Electronic Letters to:
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eLetters: Electronic letters published:
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![[Read eLetter]](/icons/misc/sectionDOWN.gif)
We need to learn from other doctors
- PRASANNA N. DE SILVA (18 June 2009)
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The Last of the Psychiatrists
- Yasir Abbasi (18 June 2009)
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The trouble with NHS psychiatry- do patients expect more from psychiatrists?
- Kamini Vasudev (18 June 2009)
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Problems in NHS psychiatry and recruitment chaos- Are they related?
- Venkata B Kolli, Dr Jonathan Lyons , Dr Danica Ralevic (24 June 2009)
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New ways of working: Are we prepared?
- Sandeep Bansal (10 July 2009)
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The Trouble With...
- Mark Taylor, Premal Shah (10 July 2009)
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The trouble with NHS psychiatrists
- Judy A Harrison (29 July 2009)
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PRASANNA N. DE SILVA, CONSULTANT PSYCHIATRIST TEES, ESK and WEAR VALLEYS NHS FOUNDATION TRUST
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prasanna.desilva{at}tewv.nhs.uk PRASANNA N. DE SILVA
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The analysis of current trends in English psychiatric services by St John-Smith et. al. (Psychiatric Bulletin, 2009;33,219-225) describes some real problems, but does not provide the jobbing clinician (or manager) any practical solutions. I believe other front-line medical services, notably military and primary care, do provide some solutions to help with quality, safety and accessibility in our field. There needs to be a robust triaging service for urgent referrals, readily accessible to GP’s and other referrers. Consultants should be available on a shift basis to review joint assessments carried out by two (ideally multidisciplinary) staff, also working shifts. This approach has a greater likelihood of avoiding biases in judgements (diagnosis, risks) and decisions (when and where to refer). The UK military field hospitals have much to offer in triaging expertise, as it utilises multidisciplinary assessment and prompt specialist review. The equivalent to field hospitals could be local A and E sites, providing safety and logistic support. Urgent triaging is currently carried out by crisis and home intensive teams, who thereby get put off their main role of avoiding inappropriate psychiatric bed use. Furthermore,there is an emerging debate whether (or not) a mental health polyclinic staffed by GP’s with a special interest (GPwSIs), jointly with non medical mental health staff, would be useful in triaging cold referrals such as anxiety/depression, medically unexplained symptoms and cognitive/memory problems. The relevant experiences stem from musculo -skeletal clinics held in primary care or at cottage hospitals around the UK, staffed by GPwSIs and physiotherapists. A mental health polyclinic could access a dual trained Consultant for advice or consultation, possibly via a telemedicine link. A polyclinic should be able to provide a second opinion to a GP with the patient returned with a diagnosis and treatment plan (including a risk/relapse plan). St John-Smith et. al. are right to point out the finite number of community mental health staff. Perhaps CMHT staff and primary care mental health staff would need to be seconded for these triaging duties including an appropriate shift pattern to avoid burnout. GP registrars will find triaging experience particularly relevant for their future role (which might include competency to work as a GPwSI). We live and work in uncertain times. I suspect most of the politics which surround secondary care mental health is due to fears of job losses (particularly managerial) in this financial climate, worsened by lack of clarity on Payment by Results; in terms of the relative priority given to new assessments compared with continuing secondary care. Hopefully these matters will be resolved over the next 18 months, but in the meantime it is well worth studying successes in other medical fields to inform the next wave of reforms, most likely driven by a new set of clinical commissioners from primary care. Prasanna N de Silva, Consultant Psychiatrist Whitby Hospital, Springhill, Whitby email prasanna.desilva@tewv.nhs.uk |
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Yasir Abbasi, ST 4 North Trent Psychiatry Rotation, Hartington Unit, Chesterfield Royal Hospital, Calow, S44 5BL
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dryiabbasi{at}yahoo.com Yasir Abbasi
