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

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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

03/11/2016 14:15:42

STP or not TP - that is the question

Let’s start with a little warm up exercise. I give you some initials, you tell me what they stand for. For example, I say NHS, and you say “outmoded concept that we cling to only out of nostalgia for the past and the sooner we get into a proper market driven system the better”, because you have been reading that Oliver Letwin again. OK, not the best example. Let’s try again. BMA. ECG. USA. Easy.

How about STP?

I am betting that caused some problems. But it might be something that you really need to know about.

STP stands for Sustainability and Transformation Plans (STPs). Some of you will be none the wiser, which is exactly the point of most initials that emerge from the NHS bureaucracy.

STPs are the brain child of Simon Stevens. I’ve mentioned him before because he is a Very Important Person. He also has a Very Big Brain (no, really he does) and for unknown reasons also now a rather fetching beard. Simon is the boss of NHS-England, high on the list of “Impossible Jobs that no-one in their Right Mind would Contemplate”. Simon wrote the NHS Five Year Forward View which I have said nice things about because it is indeed sensible, short and rather well written.

In the plan, Simon outlined the future of the NHS. He talked about how the NHS would survive in times of financial hardship, the importance of transferring care from expensive secondary care hospitals to primary and community care, why social care mattered, and why we needed to integrate physical and mental health care. All stuff we agree with.

But it was a bit light on how these things might happen. And after Lansley’s Monster, otherwise known as the Health and Social Care Act, getting things done in the NHS has not proven easy.

So he came up with the STPs. Every health and care system is now required to produce an STP, showing how local services will evolve and become sustainable over the next five years. These plans cover all CCG and NHS commissioned activity meaning commissioners and providers must come together to jointly plan services for a larger population. That’s an exercise in itself - since it becomes a bit like a version of the Prisoner’s Dilemma - everyone needs to co-operate to try and maximise the resources they can get, but equally need to compete to make sure that their own organisation gets the biggest slice of whatever cake there is.

In short, STPs are about trying to improve health and getting more care where it is needed. Nothing wrong there. But there is a sting in the tail in the words “sustainable finances”. We all know what that means, just like we know what cost improvements are. Don’t be fooled, part of the agenda is saving money. And as the NHS finances get worse this part of the agenda gets larger and larger.

So what about mental health? Well we know that NHSE is serious about making sure that CCGs spend more money on mental health, and we know that STPs are supposed to reflect it, with nine “must do” priorities, one of which is implementing the 5YFV for mental health.

But are they? When we look at what those who are drawing up the plans think it’s all about, mental health doesn’t seem to get a look in. Although NHS England has published an aide-mémoire for mental health and dementia to try and concentrate minds but this is only guidance. Which means that local areas don’t have to articulate how they will meet all of the targets of the Taskforce Implementation Plan.

And that is a bad thing. The things that the CCGs will be measured on - access standards for Improving Access to Psychological Therapies (IAPT), Early Intervention in Psychosis (EIP) and eating disorders are limited in their scope. Other priority areas - like child and adolescent mental health services - will continue to be variable across the country. And that’s certainly what we have been hearing from some of our members.

Now NHSE is not oblivious to these concerns. There is an impressive team now working on getting some results. Tim Kendall of this parish has taken on the mantel of national Clinical Lead, Karen Turner is the senior civil servant, the person who knows how the system works, and Claire Murdoch, the CEO of Central and North West London, is tasked with knocking heads together on the delivery of the 5YFV (please tell me you now know what this is).

We know that the party line is now that no STPs should be approved by NHS England that do not include a clear articulation of how they will achieve the priorities of the mental health taskforce, including the access and waiting time standards, as well as a clear demonstration of how local areas will increase their spending on mental health.

The problem - as ever - is that money is tight. History tells us that’s not good for us. We know that lurking in your local A and E or cancer centre are a host of Dick Turpins - ready to spring out, draw their pistols and shout “Your money or your life”, and for once I don’t mean that metaphorically. It will be phrased in exactly those terms. And whose money are we talking about? Ours. Unless we are careful, and perhaps even if we are, Dick Turpin and his fellow highwaymen may be able to shift money allocated for mental health improvements to supplant existing spend or balance reductions elsewhere in the system. And this is not far fetched. A recent survey found 61% of CCG leaders cite “organisational priorities” (ie balancing the books) trumping “whole system plans” (ie improving the way we deliver care) as a significant barrier to success.

