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

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06/06/2017 18:18:35

Ave Atque Vale

I was never a great fan of the late Robin Williams, at least not as an actor.  Preferred his comedy. On film I thought he was a bit saccharine.  “Patch Adams”, the doctor who used humour to heal his patients - yuk.

But did get nominated for an Oscar for “Dead Poets Society”. He played a teacher who inspired his students (you never get Oscar nominations playing uninspired teachers) via the Latin motto “Carpe diem” - seize the day.

And that’s not a bad motto for us.  Mental health is “in” at the moment.  Two Prime Ministers devoted full speeches to it.  All of the parties in the election included it in their manifestos.  The younger Royals have claimed this for their own, even if the Queen apparently still sees some merit in the oft derided essence of Englishness, the “stiff upper lip”, which by the way was originally an American attribute.  Before the Victorian era the British were if anything more likely to be seen as a nation of cry-babies.

And back in the present, last year every TV channel had a mental health week, and just how many more celebrities are there left to share their mental health stories?

Playing our part

We have played our part in this. We have achieved fantastic coverage in the last 12 months, pushing good news, combatting errors and myths and highlighting injustice and failures.  We now produce a daily summary of “RCPsych in the News” - because we need one.

I said when I took over that I wanted us to be the calm authoritative voice people turn to when it comes to psychiatry and mental illness.  We are well on the way to achieving that.

And our political impact has likewise increased dramatically.  Of the Royal Colleges only the GPs get more mentions in Hansard - and they are five times our size. 

Work to do

But it’s not all gone well.  When I took office I also spoke about improving recruitment. And I might as well confess now, we haven’t.  OK, we have stopped the decline, and in the context of what is going on across medicine that’s an achievement.

But I think we have created the foundations (pun intended) to improve on this. We have achieved the target of 45% of junior doctors doing a foundation post in psychiatry. If that recruits not a single psychiatrist, it will still have done good.  But I believe the strategy will pay dividends in time.

But we must do better, and so it’s time to seize another day. Before the General Election we did our best to influence all the parties to make commitments to improving mental health services.

So when we read their election manifestos we quietly congratulated ourselves our efforts were not in vain. Now I am not naïve, and I know that a manifesto is not the Ten Commandments. But having something there increases the likelihood it will happen, and not having it there does the opposite.

The new government - whatever, whoever and wherever it might be (who knows, it might be Belfast) - will be committed to finding ways to ensure that the expansion of medical places is linked to what the NHS needs (and I know for a fact this means general practice and psychiatry), and several of the ways they plan to do this are a direct lift from  our own manifesto for mental health.

We can also see some of our handiwork in other commitments as well, for example around schools and mental health.  These things don’t just happen, they are the result of a lot of hard work by a lot of people - and many of them belong to your College.

Prod and push

But we cannot rely on government, of whatever political persuasion, to do our work for us. We can and will prod, push and occasionally kick, but it’s not enough.

We all need to work hard in schools, universities and in the media to see that that the interest in mental health of the new generation of students is translated into career choices.

And how we do that?  By telling the truth - that psychiatry is a great profession, with a great future.  It’s on the up - if you are academically inclined and want to crown your career with a trip to Stockholm, join us.

A privileged job

If you want to practise mind/body medicine, by all means think about clinical psychology, but remember you have more chance of success if you do this via medicine.  And whatever you do, there are few more privileged jobs around than one in which people will tell you things that they have never ever told anyone else before.

Yes, we have problems. But it’s important that we don’t paint an unduly negative picture.

If you want to get to know someone better in a bar or at a party, you don’t kick off by saying how generally miserable, put upon, stressed and ignored you are. It never worked for me, and I doubt it works when persuading people to think about a career in medicine in general or psychiatry in particular.

So Carpe Diemi. But that’s not the full quote - it’s “carpe diem, quam minimum credula postero”. In other words, "Seize the day, but put very little trust in tomorrow”.

Doing more than simply raising awareness

And there are concerns for the future.

Evidence now suggests that most people are aware of mental health and what that means. Most of those who had diagnosable mental health disorders identified in the last Adult Psychiatric Morbidity Survey knew that they had.

True, many remained unwilling to do anything about it for a variety of reasons. But they were aware.

But if that’s all we have done - raise awareness - but nothing to actually help, then expectations will be replaced by disillusionment and anger. I propose that next year we replace Mental Health Awareness Day with Mental Health Delivery Day.

And then there’s the money. There always is. Or to be more precise, perhaps there won’t be.  There is a consensus that NHS finances will drop of a cliff in 2018/19.  And then there will be covetous glances thrown at us.

Joined up approach

I am convinced that the senior voices in NHS-E are serious about achieving real gains for mental health services. But will that survive a sustained assault from other parts of the service, especially if the anarchy introduced by the discredited but still extant 2012 Act continues.

Between now and then we must use every effort to continue to build alliances across our sector - charities, think tanks, media, politicians - we need a united front.

Next, integration. My career has been partly about better integration of the physical and mental.  And a lot has been achieved.  New RCPsych data confirms that we are taking the physical health of our patients more seriously. And across the road we even more of a presence in A and Es and general hospitals than before, with more expansion coming. 

But it would be a sad irony if at the same time we permit a greater separation of the physical, social and psychological in our own back yards.

IAPTS has been an amazing success, achieved partly by a remarkable single mindedness and desire to disrupt a system that was not delivering psychological treatments on anything like the necessary scale.  But in the future we need also to ensure that we don’t permit the development of silos within mental health.

In the large consultation before the start of the Five Year Forward View which occupied much of my Presidential time the commonest thing that people told us that they wanted their physical and mental health care together.

They minded less where it was, more that it was in the same place, delivered by people who worked together. We have made progress on this, but success will depend on continued vigilance

So many days seized

Carpe diem. Seize the day.  And as I look the last three years have been full of many days that we have seized. The day we launched the Crisp Commission into Acute Care, and the days we spent on implementing it.

The days spend on the Five Year Forward View, and the days working with NHS-E on how to make it a reality. Days plotting how to shame CCGs lagging behind on mental health spending.

Evenings at the College listening to so many talented speakers, reflecting the breadth and depth of our profession. Mornings hearing about our fantastic plans for modernising our approach to the promise of neuroscience.

Early mornings getting up to do battle on the Today programme. Evenings spent in the devolved administrations and countries hearing the different paths they are taking, and trying not to be jealous.

And the days spent with your staff here at the College and your Officers - two Registrars, two Deans and two Scrooges.

Democracy has had a bit of a bad press recently. Last year it delivered two results that try as we might, many of us find difficult to believe will turn out well. But when it comes to our RCPsych democratic process, it resulted in the best colleagues I could have hoped to have.

One of them, Wendy, is about to take over.  We are in good hands.

And now my favourite last words. When Ramón Maria Narváez, Spanish General and political leader, was on his death bed, the priest asked him if he forgave his enemies.  His last words were “I do not have to forgive my enemies. I have had them all shot.”

 

 

[i] Pedanticus retired last month, but I am afraid I was unable to prevent him staging one final bow. “Carpe diem” comes from the Roman poet Horace, one of his Odes. But he says that readers might think my title “Ave Atque Vale” - translated as “greetings and goodbye” is also from Horace. I told him he was being silly, and that you would all know this is Catullus mourning his dead brother, but he insists that I point this out. He does have a bit of a temper, so I am doing what I am told.