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I read with interest ' The trouble with NHS Psychiatry in England' published in your June 2009 issue. The creation of new teams with in the current psychiatric set up in the NHS and the introduction of New Ways of Working (NWW) has created a sudden increase in the need for more trained psychiatrist. But unfortunately due lack of funds and unavailability of such clinicians, these teams are run mostly by non-medical staff. The NWW is also creating a cohort of psychiatrists with comparatively less exposure to acute emergency cases, especially out of hours. I would like to share a case vignette based on true events. A GP in the North West visited a male patient at home. After her assessment she felt the patient exhibited some somatic symptoms of depression. The patient kept on saying "I want you to sort my head out" and held his head in his hands. After a thorough physical examination the GP called the psychiatry crisis team for their input. They reluctant agreed to see the patient. When the crisis nurses visited the patient at home he was referred to the A&E for a possible organic cause as he was 'holding his head with his hands.' Once he was cleared from the medics, the patient called on the GP again for help. When the GP contacted the crisis team again, this is the response she got "We are short of staff today" and " Your patient is not the only one we have to see." The GP had to create a lot of fuss and contact the consultant psychiatrist (as there was no other psychiatrist in the team) twice before the patient was seen again, diagnosed with severe depressive disorder and admitted to the hospital. The most disturbing aspect of all this is, that non-medical staff firstly made medical judgments and decisions and secondly they dismissed the expert opinion of the GP completely when they decided to refer him to the A&E. Are we really helping our patients with these new ways? Is our care truly client centered? Who shall now be responsible for negligence and malpractice now? |
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Kamini Vasudev, Specialist Registrar, Adult Psychiatry EIP Service, Monkwearmouth Hospital, Sunderland, SR5 1NB
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kamini.vasudev{at}ntw.nhs.uk Kamini Vasudev
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It was reassuring to see the debate started by Craddock et al., 2009, continue [1]. I fully support the recommendations made by St John-Smith et al. (Psychiatr Bull 2009; 33: 219-225) [2]. The clinical leadership by psychiatrists is vital in mental health teams. However, in addition to our clinical expertise do our patients expect something more from us? I would like to share my experience at a recent conference organised by mental health research network, UK at Nottingham. This was the first time I had witnessed such extensive participation by service users and carers at a scientific conference. This was an excellent opportunity to seek views of service users and carers directly or indirectly in formal and informal environment outside the boundaries of my clinical role. I was disappointed to see that the general impression regarding psychiatrists was negative. I wonder why that is. Why is it that most individuals in need of a psychiatric assessment prefer to see a psychiatrist and yet they are not satisfied with the ‘expert’. The theme that I picked up from the service users and carers was that ‘psychiatrists don’t listen’. I wonder if some of us do get carried away by the ‘diagnostic’ assessment and in doing so miss the human touch that our patients need and expect from us. Do we need to be more compassionate with the psycho-social formulation in order to individualise our relationship with our patients. Diagnosis is indeed an essential component of a psychiatric assessment but do we spend enough time discussing the meaning of the diagnosis with our patients and what impact it has on their lives. Do we need to improve our skills at helping our patients integrate their diagnosis or ‘no diagnosis’ into their lives? How can we make our patients feel ‘listened to’? References 1. Craddock N, Antebi D, Attenburrow MJ et al. Wake-up call for British Psychiatry. Br J Psychiatry 2008; 193: 6-9. 2. St John-Smith P, McQueen D, Michael, A et al. The trouble with NHS psychiatry in England. Psychiatr Bull 2009; 33: 219-225. Declaration of interest: nil |
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Venkata B Kolli, ST3 Adult Psychiatry Suffolk Mental Health Partnership NHS Trust, Dr Jonathan Lyons , Dr Danica Ralevic
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kollivb{at}googlemail.com Venkata B Kolli, et al.
