Why A+E fees are a despicable idea

With the average time patients spend in A+E rising and ambulances left queuing up outside for hours, it’s no wonder we’re trying to think of ways to ease the deluge of emergency presentations to hospital.

But one particularly bad idea keeps coming back time and time again – the idea of charging people who turn up with ‘inappropriate’ problems.

This morning it was the turn of the Northern Ireland health minister to float the proposal, targeting people who ‘abuse’ the system by having the temerity to turn up under the influence of drugs or alcohol. England is no stranger to the suggestion either.

I want to list the main reasons why this idea is at best misguided and at worst malicious.

Firstly and most importantly any fee for attending A+E, or any health care service for that matter, is a tax on the sick. The NHS was built on the founding principles that health is a right not a privilege and that no one should have to pay one penny more in sickness than would have had to in health. Sickness and disease are burdens to be accepted and borne by society, not cast onto unfortunate individuals.

Some might say that only charging people who ‘abuse’ the system or ‘bring their illnesses on themselves’ abrogates this moral duty. But I don’t think such a group is either easy to define or deserving of such spite.

So many of the patients I see labelled ‘timewasters’ are in reality the most deserving of care. They often have complex social, emotional and medical needs as well as substance misuse problems over which they have very little control. Society has frequently failed outright in providing them education, a safe and happy childhood, housing, employment and a stable emotional life, but instead of holistic intervention and understanding we are now suggesting charging them for seeking help in the only way we ever taught them – with desperation. Such a policy demonstrates nothing but the most basic misunderstanding of our most vulnerable patients.

Furthermore, how many illnesses which people ‘bring on themselves’ are we more than happy to treat for free? A broken leg from a skiing accident gets you top notch free orthopaedic care, even though you knew it could happen when you booked the holiday. Smoking for 20 years gives you COPD but there’s still an NHS bed for you if you need it when the winter chest infection season starts. But if you’re difficult to emotionally relate to, you keep coming back and have difficulty following advice, all of a sudden it’s your own fault and you should learn your lesson.

No one turns up to A+E for fun. We need to address the problems of difficult patients more thoroughly, not bat them away with a fine for being so bothersome.

There are numerous secondary reasons why charging people for medical services is counterproductive. People who are genuinely unwell will decide not to turn up for fear of it being labelled inappropriate or expensive, as the US know only too well.

The cost of implementing a system to charge so-called ‘abusers’ of healthcare would in all likelihood cost far more than it would earn, especially bearing in mind the track record of NHS IT projects, and almost by definition would target the very people who are least able to pay the charges anyway. Many also fear it would also represent the thin end of the wedge towards universal charges – something I wouldn’t put past this government.

All in all, a frighteningly frequent proposal which shows just how badly some people understand our more challenging patients and just how little they really want to help them. I hope I never see it suggested again, though I’m completely sure I will.

Dangerous Debates

I like a good public debate, especially when it comes to mental health. I’ve been to a fair few, like the Maudsley Debate on CBT for psychosis, and even spoken at one myself, on the value of diagnosis in psychiatry.

Debates are often called for, much anticipated, and generally held up to be an uncontaminated source of truth and progress in heated times.

I wonder though, whether they’re the universal answer that they’re cracked up to be. I’d never argue against issues being discussed informally on smaller platforms like Twitter, but hosting an official and well publicised event on a grand stage seems to hold quite a propensity to make the issue at hand even less clear.

Firstly, the motion sometimes isn’t fair. I was rather piqued to read the introduction to a debate due to happen in November at the Royal Geographic Society, at which speakers will argue for and against the motion that ‘Psychiatrists and the Pharmaceutical Industry are to Blame for the Current ‘Epidemic’ of Mental Disorders’. It’s a straw man – the assumption has been made that there is an epidemic of psychiatric diagnosing (when in fact, mental health services are too busy to see even the sickest patients enough and are being cut further) and someone is to blame.

The rest of the blurb is obnoxiously biased too, for example ‘Drug pushers. We tend to associate them with the bleak underworld of criminality. But some would argue that there’s another class of drug pushers, just as unscrupulous, who work in the highly respectable fields of psychiatry and the pharmaceutical industry.’