And we are not talking about a few gold sovereigns. The Sustainability and Transformation Fund (STF) currently has a pot of £1.8bn for 2017/18 and 2018/19 respectively. Gosh, that’s a lot. Surely no one can steal all of that? Well, it may have been stolen already. The plan is for £1.5bn of this to go into a general fund allocated on the basis of emergency care; a £0.1bn general fund allocated to non-acute providers; and a £0.2bn targeted fund. I am losing you, I can sense it. OK, back to plain English. The providers - ie the acute trusts - have to balance their books by 2017/18. So if it all goes to them to do just that, there won’t be much left for real changes in services.

So our Three Musketeers (Claire, Karen and Tim) have a job on their hands to stand up to Dick Turpin and ensure that the mental health money allocated through the STF must is protected appropriately and local areas held accountable for delivering what they promised. We will be cheering them on.

Professor Sir Simon Wessely

28/09/2016 18:09:35

Satisfaction Guaranteed?

Not many of us go to work to do a bad job.  Most of us hope that we do the opposite – but how do we know if we are?  How can we tell if the service we provide is a good one and whether the work we do makes a difference?  Working out whether the services we and our teams deliver is up to scratch is not an easy task.  As a clinical academic I can point to papers published, or the results of the torment visited on us every few years known as the Research Excellence Framework, but even there a paper published can vanish into thin air, leaving no trace behind, and the judgement of our peers (which is basically what these assessment exercises are for) can be flawed.

And the situation is just as complex for clinicians.  We could and frequently do measure whether or not our patients are satisfied with us and our services. That’s no bad thing, and it is better to have a satisfied patient or relative than an unsatisfied one.  But measuring satisfaction alone is, well, unsatisfactory.  Some doctors get high satisfaction scores because they are polite, charming and give you just what you want – but they may simply be promoting snake oil. Studies show that patient satisfaction with their local hospital is significantly influenced by the availability of parking – important yes, but no reflection of the standard of care.

The RCPsych has been working quietly for years to help answer exactly these questions – how do we provide a good service?  The College Centre for Quality Improvement (CCQI) is the part of RCPsych that aims to help members assess and improve the quality of care they provide.

When I took over as President I have to confess that I knew very little about the CCQI.  That’s all changed now, and the more I learn about it, the more impressed I have become.  But talking to others I find that my lack of awareness of one of the most important parts of the College was by no means unique.  So for the rest of this blog I have teamed up with Professor Mike Crawford, who has been Director of the CCQI since 2011  to fly the flag for CCQI.  If you don’t know what it does, then please read on and you might be pleasantly surprised.

Let’s take two areas in which standards matter - good prescribing practice, and improving the physical health of our patients.  We know that prescribing drugs for too long and at too high a dose can be dangerous.  We also know that we have as a profession neglected the physical health of our patients for too long, with serious consequences.  Frankly, we have to accept responsibility for this. It’s not the fault of Andrew Lansley, the GMC, local councils or any other person or organisation that we often tend to blame (sometimes with good reason).

The ‘CCQI’ has been running audits like the Prescribing Observatory and National Audit of Schizophrenia for over 10 years.  There is good evidence that their focus on things like high dose prescribing and physical health are making a difference. Fewer patients are now prescribed antipsychotic medication above BNF limits and more patients are starting to have regular assessments of their physical health. However, access to psychological treatments remains poor and the speed with which services respond to mental health crises is still very patchy. A recent audit of Early Intervention in Psychosis services showed how long some people still have to wait before being taken on by a specialist team.

Finding out that services are not delivering high quality care is one thing; doing something about it is another. This is where our quality improvement networks come in. These programmes support services to conduct a self-review against national standards. This is then followed up by a visit from colleagues working in a similar type of service, along with service user reps and staff from CCQI.  The team discusses what they find compared to the results of the self-review with the local service and highlight strengths and weaknesses. Most of the CCQI’s quality improvement networks offer services the option of applying to be formally accredited by the RCPsych.

