Chaining doctors to their jobs is no fix for the NHS

I was unsettled to read Tom Tugendhat MP’s recent article in the Telegraph. He suggests that we could resolve the doctor recruitment crisis in the UK by forcing doctors to work for NHS for a set amount of years after they qualify, to ‘pay back their debt to society’ instead of having the option of emigrating.

This is a very short-sighted solution, with multiple flaws. I don’t know how much exposure Mr Tugendhat has had to medical professionals, but if he’s had only a little he must surely be aware of the following:

The most obvious drawback to his plan is that it doesn’t do anything to solve the root problems which are making our doctors leave in droves. Surely remedying the pressurised workplaces, cuts to services and insulting contract prospects which are driving emigration in the first place would be a more logical (and kinder) step? Without these improvements doctors will continue to leave even if it has to be at the end of a period of enforced working.

Then there’s the fact that it would destroy what’s left of our morale. Doctors will stoically grind out hour after hour of work on the deck of the proverbial Titanic as long as patients benefit, but handcuffing us to a railing will only make us lose faith in the captain.

Furthermore, those of us that struggle with the inevitable strains of medical work, as so many of us do, will feel compelled to carry on, burning themselves out so badly that they won’t be able to work again for years.

And those that want to leave for Australia, or New Zealand, or wherever, but have been forced to stay, aren’t exactly going to be employee of the month, are they?

Another reason – patients will wonder if their doctor has been forced to stay. They won’t trust doctor’s motives as much, which is hugely important to us.

But it doesn’t stop there. Sixth formers won’t look at the prospect of a few years enforced labour for a flagging NHS at the end of their degree as an incentive to apply for medicine, especially those from lower income families who are watching student loans and the cost of living rise, but doctor’s wages falling. They’ll rightly think that leaving university with over £75,000 of debt entitles them to choose what they do with their degree.

There’s a philosophical point behind all this too. We don’t educate the young people of this country so they will give us something back. If we did, we’d be forcing teachers, scientists, lawyers and nurses to work for the state after graduation. But we don’t. We educate young people because education is a right, not one half of a deal.

Mr Tugendhat draws a comparison with the armed forces, who fund some medical students through university in exchange for a period of service after graduation. But this comparison is poor. The armed forces, essentially a third party, simply offers students lots of money in exchange for later work. The choice is about personal gain and is all theirs. Whereas NHS services that help train medical students already get paid for it by the state. Students pay loans to their universities for the privilege, have no choice but to train on NHS premises and their only gain is learning. Entirely different systems of motive. Maybe if the NHS started paying medical students tens of thousands of pounds in lump sums during their training, instead of them accruing massive debts, then we might be justified in forcing them to work for the NHS later on.

We should build a system in which young people study medicine and work for the NHS for their whole lives because it’s a great place to work, not chain our doctors to a sinking ship and think we’ve plugged the leaks.

Why the new junior doctor contract is a slap in the face

NHS Employers have announced that they’ll be forcing an insulting new contract on junior doctors. The BMA Junior Doctor Committee did try to negotiate with them, but talks broke down and last month the BMA decided that it couldn’t come back to the table when what was on offer was so demeaning.

The reaction from medical staff (and the general public) has been visceral. They’ve made it very clear that this new contract would be nothing less than a danger to patients and staff alike and a despicable slap on the face for junior doctors. An unofficial petition calling for strike action has already topped 30,000 signatures.

So why all the anger? Here’s why.

  1. It’s a huge pay cut

From the limited data that NHS Employers have provided about the new rates of pay, most models, including my own, are predicting around a 10-15% pay cut. Although the new deal is supposed to be cost-neutral, we find it hard to trust a Health Secretary who denied nurses their 1% pay rise but then accepted a 10% pay rise himself, and who said that mental health funding had gone up despite mountains of stats that said that it had plummeted. Doctors don’t tend to be greedy people, but almost all of them have massive student loans, many of them have a family to support, and lots of them are trying, somehow, to afford a house. Seeing NHS Employers recently advertise for 200 ‘physician associates’, who only need two years training, for salaries of £50,000 a year, didn’t help our self-esteem.

2. It turns our evenings and weekends into ‘standard working time’

Currently, 7am to 7pm Monday to Friday is seen as standard working hours, and any work done outside of that is seen as worthy of extra pay. This seems reasonable. But the new contract extends these standard hours to 7am to 10pm on weekdays and Saturday, meaning that we’ll be paid the same for an hour of work on 9pm on Saturday compared to an hour of work at 9am on Tuesday. Only Sundays and nights are paid more. This means hospitals can rota us to work far more unsocial hours than we currently do at no extra cost, which is basically theft of our personal lives. Though doctors are frequently needed out of business hours, there’s no reason why we should submit to being paid the same for working at that time. We signed up to help people, not to sacrifice any semblance of a life outside of medicine as a favour.

