthinkable to say, "No!" to a boss. But when the whole team says, "No!" and it's the Consultant writing the letter saying we'd love to provide care but we're not in a position to do so since such care would be unsafe (and we can't accept then deliver unsafe care), shifting it from a managerial to a clinical decision changes the problem (and solutions) significantly.

Team work. It has to be the way forward.

Deprivation of Liberty Safeguards

The Bournewood case generated legal inconsistencies that notionally have been solved through the Deprivation of Liberty Safeguards (DOLS).

If someone's liberty is "restricted," this can lawfully happen within the Mental Capacity Act 2005 framework, if it's in the person's best interests. An example would be someone saying they wish to leave a care home and return home, but they're guided to have a cup of tea and moments later they're happy and chatting with other residents.

If the resident was hammering at the door, 'phoning for taxis to take them away all the time, sneaking out at every opportunity and adamantly refused to stay, that crosses from "restriction" to "deprivation" of liberty and the DOLS framework kicks in.

Grand. Folks get appropriate care, within a lawful framework.

On to a conversation I overheard this week :

Community mental health nurse (band 7 CPN) : "The patient's settled, the occasional comments she'd rather be at home can be managed as 'restriction' of liberty, not 'deprivation' in the care you've now structured in the detail within your care plans."

Care home manager : "Great, thank you."

CMHN : "If she progresses and makes persistent, active attempts to leave, we'll need to consider DOLS."

Manager : "Oh yes, we use doll therapy all the time to distract them."

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.