Now I know what you thinking, that is just a voluntary version of the CQC.  And we know the CQC is, well, not the most popular institution in the country.  When a service is informed that the inspectors are calling, the reaction is rarely  “jolly good, what fun - this is something that I am really looking forward to”.  We can put to one side the question as to whether or not they do a good job - that’s for others to answer - but we can say with some confidence that the job of a regulator is not to be popular.  Just ask the GMC.

But our quality improvement networks operate differently.  For a start, they are voluntary. They work with individual clinical teams rather than descending en masse in an attempt to assess a whole trust. But most importantly of all they provide structured feedback about specific strengths and weaknesses in a service as well as tailored support and advice about what other teams have done to improve when they have faced similar types of problems. Services that take part also have access to discussion groups and learning events where members identify areas they are struggling with and share good practice.

No one fails, which could very well leave them open to be named and shamed in the Daily Mail.  All that happens is that CCQI work with you to improve your game until you pass, and as a result  a get a coveted kite mark.  It’s a bottom up system of quality improvement, rather than top down.  And as the literature confirms, top down inspections can detect egregious examples of the unacceptable and they are much less effective in raising general standards.

Here’s another example.  One of the first networks, ‘ECTAS’, has delivered big improvements to the quality of ECT services around the country - 10 years ago some of these were in a bad state. We know that ECT has a small, 'though well defined and sometimes life saving role to play.  But more than anything else when done badly it can give us a bad press that can take decades to overcome. It is just possible that people are starting to forget “One Flew Over the Cuckoo’s Nest”, but the reactions to the revival of Harold Pinter’s “The Caretaker”, whose emotional centre piece is Aston’s monologue remembering the ECT he had received, shows that this an area in which we have an absolute duty to maintain best practice if we are to maintain public confidence in something that we believe needs to remain available in extremis.

Other programmes like Accreditation of Inpatient Mental health Services (AIMS) and inpatient CAMHS services (QNIC) have done much to help improve the quality of hospital-based care that patients receive. The great thing about these programmes is that they support teams to learn from peers, share good practice and then solve problems based on the experiences of colleagues.

But there are problems. While hundreds of services are now taking part in these programmes, many choose not to.  Some don’t because they think they are already good, and others because they know they are poor. What struggling services need to know is that the College’s quality improvement networks support teams to improve through sharing the experiences of other teams that have already been through the process. Mental health services that are not quite ready for accreditation are supported by the CCQI to reach the standards required over time and with help, most services are able to achieve accreditation.

Another problem results from the very limited use of routine outcome measures in psychiatry. This means that, while accreditation programmes can help ensure that care is delivered in accordance with recommended standards, it may still not be clear that this results in better health for patients. In response to this, services aiming for CCQI accreditation are now being asked to collect and make use of clinical outcome measures. The more services that use outcome measures, the more confident we can be that our patients are benefiting from the care we provide.

Numbers matter; they help you counter criticism when something does go wrong. It is significantly easier to be able to say that this was an isolated incident and not part of a general pattern of poor care if you have the data to back that up.  And whilst it is not the point of measuring outcomes – it can also make a difference to clinicians when it comes to applying for ACCEA points and awards.  One reason that Psychiatrists don’t do as well as, for example, surgeons is because they can point to routinely collected outcome data as objective measures of service excellence, and all too often we cannot.

All Trusts in England and Health Boards in Wales now take part in the audit programmes and staff working in the quality improvement networks went on over 500 visits to hospitals across the country last year. Methods developed by psychiatrists and colleagues at the College have been taken up outside the UK to assess and improve the quality of care provided elsewhere in Europe and beyond. At a time when there seem to be continuous ‘cost improvements’ and morale is often “challengingly”  (as you can tell, we are rehearsing our entry for the annual NHS Cliché of the Year competition) low, the quality improvement networks are doing their best to give staff something to cheer about. Taking part in the network requires time, resources and commitment, but our members consistently tell us that the benefits of belonging to a peer-led network far outweigh the costs.

