Ronald McDonald to take over UK psychiatric services

Leader of the Community Mental Health Team

A fascinating and well written post on Doctors and Nurses from Seaneen, who is 22, from Ireland, living in London and suffering from what she describes as “classic manic depression”. She lists amongst her idols Viv Stanshall, Peter Cook and the Bonzo Dog Doo Dah Band. I feel in tune with her already.

The interface between doctors and nurses is a frequent source of controversy, classically summed up in that hackneyed old phrase “doctors cure, nurses care” and Seaneen’s experiences in psychiatric services suggest she has seen a lot of that precise dichotomy.

She is gently critical of my continuing fight against the dumbing down of the health service because she sees it, as do many others, as a tirade against nurse specialists. It is nothing of the sort. It is a tirade against the inappropriate use of medical and ancillary staff in positions outside their competence. It is a tirade against the government lubricated skills escalator that takes health service employees on a trip to test the Peter principal. It is not just nurses. It is doctors too, none worse than the ridiculous GPwSIs.

Seaneen is not too happy with my use of the word “lard bucket” even though I was referring to Carole Malone, the dishonest, androgynous, publicity seeking, ex lard bucket in the News of the World, and not to a nurse or doctor. I take nothing back. My contempt for Malone in boundless.

Seaneen’s post demonstrates only too well the underfunded twilight world of mental health care. Even though she has a serious mental illness, she is usually only seen by a psychiatrist twice a year. Her care has been handed down the food chain to the less qualified members of the CMHT.

Nurses, then, I think are extremely important in mental health care. For the paranoid, they are not as consistently scrutinising as psychiatrists are, nor as clinical. They’re not there to diagnose you with anything, even if it’s fairly clear that you do in fact have a certain diagnosis. They are just that little bit more human and on your level.

And, as I said, I think doctors are a massively prejudiced group of people. They see a lot of preventable or near preventable illnesses caused by lifestyle choices so, in my experience, if you smoke or you’re fat, you’re not even worth treating because everything that’s wrong with you is your fault. Tarring a lot of people with the same brush here but if Dr. Crippen can do it, then so can I. In terms of mental illness, I’ve been told in the past to “cheer up”, “stop moping”, “lose weight” and “sleep more”. Easy, innit. (Seaneen)

I agree with much of that. I am sad that she has had such a poor experience with psychiatrists. As for “tarring people with the same brush” I am not sure what she means. The “cheer up” approach to mental illness has little to commend it. Medication used to treat psychotic illness has side effects and, in particular, weight gain can be a real problem. A lot of sympathy and understanding is required. I’m sorry Seaneen does not mention her GP. Maybe she never sees him. Maybe he/she is not interested in mental health issues. A lot of GPs are not. It is too stressful and too time consuming. It is one of my interests and I spend a lot of time on it. I am therefore particularly aware of the gaping holes in the service.

The government approach to gaping holes in mental health care is to appoint people with little training. The lower the level of training, the lower the level of salary they command. This potpourri of mental health workers seen in the dumbed down CMHT are kind, and well meaning, but their ignorance of matters medical is papered over by giving them pretentious titles. Remember Amy?

I have known Amy a long time, and she will talk to me. So I have been seeing a lot of her recently and I hope I am providing her with some support. But what about the psychiatric services? She has been under their care for years. Which of them is looking after her? No one, really. Starved of funds, the CMHT is dumbed down and not helpful. The government would say I am exaggerating. They would say there are three “health care professionals” involved with Amy. Her CPN, who does see her occasionally. And then there is her “care coordinator” - someone who works in social services though is not a trained social worker. It is a grandiose title and a classical bit of New Labour flummery. Amy is not getting much care, and so little “coordinating” is needed. I have seen Amy more than any other doctor, and no one has ever attempted to coordinate me. Finally, there is Sharon. Sharon works with several “clients” in the same accommodation. She does shopping, and some cleaning, and is usually around to have a coffee if Amy wants to talk. Sharon is kindness itself. She is a patient of mine. She is not a doctor or a nurse or a social worker. She has no qualifications in mental health, and would not dream of making diagnoses or interfering with medication. Because she is the least qualified member of the “team” it is essential in the modern world of New Labour that she has a title. Sharon is therefore Amy’s “key worker.”

Thus, Amy is a success for the mental health services. She has both a care-coordinator and a key worker. What more could some one with serious mental health problems want? (Amy's story)

Psychiatric nurses do of course have some training but, sadly, (and with a handful of notable exceptions) psychiatric nursing does not attract the cream of the nursing profession any more than psychiatry (again with a handful of notable exceptions) attracts the cream of the medical profession. Because of the lack of funding for psychiatric services, these people are trying to fill roles for which they are not trained. Protocol driven, tick sheet medical care is the order of the day. It is not just in psychiatry. Look at this cry of anguish from an American Emergeny Room specialist.

Someone like Seaneen needs support from the Consultant Psychiatrist, from the senior registrar, the registrar, and the senior house officer. Most of them have gone, their jobs now done by inadequately skilled but cheaper nurse specialists.

Trouble is, you cannot tell a “nurse specialist” that they are not skilled enough to take over from a doctor. Often, you can’t tell a nurse-specialist anything. They know better. Any attempt to put them right results in a hissy fit. Fingers in ears. “I’m not going to listen, I’m not going to listen”

It is not just happening in the NHS. After eleven years of New Labour, it is happening everywhere. There is an excellent article in the Guardian today about a forthcoming book, The Gods That Failed: How Blind Faith in Markets Has Cost Us Our Future:

If that sounded an extraordinary sell-out by a supposedly Labour government, it was of a piece with the news on January 28 that commercial companies were for the first time to be allowed to award nationally recognised qualifications based on their own workplace training schemes. In a parody-defying move, the government announced that the first three accredited schemes would be run by the burger chain McDonald's, the airline Flybe and the train track operator Network Rail. The Guardian that day reported: "Staff at McDonald's will gain the equivalent of A-levels in running burger restaurants after the fast-food giant won government approval to become an exam board." (The Guardian)

Welcome, senior nurse-specialist Ronald McDonald