Society of Clinical Psychiatrists – Annual General Meeting Chairman's address

November 2009

As I commenced writing this report issues such as postnatal depression treatment, the woman who jumped off the Humber Bridge with her child and  both survived though astonishingly the mother was imprisoned, the impact of so many doctors  working part time, the puzzle about clinical psychologists,  the European Working Time Directive, prison overcrowding and psychiatric hospital beds numbers, all assailed me.  An embarrassment of poverties.

I started by googling 'NHS Hospital Scandal'.  I had in mind the appalling failure of Mid-Stafford Foundation NHS Hospital which broke in March last.  There is an abundance of material about that  and other scandals.

As if that were not dispiriting enough there has been the horror for patient Mrs Judith Rowe and her relatives publicised in national dailies in August this year.  Her family was told by an NHS Trust that a woman who suffered from Alzheimer's disease did not have a health problem. Instead Social Services deemed that she had a ‘social illness’. The NHS therefore declined to pay for the 74 year old's care because her condition was a‘social illness’.(I have already elaborated on this in a SCP website piece titled ‘Line management led by donkeys’). Eventually the Health Ombudsman awarded them £130 000

As recently as November 2, 2009 the Daily Telegraph headlined “Alzheimer’s fight daughter defies gagging order”. Mrs Pauline Hardings won a £30 000 refund for care unfairly denied by the NHS to her mother afflicted with Alzheimer’s disease. It took a year long battle to win. She was asked, by the Cornwall and Isles of Scilly PCT, when she went to collect the monies, to sign a confidentiality agreement not to speak to the media which she was told was routine. She duly signed but was so incensed by this she wanted everyone to know. Her next door neighbour secured a £130 000 refund for care provided for his father.   

A survey earlier in the year found that "hundreds of doctors, especially those involved in the care of older patients believe the NHS to be institutionally ageist and a report earlier in October 2009 from the Royal College of Psychiatrists found "tens of thousands of people over the age of 65 are being denied access to specialised mental health services because of 'arbitrary' age limits".  There is now a planned Equality Bill that is to ensure the NHS complies with age discrimination rules by 2012.  Age Concern wants it to happen sooner.

Evidence of poor NHS patient care (DT letter 19.10.09 p27) is not difficult to encounter.  The indefatigable surgeon, Mr David Nunn, commenting on (DT October 15, 09) news that one in eight hospitals is failing to achieve basic standards considers it no surprise to those trying to provide care directly to patients in the NHS.  Vast amounts of money, he claims, have been spent on employing "people who manage pathways, policies and protocols but who have no direct patient contact and who do not answer to clinicians … until the present government-driven management culture in which far too many people are employed to do far too little except to obstruct - is abandoned, the poor quality of care in the NHS will be perpetuated".

Mind you, not all doctors writing on health matters are so concise and clear as David Nunn.  Dr Frank Loeffler (JRS Soc Med 2008: 101: 434-435) in a letter 'Dazed by Darzi' referred to 'Professor The Lord Darzi's article on evidence based medicine (EBM) Darzi which reminded all that the term had been around for 36 years.  Doctor Loeffler somewhat baffled, having read the piece some six times eventually gathered that EBS was a good thing.  He was desperately disappointed that it took six readings to grasp the simple points the Lord was making.  He confessed "reading his (Darzi's) article made me feel as I do when trying to swat a fly – just when you think you've got it, the beast eludes you."

Dr Iona Heath, a London based General Practitioner, writes a regular BMJ column "Life and Death" and it is notably thoughtful in the BJM's 4 October 08 issue, V. 337 – p787. She commented on the proposed NHS Constitution, "The current draft is seven parts platitude, two parts mendacity and one part hypocrisy".  The fourth of the six platitudes Dr Heath identified exhorted compassion: that "We find the time to listen and talk when it is needed, make the effort to understand, and get on and do the small things that mean so much - not because we are asked to but because we care".  She finds this superficial, sickening in fact, because it is what so many working in the NHS try to do every day.  Indeed.  She is right to state, "I almost feel insulted".

She considers the mendacity appears most obviously in the sixth of seven "principles that guide the NHS": 'Public funds will be devoted solely to the benefit of the people that the NHS serves'.

The most striking example of hypocrisy, says Dr Heath, declares that the principles outlined in the 'constitution' preamble "Will guarantee the principles and values of the NHS, preserving best practice will be assured by parties engaged in "full and transparent debate with the public, patients and staff", when the current government indulges in covert commercialisation with no sign of full and transparent public debate".  I have but skimmed Dr Heath's critique and it deserves a full read. 