Sir Simon Wessely, speaking against the motion, is one of the best public orators I’ve ever seen but he’s starting from a phenomenally biased position. Unless the motion and backdrop are fair and balanced, a debate can turn into a pointless inquisition and show trial serving only to reinforce the skewed presumptions of the people who set the motion.

Secondly, I just don’t think that some topics are suitable for public debate, either because of the nature of the question or the state of the current answer to that question.

Public debates are not objective. They are rhetorical sniping contests won not by people with the best and most useful answers but by the people who convince the audience, who are themselves hugely biased already, using charisma, ethos, selective information and verbal trickery. The recent demand in a broadsheet newspaper by the so-called ‘Council for Evidence Based Psychiatry’ for a public debate on the harms of psychiatric medication was in my view completely ridiculous – there is no way a complex, lengthy and highly statistical issue like that should be thrown to a few angry academics in front of microphones.

In some cases too, simply having the debate lends credence to one side of the argument that it doesn’t deserve. We wouldn’t have a public debate on vaccination and autism, because we know well enough already what the answer is and we don’t want to give the other side more credit than it deserves. I suppose you could call it meta-debate. Far be it from me to ascribe that to any topic in mental health, but Nick Clegg didn’t seem to fair too well against Nigel Farage. It was over before it even started – Farage had proven that his views were apparently worthy of airtime. The fact he outdid Clegg with panache too was an added bonus for him. The sensible, grown up politicians steered clear of the no-win situation.

To finish, we shouldn’t mistake the result of a debate for closure on an issue either, which seems to be a nagging recent trend. If we can’t make our minds up about an issue after decades of research then there’s no way we’ll get there in one evening.

At the end of the day we just need to remember what a public debate is – a few highly biased people talking in a highly biased way to a highly biased audience about an often highly biased motion. They can be fun, exciting and stimulating, but they run the risk of distorting an argument even further and they certainly aren’t an absolute truth.

Overshadowing

Earlier this week I had a rare moment of cognitive lucidity and tweeted that sometimes the main role of the psychiatrist is to conclude that the problem isn’t psychiatric.

I had two broad and frequently occurring scenarios from clinical reality in mind.

The first is when the patient’s difficulties are far better conceptualised as temporary interpersonal strife or harmless eccentricities. Staff might not be getting on well with a patient, or might be struggling to figure out why they act the way they do. All that is needed in those cases is not a diagnosis or ‘treatment’ but reassurance and perhaps a few pointers on how to understand them better.

But the second scenario in which concluding that the problem is not psychiatric is even more important – when the problem could well be ‘organic’. In these situations,  it could be lifesaving.

It’s a common story. If someone without a history of mental illness goes to A+E with chest pain, confusion or any other worrying symptom, the list of tests and referrals is often generous and sometimes completely exhaustive. The doctors are keen not to miss that rare disease or that subtle sign of a hidden disaster to come. But if someone with a mental illness turns up at A+E with exactly the same symptoms, the amount of investigations that get done is sometimes the bare minimum, if any at all. The vast majority of doctors I’ve worked with are phenomenally caring, holistic and entirely free of this kind of error, but the times when it does happen are hard to forget.

In fact, as I’ve seen many times, the investigation of new symptoms will progress as normal until the very moment when the history of mental health problems is uncovered or when psychiatry show up to help. And then the tests stop.

This potentially deadly phenomenon is the result of what we call ‘diagnostic overshadowing’. Any new symptom that a person with a mental health problem complains of will automatically be put down to the mental health problem. I can understand how it happens. Doctors tend to unconsciously use pattern recognition to figure out which disease or illness a constellation of symptoms is due to, and with such a large confounding factor of a severe mental illness clouding this unconscious process the urge to ascribe the new symptom to the pre-existing problem is logically hard to resist. But sometimes, doctors can stick to this bias despite overwhelming evidence to the contrary. In her book The Centre Cannot Hold Elyn Saks describes turning up to A+E with the worst headache of her life. Despite her friends insisting that this wasn’t part of her usual schizophrenic illness, she was sent home. She was having a subarachnoid haemorrhage.

There are many reasons why the life expectancy of people with severe mental illness is decades shorter than those without. On average they smoke and use drugs more, engage with GPs less, are less able to identify worrying symptoms in themselves, eat less well and do less exercise. But I can’t believe that diagnostic overshadowing is any less significant than any one of those.