Professor Sir Simon Wessely

Read the June 2017 eNewsletter

17/05/2017 18:06:24

The New Model Armies

Left to right: Dr Justin Wilson, Professor Sir Simon Wessely, Melanie de Smith, Holly Taggart, Peter Spilsbury, Stephen Firn, Ben Dyson, Richard Murray

In my last blog I told you all about RCPsych’s calls to the next government in Five Steps to Fairness, on the need for a bigger mental health workforce. By the end of today we should have seen the manifestos from all the main parties, but in the meantime we already know that Theresa May already is pledging to increase the mental health workforce by 10,000.

Nothing wrong with that. We are calling for more mental health staff. Naturally, rumours persist that this 10,000 won’t really be ten thousand, after staff changes in recent years are accounted for and the possibility that some of these numbers may be voluntary roles.  And who is going to pay for this?

We need to make sure that the posts of  some of the most skilful members of the workforce are not mortgaged off to swiftly train up people who with the best will in world will not be able, or indeed allowed, to help the most severely ill, and the most complex.  We will fight our corner on this one.  As I’ve said before, when it comes to helping people with mental ill health, it isn’t about expensive kit, it’s about staff, highly trained, in the right numbers, how they work, where they work, the teams they work in and how they feel.   

And those teams are beginning to change right across the NHS. Our report, published today, Mental health and new models of care: Lessons from the Vanguards examines new ways of doing things that aim to move care out of hospitals and into the community, reducing traditional divides to deliver care that treats mental, physical and social needs together.

In what has been a leitmotif of these blogs, at least when they are about the NHS, your knowledge of these developments may be sketchy.  Mine is. This is not helped by the fact that as ever they are disguised by a complex system of codes that would have baffled the people who broke the Enigma codes - NCM, MCP, PAC etc.  I sometimes think there is a computer in the basement of NHS England that produces random three letter sequences, and then it is the task of the officials to produce plans to fit the acronyms, rather than the other way round.

But when it comes to transforming care, we are not just in the vanguard, but we are the vanguard of the vanguards.i We have done a lot of this. More than any other part of the NHS. Deinstitutionalising services, moving care out of hospitals into the community through the care programme approach, care coordination and investing in crisis care home resolution treatment teams.  We did the lot.  We transformed ourselves from an almost entirely hospital based service to one that is now the opposite.  No one else has achieved anything remotely similar. It wasn’t without its problems, but we got there.  So we know of what we speak.

And so common sense would dictate that as the rest of the NHS seeks to transform, they would look to us, the vanguard of vanguards, for a tip or two. But have they?ii

Through our work, jointly with the King’s Fund, we’ve found that some areas have made great advances to include mental health but have been disappointed that some others barely considered the sector at all. The bulk of mental health plans within new models of care revolve around enhanced models of primary care, with mental health expertise directly embedded into primary and community health teams. For this we can see a common and distinct move of specialists, including psychiatrists, out of hospitals and into the community, and teams of mental health nurses and allied health professionals with them.  It's not new – indeed, one Geraldine Strathdee, soon to be our latest Honorary Fellow, started her career doing just that.

Nothing radical in this.  It’s what we believe – adhering to a biopsychosocial approach based on multidisciplinary working.  So it’s nice to see new exemplars in action. In West Cheshire Way, an older people’s consultant psychiatrist post has been created to provide educational input into the integrated care teams and primary care. This  supports RCPsych’s manifesto ask that not only do we need more psychiatrists but we need a greater understanding of mental health across the wider NHS workforce. In Tower Hamlets, mental health nurses in the integrated community health team have protected time to provide training to primary care as well as community health teams.

Putting mental health expertise in places where most people access services is likewise bread and butter to us.  That’s exactly why I went into Liaison Psychiatry many years ago.  Now in Tower Hamlets and elsewhere mental health nurses are working within integrated teams, as opposed to community or acute mental health services. Many of the vanguards sites are starting with older people’s health services.  Quite right too – says someone who has just got their bus pass (BUT NOT RETIRING!).

But despite these positive steps, our overall assessment is that opportunities to integrate mental health into new models of care have not been fully realised. The level of priority given to mental health has just not been high enough. Sometimes we are an afterthought, picked up after checking in the rear view mirror, other times we don’t even make it on to the pitch.

Does this matter? Very much so. Because if the vanguards are at the front of the line, what is coming behind is the main force. These are the sustainability and transformation plans or “STPs”, which I have droned on about before.  And we need to make sure that the omissions by the vanguards are not repeated when the main army takes the field.

Ah, I hear you say, surely these new things have been evaluated.  Everything is evaluated these days. Indeed so, but there are evaluations and…er…evaluations.  And in the evaluations of the vanguard sites mental health is conspicuous by its absence. Plenty of good things being measured, but none are specific to mental health.

So we are asking that future evaluation includes the impact of this latest New Model Army of new care models on people with mental health problems. And continuing the Cromwellian analogy, leaders must not be cavalier with mental health – and need to be seen to take account of good practice where the gold standard (with mental health support successfully embedded in integrated care teams, enhanced models of general practice, and urgent and emergency care pathways) has been achieved. Until then, we will follow another acronym, this time introduced by Ronald Reagan when he was negotiating the end of the Cold War with Mikhail Gorbachev. TBV.  Trust But Verify.

[i] Pedanticus, in what may be his last message to you, notes that “vanguard” is actually a French word, derived from avant garde, meaning the front of the line. Once a military term, it is now more often used in art and culture. But as the Pub Landlord would point out, either way it is French, and now that Brexit means Brexit, surely we should find a good Anglo Saxon word instead. Arrow Fodder perhaps?

[ii] Pedanticus reminds me that is a rhetorical question. And as Pedanticus takes his final bow, a round of applause please. I would be lost without his belief that getting the facts right, no matter how trivial, matters.

Professor Sir Simon Wessely

05/05/2017 16:31:28

12550 miles later

When I sit down to write these blogs, I often wonder if anyone actually ever reads them. But finally, after 41 blogs, I have proof positive that someone does. I wrote recently about my Grand Tour of what was at that point 33 out of our 34 medical schools, with only Dundee to go. I mentioned in the blog, my preference for wine in glasses not plastic cups, and pepperoni spicy pizzas. So on Monday night I was doing my stuff, after which there was a party with staff and students. And guess what – yes, chilled white wine in glasses and really excellent spicy salami pizza. So I now know that I have at least one reader, and he/she lives in Dundee.

I don’t know if you noticed, but it seems like there is a General Election in the offing. As you know, we don’t “do” politics at RCPsych. Actually, that’s not true, we do a little on your behalf. I spend so much time in Whitehall that some of the policeman on the doors have started to call me Simon. One recently was positively effusive, saying that he had always been one of my greatest fans. I am not used to such a greeting, which became even more mysterious when he added that he loved my commentaries since I stopped playing. It finally dawned on me that he thought I was John McInroe, a mistake that has been made before, although never when I am playing tennis or indeed any sport.