Still as we choke on health political gobbledegook nowadays, I find myself breathing more easily when checking the BBC Radio 4 Science/check-up website hosted by non-doctor presenter, Barbara Myers' declaration "… there is no substitute for 1-to-1 advice from a top medical expert (and that's what we offer our callers and emails)".  How refreshing when we find ourselves seemingly surrounded by a vocal medical professional allied to medicine lobby that appears to  consider doctors are hardly necessary – until we find ourselves attempting to pick up the pieces.  The plethora of new (to me anyway) titles eg, Nurse Practitioner,  Consultant Nurse, and Consultant Clinical Psychologist. The latter confuses matters further by requiring to be addressed as 'Doctor' (a PhD) in a healthcare environment.  Clearly psychologists are less litigation conscious than medical doctors who are, inter alia, aware that to pass one's self off as a registered medical practitioner without being so qualified is actually a criminal offence. 

No wonder doctors seem to be less confident of their necessary and legitimate authority required to carry out their duties and responsibilities. Working for Patients 1989 endorsed "… the key role of consultants in the NHS in terms of their 24-hour responsibility for patient care.  It is they who are the leaders of clinical teams, responsible for all aspects of the clinical care of the patients under their charge".  Still medical morale drifts down whether by flawed government-driven policies or deliberate denial of access to necessary levers of leadership. 

In the October2009 Psychiatric Bulletin, Dr Sandeep Bansal wrote of "New Ways of Working – are we prepared?" and described an audit comparing the 60 most recent histories taken by junior doctors (including general practice trainees) and nursing staff in an outpatient clinic.  All histories were assessed for 108 variables and the data carefully analysed. 

Hardly unexpectedly, doctors generally were found to have taken a more comprehensive and detailed history than nurses.  During a presentation of the audit within the Trust, nurses' representatives were asked for their views.  They stated that history taking, physical examination and pharmacology are not a part of their nursing training, therefore, they are not confident in these aspects of history taking.  They had identified difficulties in differentiating physical symptoms because of functional and biological causes.  Bansal referenced a nursing journal study (Tom A, Mcnichol E. Can Mental Health be a Nurse Practitioner? Nurse Stand 1996; 11:39 – 44) found that 96% of nurse practitioners did not feel that their training adequately equipped them to assess people with mental health problems.  No other independent studies have been completed and there is no other evidence, claims Bansal, available which would support New Ways of Working. As I write this (November 15) the media are ablaze with a government proposal that by 2012 should possess a degree. I hope to critique this early next year.

It is difficult to imagine that any experienced psychiatrist would be surprised by these findings. [CSIP/NIME, Royal College of Psychiatrists, New Ways of Working for Psychiatrists.  Department of Health, 2005.]

Easy it is not, to escape the sad conclusion that the political pursuit striving to substitute inadequate systems of patient treatment are perhaps guided by wished-for cost savings rather than adequacy of patient care and treatment. 

The extent to which this undermines the confidence and perhaps competence of psychiatrists leads me to a BJM clinical review on management of postnatal depression (BMJ 2008; 337: 736 DOI: 10.1136/BMJ. a736) (Masters C, McDonald E, Jones I.  Management of Postnatal Depression.  BMJ 2008; 337: 399-403).  Remarkably, in describing treatment for this condition there is no mention of ECT.  This was the most obvious aspect of the paper's deficiency, but by no means the only disquieting one of a clinical review article.

I submit that few psychiatrist with, say, 2 – 3 decades  experience of treating puerperal psychotic patients would fail to regard ECT as of potential (and real) significant benefit in treating some of their most acutely and intensely psychotic patients with often a rapidity of benefit unachievable by drugs and other means.

Psychiatry, in its approach to ECT generally, seems to have been put on a permanent back foot, not by experienced clinicians but by Jack Nicholson and his muddled portrayal of psychiatric treatment in Hollywood's rendition if Ken Kesey's novel One Flew Over the Cuckoo's Nest. 

Should the subject of ECT crop up in casual social conversation, one often finds that non-medical folk have assumed that it is no longer used as a treatment.  And of course it is, albeit hedged by cautions suggesting great hazard and requiring a second opinion to justify it. 

Extraordinarily patients have virtually to be at death's door often dehydrated, refusing food and fluid, tormented by symptomotology before mercifully ECT regularly (not invariably because sometimes the call comes too late) pulls them back from the brink of death. 

Yet despite this huge achievement of ECT, a treatment that first emerged in the 1930s, patients can be allowed to suffer in an inadequately medication- treated state, some into months before ECT is mooted by a courageous consultant.

As one surveys the overall England healthcare  scene and compares it with ,say, France, we emerge badly. Perhaps this is due in part to a wider UK government incompetence not solely affecting health policy but including general infrastructure such as public transport, our position amongst larger countries in the developed world in grappling with the global recession. Left and right are mere slogans. It is government policy effectiveness that counts.    

