Patient safety

Day 581

Posted by

2

After more than a year of Saagar’s death I could see that nothing at all had changed. Nothing was going to change. There is no power behind a Coroner’s inquest report, no legal, professional or financial implications for anyone concerned. Hence no lessons learnt.

I approached the GMC for help with the view that may be they will see things as they are and have more power to influence change but this is the letter I received from them today:

“In January 2016 documents regarding Saagar’s care were referred to a GMC Medical Case Examiner for review. I can confirm that the Case Examiner was specifically dealing with Dr GP and any issues surrounding his fitness to practise when they reviewed the documents. A decision was made by the Case Examiner that there was nothing contained within the documents which would call into question Dr GP’s fitness to practise and that as such the case should be closed with no further action.”

  1. Really? Is this protectionism or is it a reflection of a deeper level of ignorance within the medical community than I thought?
  2. Am I the one who’s crazy? Imagining things? Over-reacting? Making false judgements just because I am grieving?
  3. The job at hand is clearly much harder than I thought it might be. I can teach children to ask for help. I can teach parents and teachers to identify signs of crisis and get professional help for them. They can take them to the GP. And then what?

The GP may ask them to fill out a PHQ-9 questionnaire. They may score 27/27. The GP might not discuss that with the parents. Not get anyone’s advise on the phone. Not refer them to a mental health specialist. They may send them home with a medicine that might worsen their suicidal ideation. They may also reassure them that they will get better.

That is like sending someone with terminal cancer home with the assurance that they will get better. That however would be unacceptable because cancer is a physical illness.

Severe depression can be invisible to the untrained eye. So, it’s ok for GPs to send young men with the greatest degree of depression home. Unquestionably.

‘Parity of esteem’ is a joke.

 

Day 579

Posted by

0

header_Geel-by-Gary-Porter

Hospitals can sometimes be a problem rather than a solution.  They cannot provide the collaborative information sharing needed to care for today’s typical patients who may have multiple problems. This is especially true for the elderly and the mentally ill. Royal College of Physicians has proposed the concept of “hospital without walls” which aims at providing continuity of care for patients, coordinated and delivered by a single consultant-led clinical team. The hospital ceases to be “somewhere”. It becomes everywhere.

The little market town of Geel  in Belgium is well known for its early de-medicalisation of care of the mentally ill. For at least 7 centuries, it’s inhabitants have been taking the mentally ill or disabled into their homes as ‘guests’ or ‘boarders’. These are people who, whatever their diagnosis, have come here because they’re unable to cope on their own, and because they have no family or friends who can look after them. When they meet their new families there is no clinical diagnosis. During the Renaissance, Geel became famous as a place of sanctuary for the ‘mad’, who arrived and stayed for reasons both spiritual and opportunistic.

A boarder is treated as a member of the family, involved in everything and particularly encouraged to form a strong bond with the children, a relationship that is seen as beneficial to both parties. They call it ‘family care’, possibly the best form of therapy. Often the boarder lives with the family till they die, first as a child, then a sibling and later on as an uncle or aunt. Doesn’t that fulfil a basic human need of relatedness with other beings? The tradition still exists albeit to a limited extent due to faster paced city life, fewer farms and more double income families. However, the main reason for its longevity is not just tolerance, but pride. “Half of Geel is crazy, and the rest is half crazy,” runs a local joke.

Today, in London we aim to provide ‘Community Care’ in the absence of a community and no understanding of the word ‘care’. It’s obviously not working because the basic values on which it is based are wrong ie. cost saving.

We, the people need to educate ourselves, open our hearts and develop a deeper understanding of our human condition.

To kick off the Mental Health Awareness week, here are a couple of attempts on my part:

18 Months on…

Podcast from Croydon Radio

 

 

 

 

 

 

 

 

 

Day 578

Posted by

0

image

This is the question : How can we Re-create Psychiatry?

How can we break down the“us” versus “them” approach?

How can we stop ourselves from putting people into neat little labelled boxes rather than perceiving each one as a unique individual with their own unique story and experience?