So we do “do” politics. It’s our job. We try to influence all the political parties on an ongoing basis to keep them on the straight and narrow when it comes to psychiatry and mental health. This activity however comes to a climax when an election is called, because what we want to do is influence their manifestos. And the window for doing this is very short – the small number of days between the Prime Minister turning round and heading back inside Number Ten having dropped her surprise election bombshell in April and the manifestos being unveiled, which we are expecting next week.

Fortunately the folks here at RCPsych don’t believe in sleep, so we have already put together our list. We have quickly drawn up our wish list of absolute essentials that the next government must commit to in order to improve the nation’s mental health. Perhaps because of the 12550 miles I’ve on the train to medical schools over the past three years they feature strongly in this. Yes, 12 thousand. You read correctly.

As I have said before, and I will drone on about again countless times without apology, delivering grand plans to improve mental health services requires, above all else, people. Lots of them, well trained ones, led by consultants – or in other words us, psychiatrists. But in the last two years, numbers of psychiatrists in the NHS have dropped 4%, with drops as big as 10% in child and adolescent and older adult psychiatry. This picture looks set to worsen.

This is why we are making a strong call on the next government to commit to recruiting at least 1000 more psychiatrists, a figure which is based on those needed to deliver the Five Year Forward View which sets out priorities and policies that the NHS and Department of Health have committed to, more or less, for improving and increasing access to mental health services.

So we are saying that if you are serious on the Five Year Forward View – and all the main parties have said they are – then this is the minimum you need for now. In fact we will need even more than this if we are ever to treat all the people who need support for mental illness, rather than only helping one in three in need as we currently do.

Now you can’t just walk into your local job centre and ask if there are any psychiatrists kicking their heels there. It’s a long old road, usually 13 years between Fresher’s Week and emerging as a perfectly formed consultant psychiatrist.

You may have missed it, but the Prime Minister announced at the Conservative Party Conference in the Autumn that they are committed to recruiting an additional 1500 medical students per year, starting next year. I know – I was in the audience hiding at the back. Because I failed to leap to my feet at some of the carefully planned “applause lines” as they call it, a steward came up and asked who I was and where was my ID? When I declared my psychiatric allegiance, it was a little like I announced that I had Ebola, as those on either side of me visibly moved aside.

But as soon as I heard her commitment, it immediately occurred to me that we should lobby to ensure that this expansion was used to increase the supply of what the NHS really needs in its medical workforce –namely more doctors of whatever breed with more knowledge of mental health, and second, specifically more general practitioners and psychiatrists.

So we are calling for action to raise the knowledge of mental health of all students, and then measures that will lead to more choosing general practice or psychiatry.

We know that the variation in numbers of psychiatrists produced by different medical schools is pretty huge, almost three fold. What is going on in there? Teaching varies, some will include more elements of psychiatry in their syllabus than others. Some barely include mental health at all, which is a remarkable oversight in this day and age. So we are asking for action to ensure that the curriculae and teaching more accurately reflect the needs of the next generation of doctors.

We are also pushing for an increase in the amount of psychiatry that will be tested in the new National Licencing Exam coming soon to every medical school near you.

And then there is the Foundation Year. This year we hit the target of 45% of all medical students doing a Foundation Post in psychiatry. Great, but why stop there? Let’s go for 100%. And so that’s exactly what we’re calling for.

But we also need to go right back to when medical schools admit students, by calling for psychology A-level to be treated as on a par with traditional sciences. The very brightest of today’s school students, who are undoubtedly far more interested in and fluent in the language of mental health than my generation, must not be deterred from applying to become doctors due to stuffy attitudes that two biology, physics or chemistry A-levels are a must. Many medical schools, amongst which is my own, do not list A-level psychology as a science, which I have to say is nonsense.

There are some geographical areas and specialties within psychiatry where it is pretty darn difficult to recruit and keep doctors. Many of you work in these areas, you know what I am talking about. To solve this, we want to flatter the GPs enormously by pinching their successful recruitment campaign (after all, we have already pinched their Deputy CEO to be our new Chief Exec), and call on the Government to back a similar psychiatry recruitment drive with financial incentives to encourage more trainees to work in areas with recruitment difficulties.

And while we are calling for all stops to be pulled in order to grow the future psychiatric workforce, we need to be realistic that we can’t train people fast enough to fill the current gap unless we can hang on to the talent that we have. The opportunities for us to recruit doctors from outside the UK grow less and less – can I mention Brexit now? 41% of our trainees are non-UK graduates so we are particularly vulnerable to this. All of this means that we need to keep our experienced doctors and enable them to work flexibly as they approach retirement age.

Now why am I spending so much time on this? First, because it really matters. And second, because I am quietly confident that our work not just in the last few days, but in the months since Mrs May first announced the expansion of medical school places, will bear fruit. I am not making predictions – I remember well Tony Blair once telling Jeremy Paxman that “I don’t make predictions Jeremy, I never have and I never will”. Think about it for a second, trust me, it’s funny.

So I don’t make predictions, but I do think we may get somewhere with this.

Professor Sir Simon Wessely

06/04/2017 17:41:13

The Grand Tour

2013 seems a long time ago, a time of innocence when it was possible to say someone “came up trumps” and not immediately blush and apologise. It was also when I was running for the post of President and had to write a manifesto.

Most manifestos are largely commitments so bland that no one could disagree – one way of testing this is to see who in their right mind would ever suggest the opposite – “we will reduce crime” and “be nice to old people”. If they are too specific things can go seriously wrong – just ask Nick “No Tuition Fees” Clegg.

But in mine, I did make one concrete commitment – that I would visit every UK medical school to talk to students about the virtues of psychiatry.

Since then there have been times when I have sympathised with Nick Clegg. This usually happens on the last dreary train back to London wondering how the noisy drunks in the carriage had managed to get hold of any refreshments, given the bar was always closed, and why do we always stop at Milton Keynes when no one ever gets off there.

Do I really have to go to every medical school as promised? For a start, there are 34 – who knew that? Certainly, not me in 2013.

But a promise is a promise. I have now visited 33, just one left. If anyone else has managed to visit every medical school in the Kingdom they have kept quiet about it. Louis Appleby wrote “A Medical Tour Through the Whole Island of Great Britain" back in 1994 - ask him for a copy, there is a pile of unsold ones in his attic. But he never visited a single medical school. Nick Black’s “Walking London’s Medical History” includes a few, but the title tells you it’s written for the “liberal metropolitan elite” that lost us the referendum.

So, what did I do on this Grand Tour?

It varied. The first thing was not to do “The Speech”. Cast your minds back to when you were at medical school, think of your graduation ceremony. You have your degree. You are now a doctor. But before you can get out of the hall, spend some polite time with your parents and impolite time with your friends, you have to endure "The Speech".

It’s given by someone three times your age, whom you should have heard of, but never have. They have achieved or won something, most probably a prize for smugness. And inevitably they will share with you the secret of their success, which is usually “you need to be in the right place at the right time”. Which is just about the most useless piece of advice ever.

And now I am that person. So, I try not to give “The Speech”. If pressed, and I often am, to give advice, I will with reluctance share three tips. Don’t invade Russia. Don’t email when drunk. Don’t accept a police caution. All very sound I think.