3. There are no clear safeguards on monitoring our hours

Not so long ago, junior doctors were working over 100 hours a week. It was relentless, traumatic, and frankly dangerous. Then, after years of lobbying, the European Working Time Directive was passed into law and gradually the average number of weekly hours we were allowed to work started to shrink. It’s currently 48. A complex process of ‘banding’ occurs to add on a percentage amount to our basic salary (typically 40%) to recognise how hard we work out-of-hours and another complex process of hours monitoring occurs to make sure we don’t work too many hours. There are big incentives for employers not to overwork their doctors.

But with the new contract, there is no such system of monitoring. Doctors will be expected to go to their employers and ask for a ‘work review’ if they’re worried about their hours, which they won’t do because they’re too busy, which they’ll feel bad about doing, and which they’ll be quietly punished for doing. Back to the 1980s.

4. The reason for change – Cameron’s ‘7 day NHS’ – is deeply flawed

The whole point of this new contract is that David Cameron wants a ‘7 day NHS’. But he refuses to define what that means. He refuses to acknowledge that the NHS already works 7 days a week, and that forcing doctors to work more weekends and nights isn’t necessarily going to help improve services. Though Jeremy Hunt likes to spout about death rates being raised for patients admitted on the weekend, it’s still not clear if those patients just happen to be sicker or if more weekend doctors would save any of them, let alone be value for money.

I am seriously worried that doctors are going to be forced into rotas which schedule them for ever-increasing amounts of weekend and night work, with no clear rationale for what they’re meant to be doing, and no great means of doing it (as many other services are closed at the weekends). Some specialties like psychiatry don’t have a huge call for out-of-hours work, so pulling doctors from their Monday to Friday jobs to man the hospital on weekends would only be counterproductive. And we know that GP patients don’t necessarily love weekend appointments – pilots had to be stopped early as no one booked a slot!

5. Annual pay progression is being scrapped

In the clearest demonstration of how little NHS Emplyers and the DoH know about medical training, they’ve decided that instead of getting an annual pay rise, certain grades of doctor (SHOs, registrars etc.) should all earn the same amount within their grade, no matter how long they’ve been in that grade, as they all have the same responsibility. This is horseshit.

Every doctor knows that a first year SHO is going to be calling their seniors a lot, needing more help, and working slower. But a more senior SHO will be running more of the show for themselves, and helping out their less senior colleagues more, so deserving more money.

Also, pay progression encourages people to stay in their jobs, which at a time when GP recruitment is shockingly low, is a good thing.

6. It mistakes non-residential on call hours for lazing about

The new rate for non-residential on call hours (being at home, but available), is just 5% more than a standard hour’s work. As if doctors who have to rush in from home at 4am to do procedures that only they can do are of no use, when in fact, doing such on calls is often hectic, grueling and vital. And again, specialties who don’t have a huge demand for residential out-of-hours work, like my own, will suffer disproportionately.

7. It discriminates against women and men who want a family life

Currently, if a junior doctor changes specialty part-way through their training, effectively starting again, they stay on the same rung of the pay ladder to recognise their past service to the NHS. But under the new contract, pay will revert back to the lowest rate if the doctor decides to retrain in another specialty, or become an academic. Apart from being a harsh punishment for anyone who simply decides that they want to change their career direction (how dare they?), this is a flagrant swipe at women and men who want family lives, who often retrain in specialties more suited to that end, like GP or psychiatry. As if the fact that stopping annual pay progression will disproportionately hit women who work part time, as pay rises will come every 6 years instead of every 2, wasn’t bad enough.

I can’t emphasize enough how harmful this new contract will be for junior doctors and patients alike. Masses of my friends have already left for Australia, and they aren’t coming back. Why would they? The powers that be treat our NHS staff like dirt and unless we stop it soon, there won’t be anything left to protect.

I’m still undecided about strike action. If you could guarantee me that it would have a positive effect, then I’d be the first on the picket lines to fight for patient safety in the long-term. But the ignorance and deafness that NHS Employers and the DoH have shown is becoming legendary, so we may need another option. I’m open to suggestions. Help.

What the research on hospital death rates really says

There’s a been a big media splash today about research which shows an increase in the chance of death if you’re admitted to hospital over the weekend, compared to during the week.