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The article ‘The trouble with NHS Psychiatry in England’ (St John Smith P et al Psychiatr Bull 2009 33: 219-25) coincided with the Dean of the Royal College of Psychiatrists Prof Howard’s interview on Channel 4 news on 4 June 2009. The very fact that psychiatry is one of the least favoured specialities for UK medical graduates suggests that there is trouble with NHS psychiatry in the UK. Perhaps the college and its members need to look at the possible reasons. The college has already been dealing with stigma that psychiatry and psychiatry patients face. It appears that many recent medical graduates secured a psychiatry post as part of their Foundation training on the basis of favourable placements as a medical student at the time of ‘old’ ways of working. However, unfortunately their subsequent experience with the ‘new’ ways of working for psychiatrists has been less reassuring. They have often noticed psychiatrists being marginalised, and that the psychiatrist’s role has been reduced to fire fighting with a lack of proactive interventions. This has led to many of them deciding not to take up a career in psychiatry, or even to seek higher training in psychiatry abroad. Medical graduates are often attracted to various specialities by role models. We wonder if a relative lack of role models is the reason for UK graduates not opting for psychiatry. In his interview on Channel 4 news Prof Howard suggested that psychiatry is being forced to recruit trainees who just meet the minimum criteria. However this might lead to fewer role models in psychiatry, further recruitment problems and more trouble. Perhaps the college might consider ‘newer’ ways of working, recruiting and training. References: 1. St John-Smith P et al. The trouble with NHS psychiatry in England. Psychiatr Bull 2009; 33: 219-225. 2. Hannam L and Wivell J. Psychiatry's UK recruitment crisis. Channel 4 News. 4th June 2009. 3. Eagles J M et al. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull 2007; 31: 70-72. 4. Kerby J et al. Anti-stigma films and medical students’ attitudes towards mental illness and psychiatry: randomised controlled trial. Psychiatr Bull 2008; 32: 345-349. 5. Wright S et al. The Impact of Role Models on Medical Students. J Gen Intern Med 1997; 12: 53–56. |
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Sandeep Bansal, Speciality Registrar Chase Farm Hospital, BEH-MHT NHS Trust
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drsanban{at}gmail.com Sandeep Bansal
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I share the authors’ views highlighted in this paper and would like to lend further support to his views by briefly discussing my audit about New ways of working (NWoW). We completed an audit on NWoW, to compare the 60 most recent histories taken by junior doctors (STR1-3 including GP trainees) and nursing staff in the Out patient clinic setting. The audit was done in Lymebrook centre, which is one of the resource centres that caters for Adult psychiatric patients in North Staffordshire Combined Mental Health NHS Trust. All histories, which were taken, were assessed for 108 variables. In addition to assessing whether the relevant variable was reported we also graded the information reported on whether it was comprehensive or only partially obtained. The data was collected on hard copy and was analysed on SPSS. This audit shows significant differences in histories taken by junior doctors and nurses. Doctors documented comprehensive histories for 52 %( 1459) of variables; they took incomplete histories for 8 %( 234) of variables and not asked for 39 %( 1107) of variables. Nurses have taken comprehensive histories for 32 %( 905) of variables; they have taken incomplete histories for 13 %( 382) and not asked about histories for 55 %( 1573) of variables. There were statistically significant differences (p value < 0.05) between the two groups in 44 out of the 108 variables with doctors generally taking a more comprehensive and detailed assessment. The audit was presented within the trust and nurse’s representatives were asked for their views. They stated that history taking, physical examination and pharmacology are not a part of their nursing training and as such they are not confident in these aspects of patient care (physical, pharmacological etc). They have identified difficulties in differentiating physical symptoms because of functional and biological causes. Torn A, McNichol E (1996), found that 96% of nurse practitioners did not feel that their training is adequately equipped to treat people with mental health problems and 83% of nurse practitioners do not feel adequately equipped to assess people with mental health problems1. No other independent studies have since been completed and there is no other evidence available, which supports, NWoW. It is certain that Psychiatry needs to change to provide better patient care and to overcome difficulties posed to the psychiatrists but do we think we are ready for it? Declaration of interest: None References: 1. Torn A. Mcnichol E .Can mental health nurse be a nurse practitioner? Nursing standard: 11, 2, 39-44. 1996. |
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Mark Taylor, Consultant Psychiatrist Royal Edinburgh Hospital, Premal Shah
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marktaylor2{at}nhs.net Mark Taylor, et al.
