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Wake-up call for British psychiatry

Summary

The recent drive within the UK National Health Service to improve psychosocial care for people with mental illness is both understandable and welcome: evidence-based psychological and social interventions are extremely important in managing psychiatric illness. Nevertheless, the accompanying downgrading of medical aspects of care has resulted in services that often are better suited to offering non-specific psychosocial support, rather than thorough, broad-based diagnostic assessment leading to specific treatments to optimise well-being and functioning. In part, these changes have been politically driven, but they could not have occurred without the collusion, or at least the acquiescence, of psychiatrists. This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow professionals and the medical students who will be responsible for the specialty's future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty's core values and renew efforts to use psychiatric skills for the maximum benefit of patients

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Corresponding author
Nick Craddock, Department of Psychological Medicine, Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN, UK; Email: craddockn@cardiff.ac.uk
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Declaration of interest

All authors are members or fellows of the Royal College of Psychiatrists and currently work within, or have recently worked within, the UK National Health Service. We hope that both of these organisations will be influenced by this paper.

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References
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Wake-up call for British psychiatry

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eLetters

Putting it all together.

Mark Agius, Visiting Research Associate
31 October 2008

Michael Balint has described the Doctor-Patient Relationship as follows; ‘The terapist’s tasks [are] ‘listening’,‘understanding’, ‘using the understanding so that it should have a therapeutic effect’.[Balint 1964]. I will always remember an old GP trainer who always used to tell us, quoting Balint, ‘Remember, the first drug the doctor prescribes to the patient is himself’. This , in psycho-dynamic terms is the core of medicalpractice. We must consider why doctors are such an effective ‘drug’. Clearly it is because patients assume that doctors are on their side and that they have knowledge about their condition which they will use to the patient’s benefit. Suggestion that doctors do not have knowledge which can be used to the patient’s advantage undermines the doctor-patient relationship and leads to such statements as have been made in this debate ‘It’s not a hard science, it’s subjective. Some diagnostic categories are little more than a value judgement.’[Penbroke 2008], and ‘Psychiatry is not a medical speciality that can be equally compared to orthopaedics because there are no diagnostic tests with clear demonstrable results’ [Penbroke 2008].Other letters have undervalued , probably unintentionally, modern understanding of the pathophysiology of mental illness brought about by present techniques, thus for instance ‘Consultant psychiatrists, being trained doctors, are in a position to diagnose more organic driven illnessthat presents but this is a small percentage of our caseload’.[Dickson 2008] This ironically neglects the fact that modern technology is giving us greater insight, through such new techniques as neuroimaging and genetics of how mental illness occurs- a knowledge which it behoves consultant psychiatrists to contribute to their teams, and which should give doctors the support to give proper explanations to their patients. Itis not for nothing that many of our leading Geneticists and Neuroimaging Experts have involved themselves in this debate. Elsewhere , it has been said ‘Neuroimaging has provided irrefutable evidence for a biological basis for psychiatric disorders’. [Frangou 2008]. So Psychiatry is changing, and, though we have far to go , is becoming more of an exact science, not just an attempt to apply arguably questionable ICD and DSM driven diagnostic criteria. This knowledge must be used to support the Doctor-Patient Relationship, giving patients more confidence that the doctors have some understanding of the causes of their illness. One problem is that clinicians in the field and managers have lost touch with the scientific developments, and are not using this new knowledge to guide their work and their services.Another way of undermining the doctor-patient relationship , clearly inadvertently, is the statement ‘If the psychiatrist has to assess all those referred to secondary services access to such care would be restricted increasing the burden of unmet need.’ [Boardman 2008]. This implies an unwillingness of the doctor to be available to his potential patients…..and availability is one attribute of the doctor which the patient values above all others. How the issue may be solved without overburdening doctors is a difficulty which society must ponder, and which‘New Ways of Working ‘ has had difficulty solving for the reasons that Boardman has himself described. There is only one satisfactory answer to this; to increase the number of available doctors .Alternatives to this lead inevitably to ‘the substitution of “Doctor knowsbest” with “Manager knows best.” And New Ways of Working may end up doingexactly that’. [ Yeomans 2008] Recently a senior manager in a trust asked publicly ‘what extra value is there in a consultant psychiatrist seeing a patient for fifteen minutes every three months?’ But the answer to this question is precisely the doctor –patient relationship supported by the new biological knowledge and the doctor’s communication skills applied to the advantage of the patient…..this is genuine ‘new ways of working’. The lack of managers’ understanding of this is well illustrated by the recent simultaneous imposition by managers on the profession of both ‘Revalidation’, which ‘Balint like’ wishes to test us on our communicationskills with patients, and ‘New ways of working’, which attempts to interpose other persons and professions between the doctor and the patient.Ultimately it is crucial that the ‘Wake up call for British Psychiatry’ must triumph, because it provides the basis in terms of our new knowledge of Psychopathology of the aetiology of mental illness- that knowledge, which allied with a caring attitude , is key to a Doctor-Patient Relationship devoid of inappropriate Paternalism, and which, by providing clear explanatory models of mental illness will help combat stigma. This does not at all exclude other professions; their different approaches helpcomplement our relationship with patients and enable us to provide for allthe patients’ needs.Recently the Royal College President called for a renewal of the Psychiatrist’s contract with society [Bugra 2008]. It is on the Doctor-Patient Relationship and the new Biomedical knowledge that this contract must be based.ReferencesBalint M 1964 The doctor, his patient, and the illness Churchill Livingstone LondonBoardman J, Hampson M 2008 Wake up call. BJPsych electronic lettersBugra D 2008. Renewing psychiatry’s contract with society. Psychiatric Bulletin 32;281-283.Dickson D 2008 2008 A new anti-psychiatry movement? BJPsych electronic letters Frangou S et al 2008 European Psychiatry Editorial 23;223.Penbroke L et al 2008 A new anti-psychiatry movement? BJPsych electronic letters Yeomans D 2008 Making the biomedical case BJPsych electronic letters ... More

