Psychiatry on the cheap
The sad case of Mark Corner is once again in the news. Four years ago he murdered two young women. The case is in the news again because Mark Corner is a schizophrenic who was under the care of a consultant psychiatrist, Dr Eric Birchall. A year before the murders Dr Birchall decided that it was not necessary to keep Mark Corner detained in hospital, as he was only a “low risk” to the community. He was discharged to the care of the Community Mental Health Team.
I do not know the facts of the case other than the scanty details in the newspaper. But this tragic case covers many issues that concern me.
Newspapers love “mad axe murder paranoid schizophrenic” stories. Please remember that most schizophrenics, like Emily, are helpless, hopeless people who pose no threat to anyone.
There is a desperate shortage of hospital beds for the mentally ill. Desperate. Successive governments have closed many of the traditional long stay mental units, and the ethic now is “care in the community”. It’s cheaper. Consultant psychiatrists are put under overt and covert pressure to turf mentally ill patients out of hospital at the first opportunity.
Proposition. All schizophrenics should be compelled to have life-long institutionalised hospital care. Tuck them all away, under lock and key, out of sight, out of mind. That proposition is not acceptable and, even if it were, there are not enough beds. So someone – and it should be a consultant psychiatrist – has to decide who is safe and who is not. What standards should they apply? Hunch? Balance of probabilities? Beyond all reasonable doubt? However clever, however caring they are, they will occasionally get it wrong.
It was said that Dr Birchall “failed to use approved monitoring systems”. Easily said. Sadly, there is no monitoring system short of constant one-to-one supervision that is guaranteed safe. An experienced psychiatrist will pick up early warning signs, if there are any. But he does not have the time to see all his patients regularly and personally. A psychiatrist might have 200 mentally ill patients under his care. He has to delegate. Unless he works in a teaching hospital, he is unlikely to have an experienced registrar to share the load.
So, it is care in the community, monitored by the kind, caring, hard-working, cheap, non-medically trained CMHT members. They will play at doctor by filling in their tick sheets, and complete their risk assessment protocols, and find much wood and no trees. They confuse caring with competence. They are neither qualified nor competent to make psychiatric diagnoses, but you cannot tell them that. They do not understand. They will not have it.
The tragedy of Mark Corner is a tragedy of lack of resources. Not enough hospital beds. Not enough psychiatrists. Doctors forced to discharge patients who would be best kept in hospital, and to delegate medical care to HCPs who have no medical training. It has been going on in psychiatry for years. Now the government is “rolling it out” (as they would say) in all medical disciplines. We learnt last week of HCPs doing ECG telephone triage of chest pain patients, a practice that an American doctor called “stunningly asinine”. It is much the same in psychiatry. You get what you pay for. And for the schizophrenics, that is not much.
Labels: abuse of psychiatry, CMHT, risk assessment
36 Comments:
I agree.
Re: one to one supervision. It's interesting to note that there are quite a lot of suicides amongst psychiatric in-patients on one-to-one observations. I doubt that a theoretical one-to-one homicide would be any more successful.
It's a common misconception that psychiatrists have special powers to detect what their patients will do next. Most of the time I don't complain about this, reasoning that the truth can only lead to a pay cut. It's worth bearing in mind that no mathematician has ever worked out an equation for what happens if three balls collide* and people are a good deal more complicated than that.....
*I'm bound to be corrected on this
There is a programme on Channel 4 tonight at 22:00-23:20, The doctor who hears voices
K
I understand that it is very difficult to work out who will kill themselves. However as a partner of someone who has bipolar I have experience of going to see psychiatrists and CMH's with her. Although there are good and bad workers in every field, and not all psychiatrists have been good, at least they have an obvious understanding of:
1. bipolar
2. how to talk to people when they are severely depressed or manic
All but 1 of the 6 CMH workers have been 'caring' but have seemed out of their depth. They might be fine with someone who is feeling down and wants someone to listen to their problems, but they seemed totally thrown with dealing with someone who is so depressed they are barely talking. I know it is not easy to relate to someone who is very depressed, but if this is your job you need to know how to do this.