But unlike many risk factors for earlier death, diagnostic overshadowing is within the control of health professionals – so how can we fix it?

Firstly,  healthcare professionals in other specialities need greater literacy in mental health. Hopefully, this is happening already. From August there will be a  rise in the amount of psychiatry rotations for newly qualified doctors, so they can learn more about caring for patients with severe mental illness and how to discern what’s mental from ‘organic’. In time, this should reduce the number of calls psychiatrists get from other doctors who don’t know where to start with a patient with a mental health problem as they ‘aren’t trained to deal with this’.

The divisive phrase ‘medically clear’ is no help in this. Before transfer to a psychiatric hospital a patient often has to be declared ‘medically clear’, as if medical and mental are different things, furthering the divide between us. But psychiatrists are doctors who are trained in treating organic disease, and every doctor should be able to do a little psychiatry. We all did placements at medical school. Also, as I’ve discussed before, I don’t think separating psychiatric institutions from other medical instituations either geographically, pragmatically or conceptually is doing the health of our patients any good. It breeds ignorance and therefore error on both sides.

Secondly, we need to listen to patients and their families better (whatever I write about, that always seems to be a conclusion). They need more help to speak up and make their concerns heard, for example from advocacy services or care co-ordinators who actually have the time to attend clinics with them. When they say something isn’t right and isn’t part of their mental illness, we need to believe them and investigate appropriately.

Lastly, liaison psychiatry services are vital in facilitating this and I was glad to see the release of a joint report by a series of medical colleges not long ago recommending a service in every A+E.

I know there are many personal and professional experiences of this topic out there, and I’d be keen to hear them.

 

Shouldn’t mental health units be part of general hospitals?

I’ve been working in liaison psychiatry for the last six months. For those of you who haven’t heard of it before, it’s the branch of psychiatry that see patients who are in hospital with physical health problems. Some hospitals have a dedicated liaison department, some have a team that only visit if they’re called, some have no service at all.

There’s a very instructive video about the speciality by CNWL NHS Trust available here.

Anyway, I’ve enjoyed my job, and think that every hospital should have a liaison psychiatry service – but I got to wondering, why should we need to liaise in the first place? Why should every speciality except psychiatry have their patients under one roof, with psychiatry visiting from outside to help out, while people with mental health problems are usually admitted to separate hospitals often miles away?

I tweeted about it:

Having mental health wards as part of general hospitals is something that already happens in other countries. There appear to be positives and negatives to it.

On the plus side, patients would get a higher quality of physical health care. So many patients who have a mental health problem also have physical health problems, and many need treatment for both simultaneously. Sometimes the cause of the mental health problem is a physical health problem. Being seen by doctors from a range of specialities would be easy; so would getting all the relevant tests. It would be a far better situation than currently, when patients who are unlucky enough to have both a mental and a physical health problem are often shuttled back and forth between hospitals in a time consuming, inefficient, untherapeutic and potentially risky game of musical beds.

Furthemore, some might argue that having mental health units as part of general hospitals might lower the stigma of being admitted. I’ve met so many patients who were quite happy to come into a general hospital but not into a mental health hospital, just because of the negative connotations. Having mental health patients and indeed psychiatrists mixing in the general hospital environment might serve to demonstrate that we are deserving of respect and equality and do not live up to our distorted stereotypes.

On the negative side, perhaps it would reinforce what some feel is already too ‘medical’ a model. Maybe having our mental health hospitals physically separate from general hospitals enables, or at least encourages, us to treats our patients less like disease-bearing entities and more like people. Personally I’m not sure I agree though. I don’t see why a mental health ward placed on a general hospital site couldn’t still have a holistic, non-biological ethos, and I’m not sure our mental health units are even slightly holistic currently as a result of being separate. In fact, I might argue the opposite – that by isolating mental health units, we stagnate in comparison to our forward-thinking relatives in other specialities, hide away our deficits and struggles and encourage insular practice.

So those are my initial thoughts, but there is so much left to be said. What do you think?

Brain/mind: a false divide

Every so often I’m reminded of a conversation I had some time ago with a researcher (who shall remain nameless) who wasn’t too keen on psychiatry. I want to reflect on that discussion to examine the fallacy of the brain-mind divide and how it’s just not possible to partition away emotions as something the medical model shouldn’t be dealing with.

