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The trouble with NHS psychiatry in England

  • Paul St John-Smith (a1), Daniel McQueen (a2), Albert Michael (a3), George Ikkos (a4), Chess Denman (a5), Michael Maier (a6), Robert Tobiansky (a7), Hemachandran Pathmanandam (a8), Teifon Davies (a9), V. Sunil Babu (a10), Omana Thachil (a11), Furhan Iqbal (a12) and Ranga Rao (a13)...
Summary

In ‘Wake-up call for British psychiatry’ Craddock et al explained how recent attempts to improve psychosocial care for people with mental illness focus on non-specific psychosocial support. This has been at the expense of proper diagnostic assessment and prescription of treatment by psychiatrists aimed at treatment of specific disorders and recovery. They describe a creeping devaluation of psychiatry which is caricatured as narrow, biological, reductionist, oppressive, discriminatory and stigmatising. Some trusts have implemented ‘New Ways of Working for Psychiatrists’ in a way that undermines the central importance of psychiatrists in mental healthcare. Consequently, patients may be treated in secondary care without ever being seen by a psychiatrist. We consider a number of different changes that have interacted in unforeseen ways, with unintended adverse consequences for psychiatric services in England. We aim to continue the debate here.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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The trouble with NHS psychiatry in England

  • Paul St John-Smith (a1), Daniel McQueen (a2), Albert Michael (a3), George Ikkos (a4), Chess Denman (a5), Michael Maier (a6), Robert Tobiansky (a7), Hemachandran Pathmanandam (a8), Teifon Davies (a9), V. Sunil Babu (a10), Omana Thachil (a11), Furhan Iqbal (a12) and Ranga Rao (a13)...
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eLetters

The trouble with NHS psychiatrists

Judy A Harrison, consultant psychiatrist
29 July 2009

St John Smith et al provide a useful overview of the political imperatives which have shaped British psychiatry in the last five years (Psychiatric Bulletin, 2009, 33, 219-226), but as with other overviews (1) it is difficult for the reader to come away with any constructive message.

The authors rightly recognise the original New Ways of Working project as a practical response to a shortage of psychiatrists, but believe this has become a shorthand for cutting the number of medical staff and reducing the psychiatric orientation of the service. The national manpower figures suggest otherwise: between 1999 and 2007, the number of psychiatrists in England rose by 46% (2) and few can argue that recruitment is not vastly improved compared to 10 years ago.

The reality is that new services have grown even faster, with an estimated £2 billion of additional investment since 1999 (2), mainly in specialist teams. The recruitment of medical staff and the establishment of suitable training placements have lagged behind, as outlined by the Audit Commission finding (3) that almost one third of Crisis Resolution teams had no dedicated consultant sessions.

It is inevitable, and many would argue desirable, that non-medical staff will be involved in front line assessment, as they are now in most other branches of medicine. The solution is not to decry “proforma tools and guidelines” but to argue for these to be used by suitably trained and supervised staff working in teams with ready access to psychiatrists, as originally envisaged in New Ways of Working (4). The College should lead on an overview of the medical staffing of specialist teams, and Trusts andcommissioners should be obliged to fund dedicated consultant sessions in order to meet their quality targets.

While specialist teams provide some benefits, they have undoubtedly lead to greater fragmentation of care and may not all survive beyond “New Horizons” (2). Our battle should be to ensure that the additional money which came with these teams is not clawed back in times of greater austerity.

1.Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P et al. Wake up call for British Psychiatry. British Journal of Psychiatry,2008, 193, 6-9.2.Dept of Health 2009 New Horizons: Towards a shared vision for mental health 3.National Audit Office 2007 Helping People through mental health crisis: The role of crisis resolution and home treatment services.4.Dept of Health. New Ways of Working for Psychiatrists. Dept of Health, 2005.

(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4122342)
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Conflict of interest: None Declared

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The Trouble With...