So instead we talk about anything and everything. Sometimes they want a “set piece”, but more often it’s a PowerPoint free for all. And all sorts of things can happen. The GMC would like the public to believe that all medical schools are the same. They aren’t.

A slice of student life

Some things though don’t change. Medical students’ desire for pizza remains insatiable. Birmingham and Manchester had the best selection. Nottingham meant well - pizza was ordered, but unfortunately in the singular not plural, and one duly arrived for a full lecture theatre.

Audiences varied - Brighton filled the main lecture theatre, only to be beaten by Newcastle where we had an overflow. Wooden spoon to UCL though - we barely filled a broom cupboard because of a clash with a surgical revision lecture. Exams still conquer all.

Some were more active than others – at QMUL my visit was linked to a premiere of a Wellcome-funded play on veterans and PTSD. Cue an amazingly lively discussion – ditto watching films on trauma in Belfast.

Different debates

Topics raised also differ. Oxford seemed split down the middle on the need for safe spaces and trigger warnings, but Swansea didn’t seem to know that the debate was even happening (and no, it wasn’t because the Welsh have a different word for it).

But the least PC evening of all was spent at the Med Soc dinner at an unnamed Cambridge college, where I gave what I thought was a slightly risqué after-dinner speech.

I always try these out first on my sons, who like most of the youth of today turn out to be rather more censorious than we were. "Dad, don't you dare say that" being both frequent and wise advice.

But after I had finished, each student had to tell a joke, and I was transported back 35 years to a junior doctors’ trip to a Gateshead Working Men's Club to listen to Roy “Chubby” Brown, a northern comic whose act was so utterly blue that he made Jim Davidson or Bernard Manning sound like Marcel Proust.

I gradually became a convert to new medical schools and graduate entry. At Lancaster, UEA, Brighton and elsewhere there seemed to be a correlation between the number of graduate entrants and interest in psychiatry.

There was also a correlation between senior turn out and student interest – step forward Belfast, Birmingham, Exeter, St Georges, York and a few others. The presence of the Dean made a difference – chapeau to Plymouth, Swansea and York. And so on.

Ask the audience

What was obvious everywhere is that interest in mental health is soaring. Sooner or later I was asked about why there has been a rise in mental disorders on campus, and what should we do about it.

As I don’t know the answer to either question I would usually ask the audience.

Inevitably there was a range of opinions and solutions, although not many went beyond the need for more counsellors.

Many quoted the recent NUS survey (or indeed had carried out similar surveys on their own campus) that found that 80% of students had “mental health problems”, but fewer seemed to be willing to critically evaluate this unlikely finding.

It’s important that we apply some critical thinking and appreciate the difference between “mental health” and mental disorder. But NUS surveys aside, mental disorder is indeed on the rise, at least among women who are aged between 18 and 24.

However, the best estimate is a prevalence rate of 26%, not 80%. So we can agree that there are more students needing more support, including on occasion specialist support from psychiatrists.

Beyond that I found myself falling back on the need for more evidence about the causes of this increase and the need to respond in an evidence-based way.

This is not a final appearance in these columns by my old friend “Pedanticus” – it’s because if we don’t we may end up sometimes at best wasting resources for no benefit, and at worst making things worse.

So in order to encourage more critical thinking I sometimes ask the audience how many of them are making friends that they would keep for life - 80% raise their hands, and then how many were being intellectually stimulated by their studies (a similar proportion) and finally how many were having better sex lives (we don’t vote on this, but judging by the smiles it was also a majority).

A time of challenge and change

I did this to suggest some continuity – university remains a time of challenge and change, incorporating both the negative (such as loneliness, isolation, exam stress) and the positive (such as emotional growth, friendship, stimulation and experimentation), and that we should be cautious of invoking mental health problems for all of these.

Of course, there are also discontinuities - social media acts as a great amplifier of both the bad and good, but we should be careful of blaming the medium for the message. Parenting styles and risk obsession have changed over a generation. And let’s not forget the additional burden of debt (thanks, Nick).

But whatever the answer to rises in mental ill health, and at the moment I think we have to say we don’t really know, the challenge for us in psychiatry is to harness this interest into making more psychologically minded doctors in general, and more psychiatrists in particular.

The interest is there, believe me, despite the rear-guard actions of some of our colleagues in other disciplines (when I asked those who had decided to do psychiatry how their teachers had reacted, the answers were predictable and depressing). The challenge remains to translate this enthusiasm and interest in mental health into a similar enthusiasm for psychiatry.

And then we would finish. Sometimes we adjourned to a lovely country pub (Plymouth and Swansea score highly) or a student bar (Birmingham, Glasgow remain in the memory) or trendy restaurant (Leeds and Brighton). And then to either a nice hotel (thanks, Edinburgh and Exeter), a not so nice hotel (lips sealed) but more often on to that dreary last train.

My favourite

Which was the best? As Bruce Forsyth tells every Strictly contestant “You are my favourite,”, and so it proved. Wherever they are, medical students remain bright, committed, lively and engaged, much more so than my generation ever was.

And now there is just one medical school left to visit. Dundee in May. So, if you reading this, Dundee, you know how to make me happy.

Lively students please – although I am not sure there is any other kind which is reassuring. Some food afterwards – a country pub is good, pepperoni pizza if not.

And if there is white wine, any chance that it might be chilled and not served in plastic cups? And please can I take the train home that doesn’t seem to have a fatal attraction to Milton Keynes?

Professor Sir Simon Wessely

21/03/2017 10:50:38

Psychiatry without borders but with at least one wall: our International Congress will be the biggest ever. Fact.

2017 for me began, as I suspect it did for many of you, with being asked to offer diagnosis on the U.S president. I declined, not least because many of the things that people find unpleasant or scary about him - misogyny, aggression, rudeness and so on - are not evidence for mental disorders.

But if not as a psychiatrist, just as a member of the public, it is hard to avoid a certain morbid interest in the man - one can't get him out of one's mind, no matter how hard one tries, and believe me, I do try.

As I start to make notes for my final speech as president at Congress 2017 I can't help but think how would Donald do it. I did ask him over for the event, promising we would all be off-duty, but he declined. So what follows is the product of a fertile imagination, access to a twitter account and switching "Verb Block' on spellcheck.

Loyal congress attenders (you are very good people) will know that the Royal College of Psychiatrist’s International Congress is always great.

Birmingham 2015 and London 2016 saw the Congress’s biggest gatherings ever. That's a fact. 3000 delegates from about 50 countries. The experts, the top ones, said the academic programme was the best ever. It was. Anything else is lies. From extremely dishonest media.

But it can and will be greater in 2017. LET'S MAKE PSYCHIATRY GREAT AGAIN.

A great city

We’re off to Edinburgh this June. It's a great, great city folks, seriously, I go through it regularly on my way to play golf. It looks lovely. And Congress 2017 is going to be huge.

They tell me it always rains in Edinburgh. Nonsense. I have talked to the right people. There will be no raining falling upon Scotland during the congress. Guaranteed.

Walls? Yes, we can do walls. They tell me there is a good wall up there to keep the English out. We will get it working again. And the Romans will pay. They shouldn't never have let it get into that state.