How can we communicate in a way where we respect boundaries but do not create barriers? How can we truly listen in a way that we can put ourselves in someone else’s shoes?

There is a hierarchy in knowledge. Intellectual knowledge is considered superior to emotional or experiential knowledge, which in turn is rated higher than seemingly irrational knowledge, which could come from ‘patients’ with seemingly little insight. Who makes these decisions? How come the power balance between psychiatrists(intellectual/clinical) and patients(experiential/seemingly irrational) is so extremely warped? Does looking at people through templates give us any idea of who they truly are?

The Open Dialogue approach is a philosophical/theoretical approach to people experiencing a mental health crisis and their families/networks, and a system of care, developed in Western Lapland in Finland over the last 25-30 years. In the 1980s psychiatric services in Western Lapland were in a poor state, in fact they had one of the worst incidences of ‘schizophrenia’ in Europe. Now they have the best documented outcomes in the Western World. For example, around 75% of those experiencing psychosis have returned to work or study within 2 years and only around 20% are still taking antipsychotic medication.

Working with families and social networks, as much as possible in their own homes, Open Dialogue teams work to help those involved in a crisis situation to be together and to engage in dialogue. It has been their experience that if the family/team can bear the extreme emotion in a crisis situation, and tolerate the uncertainty, in time shared meaning usually emerges and healing is possible.

This Open Dialogue training launches in London next month.

 

Day 574

Posted by

0

It’s official. Core Psychiatry Training is on the ‘shortage occupation list’ which means there are not enough resident workers to fill all the vacancies.

“Catastrophic is the word I would use for the shortage we are now facing. We have always struggled to recruit significant numbers but this year is particularly acute. It has got to the point where you can count the number of UK doctors coming into it in tens, when we have hundreds of training posts to fill” says Prof Robert Howard, dean of the Royal College of Psychiatrists (RCP) in the Telegraph.  He goes on to say that due to the lack of competition, jobs are given on the basis of ‘appointability’ rather than great ability. This means that the standard of competence of those selected is just above the basic minimum rather than excellent.

One reason trainees may be reluctant to apply for specialty training in psychiatry is because of the misconceptions and stigma associated with the speciality. For instance, a study presented at the Royal College of Psychiatrists’ 2013 congress found that 26% of medical students and 47% of the public said they would be uncomfortable sitting next to a psychiatrist at a party for “they would know what you are thinking.”

Another reason may be that medical students and other doctors often think that treatments in psychiatry are “unscientific,” and that they lack the same evidence base as treatments in other specialties. Other myths include a sense that psychiatric treatment is inhumane and that psychiatrists resemble those portrayed in films such as One Flew Over the Cuckoo’s Nest and Silence of the Lambs.

While speaking with a young Consultant Psychiatrist it was clear that the prospect of working with very limited resources and support is what makes a career in Psychiatry very unattractive.

A huge recruitment drive is on. Medical students and junior doctors are being introduced to various possibilities within psychiatry early on in their education. Let’s hope it works.

 

 

 

Day 570

Posted by

0

She lost her son to suicide in 1993. One year before Saagar was born. She wrote to me in response to an article I wrote for the Papyrus newsletter in March 2016 entitled “Mandatory Suicide Prevention Training- Why not?”

It is a beautifully hand-written letter. In her slightly shaky cursive writing she says “I wholeheartedly agree that the profession of GPs must be more tailored to suicide prevention. When Claire Gerarder was chair of the College of General Practice, a fourth year of GP training was discussed. If the length of GP training was as long as Specialist Medical training (7 years), hopefully more disasters could be prevented. For many years I have suffered the indifference and stigma of colleagues and society. Since my son died in 1993 I have worked on ways of prevention of Suicide.”

She signed off with, ”Yours in hope of help, EP.”
“PS: I am not on the internet. I have no e-mail.”
For her, 23 years have passed. Clearly, she is still hurting.
And nothing much has changed.
She sounds a bit like me.

How would she have coped so many years ago?
How did she get through all these years?
Where will I be in 23 years? How would that feel? Will anything change?
It is quite unthinkable.