For the May, not the few

Academic critical psychiatry

I've never really been an academic in my working life, apart from being lecturer for 2¹/2 years in Sheffield 1989-92. Now I'm semi-retired and just doing 2 days clinical work as a consultant psychiatrist, I'm looking forward to going back to Trinity College, Cambridge in October to do a part-time PhD in the Department of Psychology on "The foundations of critical psychiatry" (see my critical psychiatry blog). If anyone's interested in funding the Institute of Critical Psychiatry, do let me know. Cambridge University may even be interested to know if you are.

The club of consultant psychiatrists

I started as a consultant psychiatrist 25 years ago today. This was in Sheffield. I had been told at my interview that it was like I was joining a club. I guess it has been a privileged position.

At that time, my contract was with Sheffield Health Authority, although I was working for the mental health service unit. This was before the days of NHS Trusts and Foundation Trusts. Consultant contracts were subsequently transferred to these provider organisations, even if, as I mentioned in my previous post, mine has been suspended twice. Health Authorities were also replaced by purchaser GP organisations, now Primary Care Trusts.

Have I been right all along about critical psychiatry?

In an article I mentioned on my critical psychiatry blog (see post), Professor Sir Robin Murray says he wishes he had tried "harder not to follow of the fashion of the herd" (sic) in his research career in psychiatry. He thinks the mistakes he has made "have usually resulted from adhering excessively to the prevailing orthodoxy".

That's as may be. I'm glad he is now admitting his mistakes. As I implied in my post, I wish he would go further in realising the conceptual mistake he has and still continues to make about the nature of mental illness.

Actually, I think it's understandable the reason he has taken the position he has in his career. He has been a professor in psychiatry and knighted for his research efforts. I have tended to concentrate on my clinical work and been suspended twice for my efforts (eg. see previous post). So what if I've been right about critical psychiatry all these years!

Returning to Lancaster University

Returned to Lancaster University today for neuropsychology course. I was here over 40 years ago having enrolled on MA in Religious Studies, which I did not complete, in the department set up by Ninian Smart. He defended religious studies as a secular discipline and distanced it from tradional theology. I had been introduced to this approach in Cambridge by John Bowker, who was also at Lancaster for a while.

Blogademia

The term 'blogademia' was coined by Craig Saper (2006), before I fully understood what blogging was. I started blogging myself at the end of 2008, particularly my Critical psychiatry blog. Jolly et al (2016) reflect on 'blogademia' in a recent article in The Psychologist.

I've commented before on why I blog (Writing down thoughts on your mind for everyone to see and Blog resistance). Blogs are publicly available. There's no reliance on finding a publisher. Social media in general is user-generated, deinstitutionalised, interactive communication, which makes some academics wary of these publications as they are outside peer-reviewed journals.

Blogs do need to be of sufficient quality to merit publication. They can help maintain academic freedom in a university system motivated by commercial interests.

How computers are changing the world of healthcare

I have been reading The digital doctor: Hope, hype, and harm at the dawn of medicine's computer age. As I have done previously (eg. see my critical psychiatry blog post), I have tweeted quotes or modified quotes as I have read the book:-

DBDouble Rather than delight users, as Apple and Google do regularly, the electronic health record is a towering source of physician dissatisfaction 08/03/2016 08:16

DBDouble Though child can operate iPhone, physicians with 7-10 years postcollegiate education are brought to their knees by electronic health records 08/03/2016 08:17

Actually it's not the doctors' fault. They do have genuine concerns (see Health Affairs blog):-

DBDouble Physicians are not Luddites, technophobes, or dinosaurs about electronic health records 08/03/2016 08:31

The essence of the problems is poor usability; taking too much time; interference with face-to-face patient contact; and degradation of clinical documentation.

DBDouble Only one in three physicians say electronic health records have improved job satisfaction 08/03/2016 17:37

Remarkably, electronic health records have not been developed to improve clinician satisfaction:-

DBDouble Medicine is an unusually expert-centric and somewhat arrogant field, so IT companies were slow to embrace user-centered design 08/03/2016 17:42

Doctors will need to adapt to electronic health records. There may be a role for the use of scribes, which a training doctor or medical student could fulfil in the interests of their learning (see NYTimes article).

