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The Royal College of Psychiatrists Improving the lives of people with mental illness

It's official - society does exist

When Napoleon was asked what he wanted in his Marshalls he answered “to be lucky”.

He would have been pleased with Theresa May. A year ago David Cameron gave a good speech on mental health - I know, I was there. But hardly anyone else does, because he chose the morning that David Bowie died. There was zero coverage.

Theresa May chose a day in which for some reason Donald Trump said nothing and the only other news was the London tube strike and so she dominated the airwaves. Even the strike worked in her favour - more people at home twiddling their thumbs with nothing better to do than follow the news.

A Prime Ministerial speech is important. It sets a tone. The political and civil service bandwidth for AOTB (Anything Other Than Brexit) is going to be narrow for years to come, so knowing what Downing Street is keen on really matters.

And there is no going back from this - Theresa May meant what she said on her first day in office – she wants to see a transformation in how we approach mental health. So we must applaud the fact that the speech happened at all.

But what about the content? Again, there was much to like. There was a spirited defence of the importance of social networks and social cohesion for mental wellbeing. Nothing that we would not agree with and perhaps a little dig at the first woman Prime Minister, who famously or infamously claimed there was no such thing as society. In our world there most definitely is.

We heard a lot about the early years - again, little we have not been saying ourselves, but still very welcome.

There was a commitment to ending using police cells as a place of “safety” for mentally ill adolescents. We have been pushing for this for some time. There will be more mental health education for teachers - Mental Health First Aid will be rolled out across the sector.

My alter ego, The Boring Boffin, might point out that the best trial of this showed that it did improve teachers’ knowledge of mental health, but had little impact on the children. However, this is probably the occasion to keep Boring Boffin in the kennel.

And to be fair, the pre-speech briefings (I will riff on the subject of what really goes on before, during and after a political speech in a later blog) did include the word “trials”. Boring Boffin worked hard to get that - not “pilots”, still less “evaluations”, but “trials”. Well meaning interventions, especially with children, can do harm as well as good.

It is our role as a calm but authoritative voice, to point this out. Where we have evidence - as in parenting programmes to reduce behavioural difficulties in children - we will shout this from the rooftops. But the only way we can find out what works and build our evidence-base, is through trials. There is no other way of assessing the balance between benefit and harm.

But we don’t need more trials to know that Prime Ministerial support for putting mental health services into A & E is a good thing. A & E services will always be seeing those with drug, alcohol, deliberate self-harm, comorbidity and so on. And they will also always have to see those with serious mental health problems who have developed acute physical health care issues. And so they will always need us.

Digital is all the rage, so not surprising that a lot was made of this. From our perspective it was good to see that six mental health trusts will be designated as “Digital Exemplars”, which comes with £5 million in extra funding, after competition.

I say good, because that would not have happened without our strenuous interventions when it became clear from the first announcement that mental health trusts were not originally included in the scheme.

As ever, what was not said was as important as what was said. We tried to get more in about the workforce - this wasn’t successful, but back chat indicated that our hope that the commitment to provide up to 1,500 extra places for medical students will include measures to ensure that they don’t all want to be surgeons (of which we need fewer, not more, in the future), but GPs and psychiatrists (of which we definitely need more) will be heeded soon. 1,700 new therapists were promised for CAMHS services - but not the 350 CAMHS psychiatrists that both ourselves and HEE have indicated are needed.

Nor did we get the PM backing to end out of area placements for adults. We created the Crisp Commission soon after I took office and were pleased when NHSE accepted its findings and recommendations, but not the deadline we had proposed to this practice finally outlawed. We had hoped the PM might advance this, but she remained silent.

But we return, as we almost must, to the money. The PM promised some – as far as I can gather, the only truly new money was £15 million allocated for out of hospital crisis care, such as mental health cafes.

Some previous commitments were repeated - liaison and court diversion schemes to keep people out of the criminal justice system being extended across the country. I actually thought that was already happening, but having the PM repeat it does no harm. Ditto the extra investment for A & E liaison psychiatry services.

But overall the picture is gloomy. Between 2010 and 2015 funding to the mental health trusts went down by over 8%. Not up, down. Since 2010 we have lost more than 2000 beds in England alone. But demand has risen - referrals to community mental health teams have gone up by 20%. So has there been a concomitant increase in staff?

Don’t hold your breath - that went down by 5%. Meanwhile, you probably have seen the coverage of the 50% rise in mental health attendances at A & E over the same period - with a particularly worrying increase in children. Some, but not all, of this is due to better coding, but clearly the underlying trend is not good.