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Considering psychiatry as a career

N J O Jacobsen, F2 / SHO
31 October 2008

I came into medicine as a mature student of thirty two with a PhD anddid a four year graduate entry medical degree. I am now a Foundation Programme trainee currently in my F2 year and am now at the point of decision about specialist training. I am fascinated by psychiatry and have been seriously considering it as a career for many years. As a consequence I have done two four month postings in general adult psychiatry, and old age psychiatry. This is a fairly unique position in terms of the level of exposure to psychiatry prior to specialist training entry. My two postings in psychiatry have been interspersed with medical and surgical positions and it is this mix that has created a perspective that made Professor Craddock’s article resonate for me. I spent many yearsat medical school acquiring the medical knowledge and skills necessary to do my job correctly. In my short experience of psychiatry, especially general adult psychiatry, the lack of emphasis on medical approaches was at times very concerning. Although I am a great advocate of psychological and social intervention, at times I felt that the medical side was side lined and devalued and I felt at times that the patient was not given the best possible treatment as a consequence. Much of the time I felt that the service in my locality is more nursing and MDT lead with the psychiatrist being present merely as an advisor or prescriber. As a consequence, my principle concerns when contemplating a career in psychiatry is that my core medical knowledge and skills will be eroded over time and this makes me feel decidedly uncomfortable and sad. My decision to enter a career in psychiatry is therefore no longer straight forward. This should not be the case because I anticipate opportunities for major improvements in understanding and patient care over the course of my career and with the correct medical approaches I know that I would contribute a great deal to British psychiatry. ... More

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Wake up call: Response from authors

Nick Craddock
20 October 2008

Sir

We are pleased that our article has stimulated debate. This was our intention. We are disappointed that some correspondents dismiss our argument by attacking a stereotype of who they think we are or a caricature of what they think we might have said, rather than addressing what we actually did say. Such correspondents have missed, or ignored, the point of the article – namely, to ask whether the de-medicalisation that has taken place over recent years in British psychiatry is bad for the health of patients and the specialty. We believe this is a question that is worth taking seriously. It is clear from the substantial eletter correspondence and other feedback that many psychiatrists share our concerns and wish for constructive debate.