Alan Partridge 100/1 to be first Mayor of East Anglia

East Anglia was one of the earliest settlements of the Anglo-Saxons. North Folk and South Folk may well have existed before any East Anglian King. East Anglia, with much of its earnings based on wool and textiles, was a rich area of England until the effects of the Industrial Revolution moved manufacturing to the Midlands and the North.

Duncan Smith has failed on welfare reform

Despite all his passion for welfare reform, the real reason Iain Duncan Smith has resigned as work and pensions secretary is that his reforms have failed (see resignation letter). The immediate focus is on PIP (personal independence payments). The introduction of this benefit has not generated the savings that the government expected. In fact, more people have been given it than expected and the average payout is higher than expected (see BBC report). The introduction of PIP was slowed to try and implement it properly and avoid the number of successful appeals, as was the case with Employment Support Allowance (ESA). There are still many people waiting to be reassessed. It's not going to be easy for the new work and pensions secretary to get this budget under control. I suspect Stephen Crabb has a recognition from George Osbourne that he can't.

Of the great climacterical year, that is, sixty three

Now I know what the problem is! I am now in my grand climacteric year. I am in the "mysterious period of life when the the numbers of seven and nine multiplied into each other" (see quote). According to Sir Thomas Browne, this is a vulgar error. Hopefully I will escape this dangerous year.

I now have to wait to see what happens when I'm 81.

Not yet a twitaholic

Doctors' unhappiness

As I tweeted, 'Junior doctors are not happy'. David Hunter usefully sets the dispute over the junior doctor contract and the likely strike action in the wider political context (see BMJ editorial). When doctors were happy, they:-

sacrificed early evenings, studied hard, saw patients, and provided “good” care. In return for these sacrifices doctors got reasonable remuneration; reasonable work-life balance later; autonomy; job security; deference; and respect. 

The drive for greater accountability over recent years has not always been well implemented (eg. see previous post). Care did need to change to be more patient-centred rather than doctor-centred (eg. see previous post). But practice has become too fragmented and dysfunctional. As Hunter concludes:-

resolving the concerns [of unhappy doctors] remains as big a challenge now as [15 years ago], regardless of the immediate outcome of the present dispute.

A sunny ferry trip

Now waiting to sail from Hook of Holland because of fog disruption yesterday to flight to Norwich (see EDP article). At least The Scotsman reports a problem (see article). Could be why I was redirected via Edinburgh tomorrow. I couldn't spend another night on a make-up bed in Schiphol in M terminal, but it's actually very warm and sunny on the ferry! Sailing now.

The case for the Physician Associate

The Department of Health is promoting the development of the new profession of Physican Associate (PA) (see NHS careers webpage). The role has been seen as "doctors on the cheap", but in fact, although Physician Associates are trained in the medical model, they are not doctors. The competition is more with other allied health professionals.

There are advantages in having allied health professionals trained in the patient-centred medical model. A PA is always responsible to a doctor. The Royal College of Physicians has set up a Faculty of Physician Associates (see webpage).

After training, it is important that Trusts support newly qualified PAs in a professional academy, as my own Trust has done for nurses and plans to extend to other disciplines (see webpage).

Corbyn takes on the media

Pleased to see the anger of Jeremy Corbyn against the media. His sartorial elegance is not relevant. The new kind of politics is not a fashion parade.

Has using mortality as a quality indicator for hospitals died?

BMJ editorial confirms that academic opinion is finally coming round to accepting that Hospital Standardised Mortality Ratios (HSMRs) are not a useful signal of whether something is going wrong in hospital care (see previous post). A linked article did not find a significant association between HSMR and avoidable deaths. Even measuring avoidable deaths is open to interpretation and not an exact science. As a rapid response says, "Monitoring hospital quality by means of HSMR and other mortality indicators has failed to benefit any one except Dr Foster" (see previous post).

People who cause a stir

I've just had a week in Arncliffe, Yorkshire Dales, where John Robinson, my Director of Studies at Trinity (see previous post), is buried. His 1963 Honest to God book, written when he was Bishop of Woolwich, recognised the need for a "secular theology". 

Out of hospital care can learn from mental health services

Great Yarmouth and Waveney CCG (Health East), in whose area I work, have a public consultation (read the consultation document) on introducing out of hospital teams and closing GP community hospitals. This follows a pilot in the Lowestoft area which reduced emergency admissions compared to the previous year (see evidence), whereas nationally figures increased.

