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Original papers: Sunil Mehta, Abhijeetha Salvaji, and Riadh Abed Roles of general adult psychiatrists in follow-up clinics Psychiatr Bull 2007; 31: 381-384 [Abstract] [Full text] [PDF]

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New Ways of Working - not without challenges

Adhiraj Joglekar, Manjiri Lele   (11 October 2007)

Consultant Follow up clinics- Are they wasted?

Premraj Muthuvelu   (12 October 2007)

New Ways of Working - not without challenges 11 October 2007
Adhiraj Joglekar, SpR West London Mental Health NHS Trust, Manjiri Lele Send letter to journal: Re: New Ways of Working - not without challenges adhirajjoglekar{at}hotmail.com Adhiraj Joglekar, et al.	We read the article ‘Roles of general adult psychiatrists in follow-up clinics’ with great interest. Although we are subscribed to the principle driving New Ways of Working, the findings reported raise several questions. Results suggest that over 50% of patients were attending for more than five years, another 55% between 1- 5 years. Significantly, 94% of the contact was for review of medications. Although surprisingly only 16 % were on enhanced CPA, well over 80% suffered from mood disorder or psychosis. The issues arising are – 1) What proportion of these patients may have once been considered as ‘complex’ rather than routine care? 2) There is a presumption that outside the out-patient appointment, these patients are not receiving care from other health workers (CPN, Social workers) or non-statutory agencies. 3) Well over 50% of the case load suffered from depression or neurotic disorders. Is lack of resources i.e. psychologists or nurse specialists who could deliver treatments like CBT a reason for these patients having to be prescribed medications, in turn needing involvement of a psychiatrist? 4) The need for long term follow-up is apparent within the given case load. Who would the consultant hope to delegate this work? Trainee doctors working in shifts and working for 6 months on average may not be best suited as continuity of care may be a vital component within the system that helps keep these patients stay well over long periods. Non-training grade doctors are often burdened with similar case loads. Also user empowerment is increasingly vital, what if patients wish to see the doctor they have had the longest association with? 5) Interestingly only one of the patients was discharged. Reasons for this need to be explored. Services differ in the shared care protocols, also a given consultant will need reasonable confidence that the patients needs will be met by what is available within the primary care settings. 6) Finally, if ‘struggling with long hours, multiple demands, risk management and ‘little time to practice the art of psychiatry’ is what we hope to reduce, is New Ways of Working, where ‘the skills of consultant psychiatrists are used for managing the most complex needs’ the answer? A constant involvement in managing complex, and hence potentially high risk cases where the focus may be resolving crises could well become a reason for burnout. Each service will have its strengths and weakness with concurrent threats and opportunities. The authors efforts indicate that service- mapping exercises or similar may have to become important part of undertaking reorganisation of teams where consultants hope to have job plans in keeping with the New Ways of Working.
Consultant Follow up clinics- Are they wasted? 12 October 2007
Premraj Muthuvelu, Specialist Registrar North West Wales NHS trust Send letter to journal: Re: Consultant Follow up clinics- Are they wasted? premraj.muthuvelu{at}nww-tr.wales.nhs.uk Premraj Muthuvelu	Dear Sir, I read with interest the article on the' Role of general Adult Psychiatrists in follow-up clinics'. They state that 'the majority of patients were either not on CPA or were on standard level'.The authors also note that 'around half the sample (51%) had no changes made to their care plan whatsoever, which raises the possibility that a consultant review might not have been required.' The outcomes they have used to substantiate their view are in my opinion, not valid. A review of the patient along with the care plan , even if no changes are made is an essential part of clinical management. A consultant making'no changes to the care plan' as an outcome by itself cannot be taken to indicate a waste of consultant time. A decision not to change the care plan is a positive act in itself and it should be considered as such. An argument that reviewing patients not on enhanced CPA by a consultant is being made which is again, in my view, fallacious. A review might still be appropriate. Declaration of interest-None