Most of it has been reasonably accurate and clear, like the Guardian piece. But some has been misleading, like this Telegraph piece which states that you’re ‘twice as likely’ to die if admitted at the weekend, which seems to be nothing short of fictional.

The actual research paper can be found here [subscription required]. So what does it actually say, in simple terms?

The researchers looked at just under 15 million UK hospital admissions for 2013-14, of which around 280,000 led to death.

They worked out that the chances of a patient dying within 30 days of being admitted were 10% higher if they were admitted on a Saturday and 15% higher if they were admitted on a Sunday, compared to if they were admitted during the week. This sounds pretty damning, and frankly scary.

But it’s more complicated than that.

The first thing to note is that these numbers are what we call relative risks, i.e. the difference in risk compared to the same risk for another group of people. Relative risks can sound impressive, and they make for good headlines.

But the absolute risk of dying if admitted to hospital, i.e. the risk all by itself, is very small. Overall it was 1.8%, rising to roughly 1.98% for Saturday admissions and 2.07% for Sunday admissions. Not such a punchy headline anymore.

The researchers were also well aware that patients who are admitted over the weekend are sicker to start with. In fact, 50% of Saturday and 65% of Sunday admissions were emergencies, compared to 29% during the week.

The researchers did try to correct for this problem. They reanalysed their data after excluding all patients who died within 3 days of being admitted, to try to limit the impact that emergency admission had on the results. The relative risk of dying if admitted at the weekend dropped – to a 7% increase for Saturday admissions and a 10% increase for Sunday admissions.

As the study itself points out, we should be seriously cautious about interpreting these numbers, especially when it comes to blaming them on staff who prefer a ‘Monday to Friday’ working culture, as Jeremy Hunt is so keen to do.

Simply excluding everyone who dies within 3 days of admission isn’t a great way of excluding all emergencies. As any doctor (or friend, or relative) will tell you, many severely unwell patients don’t die as soon as they reach hospital. Modern medicine can support them for days if not weeks, so they could still be contributing to that increased weekend admission death rate.

Furthermore, during my days as a general medical doctor, it was routine to see patients admitted at the weekend not as critical emergencies, but as the result of deteriorating slowly over the previous few days, not being able to see a GP on a Friday, and eventually ending up in the option of last resort, an A+E bed on a Sunday, in worse shape than if their issue had started on a Monday. There’s a real case for poor access to other services being the real cause of increased weekend admission deaths, not a ‘Monday to Friday’ culture in hospitals.

This tallies with the fact that Saturday admissions do better than Sunday admissions – because they’ve only had to survive one day’s deterioration without their GP before coming into hospital, not two. If poor care in hospitals was really the problem, we’d expect Saturday admissions – who’d have to spend two whole days in hospital over the weekend – to do worse. But they don’t.

It’s important to note that no more deaths actually occurred on weekend days compared to weekdays. Weekend staff seem to be doing an amazing job of keeping people alive once they make it to hospital.

Another thing that any doctor will tell you is that care in the first few days of an admission isn’t likely to be much different if you’re admitted on a weekend compared to a weekday. A+Es and medical assessment units – the first two stops during most admissions – routinely have as many staff on at the weekends as during the week, and urgent tests and procedures still happen quickly. It’s only when a patient has been moved on to a general ward, maybe 2 or 3 days later, that they might feel the effects of the weekend slow-down, as routine investigations have to wait. This doesn’t tally with staffing factors being the cause of increased weekend admission deaths.

Don’t misunderstand me; doctors couldn’t be keener to ensure that patients get good care on every day of the week. Contrary to popular belief, only 1% of consultants opt out of weekend working. And I’d never deny that junior doctors can feel overworked and undersupported at the weekends, meaning that there is room for improvement in senior doctor hours.

But we have to understand what statistics really mean before using them as the basis for policy and contract changes which will profoundly affect our health service for decades to come. To assume that the increased death rate for weekend admissions is preventable, in the words on the researchers themselves, would be ‘rash and misleading’. Take note Mr Hunt.

We already have a 7-day NHS. Don’t believe the hype.

Seven-day psychiatrists

Unless you’ve spent the last few months in a cave, you’ll know that David Cameron is dead-set on turning our NHS into a ‘seven-day service’.

He hasn’t given much detail on what it’ll look like, or how it’ll differ from the current set-up (in which doctors already routinely work 7 days a week), but the current arm-twisting of doctors into a contract which would force them to work more weekend days for the same pay shows that he really wants it to happen. Whatever it is.