Mark Taylor, Consultant Psychiatrist
10 July 2009

In two related articles – “The trouble with NHS psychiatry in England” (St John-Smith et al), and “New Ways Not Working? Psychiatrists’ Attitudes” (Dale and Milner) - misgivings about the role of the psychiatrist and service delivery in England are described. As psychiatrists working in Scotland we have witnessed a divergence between the two National Health Services since devolution. The National Service Framework, for example, was not implemented in Scotland. Further, bed closures have happened more slowly and the rushed ‘top down’ functionalisation of mental health care enacted in England, has been generally more measured north of the border. Indeed it appears that only crisis resolution and home treatment teams have been widely adopted (reflecting in part the supporting evidence eg Cochrane 2006), there beinga more conservative adaptation of ‘New ways of working’.

Partially, this reflects a different politico-cultural backdrop in Scotland - there is, for example, a substantially smaller private and independent sector in mental health care here compared to England. Funding, therefore, is not (usually) diverted in that direction. Furthermore, there is less preoccupation with risk to others, again limiting private secure facility expansion.

Additionally, ‘New ways of working’ was in part a pragmatic solution to endemic problems with recruitment and retention into psychiatry. In Scotland, this has been less of an issue overall, with notable exceptions.Scottish workforce planning indicates that only CAMHS consultants in Scotland are difficult to recruit, and there has been a genuine uplift in consultant numbers in the last 5 years. Whilst there are important imminent universal challenges which could change the landscape, (like the diminishing number of junior doctors, and the evolving role of the psychiatrist as a medical doctor providing leadership within the multi-disciplinary team), we contend that there is probably less dissatisfactionwith current service configurations, less urgency to overhaul systems, andmore opportunity to plan service change meaningfully on the basis of evidence and other’s experience.

Thus we have naturalistic experiment with separate and diverging systems of government based healthcare in adjoining countries with similarunderlying populations. This could be an ideal opportunity to examine optimal service configuration, as long as consensus on the best outcomes for patients could be achieved.

Yours,

Mark Taylor and Premal Shah
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Conflict of interest: None Declared

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New ways of working: Are we prepared?

Sandeep Bansal, Speciality Registrar
10 July 2009

I share the authors’ views highlighted in this paper and would like to lend further support to his views by briefly discussing my audit about New ways of working (NWoW).

We completed an audit on NWoW, to compare the 60 most recent histories taken by junior doctors (STR1-3 including GP trainees) and nursing staff in the Out patient clinic setting. The audit was done in Lymebrook centre, which is one of the resource centres that caters for Adult psychiatric patients in North Staffordshire Combined Mental Health NHS Trust.

All histories, which were taken, were assessed for 108 variables. In addition to assessing whether the relevant variable was reported we also graded the information reported on whether it was comprehensive or only partially obtained. The data was collected on hard copy and was analysed on SPSS.

This audit shows significant differences in histories taken by juniordoctors and nurses. Doctors documented comprehensive histories for 52 %( 1459) of variables; they took incomplete histories for 8 %( 234) of variables and not asked for 39 %( 1107) of variables. Nurses have taken comprehensive histories for 32 %( 905) of variables; they have taken incomplete histories for 13 %( 382) and not asked about histories for 55 %( 1573) of variables. There were statistically significant differences (pvalue < 0.05) between the two groups in 44 out of the 108 variables with doctors generally taking a more comprehensive and detailed assessment. The audit was presented within the trust and nurse’s representatives were asked for their views. They stated that history taking, physical examination and pharmacology are not a part of their nursing training and as such they are not confident in these aspects of patient care (physical,pharmacological etc). They have identified difficulties in differentiatingphysical symptoms because of functional and biological causes. Torn A, McNichol E (1996), found that 96% of nurse practitioners did not feel thattheir training is adequately equipped to treat people with mental health problems and 83% of nurse practitioners do not feel adequately equipped toassess people with mental health problems1. No other independent studies have since been completed and there is no other evidence available, which supports, NWoW.

It is certain that Psychiatry needs to change to provide better patient care and to overcome difficulties posed to the psychiatrists but do we think we are ready for it?

Declaration of interest: None

References:

1. Torn A. Mcnichol E .Can mental health nurse be a nurse practitioner? Nursing standard: 11, 2, 39-44. 1996.
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Problems in NHS psychiatry and recruitment chaos- Are they related?