"carefree in the community" as my parents always term it.
You see people talking to and kissing clasped pigeons, or banging baby dolls against bus windows and then cuddling them and can't help but wonder if they really should have more in the way of care.
This is the stuff that people overlook when they complain about doctors' pay. There is so much responsibility laid at your feet, which can directly be attributed to you even when you're doing the best you can.
I agree.But their complain is not about doctors' pay but it is about their inability to afford better and high cost medical service.I mean if someone could pay on behalf of not-so-rich patients then it would be alright.Patients do feel that doctors deserve high pay.
So you admit you know no real details of the case, but you've already decided this is all the fault of those awful non-doctors.
Risk assessment is not an exact science and there is absolutely zero evidence that psychiatrists are any better at it than any other member of the CMHT.
This post has been removed by the author.
Now I'm sure I'll be accused of fuckwittery for this, or for demanding tomato ketchup on my chips, or even being paranoid and vociferous, but I just want to make a couple of points.
You have used this sad case as another opportunity to rail against HCPs, at least, to your credit you have avoided using the 'Q' word.
I've had a read of the article in the Liverpool post which you use as your source. Several quotes caught my attention.
'A tribunal heard how consultant psychiatrist Eric Birchall discharged highly disturbed Mark Corner against the advice of other doctors and his own family'
'Dr Birchall authorised the release and failed to use approved monitoring systems despite knowing Corner was a cannabis smoker, had a history of violence and harboured murderous thoughts.'
'They have said that Dr Birchall was to blame but that he should not pay the price for what they call a ‘one-off mistake’.'
Corner’s father pleaded with the doctors to re-admit his son, but again Corner was discharged.
'In the months before the killings, he missed two of three outpatient appointments and was seen just once by his GP.'
The Panel found proved that you did not keep in close touch with Patient A and monitor his care.
'The Panel also found proved that you did not take any or any adequate or sufficient, steps to manage, treat and care for Patient A after he failed to attend at his out-patients appointments on 13 January 2003.'
I could go on, however what's the point. You'll only see what you want to see.
The nub of it is, there is no mention of any failing on anyone elses part, other than the psychiatrist. No mention of an OT fucking up, the CMHT failing to monitor the patient, or social workers drinking tea and reading the Guardian instead of looking after their charges.
Like you, I have a hige problem with HCPs undertaking jobs that they are not trained for. Unlike you, I don't see reds under the bed and don't feel it necessary to turn much of my posting into a jibe against others using the most tenuous links
The thing is, there is a lack of funding for mental health services because the public doesn't care. The long-term mentally ill (bi-polars, schizophrenics) are seen as basket cases who suck money from the NHS without getting any better. I believe a substantial minority would be in favour of Nazi-style euthanasia of the 'feeble-minded'.
Mental health is the first to feel the slash of funding cuts, and the public, in general, says nothing. Until, that is, a very rare case of a seriously disturbed person killing someone appears in the news. Then 'something must be done'.
Quite what, I'm not sure.
Dr. Crippen, what happened to "Brits for Barack Obama"? Seems the site is closed.
.........arf
Hi Arf
Time. Not enough. Can't do two blogs. Have to work occasionally. Sad. Am glued to Pennsylvania. The most interesting US election for years.
John
Hi Arf
Time. Not enough. Can't do two blogs. Have to work occasionally. Sad. Am glued to Pennsylvania. The most interesting US election for years.
John
Is one of the reasons that mental health gets a low priority because psychiatry has a lack of success in curing the mentally ill?
I believe psychiatry provision is the litmus test of a decent society. We currently have a cinderella service, that has approximately halved in-patient care. Care in the community is not and can not ever be the same. You get a snap shot of the illness, whilst you need longditudinal information. I fear England would fail the litmus test.
Thanks for the article Dr Crippen.
This is right on the money, for General Adult psychiatry throughout much of the UK, at the moment.
This lack of resources is why Lord Darzi is (incomprehensibly) suggesting fragmentation of the services. Quack quack.
