Preventing access to psychological therapy?

Interesting article in the BMJ on the Improving Access to Psychological Therapy (IAPT) initiative started under Labour and continuing under the Tories. It remains unpopular with GPs while being heralded as an outstanding success by central government:

"The impact assessment on the expansion of the programme, signed off by Mr Burstow, estimates that the cost of providing a course of treatment is £136 for mild mental health problems and £754 for moderate or severe cases. This, the assessment says, is substantially lower than the estimated costs for talking therapies before IAPT, which are quoted as £255 and £1298.

"Quite where these figures come from is a bit of a mystery because they conflict with those collected by a team led by Professor Glenys Parry of the University of Sheffield, which evaluated the first two pilot sites for the programme, in Doncaster and Newham, comparing them with neighbouring services (Wakefield and Barnsley and City and Hackney). They found that IAPT treatments cost more, not less, than those provided in the neighbouring boroughs, and that it was not possible to say whether the extra costs were justified by better outcomes."

This accords with the experience of many GPs, mental health professionals, and patients (e.g. see the Shrink here).

Service level agreements in medicine

Apparently:

All aspects of NHS care for entire diseases are to be put out to tender under radical plans to dramatically expand the role of private companies and charities in running the health service, Pulse can reveal.

A pilot set to launch across the east of England will put entire NHS care pathways out to tender, starting with musculoskeletal medicine, respiratory care and elderly care.

As anyone who has seen their local IT services outsourced will be able to identify with, I am wondering what the response time for a chest drain will be under the 'service level agreement'?

No shit Sherlock

Saw this paper today:

Occurrence of depressive disorder was best predicted by a combination of a history of depression and subthreshold symptoms, followed by either one alone. Occurrence of anxiety disorder was best predicted by both a combination of a history of anxiety disorder and subthreshold symptoms and a combination of a history of depression and subthreshold symptoms, followed by any subthreshold symptoms or a history of any disorder alone.

Now I realise that they were trying to make the point that:

Past episodes of depressive or anxiety disorders and subthreshold symptoms have both been reported to predict the occurrence of depressive or anxiety disorders. It is unclear to what extent the two factors interact or predict these disorders independently.

But it did just make me ask whether it was really worth the effort to show that, when all is said and done, people who have had a common mental disorder in the past, and are showing symptoms of it now, are more likely to be diagnosed with it in the future.

Clinical governance

I've just started working in a new NHS Foundation Trust. Last night I was on-call. During my on-call I got summoned to a ward and told by the nurses to do something - something both illegal and likely to have me up in front of the GMC - 'not bloody likely' I said, 'but it's trust policy they whined'. Eventually they called in the on-call consultant, who wouldn't do it either.

'Silly nurses' I thought, 'policy indeed!' Now, officially, I'm supposed to have read all 30 of the clinical policies (and the other non-clinical ones too), I've never had the time set aside to do this but the trust have told me to do it so that's their arse covered. They're each 20+ pages long and written in a dreary bureaucratic speak that makes it impossible to easily extract the approximately one line that is actually relevant to clinical practice.

Having a few minutes of downtime I thought I'd check the relevant policy, and sure enough, there it was, an explicit instruction that in these circumstances a doctor should do something both illegal and likely to get them struck off. I looked at who wrote the policy, a nurse and an admin person (sorry, 'organisational risk lead'), no doctors seem to have been involved.

So, feeling like a good little boy, I contacted the 'Risk & Clinical Governance Department' to point out this gross oversight - 'oh yeah, someone mentioned something similar in 2008 but the policy isn't up for review until 2012 so we'll take a look at it again then'. Fantastic.

NHS Whistleblowers

People often ask me why I spend so much time bitching about how craply run the NHS is in my area rather than submitting incident forms at work and tipping off the local press. The answer is that I want to continue to work in the NHS, and to continue to work as a doctor. The NHS hierarchy, whether that's local management or the people at GMC towers, do no tolerate dissent as seen in this via the Jobbing Doctor:

Dr Raj Mattu, a consultant cardiologist in Coventry, has finally been dismissed by his Hospital. Dr Mattu made the mistake of criticising the conditions in which patients were being treated in his hospital department.

No cuts in frontline services - whiteboards to take up the slack

We're constantly told by the government that its squeeze on public finances will not affect frontline services in the NHS. We all know this is nonsense. I was at a meeting today where we saw what the cuts, sorry, efficiency savings, actually mean for our trust.

They have abolished several consultant psychiatrist and junior doctor posts and a great tranche of CPNs, social workers, support workers, and secretarial staff. But fear not, because this will not affect frontline service delivery. How? We all asked. By 'working smarter' we were told by the newly employed 'Team Building Manager', 'Productive Community Champion', and 'Performance Advocate'.

And what, specifically, does this 'working smarter' entail? We all asked again, because we weren't sure where the extra hours in the day were going to come from to see the same number of patients. And the answer we got was fiendish in its ingenuity. We're going to have a big whiteboard in the reception area of our CMHT community bases. Truly the NHS is safe in their hands.

The Future of the NHS

Schizophrenia in the Guardian

A rather nice little piece on a man with schizophrenia and his father who have written a book about the experience:

"To Patrick Cockburn, it's an illness that has eaten away at his oldest child. To Henry, it has been a revelation. Father and son tell Amanda Mitchison how schizophrenia has changed them both"