You’ll get the best

And we get you Congress goers the best.

Professor Karl Deisseroth, who is more hotly tipped to win the next Nobel than Chelsea is to win the Premiership, joins our campaign from Stanford University. Professor Deisseroth is a practising psychiatrist and pioneer of optogenetics (in Trump-speak this translates to lighting up brains in a very clever way). Very high tech, great, great stuff.

OK, enough already. I can't write this stuff anymore. Verbs and references to the Premier League keep slipping in. So let's return to something more like English and which hopefully won’t trigger panic attacks in the reader.

The biggest brain

We will also have last year's winner of the world’s biggest brain prize, the Brain Prize, Professor Richard Morris, known for ground breaking work on tackling Alzheimer’s through understanding memory. He will be exploring novelty and familiarity in consolidating memory. And conveniently for us, he just needs a bus fare across Edinburgh.

Those of you who joined us in London for Congress 2016 might have enjoyed seeing me royally outwitted by Jo Brand. Or not. Jo is known for many things but not for fancy footwork. Unlike Deborah Bull, the prima ballerina turned cultural tsarina, who will be keeping me on my toes in interview this year.

Thought for the day

We will also welcome Professor Mona Siddiqui, the doyenne of Thought for the Day and much more, who will talk on passion, piety and psychosis in medieval Islam. Or do I mean with passion on piety and psychosis?

I can personally recommend Professor Ian Deary's session on cognitive ageing. I have known Ian since we were trainees together back before the First World War. Which means on the topic of cognitive aging he knows his stuff.

A strong pitch for the least Trump-friendly session is made by Professor Michael King, talking of the impact of stigma in psychiatry through the lens of sexuality and gender. Although I doubt Donald would be first in line to attend our debates on climate change and mental health or the advocacy role of psychiatrists working with LGBT people either.

He may still put in an appearance at our guaranteed sell out show (and that is a real fact) "Neurology for Dummies" by Carson and Stone, Edinburgh's answer to Laurel and Hardy. And then you get me, giving my last speech as President. Turn up just to make sure it is my last. Turn up to make sure my last audience is the biggest.

Register to attend here - it's cheaper if you do it before 31 March 2017. We don't have any numbers but I guarantee that International Congress Edinburgh 2017 will be the largest ever. It's a fact. Look at the photos. They never lie. Unlike the media.

Oh no, it's happening again. I have to stop. Need to tweet. Now. Fact.

Crowded Street in Edinburgh Deserted Street in Edinburgh
Copyright William Starkey and licensed for reuse under the Creative Commons Licence Copyright Adam Ward and licensed for reuse under the Creative Commons Licence

Professor Sir Simon Wessely

07/03/2017 11:45:56

The gentle art of winning friends and influencing people

Dale Carnegie’s “How to Win Friends and Influence People” is one of the most successful books ever written. Since 1936 it has sold over 30 million copies, and is the 11st highest selling non fiction book on Amazon. It is part of a self help tradition that goes back to Samuel Smiles, although I prefer Toby Young’s “How to Lose Friends and Alienate People”. Failure is always more amusing than success.

But making friends and exerting influence is a core part of what I am supposed to do as President. And like everything that is important, no one ever tells you how to do it, although they are always on hand to let you know when you have done it badly. Indeed, much like Toby Young, I remember rather more easily how I failed to influence people than when I succeeded.

But let’s have a go. A journalist writes a bad piece on antidepressants. I immediately write an email telling him that this is ridiculous, ill informed, prejudiced and will cause great harm and distress, and I will be complaining to the editor. And then delete it. Why? What does Dale say? “Try honestly to see things from the other person's point of view”.

You are dealing with a professional journalist. They are just reporting what someone told them, or what was in the press release. It’s a story. And as anyone who has read Nick Davies “Flat Earth News” knows, they will probably have written three other stories today, plus tweeted, blogged and so on. They are tired, and don’t have time to do a literature search, Cochrane review and lots of interviews. They are just doing their job.

So now you try again. Send another email, or even better pick up the phone. You congratulate them on a well written piece. Perhaps however because of space they over simplified a bit. Maybe they would like to return to the subject at a later date? How can you help? Would they be interested in a “comment” piece, bringing the reader up to date with some new research?

Always have a story

Now what about a politician? Two rules. First tell a story. Politicians love stories. I have given evidence on numerous occasions to select committees, commissions, ministerial round tables, consultations etc on the subject of military mental health.

Often we turn to the topic of mental health screening. They tell me of a terribly sad case of a young man recruited to the Armed Forces who comes back from deployment in a very bad way, and sometimes has done something terrible to himself or someone else.

The politician says it’s a disgrace that they weren’t screened before they deployed – because all this would never have happened. I can talk statistics, NICE criteria, evidence – I can see their eyes glaze over. But if I agree, and then ask them if they can think of another constituent, from the same sink estate, left school at the same age with no qualifications, had a father in prison and a mother on the bottle and so on, and who also joined the Army?

They usually can. How did that person do? “Really well, actually, became a Sergeant Major, I gave him a medal on the home coming parade a few months ago”.

“Well, if we had screened out your first case, we would also have screening out this chap and four more like him”.

They get that. I could have sent them our study showing this, and our new randomised controlled trial only out last week, and they wouldn’t even have opened the email. But a story they will remember for ages… (BMJ research article, IOPPN press release)

So always have a story.

Enlist help

And even better than you doing this, get patients and relatives to do the job for you. Give them the address of their MP. One of the virtues of our system is that even if your MP happens to be a Secretary of State or even Prime Minister, sooner or later they really will see you. It makes a difference.

And ride the wave. Mental health is fashionable. More and more people “get it”. And even those who don’t really get it, which is probably still the majority still, they know that they are supposed to, and that’s almost as good. You and I know that we deal with mental illness, but, button your lip for the duration of the meeting, and talk mental health and well being until you are out of the door with the commitment that you wanted.

Get allies. When I started in psychiatry it was fair to say that the main user group, MIND, didn’t like us and the feelings were reciprocated. A lot of careful work by my predecessors has reversed this. And now we are alongside MIND in the Mental Health Policy Group, which contains the six key influencing organisations in the field. When we hunt as a pack we are a very powerful lobby – as was the case with the Five Year Forward View and also getting a voice, not a large voice, but still a voice, in the Holy of Holies, the Treasury.

And then lobby, lobby and lobby again. Politics finally depends on people. Get to know them. It is fashionable to be cynical about politicians, but I have a shameful secret that only now as I come to end of my term I am now prepared to admit. I like most politicians. There, I have said it. Nearly all work very hard and don’t actually get that much pay for the hours.

Try, try again

Very few will reach the glittering prizes, but that doesn’t deter them. I have now dealt with 11 ministers for veterans’ health during my time working in that field, from all main parties. All but one were very good. 90%, wasn’t party political. Most really wanted to do the best they good for those who have served. And I find most politicians, once they have decided that you aren’t secretly filming or recording them, are decent people with a sense of humour and of the absurd. I did say “most”, not “all”.