In the interests of babies and bathwater I would say things are typically better in Old Age services (Mental Health Services for Older People, if politically correct, but I still see myself as a psychogeriatric shrink who's oft times neither political nor correct).
In my Trust we've currently several beds free on each ward. For me, not being able to admit when I need to is a major stress that I can't abide, so there's always a need for extra capacity. Colleagues tell me it's not uncommon to have beds free in MHSOP units, so my hospital's not alone. Ah, apart from colleagues I know personally in London who are in apoplexy.
But I'm thankfully not braving the tempestuous changes Lord Darzi's suggested which have been foisted 'pon London where, more than anywhere in the UK of late, it's all gone to Hell in a handbasket.
This post makes a lot of valid points - about the shortages of hospital beds, about the pressure to discharge as quickly as possible, shortages of aftercare, unmanageable caseloads, the sheer impossibility of trying to guarantee the whereabouts and safety of somebody who is out wandering the streets...
...but yet A-BLOODY-GAIN Dr Crippen goes and spoils by turning it into yet another childish and ill-informed rant about anybody who has the galling stupidity not to be a doctor.
It's true that the bulk of the monitoring in the community of a patient post-discharge will be done by the CPNs - after, that's what nurses are for, to keep the continuity of care going on an everyday basis. They shouldn't and in fact don't make diagnoses (though they often triage the routine referrals and then discuss the results of the assessment with the doctors to see if further assessment is needed).
How good are CPNs at the (highly inexact) science of trying to work out whether somebody is likely to harm themselves or others? Well, they don't have medical degrees, but they have spent years working with people with mental health problems. As a broad generalisation (not a fixed rule), I'd say they're not as good at it as psychiatrists, but better at it than GPs.
But as with psychiatrists they're not infallible in this respect, and they can't be everywhere, especially if their caseload piles up to unmanageable proportions.
Out of all I've written above, I think I know exactly which sentence is the one that will cause Dr Crippen to explode with rage.
Dr. Crippen. Stay glued to Pennsylvania. Maybe you should vote in the election. Or if it's too late for you to register, your dog might have a shot at voting:
http://tinyurl.com/54yk2x
(links to AOL video)
.........arf
I agree that the pop at Community Mental Health workers is a little artificial in this piece - but it is a fair comment none the less. Whilst the idea of CPNs (although increasingly we have a whole panoply of sub-CPN types) providing ongoing support in the community is sensible and can work well, we are increasingly seeing referrals to such professionals in place of referral to a Psychiatrist.
This is fine if the CPN can accurately diagnose most mental health problems and, more importantly, spot when they are out of their depth and get a doctor involved. Sadly neither of these two are givens, and all too frequently serious problems are missed.
For years it has been only psychiatric services, with their long term under-investment, which has suffered the effects of too few doctors with other HCPs having to/trying to fill in the gaps. Now we see this spreading to the rest of medicine - psychiatric care in this country is little to be proud of (though not for lack of the staff trying), why the rest of medical practice is being similarly undermined is beyond me.
Yet again Dr C uses a post that otherwise makes many good points to bash Nurses.
Doctors forced to discharge patients who would be best kept in hospital, and to delegate medical care to HCPs who have no medical training.
What do you suggest - a Psychiatrist to see every patient every week? Surely then you would be banging on about a waste of education? CPN's (at least in my team) DO NOT DIAGNOSE MENTAL ILLNESS. What we do is monitor those that have been diagnosed and discuss concerns we have with our Psychiatrc colleagues.
An experienced psychiatrist will pick up early warning signs, if there are any.
As will an experienced CPN on as many occasions - the failings identified by this case (although I am admitting to be as clueless about the details as you Dr C) seems to have been that the Psychiatrist decided that he was fit to be discharged. His fuck-up - but it happens.
Seriously, the cheap shots at Nurses are getting very tiresome now.
CPNs are great but like the rest of the Nursing Profession they are being reorganised, regraded and "upskilled" to destruction and just like we doctors being replaced by less qualified workers to save money.