Doctors are quite within their rights to treat brain diseases, this man said. Problems with moving your arms and legs, physical sensation or balance are all perfectly suitable ailments to see a neurologist with. But emotions and the mind are different things entirely. For a doctor to go interfering with those would be quackery.

So I asked him – what did he make of the fact that people with Parkinson’s disease suffer more frequently with depression than the background population? This sadness was understandable psychologically, he said, as a result of being ill. And he seemed quite satisfied with that. The emotions were not brain symptoms but something separate.

But people with Parkinson’s disease, I replied, get depressed more often than people with equally distressing and disabling diseases which don’t involve the brain tissue, like rheumatoid arthritis. Surely the brain being affected by disease must be changing the emotions of the patients? Where on earth are emotions from if not the brain?

Eventually he retreated at this point, conceding pretty reluctantly that brain diseases could affect emotions and therefore these emotions could be treated by doctors. But never, he was firm, should they be conceptualised using the medical model when there is no sign of brain disease. If there’s no organic disease for the neurologists to treat, then no one should go treating emotions – a seemingly convenient divide.

But is that really so simple a segregation? Let’s take an example – epilepsy. People with epilepsy are three times more likely than the background population to have a psychotic episode. So by the rule of treating emotions when there’s a brain disease present, we can go ahead and treat. But hold on – using simple maths, a third of those people would have had a psychotic episode anyway, just like the background population do. And there’s no way of telling which third they are. So what do we do, treat them all or treat none of them as medical symptoms? Or guess?

The same argument can be applied countless times to other scenarios. People who use cannabis are about twice likely to become psychotic than the background population, but that means around a third to a half of people who smoke cannabis who become psychotic would have become psychotic anyway. Who do we treat as genuine organic drug-induced reactions and who do we say are just having ‘non-medical emotions’? Should we draw a line at one spliff a day, one spliff a week, maybe one spliff a year…?

People given steroids for tumours or inflammation can become manic. I’ve seen it many times. But by simple probabilities we know some of them would have become manic anyway, because of the stress of the illness. There’s just no way of telling which are which.

People with multiple sclerosis have a 50-50 chance of being depressed at some point, compared to a variable but lower number for people without the disease. Should we call it disease-related depression if there are only one or two tiny plaques on the brain scan, or not? Where is that divide now?

This all boils down to a simple point. If something is a symptom in the presence of an obvious brain disease, it’s still a symptom if there is no obvious brain disease. It is valid to conceptualise depression, mania, and psychosis in medical terms because there is no convenient dividing line between “brain disease-caused” and “non-brain disease-caused”. In the end, all emotion comes from the brain whether something worrying shows up on a scan or not. Furthermore, the thought of denying people effective medical help for their highly distressing emotions unless they have evidence of a coarse brain disease is actually pretty perverse.

But this is not to say that emotions should be treated like cold, hard neurological signs like loss of sensation or power in your limbs. Every medical discipline has their tools of treatment – surgeons their scalpels, dermatologists their creams, public health doctors their policies, medics their tablets – each catered to their relevant illnesses. We can still use social and psychological treatments to relieve and limit symptoms whilst calling them just that.

Likewise, just because something is a symptom doesn’t mean it has to be treated. Not every cough is a chest infection, not every knee twinge needs a joint replacement. So not every low spell needs a tablet and not every bizarre thought needs a section.

As for the man who I was talking to, I’m not sure he agreed with me. He told me frustratedly that “fine, you can believe in the brain, and I’ll believe in the hand”, and strode off. He never did explain what he meant.

‘In case of crisis, go to A+E’

A+E can be an intensely frustrating place for mental health patients in crisis. Having recently finished another set of night shifts in the department, I thought it might be a good time to discuss why visits there seem to be so unsatisfying.

When I asked people for their experiences on social media, some did have very positive memories – but many others couldn’t have been less pleased with the treatment they received. Their responses were very useful in the writing of this blog and I’ve included some of their illuminating tweets throughout.

It seems that a lot of the time, these bad experiences were generated by a fundamental mismatch between what A+Es are designed to provide and what patients in mental health crisis actually need.