The CCQI plays a vital role in justifying why we continue to need institutions like the Royal College in the 21st century. The RCPsych does indeed represent our profession, and long may that continue.  But the public can lose sight of the fact that the purpose of the profession, and therefore the College, is ultimately to improve our understanding and treatment of mental illness. And part of that must be to improve the quality of care that patients receive.  This is not a peripheral objective, but a substantial part of why we exist.

So to go back to the beginning.  We know that no one reading this will go to work tomorrow determined to do a bad job.  We were attracted to psychiatry to do the opposite - to in some shape or form improve the lives of those with mental illness, both presently and for the future. The CCQI is here to help you achieve it.  Try it.

Professor Sir Simon Wessely

 

02/09/2016 07:47:08

Planned strikes by Junior Doctors

This morning’s papers are full of the news that the Academy of Medical Colleges has issued a statement saying that it is ”disappointed at the prospect of further industrial action by junior doctors”, and that RCPsych has signed up to this. As far as I know only one College did not.

Until now our position has been to be supportive of our juniors in terms of the goals they wish to achieve, but to refrain from taking a position on the tactics being employed; in other words industrial action.   In various fora I have made it clear that I strongly believe that the causes of the obvious dissatisfaction felt by so many juniors (and of course not just juniors) are wide ranging and have been a long time coming   On Wednesday of this week, before the crucial meeting of BMA Council, I had a piece in the Times,  again outlining what I saw as the many serious issues affecting morale and well-being which would not be addressed by industrial action.

Many seem condemned to spending years rootlessly shuffling from one place to another like lost luggage, buffeted about by a promotion system that seems to be little more than a lottery.

Whilst terms and conditions are not issues for medical Royal Colleges, training, standards, morale, safety, health, satisfaction and so on definitely are.   Royal Colleges are also concerned with not just the welfare of psychiatrists, but also the welfare of those who we treat – our patients.  Sometimes those words sound like empty slogans.  How many times I have I heard “we must put the patient at the heart of everything we do” used as a clichéd rhetorical device to justify something that has at best peripheral relevance to patient care.

But a five day strike must inevitably threaten patient safety.   And to be fair, those who have been advocating industrial action accept this.  After all, if such a prolonged withdrawal of labour did not affect patient safety, one might wonder what on earth are we all doing for a living anyway?

So patients may well be harmed.  Perhaps not in such obvious and eye catching ways as might happen in Accident and Emergency departments, intensive care units or operating theatres – but our patients may also suffer.  We can be sure there are members of the media keenly waiting for the first death in order to unleash a wave of synthetic outrage.  The stories are already written, all that is missing is a name and face.  Even if a year and one public inquiry later it is concluded that such an event was not related to the strike, the damage will be done.  Unlike journalists and politicians we are trusted – trusted not to harm our patients – but we should remember that trust is earned, not a right.  It can be lost swiftly, and then take a generation to recover.

I have seen some social media postings saying “there is no pain without gain”, or “you need short term pain for long term gain”.   That pain is going to be felt by patients.  I don’t think that doctors should be making those arguments.

I have also seen other messages saying “if you are not with us, you are against us”.  I reject that.  It is specious and false. One can be with you, share your aims and cause, but still disagree with the tactics employed.  We remain as committed as we ever were to the long term ambitions that we all share. We all want to improve the working lives of our members, knowing also that unhappy, demotivated doctors who no longer feel in control of their careers or lives, deliver poorer care to patients. 

We all know that the NHS is also facing the biggest crisis in its history.   We know that promises that have been made such as increased funding have yet to be honoured   We know that demand has increased, sometimes unavoidably, but sometimes by  eye catching initiatives that turn out to been based on quicksand – chief amongst these being the “7 day NHS” - uncosted, untested and understaffed.    

None of that has changed.

So as before, you will make up your own minds.  I can only ask you to consider whether or not a prolonged industrial action is the best way to achieve our shared objectives. I can only ask that you consider the serious risks that such a path runs, to our patients, and our profession.  If you do decide after sober reflection that this is a risk that you are prepared to take, then so be it.  You will still be valued members of this College, and we will continue to do our best to support you.  In psychiatry we have a tradition of vigorous debate and dissent, whilst still remaining loyal to each other and proud of our profession.  Disagreement is not the same as division, and never more so than today.

 

 

 

 

 

 

 

 


 

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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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