I used to know many of the CPNs in my area, they had long term, beneficial relationships with my chronically or intermittently ill patients, were excellent at picking relapses up early and referring them back to me with sound advice or referring them back to a Psychiatrist. They really were like my District Nurse but within the Psychiatric service
This is no longer the case, they no longer seem to be CPNs but CBT practitioners, or Team leaders, or Patient Liaison workers. They all seem to go on courses and change jobs just before either I or my patient gets to know them. I no longer know what qualifications or experience they have, are they all qualified nurses or are many of them unqualified carers/be-frienders/family support workers?
John rails at Nurses, perhaps with excessive vitriol at times but there is a core of truth in the argument that the NHS is being "dumbed down" for financial reasons and to the detriment of the user and the workers.
It is interesting to see how there are in all our professions some who collude to a greater or lesser extent and with greater or lesser excuse, the junior doctors who winged about excessive hours and menial tasks - result - nurses doing their jobs, nurses complaining about lack of status and menial jobs - result - promotion for the few but Care assistants replacing the many, GPs complaining about too much work and too much trivia - result - various non doctors doing their job more cheaply with a decreasing "need" for GPs
Surely the best argument for all of us is to start with patient needs, both met and unmet and try to argue for a service which addresses these needs safely and efficiently with "skill mix" appropriate to the abilities of each profession.
(except midwives of course, they really are just beyond the Pale)
Oh and I am in favour of motherhood and apple pie as well!
I agree
There are some excellent CPNs and it all used to work well until they were "upskilled"
It's the peter principle.
John
they no longer seem to be CPNs but CBT practitioners, or Team leaders, or Patient Liaison workers
So Nurses should not upgrade their skills in any way. What is wronf=g with a CPN also parcticing CBT (although I happen to think it is a bag of bollocks in most cases). What is wrong with a Nurse being a Team Leader - our Team Leader is a Nurse. She works in partnerhip with our Clinictal Director (Psychiatrist). She does all the shit jobs that the Psychiatrist hasn't got teh time or inclination to do, and supervises six WTE Nurses and carries a caseload of her own.
I used to know many of the CPNs in my area, they had long term, beneficial relationships with my chronically or intermittently ill patients, were excellent at picking relapses up early and referring them back to me with sound advice or referring them back to a Psychiatrist. They really were like my District Nurse but within the Psychiatric service
I, respectfully, find that many of my GP colleagues ignore any advice I have to give about a patient despite the fact that may have seen them once in the last 6 months and I see them every week.
So now nurses shouldn't acquire psychotherapy skills or get promoted into team leader jobs?
Is there ANY job in the NHS that you think shouldn't be performed by a doctor and only a doctor? There's a bit of a nasty floater in my hospital toilet at the moment, but the cleaner wants to flush it away. I think I ought to send him off and demand a doctor come and do it.
I'm a mental health nurse. I don't diagnose and I don't have any interest in going on any nurse prescriber courses. However, I have been completing extra training in CBT because I feel this will make me a better nurse.
As I said earlier, there were some highly valid points in this post, but then you had to go and ruin it all by turning it into yet another set of cheap shots at non-doctors.
And you do it every time. Every single time.
Of course he does it every time, zarathustra - he is gagging for the kind of response you give him.
Think of Crippen as huddling under a ricketty bridge, waiting for the billy goats Gruff.
Nurses should develop their career in any way they want but sometimes the service suffers with a decrease in continuity and excessive staff turnover.
I think part of the problem is the lack of recognition (both status and financial) given to actual nursing by which I mean direct patient care, and the assumption that if a nurse is good he or she must develop managerially and usually move away from providing care or specialise into a small area, again moving away from generalist care.
My point was that a few reorganizations ago I and my psychiatric patients worked with about three CPNs whom I knew, whom I recognized and chatted to when we met in the supermarket, and this relationship fostered trust so that if they phoned me and said "you need to see Mr X and change his meds", I did it.
Now I deal with four different Teams, each of which has a Team Leader, there are over 20 people who may or not be or have been CPNs (I genuinely do not know) some of the CPNs do not see my patients unless another CPN refers them to him/her, others do, some write me letters, some do not, some have waiting lists to be seen that are longer than any others in secondary care (including the consultant psychiatrist). Most of them have never spoken to me, I have met about three of them at meetings.