I’ve worked in A+E as a general medical doctor. The modern vision of an emergency department, especially following the implementation of the 4 hour breach target, is of a fast-paced and well-oiled machine designed to treat people quickly and move them on. The most urgent of procedures are carried out in the department (setting broken bones, resuscitation, stitching up cuts) but the onus is very much on getting the patients out.

Now, there are several ways in which A+E can be very useful to mental health patients using this style of working:

Ruling out a physical cause for your symptoms. Is this ‘psychosis’ actually an encephalitis, a thyroiditis or a brain tumour? Especially for patients presenting for the first time, performing a thorough batch of tests is essential. In my experience we hugely under-investigate psychiatric symptoms and probably miss quite a lot of treatable disease.

Providing a brief place of safety. Though many patients should undoubtedly go to 136 suites, there are certainly also a subgroup for whom A+E is appropriate. Acutely,  grossly intoxicated people who express a fleeting wish to harm themselves, for example, can be physically monitored and sleep off the risky thoughts.

Treatment for self harm and overdose. Having easy access to efficient medical help for these problems is a vital part of mental health care.

Getting an urgent prescription. It’s hardly ideal, but if you desperately need more of your tablets in the middle of the night, A+E is the only place to go.

Being the gateway to an emergency admission. Community and home treatment teams, in a perfect world, should be spotting and dealing with potential admissions during the day, but for the genuinely unpredictable emergencies, A+E can get you into psychiatric hospital – if there’s a bed.

But these positives struggle to cancel out the fact that the atmosphere and structure of A+E departments are directly at odds with perhaps the most important thing mental health patients actually visit the department for:

Emotional support during a crisis.

A+E departments are necessarily busy, noisy and impersonal. Because they’re used to caring for people on the edge of death and disaster all day, they’re built to ensure the emergency medical care is given efficiently – at the cost of ‘optional’ extras like complete privacy and tranquillity. Patients frequently overhear their names and conditions discussed in cold medical terms just outside their cubicle, detracting further from any sense of warmth.

The medical and nursing staff, used to taking bullet-point histories to exclude life-threatening disease and working long, exhausting shifts, don’t find it easy to suddenly switch into calm, reflective, empathic mode when someone comes in with self harm or another mental health problem. In fact sometimes their tiredness, mixed with a lack of mental health training, can even boil over into blaming the person for coming in.

The environment isn’t easy for mental health professionals either. As much as we want to help patients who turn up in the depths of despair in the middle of the night, it’s difficult to give them what they need. We often don’t know their history very well, it’s hard to form a rapport with someone you’ve just met, and we have a long list of other patients who need to be seen urgently too. That’s even if there’s a liaison psychiatry service – many hospitals still don’t even have one, meaning patients have to sit around in the department to see the team they need.

The opposite can happen too. The four hour target pressures departments to get people out quickly, when what patients in mental health crisis need is the exact opposite – somewhere to feel relaxed without any threat of rejection.

All in all, the lack of services on offer in A+E can lead to a complete disillusionment with the prospect of going there. So many patients tell me that despite the fact that patients are often told to go there, they are then simply told to ‘go home’, ‘take these tablets’ or ‘see their care team in the morning’. It can feel dismissive – but what else can A+Es offer? The things they’re good at – heroic lifesaving procedures, CPR, broken bones – isn’t any use to them with these problems.

It doesn’t help that often we put ‘in case of crisis, go to A+E’ on crisis plans. We need more appropriate places for people in mental health crisis to go. Drop in centres and crisis houses are far more suitable environments, but are just the type of services that get cut when the going gets tough – which it has. We need to prove that they’re good at making people feel better, deal well with crises and are therefore worth recommissioning. Going to a place where people are highly experienced in mental health and know you well, instead to A+E to see a random, bleary-eyed doctor, perhaps with little mental health training at four in the morning, shouldn’t be difficult to sell as a more therapeutic option.

Furthermore, to really get to the heart of this problem, we need to think systemically. Better staffed and funded community teams, social services and psychological therapy services could prevent crises before they even happen. By the time the patient gets to A+E, the horse has already bolted.