But whatever their personality or party affiliation, my job is to get to know them. It is important to develop personal links. It sounds cheesy but it is. And how does one do that? If at first you don’t succeed, try, try and again. And if that still hasn’t worked, befriend the person who keeps the minister’s diary. They know what’s going on.

Lobbying works. Sometimes. We have lobbied I think successfully for changes to the Prevent programme, Mandatory Reporting on Child Abuse, sensible outcome measures (well, more sensible than they would have been if we hadn’t bothered). the way in which NHS Digital use data, persuading NHS-E to accept the findings of the Crisp Commission on beds, and many more.

And what about the longer game? When I started this role we went through a big review of our communications, which wasn’t easy. But in the end we decided that what we really wanted to be was not so much a campaigning organisation - there are organisations better placed to do this.

We want to become a trusted source of advice – to be in effect a calm, authoritative voice for mental health, one that is visible, credible, and useful. And I think we are achieving that. Here’s one example – in February 2015 we had 106 media pieces with audience reach of 30 million, Last month it was 283 media places reaching 100 million.

We’re trying to use digital more effectively too. See our short video for Members which explains what you can do to embed recommendations to improve acute adult psychiatric care in your Trust. It’s just one of many improvements we’re introducing, I hope you like it.

Finally, being a psychiatrist can be a help. After all, Dale Carnegie said that one of the best ways to exert influence was to “become genuinely interested in other people”. If we aren’t, then who is?

Professor Sir Simon Wessely

27/02/2017 11:47:29

Happy Birthday to the Crisp Commission on Beds, sorry, the Independent Commission on Acute Adult Psychiatric Care, CAAPC

What you can do to bring about its findings and why you should.

Anniversaries are great. Excuse for a party. An excuse for attention. Also an occasion to review work and monitor how it’s going.

We have a one-year anniversary to celebrate. One year ago the independent Commission that we set up to review the provision of acute adult psychiatric care published its findings.

Gosh, that was ponderous. Let me try again.

The Crisp Commission on Beds, as we definitely don’t call it but let’s be honest that’s what it was all about, hit headlines a year ago. I hit local radio (“Good morning Professor, this is Radio Three Rivers, please let the people of LoamShire know what your report means for them, before the traffic news”). Lord Crisp, who ran the NHS and is still a Big Cheese and thoroughly decent bloke, did the top billing on the Today Programme. He scored a blinder when John Humphrys tried to change the subject, only to be firmly put in his place: “No, this is what always happens when we talk about mental health – you try and change the subject”. Blissful.

OK, what did it conclude?[i] A lot, all on how to improve access to and quality of acute mental health care, as you can see here)

And what has happened since? Again, a lot - you can find our progress report here - and we expect even more to come, with a formal response to the report from the central NHS bodies expected to land on our desks in the next few months.

For those with short attention spans here are some of the Commission’s key recommendations and the progress made so far towards their implementation:

  • Recommendation: Out-of-area-placements (OAPs) to be eliminated
    Progress: The Government has committed to eliminating OAPs by 2020/21. A national definition of OAPs has been agreed at long last and national data is now collected.
  • Recommendation: Introducing four-hour waiting time targets for access to acute mental health care
    Progress: An evidence based treatment pathway (our favourite sort) for acute mental health care is currently being developed and will be published this Spring, including clear recommended response times and quality guidelines and benchmarks.
  • Recommendation: Ensuring Crisis Resolution and Home Treatment Teams (CRHTs) are well enough resourced to offer alternatives to inpatient admissions
    Progress:
    More that £400m for CRHTs will be introduced over 4 years from April 2017.
  • Recommendation: Better collection and availability of mental health data and transparency around funding
    Progress: More dataset changes will be implemented this Spring to provide more robust information on acute care services including use of different types of bed and delayed transfers of care.

But those of you who haven’t retired, left the country or joined a quango, must have noticed that despite this progress pressures upon acute adult services have not disappeared.

One of the most visible symptoms of this is out-of-area placements, where unwell patients have to travel long distances for care due to lack of local beds or appropriate care in the community. Last December more than 500 patients still had to travel out of area to receive care.

Don’t despair. Skilful footwork meant that we got many of our recommendations incorporated in the Five Year Forward View for Mental Health, which has been accepted by NHS England (Five Year Forward Views are all the rage at the moment, and if you haven't got one you are not just at the back of the class, you are outside the school gates pressing your nose against the bars). This means that the implementation of these recommendations really will be pushed with support of central bods, or at least they should if we continue to keep our beady eyes peeled.

But it’s not all about government, NHS England and a jumble of quangos. Frontline efforts are equally important when it comes to changing things and stopping OAPs. And that means you. So what you can do?

And for those who still have a sentimental liking for the printed word, read on. I do apologise if unacceptable levels of NHS jargon slip in

1. Achieving the right balance of provision between inpatient and community care

As the Commission stated, the solution to pressures in adult acute care is not necessarily more beds. Sometimes it is, sometimes it isn’t. Delivering accessible, high-quality care requires sufficient local beds but is also reliant on sufficient alternatives to admissions, including crisis resolution and home treatment teams, rehabilitation services, community mental health services and supported accommodation.

Robust service capacity assessments are crucial for determining care needs, eliminating OAPS, reducing waiting times, and high-quality assessments. Good models of service capacity assessment are already used by many Trusts across the country. Now is time to do this systematically.

You can help your local area deliver the right balance between the different elements of the acute pathway by encouraging your Trust to undertake a service capacity assessment with commissioners, and to act on this.

Once capacity is assessed, encourage your Trust to undertake a quality assessment. The College Centre for Quality Improvement (CCQI) is developing a scheme to allow your areas to self-assess against access and quality guidelines. These guidelines – developed by our own National Collaborating Centre for Mental Health (NCCMH) for NHS England and NICE - will be published this year and recommend a four-hour standard for accessing acute care. Exactly what the Crisp Commission recommended. What a coincidence.

2. Improving services through better data

As psychiatrists, we spend hours inputting data and can be disheartened if they are not well used. Nonetheless, better data is essential to improving services and accountability. As mental health has long lagged behind physical health data this is doubly important. I have bored for England on this before.

But before you yawn, remember - robust data is a Good Thing. It can be used to hold commissioners and providers to account. We can tell when they are being naughty, not eliminating OAPs, or implementing guidelines and benchmarks. And Lord be Praised, the data we need to torment and chastise them will be available from April. And we sure will torment and chastise.

You can help. Please encourage your Trust to: (1) submit OAP data monthly; and (2) return data to the Mental Health Services Data Set (MHSDS) which will be annually reviewed to ensure information is fed back to you in a way that makes sense.

This will mean a bit of your time. So whilst you are at it, continue to encourage your Trust to implement streamlined IT systems. Some do, some don’t. Those that do make your life easier.

3. Revolutionising ways of working through Quality Improvement

While you might be familiar with clinical audits and peer reviews, it’s less likely that organisational Quality Improvement (QI) approaches are part of your team’s day-to-day. QI techniques can revolutionise ways of working and help reduce bed occupancy, length of stay, OAPs, sickness absence and patient complaints.