And looming over it all remains the fact that sightings of the large sums (now we are talking not a few million, but over a billion) promised by George Osborne before he was defenestrated, remains as elusive as sightings of the Loch Ness Monster or the Beast of Dartmoor.

Confirmed sightings of the money continue to be of small kittens rather than the Sabre Toothed Tiger sized felines that we were promised. Certainly eating disorder and perinatal services are benefiting, which is great, but the radical transformation that the speech promises remain to be delivered.

We are responding, helped it must be said by the new NHSE “dashboards” - which give at least some evidence of what CCGs are actually spending on mental health. Before Christmas we had a blitz on CCGs that made Scrooge look like the Bill Gates Foundation when it came to funding CAMHS services.

Armed with the data, we targeted local MPs and media, in a bid to name and shame errant performers, this being almost the only weapon we have in the post Lansley/Health and Social Care Act era. Expect a lot more of the same as we get down to looking at numbers of Out of Area Transfers (OATS), or who is honouring the expected 1.5% mental health uplift.

But I am afraid talking to Medical and Finance Directors up and down the land, we know that the famine continues and the broad sunlit uplands remain a distant prospect. We are not alone in this – as I write you cannot help but notice the tension between Number 10 and Simon Stevens about the overall level of NHS spending - who promised what and where is it?

Simon seems to have the facts on his side, but this is now about politics and where this will end we can’t say. I hope that it will settle, because Simon Stevens has been a good friend to mental health (it is where he started his career) and it is also hard to see anyone who would want to do his job, let alone do it better than he does.

So where does that leave us? I don’t think I can improve on this week’s (Jan 14) Economist – “The Prime Minister makes a big speech but signs a small cheque”. Big speeches are good, cheques would be even better.

Professor Sir Simon Wessely

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Comments

Gift to see ourselves
Hi Simon, whilst waiting for mirage of the ‘fat cheque’, I have just completed a 2 year attachment with the CQC, and in the process, attended 24 mental health services. Contrary to the perception of most doctors that the CQC is mainly concerned about furnishings, laminated leaflets and policy documents, the reality is its focus on whether doctors and allied staff treat patients and carers decently (and effectively), alongside communicating constructively with other professionals including management.

It could be argued that the CQC have not adequately engaged the medical workforce in what they want to accomplish, and this is a continuing challenge, in my opinion, for the CQC medical leadership.

Over the last 2 years - partly through my CQC experiences - the following questions have challenged me, having had prior teaching in polarity management (1); essentially Robert Burn’s desire for ‘the gift to see ourselves as others see us’. The following is a bit longer than my usual commentary, as I felt incumbent to attach some references. I also write this in the hope that the various contenders to replace you will reflect on these points during the forthcoming hustings.