The Crisis Care Concordat highlights many of these problems, but I won’t be the first to reserve judgement until the money to fund the improvement appears and change genuinely starts to happen. Until then, unfortunately, for many people it’s A+E or nowhere.

Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists

Some aspects of the crisis in mental health care, like the 1,700 bed closures and 101% ward occupancy rates, have been relatively easy to estimate. But worrying practices associated with the strain on resources, like patients being sent home in the absence of a bed or being sectioned to secure one, have been far harder to quantify – until now.

The Royal College of Psychiatrists Trainees Committee has surveyed all junior doctors working in psychiatry in the UK for their experiences over the last 6 months. These doctors are fully exposed to the problems, having an unrivalled view of care from 9am to 5pm and often making decisions about admitting or sectioning patients themselves when consultants are at home in the evenings and at weekends.

576 such doctors responded, and what they told us was deeply concerning.

Over 70% had experienced difficulty finding an appropriate bed for a patient. In child and adolescent services (CAMHS), that number was 83%. Sadly these findings weren’t unexpected, but the rates of various practices associated with the scarcity of beds certainly were.

A shocking 37% told us that a colleague’s decision to section a patient under the Mental Health Act had been influenced by the likelihood of finding a bed – perhaps that by doing so it would legally force the provision of a potentially otherwise unavailable bed. 18% were even willing to tell us that their own decisions had been influenced in such a way. A Health Select Committee report published to widespread concern last summer suggested that patients had been deprived of their liberty to secure a bed in isolated cases, but the true rate seems to be far greater.

Doctors usually use the Mental Health Act as a last resort for patients who desperately need hospital care but are so unwell that they refuse. Now they are presumably beginning to use it increasingly often for patients who aren’t actively refusing an admission, because it’s their last remaining option to make sure very unwell people get the care they need. And it’s no wonder they have to do so, when 24% reported that a bed manager had told them that beds were closed to all patients except those under section. Again, a policy of desperation in the face of pitifully limited resources.

Even if a bed is somehow found, it could be absurdly far away. 80% of respondents had been forced to send a patient outside the boundaries of their trust, with over a quarter sending a patient over 100 miles away. In CAMHS, this was a heart breaking 37%. Unsurprisingly, such transfers were reported to be detrimental to care. Dragging a mentally exhausted, fragile and often acutely distressed person away from their families is not a form of care I recognise – especially if that person is a child.

As an alternative to being exiled hundreds of miles, three out of ten doctors had seen a patient admitted to a ward but without a bed, presumably leaving them to sleep on a sofa. One in five reported that they’d admitted people to beds belonging to patients on periods of trial leave – at least giving a temporary fix. But when the original owner of the bed comes back, as they often do, out comes the sofa again.

After a decade in medicine the only circumstances in which I have known patients to be admitted to hospital without an official bed have been whilst volunteering in the developing world and in UK mental health.

Still, a sofa may be better than sending a critically ill patient home because no bed can be found. An alarming 28% admitted to doing that. The rate in CAMHS was even higher at 37%. If just one paediatrician reported that they’d sent a sick child with asthma or appendicitis home simply because there wasn’t a bed, the reaction would be swift and scathing. But if the child has a mental health problem, their suffering appears not to warrant the same level of concern.

It would be easy to conclude that the answer to this nightmare is additional beds. That would certainly help, as would providing emergency support to forestall the plans to close more beds in some places, but the cause of this crisis is more pervasive. A chronic institutional bias against mental health has suffocated the funding of our speciality in every area. Community teams have seen their funding plateau in the face of a 13% increase in referrals despite the fact that a recent report suggested that for every £1 invested in early intervention we could save £15 in later hospital admission costs.

As reassuring as it is to read the recent Closing the Gap and Crisis Care Concordat policies, only a clear, urgent and substantial pledge of extra funding will convince mental health professionals that things are about to get any better. Despite the heartening rhetoric, such funding has not been forthcoming.

In fact, following February’s NHS England announcement that mental health services would ironically be subject to greater tariff cuts than our counterparts in acute services, Professor Dame Sue Bailey suggested that the frankly dangerous levels of under-resourcing might lead us to become the next Mid Staffs.

Based on these stats, I would go further. What will it take for us to admit that we’re already there?

The full results of the survey can be found here.
The results of the survey specific to CAMHS can be found here.

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