This primary concern with the decline in medical standards of care and the deliberate politicization of debates about service delivery does not imply that we cannot (a) embrace the importance of the full range of biological, psychological and social interventions for psychiatric illnessand (b) value our non-psychiatric fellow professionals, and their integralcontributions to mental health care. We also believe to be self-evident that services should be informed by the experiences of patients, their relatives and carers and that multidisciplinary team work is crucial for optimal management of psychiatric illness. We are not terribly interested in what is past. We are much more interested to look ahead.

Of the wide range of views expressed by respondents, we believe the voice of trainees and those contemplating a career in psychiatry should carry particular weight and we should like to hear more from them. They are the future of British psychiatry.

Declaration of interest: NoneAuthors

Nick Craddock1*, Danny Antebi2, Mary-Jane Attenburrow3, Tony Bailey3,Alan Carson4, Phil Cowen3, Bridget Craddock5, John Eagles6, Klaus Ebmeier3, Anne Farmer7, Seena Fazel3, Nicol Ferrier8, John Geddes3, Guy Goodwin3, Paul Harrison3, Keith Hawton3, Stephen Hunter9, Robin Jacoby3 Ian Jones1, Paul Keedwell1, Mike Kerr1, Paul Mackin8, Peter McGuffin7, Donald McIntyre4, Pauline McConville4, Deborah Mountain4, Michael C. O’Donovan1, Michael J. Owen1, Femi Oyebode10, Mary Phillips1,11, Jonathan Price3, Prem Shah3, Danny J. Smith1, James Walters1, Peter Woodruff12, Allan Young13, Stan Zammit1

1Department of Psychological Medicine, Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN; 2Gwent Healthcare NHS Trust , 6 Goldtops, Newport, NP20 4PG; 3University of Oxford Department of Psychiatry, The Warneford Hospital, Oxford OX3 7JX; 4Royal Edinburgh Hospital, Morningside terrace , Edinburgh, EH10 5HF; 5ABM University NHS Trust, 71 Quarella Rd, Bridgend; 6 Royal Cornhill Hospital, Cornhill Road,Aberdeen AB25 2ZH; 7 Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF; 8Institute of Neuroscience (Psychiatry), Newcastle University, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP; 9 Gwent Healthcare NHS Trust, range House, Llanfrechfa Grange, Cwmbran, Torfaen NP44 8YN; 10 Department of Psychiatry, Universityof Birmingham, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ; 11 Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Loeffler Building,121, Meyran Avenue, Pittsburgh. PA 15213, USA;12 Department of Academic Clinical Psychiatry, Sheffield University, The Longley Centre, Norwood Grange Drive, Sheffield S5 7JT; 13 Dept. of Psychiatry, University of British Columbia, Suite 430 - 5950 University Blvd., Vancouver, BC V6T 1Z3, Canada.

*Correspondence: Department of Psychological Medicine, Medical School, Cardiff University, Heath Park, Cardiff CF14 4XN; Email: craddockn@cardiff.ac.uk
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wake up call for British Psychiatry

Kamini Vasudev, Specialist Registrar, Adult Psychiatry
24 September 2008

I read with keen interest the article ‘Wake-up call for British Psychiatry’ by Craddock et al., BJPsych July 2008. I completely agree withthe concerns raised by the authors. As a trainee psychiatrist working in United Kingdom for the last few years, I have had an opportunity of working with several community mental health teams (CMHTs). I have observed implementation of ‘new ways of working’ in different teams and its impact on patient care. Unfortunately, at some places the psychiatrists themselves have misinterpreted the meaning of their ‘consultative role’ in the ‘new ways of working’ model. They seem to be reluctant to assess new referrals. They tend to rely on the assessments conducted by other members of the team, who present the new cases at the team meeting, to decide if the patient needs to be reviewed by them. It might be that this reluctance stems from the need to carry out time-consuming paper work including the care co-ordination document and risk assessment document for the new referrals. However, this deprives the patient of the benefit of being assessed by ‘the most experienced and skilled professional of the team’, as rightly pointed by the authors.