The case for change document includes an appendix on the clinical evidence base from national initiatives. Health policy has encouraged a greater range and volume of care to be delivered outside hospital for some time now. Implementation of this policy has been tentative and the SeeSaw simulation by the Kings Fund looked at the reasons why. Primarily this is about commissioning and HealthEast do seem set on making integrated out of hospital care a reality.

The implementation of home based treatment was different for mental health services. It proceeded before that for physical health care. The evidence for Crisis Resolution and Home Treatment (CRHT)  in psychiatry came from several major controlled research studies (see Tyrer & Creed, 1995, for a summary of this evidence). CRHT teams were then implemented as part of a national service framework that modernised services.

There does not seem to be the same controlled research evidence for physical health care. National policy is also more piecemeal with each area being expected to 'reinvent the wheel'. Data from the Lowestoft pilot project is anecdotal. It may be valuable nonetheless but it is limited. The mental health studies did not really show much improvement for clinical symptoms for home care over hospital care, although there was some evidence of greater satisfaction, perhaps particularly for relatives. Bed reduction was possible, although there is evidence over recent years that this has gone too far (Tyrer, 2011).

It is important to be clear about what can be achieved with out of hospital care, particularly for clinical symptoms. It's just that I would have felt more confident about it succeeding, if there had been the controlled research studies to back it up. Nonetheless, I don't think there's any turning back (except, as I said, perhaps on mental health service beds) and its nice to see this initiative leading the field in the area where I work.

The people didn't bother if the Tories won

Only Norwich South (where I live) and Cambridge (where I used to live) are Labour in a sea of blue in the east of England (although North Norfolk stayed with Norman Lamb and Clacton with Douglas Carswell). Even Great Yarmouth is a natural Tory seat with affluent Norfolk farms and villages offsetting areas of depression and unemployment in the town. London did buck the trend with Labour gaining seven seats and increasing their number of MPs. Since the Wilson years and apart from the Blair years, it's familiar to have hopes raised for Labour and dashed on the night.

Speaking up in the NHS

Robert Francis' report on NHS whistleblowing, Freedom to speak up, seems a little bland to me. Maybe this is because, although he heard evidence from individual cases, he hasn't described any specific details of any of them in the report. As he says, "cases are not always clear-cut", but I'm not sure if this justifies his decision to describe generalities only, including ruined lives in some extreme cases. Still, a Guardian article highlighted four cases.

Nor does Francis really attempt to explain the context for the problem. As another Guardian article says, the issue is at least partly managerialism in society in general, not just the NHS. But I think there have been, historically at least, specific elements in the NHS. The financial cost of delays to disciplinary proceedings hardly impinges in some NHS trusts, so that cases take too long to resolve. And, there was a particular phase of command and control leadership in the NHS, associated with the previous chief executive (see eg. previous post), that encouraged a bullying culture (eg. see another previous post). Problems with healthcare regulation related to the annual health check (e.g. see previous post)  and the Healthcare Commission (see another previous post) led to the Care Quality Commission (CQC) being formed, which had to be revamped after going through a rough phase (eg. see another previous post). CQC is still improving its methods and I'm not sure how valid its ratings always are. Nonetheless, special measures do seem to have been helpful for NHS providers that have been through the process (see Independent article, although I'm not sure how much should be made of the mortality statistics), and there may well be benefits from using them more widely.

The exhortation for a healthcare professional to speak up about concerns about the conduct, performance or health of others is important, but this can be misused. Clinical practice is not always objective and there may well be uncertainty about the best course of action for medical interventions. Francis did hear evidence that some people raise concerns for dubious motives. The increasing regulation of doctors over recent years, following the case of Harold Shipman, may have contributed to a climate of fear and culture of defensive practice (eg. see my BMJ letter). This is promoted by managerial over-reaction. Medical errors are not always manifestations of incompetence, carelessness or recklessness (see previous post). Naming, blaming and shaming may not always be the most appropriate response. The form of statements of intent can easily be persuasive, whereas the content doesn't really relate to quality. For all the merits of revalidation, for example, it is easily diverted into a bureaucratic exercise.

As I have mentioned before (see previous post), I am someone who has been suspended twice in my career. I have also been further investigated without being suspended (eg. see another previous post).  My first suspension was related to ideological conflict about critical psychiatry (see THES article). My second was a professional conflict with management, with me raising concerns that relationships between management and consultants needed to be improved. Instead it was me that was accused of bullying, and found guilty, in my view wrongly.