This is why the College is supporting development of QI knowledge and skills amongst members, mapping learning needs, setting up a network and ensuring QI is embedded in the curriculum of future psychiatrists. Pedanticus may point out that QI seems very similar to “clinical audit cycles”, and Pedanticus might have a point. But for a thing to keep happening, it has to change its name once in a while. Remember, “standing still is not an option” even if it’s the right thing to do.[ii]

Again, you can lead by highlighting to your Trust the importance of implementing a system-wide approach to QI and setting up QI training for inpatient staff. Your Trust can work with commissioners and clinical networks to share good practice which other areas less fortunate than ourselves (your neighbouring service, not your own of course) can learn from.

You may find it hard to believe, but psychiatrists, indeed all doctors remain incredibly important in bringing change. One mental health CEO recently said to me – “I am not a great fan of doctors, but if you want change, you have to bring the doctors with you, or it won’t happen”. Most CEOs really do like us – they wish we got more involved in these issues, not less. Like it or not, as leaders within your local services, you are well-placed to spot triggers for action, and to take action. By doing so, you will play your part in bringing about the changes suggested by the Crisp Commission on Beds, sorry, the Commission on Acute Adult Psychiatric Care. And then we will invite you to the champagne second anniversary party next year.

Our animation to mark the report’s anniversary contains a checklist of actions you can take to improve acute care in the areas discussed above.

Further information about the progress made so far can be found on our website.

To find out more about the Commission, visit http://www.caapc.info/.

Join the discussion on social media using #CAAPC.

 

[i] My old friend Pedanticus has popped up to remind us that:
a) the Commission didn’t cover Scotland or Wales.
b) it did cover Northern Ireland, but in a separate report and I’m afraid its first anniversary isn’t for a few months, so it doesn’t get the champagne and flowers 'til the summer.

[ii] To be fair, which I rarely am, QI isn’t quite the same as clinical audit, but I like to have a rant from time to time.

Professor Sir Simon Wessely

03/02/2017 14:32:59

Busy times, a royal riddle and dinner with a prince

It’s all happening at the moment, folks. I used to moan that we never got enough publicity. Suddenly I am nostalgic for those good old (quiet) days.

We have been talking on prison suicides (a predictable and self-inflicted disaster for which someone, and we all know who, should be held accountable). There has been the regular drum beat that antidepressants spell the end of civilisation (no they don’t).

There is a Panorama running on Monday night about problems in mental health care. I haven’t seen it, but am confident about two things. First, that my long interview will be reduced to ten seconds, missing out all the important bits and second, yet another Chief Executive will be heading for the tumbrils.

Their life expectancy is not much better than a first world war Flying Officer.

On the other hand, if you want something funny (funny peculiar I am afraid, not funny ha ha) listen in to the Life Scientific (BBC R4, Tuesday 14 February).

 

On the move

And I have been using my new bus pass. How long I will have it remains to be seen, since 30 minutes after it dropped on the mat, Simon Stevens was on the radio announcing that stopping perks like free bus passes was the only way to save the NHS.

But before he removes the only good thing about turning 60 I have been on the move. Health Education England to talk about the mental health workforce – yesterday the new data on career destinations of Foundation Year was slipped into the public domain.

It’s bad news for the profession – numbers of those going into higher training has declined for the fifth year running – but actually a little glimmer of light for us – psychiatry has shown a small but definite upturn.

Then back on the bus for multiple trips to the Department of Health and NHS-England– IAPTS, Out of Area Placements, CAMHS leads, addiction services and the lack of them, and so on.

Then the Ministry of Justice, followed by a stroll round the corner to talk sex with the Bishops, and then back to Home Office, and more Prevent.

We continue to work with them, DH, GMC, the police services and Uncle Tom Cobley about this.

Come to the Presidential Lecture on 14 March for a real bean fight about this, as we let Derek Summerfield off the leash.

But in the meantime we continue to steer the difficult path between our legal duties to prevent terrorism (a duty on every citizen), our duty to try and help those with mental disorders who might also pose some risks to themselves or others (familiar territory) and our duty not to cross ethical lines.

 

Knowing our history

One of the reasons I like psychiatry is that we as a profession are aware of past and present misdemeanours - political abuse of psychiatry in the old Soviet Union, or more recent dubious practices by psychologists in Guantanamo Bay. We know, and need to know, our history.

Which brings me by a tortuous and twisting path to history, which is what I want to write about today. I and probably you need a break from NHS politics and the constant game of “Cherchez l’argent”.

So I want to talk about America and a despotic ruler who many think is mentally ill. No, no, no, not him – I said this was history. We are talking George III.

Most of us only know two things about George. He lost us America and he went mad, although those with a degree in Advanced King George Studies might have heard that he wasn’t actually mad, but suffering from porphyria.

You may have caught last Monday (31 January) a BBC 2 documentary called “George III: The Genius of the Mad King”, which challenges all the above, as well as including a cameo from the Queen, standing next to a historian in full flight, whilst her expression says “I have no idea who you are, but you are clearly deranged”.

I shall leave the “Losing America wasn’t George’s fault” to others, and stick to psychiatry. Now making retrospective psychiatric diagnoses of historical figures is fraught with difficulty. There usually aren’t medical notes, and even if there are, the meaning of the words used have usually changed over time. The disorders themselves may also have changed.

However, one advantage of being a monarch is that there is plenty of material to study, especially as now we can read the letters he wrote whilst ill and when well. Even then, caution is needed. The illness of a King was a delicate matter – one of his doctors resorted to hiding the unpalatable truth behind Latin even in his private diary, writing that “Rex noster insanit” - Our King is mad.

 

The most likely diagnosis

The most likely diagnosis is that he was suffering episodes of mania, a severe version of what we now label “bipolar disorder”.

The over excitement, pressure of speech, sexual disinhibition, excessive disorganised activity, sleep problems and so on are characteristic. We are taught to look out for grandiose delusions - such as believing one is, or is related to royalty, as another feature of mania.

This doesn’t work so well when the patient is a genuine King, but the records give plenty of other evidence of delusional thinking common in mania.

Watch the programme also if you want to know why 5 December 1788 is the birth of our speciality and indeed ourselves.

But what about the porphyria? Everyone who has seen “The Madness of George III”, with the King so brilliantly played on stage and screen by Nigel Hawthorne, will remember that the film concludes by informing the audience that the King wasn’t mad at all, but had a rare metabolic disorder that only looked like madness.

The script suggests that the pompous doctors, played as comic turns, overlooked this, and it was only his servants who noted that the King’s urine returned to its normal colour as his mind returned - a classic sign of an episode of porphyria.

It was two psychiatrists, the mother and son team of Ida MacAlpine and Richard Hunter, who first proposed this diagnosis in 1968.

True, there were symptoms that might have suggested porphyria, a genetic disorder which has been found in some members of the Royal Houses of Europe. But later critics highlighted serious mistakes and inconsistencies in the sources, and that mania was more likely.

The question resurfaced ten years ago when scientists analysed a lock of the King’s hair, hoping this would prove that he had genetic evidence of porphyria, but they failed to extract any DNA, so it is as you were.

Why did the theory of porphyria gain such traction over the years? MacAlpine and Hunter were disillusioned. They were fed up with psycho analysis, and instead believed that most mental disorders were caused by either known (such as porphyria) or as yet unknown organic physical conditions.