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In two related articles – “The trouble with NHS psychiatry in England” (St John-Smith et al), and “New Ways Not Working? Psychiatrists’ Attitudes” (Dale and Milner) - misgivings about the role of the psychiatrist and service delivery in England are described. As psychiatrists working in Scotland we have witnessed a divergence between the two National Health Services since devolution. The National Service Framework, for example, was not implemented in Scotland. Further, bed closures have happened more slowly and the rushed ‘top down’ functionalisation of mental health care enacted in England, has been generally more measured north of the border. Indeed it appears that only crisis resolution and home treatment teams have been widely adopted (reflecting in part the supporting evidence eg Cochrane 2006), there being a more conservative adaptation of ‘New ways of working’. Partially, this reflects a different politico-cultural backdrop in Scotland - there is, for example, a substantially smaller private and independent sector in mental health care here compared to England. Funding, therefore, is not (usually) diverted in that direction. Furthermore, there is less preoccupation with risk to others, again limiting private secure facility expansion. Additionally, ‘New ways of working’ was in part a pragmatic solution to endemic problems with recruitment and retention into psychiatry. In Scotland, this has been less of an issue overall, with notable exceptions. Scottish workforce planning indicates that only CAMHS consultants in Scotland are difficult to recruit, and there has been a genuine uplift in consultant numbers in the last 5 years. Whilst there are important imminent universal challenges which could change the landscape, (like the diminishing number of junior doctors, and the evolving role of the psychiatrist as a medical doctor providing leadership within the multi- disciplinary team), we contend that there is probably less dissatisfaction with current service configurations, less urgency to overhaul systems, and more opportunity to plan service change meaningfully on the basis of evidence and other’s experience. Thus we have naturalistic experiment with separate and diverging systems of government based healthcare in adjoining countries with similar underlying populations. This could be an ideal opportunity to examine optimal service configuration, as long as consensus on the best outcomes for patients could be achieved. Yours, Mark Taylor and Premal Shah |
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Judy A Harrison, consultant psychiatrist Manchester Mental Health and Social Care Trust
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judy.harrison{at}mhsc.nhs.uk Judy A Harrison
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St John Smith et al provide a useful overview of the political imperatives which have shaped British psychiatry in the last five years (Psychiatric Bulletin, 2009, 33, 219-226), but as with other overviews (1) it is difficult for the reader to come away with any constructive message. The authors rightly recognise the original New Ways of Working project as a practical response to a shortage of psychiatrists, but believe this has become a shorthand for cutting the number of medical staff and reducing the psychiatric orientation of the service. The national manpower figures suggest otherwise: between 1999 and 2007, the number of psychiatrists in England rose by 46% (2) and few can argue that recruitment is not vastly improved compared to 10 years ago. The reality is that new services have grown even faster, with an estimated £2 billion of additional investment since 1999 (2), mainly in specialist teams. The recruitment of medical staff and the establishment of suitable training placements have lagged behind, as outlined by the Audit Commission finding (3) that almost one third of Crisis Resolution teams had no dedicated consultant sessions. It is inevitable, and many would argue desirable, that non-medical staff will be involved in front line assessment, as they are now in most other branches of medicine. The solution is not to decry “proforma tools and guidelines” but to argue for these to be used by suitably trained and supervised staff working in teams with ready access to psychiatrists, as originally envisaged in New Ways of Working (4). The College should lead on an overview of the medical staffing of specialist teams, and Trusts and commissioners should be obliged to fund dedicated consultant sessions in order to meet their quality targets. While specialist teams provide some benefits, they have undoubtedly lead to greater fragmentation of care and may not all survive beyond “New Horizons” (2). Our battle should be to ensure that the additional money which came with these teams is not clawed back in times of greater austerity. 1.Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake up call for British Psychiatry. British Journal of Psychiatry, 2008, 193, 6-9. 2.Dept of Health 2009 New Horizons: Towards a shared vision for mental health 3.National Audit Office 2007 Helping People through mental health crisis: The role of crisis resolution and home treatment services. 4.Dept of Health. New Ways of Working for Psychiatrists. Dept of Health, 2005. (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4122342) |
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