We must leave for the moment such broader contemplation of healthcare and segue back to the medical profession and its contemporary historically low morale. Self-confidence has plummeted since the 1980s. I ask myself can I think of one figure that has damaged the profession (and with that, inevitably patient care).

One name suggests itself. Enter Sir Ian Kennedy, academic lawyer whose somewhat jaundiced perception of the whole profession influenced some (especially politicians) with his 1980 BBC Reith Lectures ‘Unmasking Medicine’. It would be difficult to dredge up any low profile (in political terms) person who so singularly influenced the misdirection of the medical profession and what used to be its self governance, its self-regulation via the General Medical Council. He said of doctors I quote from a BBC health websites “The past has been characterised by a type of professional arrogance – born of indifference”. It would be foolish to claim that doctors are without their imperfections.

But if arrogance and indifference to patients were significant medical profession personality traits, traits which most sentient human beings tend to regard as somewhat obnoxious it is puzzling that doctors consistently, in public attitude surveys, enjoy a high level of public trust and respect that both politicians, and, yes, lawyers might well envy. So, that gratuitous global denigration of doctors hardly stands up to simple examination.

Still, such shallow and shabby attempted general smearing of doctors did not inhibit this academic lawyer from effectively overruling expert medical opinion when in the late 1980s, records the BBC, the rather terrifying threat of an HIV/AIDS epidemic was emerging in the United Kingdom. Some researchers were keen to anonymously check the blood of all women to see how prevalent it was in the general population.

When the suggestion was discussed at a House of Commons Select Committee shortly afterwards it was fiercely opposed by Ian Kennedy who, despite reassurances that no positive result could be traced back to a particular woman, said it was a violation of their rights. The committee accepted this and such testing was delayed by a number of years – much to the disgust of many doctors. One senior figure in the British research establishment says now: “We needed that data then, not a few years later - it was too bloody late by then”

On the basis of Kennedy’s eccentric global antipathy to what the profession has stood for (let it be said in stark contrast to the late historian Roy Porter’s monumental medical history of humanity from antiquity to present times titled, The Greatest Benefit to Mankind) the choice of this doctor detester to chair the Bristol Inquiry into paediatric cardiac surgery was indeed a surprising choice. Surprising that is if one considers, as I do, that the most desirable choice of chairperson for such contentious task is one characterised by an appropriately and proportionately more neutrally balanced individual. Sir Ian in such locus appears almost uniquely inappropriate.

None of the above remarks should be taken as impugning the integrity and sincerity of Kennedy and his perhaps eccentric preoccupation with the medical profession. And one could point also government complacency and the BMA’s failure to mount a more robust rebuttal of his claims and criticisms, starting perhaps with that ludicrously paranoid and certainly novel take on the medical profession, his 1980 Unmasking Medicine Reith lectures.

Let me end with a quote from The Observer (25.01.1981)  penned by its then editor, renowned international statesman and historian, Dr Conor Cruise O’Brien. He critiqued those Reith lectures and that editorial still makes relevant reading. He did not consider the medical profession flawless but he picked up but, inter alia, on the title of the first lecture of the series, ‘We must become masters of medicine, not its servants’. “Sounds good,” says Cruise O’Brien, “but who are ‘we’ supposed to be?”......”Mr Kennedy says that medicine is too important to be left to doctors. Very well, but if mastery of medicine is to be taken off the doctors and given to some other people, then I should very much like to know, please, who they are....Mr Kennedy doesn’t tell me”. It is difficult to fault Cruise O’Brien on logic.

The profession is no longer self regulated although the recent past president of the GMC admitted that anywhere self regulation had been replaced by external governance has resulted in a poorer service to patients. Kennedy has played a significant role in generating the chaos that is now the General Medical Council and he also chairman of the latest Care Quality Commission.

Today we have a self-regulated press. Despite its imperfections (considerable!) I would forever defend its freedom and that self-regulation as an essential component in a civilised democracy. To many it seems shameful that the medical profession has, in the United Kingdom a near monopoly healthcare system and effectively lost its freedom of speech. In the early 1990s following the introduction of NHS Trusts the previously explicit right  enshrined right to freedom of speech in  Whitley Council Terms and Conditions of Service Clause 330 was withdrawn as work contracts moved to Trusts. Calls for its reinstatement in new consultant contracts failed.

For so long as the pliant BMA, remains wedded to the ‘NHS’, essentially a state politician driven healthcare system with a mere junior partner  marginal impact medical profession a downward trajectory  morale seems likely. The outlook is bleak. Turkeys voting for Christmas is the metaphor that springs to mind.   

Dr Dermot J Ward