I do not wish to denigrate nurses, nor decry their career development but this new system is over complicated, less personal, less efficient and, in short, worse than the system it replaced and I believe that the main change was the development of the nusing role away from that of a generalist to that of a specialist.
I would accept the same argument about a lot of medical care in hospital which is one of the reasons i believe Primary Care is so important, patients need generalists to co-ordinate, interprate their care and at times protect them from specialists
Anon - the changes you describe have little to do with developments in nursing roles and more to do with government importing some snazzy ideas from the USA - assertive outreach, crisis resolution, home treatment and early intervention teams in the community, each with their own remit. This Balkanisation of has complicated the picture of community mental health, I agree, but it has also led to some real improvements in patient care, particularly on the part of the home treatment team who alleviate pressure on beds by providing an alternative to hospital admission.
Okay I know this is anecdotal.
It is true that CPN's are used to prevent hospital admission. In my experience this can be good as hospitals are rarely conduicive environments for people with serious mental health problems. I was able to prevent my partner being sectioned by agreeing to nurses from the crisis team visiting twice a day.
My complaint is more about what CPN's do with patients. This seems to be nothing more than a 'chat' where they suggest solutions such as 'try and do one thing a day so that you can feel you have achieved something'. Absolutely useless when you are dealing with someone who was so depressed that it takes quite considerable encouragement to get them to eat and drink enough. They seemed to have no understanding of someone with this level of mental health problems.
I have talked to other people who have said their CPN pops round and chats to them regularly and they enjoy the chance to talk to about their worries and have someone listening to them. Okay, up to a point, but I am not convinced it really makes that much difference to the patient. And from my experience makes no difference to people with serious illnesses such as bipolar.
Yeah lets sack all CMHT HCAs/Quacktitioners and leave the Doctors to cope just to see what happens...
Lets just spend money where we know it works. Sometimes taht will be on nurses or HCA's, other times on Dr's. But so much money is wasted on initiatives that make little or no difference.
anonymous 12.49
stop being so aggressive and defensive.
I value the input of my Nursing colleagues from the CMHT, nowhere did I disparage their skills.
What I did question was the increase in second level nurses at the expense of primary care giving CPNs, the lack of continuity of care and the lack of communication I receive from the Team.
I believe the Nursing Staff are as much victims of this as anyone else.
It's the same in District Nursing, I actually have fewer district nurses working alongside me now than I had 10 years ago despite all the extra care they are expected to provide, and again whereas they used to be permanent staff who stayed for years they are now on short term contracts and are off by the time I get to know them. Despite this there has been a huge expansion in Tissue Viability Nurses, Incontinence Nurses, Stoma Nurses, Intermediate Care Nurses, Step Down Nurses, Step Up Nurses, Palliative Care Nurses, Urology (oncology) Nurses, Urology (LUTS) Nurses who all advise the District Nurses (aka the poor bloody infantry) from afar.
And I AM NOT DISPARAGING THESE NURSES (sorry for shouting but I want to make sure you understand that) I am questioning the balance of the skill mix. And a point I made earlier there is a tendency among the Nursing hierarchy to disparage those nurses who stay on the district or on the ward rather than developing into something else which is unfair on nurses who want to nurse.
I guess I am disparaging a lot (although not all) CPN's as I don't believe they have enough training to help effectively people with serious mental health problems such as bipolar and szichoprenia. That would be fine if they weren't being used as part of the monitoring mechanism and treatment for people with these illnesses. But I am not disparaging individual CPN's. It isn't their fault they don't receive adequate training, and nearly all are caring committed individuals who do want to make a difference.
NI GP
Fair enough, I take your point that you're not disparaging nurses (though I think Dr C tried to turn it into a disparagement with his crack about the "Peter Principle")
Anonymous
I have talked to other people who have said their CPN pops round and chats to them regularly and they enjoy the chance to talk to about their worries and have someone listening to them. Okay, up to a point, but I am not convinced it really makes that much difference to the patient. And from my experience makes no difference to people with serious illnesses such as bipolar.