Diagnosing an organic metabolic disorder in one of the most famous “madmen” in history would be a wake up call to modern psychiatry, and also remove the stigma or taint of mental illness from the Royal Family.

 

What can we learn?

Are there any lessons here for us? MacAlpine and Hunter’s wish to remove the stigma associated with mental illness remains a noble cause.

But instead of directly combating that stigma, their preferred method was to say that he wasn’t really mad at all, but had an organic and hence legitimate disorder.

They were probably mistaken in their preferred diagnosis, but that misses the point. It is wrong to go looking into the urine, even if Royal, solely to prove that this is a real disorder, as opposed to unreal mental illness, which was MacAlpine and Hunter’s position.

We do research to better understand bipolar disorder, and to develop better treatments, but not to prove it exists.

Now let’s fast forward to King George’s descendants to see how much times have changed. And a quick warning that the noise you are about to hear is the sound of a name being dropped.

Last week I hosted a private dinner at the Royal College of Psychiatrists attended by HRH Prince Harry on how we can improve the mental health of our current serving and ex serving personnel.

These things are off record, but I can say (and I swear I am not grovelling) that he was bloody good, and impressed even the old lags like me around the table.

The Heads Together campaign which the younger Royals lead is directly challenging the Hunter/MacAlpine assumptions that there is a hierarchy of illness, in which physical illness is placed above mental illness. King George would have approved.

Professor Sir Simon Wessely

 

23/01/2017 10:32:04

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

06/12/2016 14:29:11

All I want for Christmas is some good data

It’s not been a great year, has it? If there was an award for “Worst Year Ever”, 2016 would be up there in the Top Ten. OK, 1914 and 1939 are above it – 2016 hasn’t heralded the start of a World War. In 1347 the Black Death reduced Europe’s population by a third - so things could be worse.

But for my lifetime at least, 2016 is going to get the Oscar. It has been rubbish, hasn’t it? We had the referendum which doesn’t seem to have magically released millions a week for the NHS.

Then there is that man with the terrible haircut. Yes, our American friends have elected a bull and placed him in the china shop. Perhaps it will all be all right on the night. And perhaps it won’t.

We had the junior doctors dispute, from which no one emerged a winner. A Secretary of State who finds it difficult to visit front line medical services because of the welcome he might receive. Junior doctors demoralised and still angry. A host of issues around the workforce that are nothing to do with the contract unresolved.

And England lost to Iceland [i].

OK, I feel I am about to succumb to what the poet Horace called “laudatory temporis acti”, loosely translated as “it was better in my day”. And in some ways, it was. But it’s not all been bad. Yes we lost to Iceland - but I was spared watching the ignominy because I was at a dinner celebrating our Pathfinders - 50 of the best and brightest medical students being supported by a generous donor to help them kick start a career in psychiatry. And that dinner took place on the first day of our International Congress at the Excel - our biggest and best yet. Yes, John Sweeney made me demonstrate my inner dancing Ed Balls on stage, a ghastly sight. But apart from that, it was plain marvellous. We had the serious - I don’t think anyone who saw the exhibition bringing back to memory those murdered by the National Socialists for the sole “crime” of being mentally ill or learning disabled, would not have emerged moved to the point of tears by the experience. We had the playful - interviewing the magnificent Jo Brand being my favourite. We had the spectacular - dinner in the Painted Hall at Greenwich Naval College as part of our send off for the longest serving Admiral in our fleet - Vanessa Cameron. And throughout it all a steady stream of exciting, challenging, thought provoking, entertaining and informative symposia, lectures, debates and more.

Congress is but once a year, but the work of the College goes on. And there is much to cheer us up. Now I am not going to give you all the Xmas presents at once, as I think we will all need a bit more cheering up in the months to come. So instead I will wrap a couple of successes in Christmas tinsel and keep back some others for later, perhaps when TIDS really starts to bite (Trump Induced Depression Syndrome).

So let’s talk data. The boring boffin that lurks in me gnaws at my conscience over the issue of data in all shapes and forms. We need reliable and transparent data so that we can make the right decisions about how to shape our services and so that the public and their representatives can hold those who make the decisions to account. That’s why we have worked collaboratively to get a system in which everyone can see how much and on what their local CCG is spending our money on mental health services in particular. In NHS Speak, this means a “dashboard”. And last month we finally got one. We immediately started analysing the mental health spends, current and projected, and naming and shaming those CCGs not pulling their weight. We used what the military would call a “combined arms” operation - using policy to get and analyse the figures, our parliamentary liaison to let local MPs know who was being naughty, and then our media and digital teams to get in touch with local media. In CAMHS for example, the spend per person varied from a low of £2 to a high of £144 - a massive variation. The squeals from those at the bottom of the class was a joy to hear and it turns out that some of them hadn’t supplied NHSE the correct numbers, and omitted to check their entries for accuracy either pre or post publication. This transparency lark is clearly a bit new to some of them, but hopefully they are on a steep learning curve because we’ll be checking, analysing and publishing our findings every quarter.

Over the lifetime of my career, it has become harder and harder to get good data for research. Nearly 30 years ago I needed to obtain the criminal records of over 1,000 patients known to have had schizophrenia in Camberwell over the previous 50 years. I wrote to the Home Office with the request, and a few months later the data arrived, all hand written by some poor junior civil servant. I think I had to sign a form, but frankly it wasn’t much more onerous than that. Looking back, I can see that system was probably too slack, but in the intervening years more and more barriers have been erected to the sharing of clinical data for bona fide purposes. But the good news is that over the summer we managed to prevent the erection of yet another barrier that would have had a very serious impact on mental health research and much else besides. NHS-Digital decided with the best of intentions that special safeguards were necessary to protect mental health data flows within the NHS, because these were seen as particularly sensitive and vulnerable to re-identification or hack attacks. We disagreed, arguing that it would hinder vital research and further disadvantage the already disadvantaged and marginalised. I made the case at the Board that if parity meant anything, it meant that we should treat mental and physical data the same. And I am pleased to say that NHS Digital did not dig in their heels, rather the opposite, and our suggestion is now policy.

Yes, I am indeed a boring boffin when it comes to data. But boring boffins are important, because data is important. Access to good quality data is fundamental to understanding our health care system. I would go further and say that it is a pre-requisite for a functioning democracy and civilised society. If you don’t believe me, check out Andrew Dilnot’s “A History of Britain in Numbers” or follow the marvellous “More or Less” Radio 4 series.

OK those are your Xmas presents for the moment. But if you were struggling to curb your excitement as they were unwrapped, I promise I have a few more bits of good news to see you through to the Spring.

But for the now, best wishes to one and all. Have a good break if you can. Notwithstanding some pieces of good news for us, there is no point in hiding the fact that overall it’s tough at the moment in the Health Service, and it’s going to get tougher. So as Sgt Esterhaus said at the start of every episode of the best cop show of all times, Hill Street Blues, “let’s be careful out there”.

[i] Pedanticus writes “not everyone reading this blog supports England, Simon. And the Welsh really did well."

Professor Sir Simon Wessely

 

 

 

 

 

 

 


 

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Professor Sir Simon Wessely

   

Professor Sir Simon Wessely

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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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