1.Why do we not face up to stigma from other doctors? Most research on stigma has focussed on the general population (2), despite equally strong evidence of stigma evidenced as reasons doctors give for not considering psychiatry (3). We tend to defer to national organisations (like the R.C.Psych) to tackle stigma, instead of dealing with this in our day to day communication with medical colleagues, and when teaching medical students. Perhaps one way of combating stigma, is for us to demonstrate knowledge and competency in physical health care in our clinical discussions.
2.Why are we ambivalent about focussing on closing the physical health gap in morbidity and mortality of our patients compared to the general population? (4, 5). We tend to see physical health care as the responsibility of our primary and secondary care colleagues (problem; see question 1). In comparison with mortality and morbidity of self-harm, we could save more people if we became smarter in dealing with our patient’s medical issues. Perhaps the extent the physical health gap with the general population is closed in key areas such as hypertension, diabetes, ischaemic heart, metastatic cancer and stroke could be the main outcome measure for consultant led psychiatric firms.
3.Why have we been reluctant to avoid or truncate acute hospital admissions of frail people with dementia? There is good quality evidence that frail elderly people with dementia get a poorer service in acute care (6), with a greater likelihood of dehydration, pressure sores, hospital acquired infections, fractures, delayed discharge and a higher likelihood of being moved to care homes. However, admission avoidance is not seen as a priority for community psychiatric teams, with hospital liaison teams being more active in discharging adult non-frail clients. There has been limited psychiatric involvement in re-engineering frailly pathways including involvement in intermediate care.
4.Why do we perpetuate ‘urban myths’ and ignore emerging evidence from neuroscience? Describing ‘imbalances of chemicals in the brain’ as explanations for psychosis and mood disorders (and to some extent in senile dementias) doesn’t wash with internet savvy patients and carers, as there is no actual data to back this notion in terms of whole brain neurochemical studies (7). Most studies suggest that it is difficult to separate cause and effect in the various neurochemical changes observed, with reduced frontal lobe neuroplasticity and stress induced systemic cortisol changes having a much stronger evidence base in depression (8), with reduced frontal activation with excess synaptic pruning in schizophrenia leading to dopamine diversion to the striatum (9) as a secondary effect. We also ignore emerging evidence from psycho-immunology in terms of microglial activation and the complement cascade in frontal areas of the brain in both schizophrenia and major depression; a more evidence based narrative, with future therapeutic potential (10).
5.Why have we been slow to incorporate the benefits of new technology in our practice? Equipment such as smart phones and laptops can help remote and flexible supervision of initial assessors (both medical and nursing) and allow rapid treatment planning, with the option of communication between psychiatrists, patients and carers at the time allowing us to ‘hot desk’ and work from home. Furthermore, use of templates which you can type on to, both for letters and sections forms will be a major improvement in efficiency (no dictation) and clarity (shorter content).
6.Why are we reluctant to change our practice to incorporate non-medical prescribers (11) and non-medical Responsible Clinicians to assist our ward and community work? These staff can help with repeat prescribing after diagnosis, help write tribunal reports and ensure safe planning of leave periods (with appropriate supervision from senior medics). Each ward should, in my opinion, include a non-medical prescriber and responsible clinician to assist a consultant, allowing us to concentrate on treatment planning and improving physical health (see question 2).
7.Why don’t we allow central bed management / discharge teams to plan discharges from mental health beds? Most acute hospitals (and a few mental health hospitals) use discharge teams to coordinate safe discharges including pre-emptively looking for options of accommodation (12). This will improve the duration of stay and provide more robust discharge plans. It would also free up psychiatrists to liaise more productively with primary and acute care colleagues to improve quality in terms of seamless care delivery.

References
1. Scott, E., Cleary, B. (2007) Professional polarities in nursing. Nursing outlook. Vol 55(5) pp 250 – 256
2. Byrne, P (2000) Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment. Vol 6(1) pp 65-72
3. Deb, T., Lomax, G.A. (2014) Why don’t more doctors choose a career in Psychiatry? BMJ Careers Date of publication 9/1/14
4. Hoang, U., Stewart, R., Goldacre, M. (2011) mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English Hospital episode statistics 1999 – 2006. BMJ 343:d5422
5. Lawrence, D., Hancock, K.J., Kisley, DS. (2013). The gap in life expectancy from preventable physical illness in psychotic patients in Western Australia.; retrospective analysis of population based registrars. BMJ 346:f2539
6. Zekry D, Herrmann FR, Grandjean R, Vitale A-M, De Pinho M, Michel J-P, Gold G, Krause K-H (2009). Does dementia predict adverse hospitalization outcomes? A prospective study in aged inpatients. International Journal of Geriatric Psychiatry 24:283-291
7. Moncrieff, J.(2009) a critique of the dopamine hypothesis of schizophrenia and psychosis. Harvard review of Psychiatry Vol 1793) pp 214 - 225
8. Pittenger, C., Duman, R.S. (2008) stress, depression and neuroplasticity: a convergence of mechanisms. Neuropsychopharmacology. Vol 33, pp 88-109
9. Krabbe, s., Duda, J., Schiemann, J et.al. (2015) increased dopamine D2 receptor activity in striatum alters firing pattern of dopamine neurones in the ventral tegmental area. Proceedings of the medical Academy of sciences. Vol 112, no 12
10. Bloomfield, P.S., Selvaraj, S., Veronese, M. et.al. (2015) Microglial activity in people at high risk of psychosis and in schizophrenia: an 11c PBR28 PET Imaging study. American Journal of Psychiatry Vol 173(1) pp 44-52
11. De Silva, P., (2013) Applying SBARD to electronic notes, letters and reports in Old Age Psychiatry. Progress in Neurology and Psychiatry. Vol 17(2) pp 10-12.
12. Kwentoh, M., Reilly, J. (2009) Non-medical prescribing; the story so far. BJPsych Bulletin Vol 33(1) pp 4-7.


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Professor Sir Simon Wessely

   

Professor Sir Simon Wessely

President


Sir Simon Wessely is Regius Professor of Psychiatry and Co-Director King’s Centre for Military Health Research and Academic Department of Military Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.  He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes. 

He has responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.

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