Part of the reason CPNs go round and "have a chat" to patients isn't merely to give them someone to talk to (which, as you say, a lot of people find helpful but is not likely to get someone out of a psychotic episode).
What's missing from this picture is what's going on inside the CPN's head while they're chatting. A good CPN (and yes, they do exist) will be thinking, "Is this person exhibiting any relapse signatures? What's their mood state? Depressed? Manic? Are they displaying any behaviour that might cause them to become a risk to themselves or others? Do they have enough social support?"
One can tease out some of the answers to these questions by simply sitting with the patient and spending some time chatting with them. There's more going on in these cozy chats than meets the eye.
Hi Zarathustra
I understand that it is possible to do a meaningful assessment of someone through what looks like a cosy chat. Indeed it is probably the most productive way to get the information you need to monitor someone. What I have been unhappy about is my personal experience of CPN's who apart from 1 excellent one, did not appear to be able to cope with someone who is severely mentally ill.
I personally have visited a Mental Health Worker due to stress of caring for someone with severe mental health problems. I found it helpful, although I was annoyed at some of the assumptions the individual made. However, the level of skills needed for someone who is temporarily depressed or very stressed is not the same as the level of skills needed to work effectively with someone who has serious long term mental health problems. My experience has been of CPN's who don't have the necessary levels of skill.
“So, it is care in the community, monitored by the kind, caring, hard-working, cheap, non-medically trained CMHT members. They will play at doctor by filling in their tick sheets, and complete their risk assessment protocols, and find much wood and no trees. They confuse caring with competence. They are neither qualified nor competent to make psychiatric diagnoses, but you cannot tell them that. They do not understand. They will not have it”.
Most of this has already been said but here goes:
They will play at doctor - no we will not we will do our jobs just as we have always done them. This may come as a surprise to Dr C but I can assess risk as well as he can, you don’t need a degree in medicine to assess risk.
They are neither qualified nor competent to make psychiatric diagnoses – just as well we aren’t going to try then isn’t it.
They do not understand. They will not have it - no one understands apart from Dr C boo hoo, pathetic, it must be so lonely in that ivory tower but I expect the view is good from up there. What would the good doctor have us do I wonder ah yes I remember washing bed pans in the sluice presumably while a consultant psychiatrist goes round every one of his or her two hundred or so case load assessing whether they are relapsing or not because only a consultant psychiatrist can do that.
(I am pleased to note that the psychiatrists I have worked with have usually only been too happy to rely on my observations and judgment, using me as their “eyes and ears” in the community.)
Risk assessment is difficult also for psychiatrists.I'm really sorry, but that is evidence based. At www.scotland.gov.uk/topics/justice/criminal you can find the scottisch guidelines. Riskassessment should be multidisciplinary, include evidenced based tools. I was very sursprised to see and hear that in different Trusts in the NHS non-evidenced based tools are being used by psychiatrists and CPN's. It is my opinion that that would not be the case if psychiatrists would be more involved in decision making. A well trained CPN might be better in risk assessment than an untrained doctor.
Dr Crippen - have I understood you correctly ? Only consultant psychiatrists are competent to perform (psychiatric) risk assessment ?
You may be interested in reading 'Treating Violence: a guide to risk management in mental health' written by Anthony Maden, a Professor of Forensic Pscyhiatry.
It begins, "the most important event in the history of British mental services occurred on the platform of Finsbury Park tube".
It refers, of course, to the murder of Jonathan Zito, on 17th December 1992.
Curiously Maden doesn't blame the quacks, perhaps because they were few and far between in those halcyon days, but there is section in the book (on p160) entitled "I blame RD Laing".
Perhaps it's inevitable that scapegoats must be found when things go dreadfully wrong, once upon a time we could blame an anarchic, and whisky loving anti-psychiatrist (who at least had a certain intellectual cache) but nowadays the finger is pointed at the the humdrum quacks, even when they are not in the same building.
If RD ended up depressed and paranoid think what effect the constant put downs might have on us poor monkeys ;o)
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