Venkata B Kolli, ST3 Adult Psychiatry
24 June 2009

The article ‘The trouble with NHS Psychiatry in England’ (St John Smith P et al Psychiatr Bull 2009 33: 219-25) coincided with the Dean of the Royal College of Psychiatrists Prof Howard’s interview on Channel 4 news on 4 June 2009. The very fact that psychiatry is one of the least favoured specialities for UK medical graduates suggests that there is trouble with NHS psychiatry in the UK. Perhaps the college and its membersneed to look at the possible reasons. The college has already been dealingwith stigma that psychiatry and psychiatry patients face.

It appears that many recent medical graduates secured a psychiatry post as part of their Foundation training on the basis of favourable placements as a medical student at the time of ‘old’ ways of working. However, unfortunately their subsequent experience with the ‘new’ ways of working for psychiatrists has been less reassuring. They have often noticed psychiatrists being marginalised, and that the psychiatrist’s rolehas been reduced to fire fighting with a lack of proactive interventions. This has led to many of them deciding not to take up a career in psychiatry, or even to seek higher training in psychiatry abroad.

Medical graduates are often attracted to various specialities by rolemodels. We wonder if a relative lack of role models is the reason for UK graduates not opting for psychiatry. In his interview on Channel 4 news Prof Howard suggested that psychiatry is being forced to recruit trainees who just meet the minimum criteria. However this might lead to fewer role models in psychiatry, further recruitment problems and more trouble.

Perhaps the college might consider ‘newer’ ways of working, recruiting and training.

References:

1. St John-Smith P et al. The trouble with NHS psychiatry in England.Psychiatr Bull 2009; 33: 219-225.

2. Hannam L and Wivell J. Psychiatry's UK recruitment crisis. Channel4 News. 4th June 2009.

3. Eagles J M et al. What impact do undergraduate experiences have upon recruitment into psychiatry? Psychiatr Bull 2007; 31: 70-72.

4. Kerby J et al. Anti-stigma films and medical students’ attitudes towards mental illness and psychiatry: randomised controlled trial. Psychiatr Bull 2008; 32: 345-349.

5. Wright S et al. The Impact of Role Models on Medical Students. J Gen Intern Med 1997; 12: 53–56.
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The trouble with NHS psychiatry- do patients expect more from psychiatrists?

Kamini Vasudev, Specialist Registrar, Adult Psychiatry
18 June 2009

It was reassuring to see the debate started by Craddock et al., 2009,continue [1]. I fully support the recommendations made by St John-Smith etal. (Psychiatr Bull 2009; 33: 219-225) [2]. The clinical leadership by psychiatrists is vital in mental health teams. However, in addition to ourclinical expertise do our patients expect something more from us?

I would like to share my experience at a recent conference organised by mental health research network, UK at Nottingham. This was the first time I had witnessed such extensive participation by service users and carers at a scientific conference. This was an excellent opportunity to seek views of service users and carers directly or indirectly in formal and informal environment outside the boundaries of my clinical role. I wasdisappointed to see that the general impression regarding psychiatrists was negative.

I wonder why that is. Why is it that most individuals in need of a psychiatric assessment prefer to see a psychiatrist and yet they are not satisfied with the ‘expert’. The theme that I picked up from the service users and carers was that ‘psychiatrists don’t listen’.

I wonder if some of us do get carried away by the ‘diagnostic’ assessment and in doing so miss the human touch that our patients need andexpect from us. Do we need to be more compassionate with the psycho-socialformulation in order to individualise our relationship with our patients. Diagnosis is indeed an essential component of a psychiatric assessment butdo we spend enough time discussing the meaning of the diagnosis with our patients and what impact it has on their lives. Do we need to improve ourskills at helping our patients integrate their diagnosis or ‘no diagnosis’into their lives? How can we make our patients feel ‘listened to’?

References

1.Craddock N, Antebi D, Attenburrow MJ et al. Wake-up call for British Psychiatry. Br J Psychiatry 2008; 193: 6-9.

2.St John-Smith P, McQueen D, Michael, A et al. The trouble with NHSpsychiatry in England. Psychiatr Bull 2009; 33: 219-225.

Declaration of interest: nil
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