In the best interest of the patients, it is important that most, if not all the new referrals to the CMHTs should be assessed by the consultant psychiatrists or the trainee doctors under their supervision along with/without another member of the team, as appropriate. The management plan thus formulated could be implemented with involvement of other members of the team and sometimes in the primary care. The psychiatrists thus would have minimal number of patients in their follow-up clinic. After providing their ‘consultation’ the consultant psychiatrists should be able to discharge the care of the patients back toprimary care. Alternatively, the more complicated patients could be followed up by other members of the CMHT with once or twice yearly review by the psychiatrists. This would free-up their time to make themselves available for urgent or new referrals. It is understandable that GPs mighthave their reservations to take the burden of care of all the stable psychiatric patients unless they get reassurance that the consultant psychiatrists would be able to review the patients as soon as possible should the need arise.

There is a need for the psychiatrists to be forthcoming and take the initiative to implement the ‘new ways of working’ for patient-centred care. They would, however, need co-operation of other members of the team to make this happen, which can be challenging.
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Re: Vision for the Future, not harking back to the past

Christine Vize, Consultant Psychiatrist
24 September 2008

Full list of authors for this letterPlease could this be addedPeter Atkinson Vice Chair UNISON National Nursing Committee,Simon Baugh Medical Director Bradford District Care Trust,Angus Bell Consultant Psychiatrist and Clinical Director Tees Esk and WearValleys Mental Health Trust,Desmond Benn Consultant Psychiatrist Tees Esk and Wear Valleys Mental Health Trust, Neil Brimblecombe Director of Nursing Research and Development South Staffordshire and Shropshire Healthcare NHS Foundation Trust,Tim Cate Associate Director of Psychology Tees Esk and Wear Valleys MentalHealth Trust, Martin Crawshaw Chair British Psychological Society Professional Practice Board,Bill Davidson Service User Lead NIMHE National Workforce Programme,Barry Foley New Ways of Working Programme Lead NIMHE,Stuart Hatton Director of Service Delivery Bradford District Care Trust,Elizabeth Holford mental health services patient,Nicki Hollingsworth National Creating Capable Teams lead,Roslyn Hope Director NIMHE National Workforce Programme,Ian Hulatt RCN Mental Health Adviser,Steve Humphries Consultant Psychiatrist Associate Director for New Ways ofWorking CSIP,Jen Kilyon Carer Lead NIMHE National Workforce Programme,Peter Kinderman Professor of Clinical Psychology University of Liverpool,Tony Lavender Professor of Psychology and Pro Vice Chancellor/Dean Canterbury Christ Church University,Liz Lightbown Deputy Director Operational Services (Mental Health) Barnsley PCT,Laura McGraw Nurse Consultant Tees Esk and Wear Valleys Mental Health Trust,Malcolm Rae Joint Lead Acute Care Programme NIMHE,Hugh Middleton Consultant Psychiatrist Nottinghamshire Healthcare NHS Trust and School of Sociology and Social Policy University of Nottingham,Wendy Osborn Allied Health Professions Consultant and member National Steering Group for New Ways of Working,Sally Pidd Consultant Psychiatrist Lancashire Care Foundation Trust,Paul Rooney Joint Lead NIMHE National Acute Care Programme,Kim Shamash Executive Medical Director Sussex Partnership NHS Trust,Yvonne Stoddart Director National Acute Mental Health Project NIMHE,Graham Turpin Professor of Clinical Psychology University of Sheffield. ... More

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