So how might psychiatrists adapt to working routinely at the weekend, instead of just being on-call for urgent jobs and emergency assessments? Despite the mean and unthinking way that the government have gone about their proposals, I do think that psychiatrists could make substantial changes to their practice to acknowledge that mental illness doesn’t just work 9 to 5, Monday to Friday. It depends on the setting though.

I see relatively little point in asking consultant psychiatrists on inpatient units to work routinely at weekends. If they work on a Saturday or a Sunday, it would only mean they’d have to make up their time off on a weekday at some point, so nothing would move quicker overall. Unless other staff were in work on the same weekend days, like junior doctors and OTs, there would be limited effect from a consultant presence anyway. There would also be substantial legal and practical issues to having a different consultant work routinely on the weekend on another consultant’s ward (for example, if all the inpatient consultants were on the rota to come in at the weekend). Patients under section are meant to be under the care of their responsible clinician, and they’re the only people who can give them leave or discharge them. This person shouldn’t be chopped and changed. Also, psychiatric care is like painting a picture – no matter how good the artists are, if too many of them help with the project, you’ll just end up with a confused mess.

Could psychiatrists work more routinely in A+Es? After all, we know that liaison psychiatry services are patchy, but would consultant presence at the weekend fix this? Well…possibly….but in many smaller A+Es a consultant psychiatrist would be sitting around drinking coffee all day. In the larger ones, their juniors would still be seeing patients first (or else how would they learn), limiting their workload. I don’t see why they couldn’t be at home, available for emergencies, as they already are.

What about community and crisis teams – could psychiatrists work more for these at the weekends? For me, this is the most likely setting in which psychiatrists could be seven-day beings. It seems entirely feasible for them to hold emergency clinics and do emergency home reviews, as well as follow-up on the more distressed patients that have arisen during the week. If they work in a team of many consultants, there would be relatively little stress in running a rota of weekend shifts, as the weekdays would still be covered by colleagues. But this too could meet with implementation problems. Weekend GP surgery pilots have had to be cancelled recently as no-one turned up; perhaps that might happen to consultant psychiatrists too.

Whatever the proposed plan, there needs to be recognition of the following:

  • Psychiatrists work hard at weekends already
  • We are chronically short of doctors (and other staff), seven-day working is not a fix for this
  • Psychiatry requires continuity of care, seven-day working should not jeopardise this
  • Working more at the weekends will leave staffing holes during weekdays
  • Doctors should be adequately compensated for working more at weekends. The current contract offer is a joke.

As always I’m keen to hear how things work (or don’t work) in your area, and your ideas for the way forward.

Advice for new doctors

It’s been 6 years since I qualified from medical school, and 6 days since my final shift as an SHO. Between those points I learnt a thing or two about being a junior doctor. Before I ascend to the heady heights of registardom and forget it all, I want to pass along a few bits of advice to the new crop of F1s. I hope it will be of use.

Firstly, get ready for a surprise. All that studying you did, all those placements and modules you went through, all the exams you sat and OSCEs you survived…are poor preparation for being a doctor. Real life on the wards is very different to textbook land, and the problems you have to deal with are entirely unrelated to your finals. Instead of being asked for 4 differential diagnoses for a third cranial nerve palsy you’ll be faced with questions like ‘does this wound look a bit funny?’ and ‘do I need to do anything about a bilirubin of 32?’

It’s normal not to have the foggiest idea about these things – you’ll simply learn to sound more confident in your totally un-evidence based answers over time – but if you aren’t sure, just ask. You never know if it might actually be important. You don’t know what you don’t know, and having a junior doctor who asks questions all the time is far better than having one who doesn’t (we wonder if they aren’t interested or are a bit full of themselves).

Thankfully though, in another strange twist of events, situations in which you’ll have to make a decision won’t be as common as you think. The vast majority of your time will be spent writing in the notes, ordering scans, taking bloods and chasing the results, and writing discharge summaries. For some new doctors this can be a let-down, but these are actually all deceptively important jobs that require practice and effort. Don’t knock them. A clear discharge summary which explains the details of the admission and the plan can be priceless for a patient who would otherwise have no idea what was going to happen next. An efficiently ordered and chased scan can save someone days in hospital (near all those resistant bacteria). Making sure follow-up appointments are booked ensures that your patients don’t just deteriorate unchecked at home and get readmitted. Be proud of running a tight ship.

All that said, there will be times when you’re the one in charge of an emergency situation, usually when you’re on call or managing the ward when everyone else is away. In these spots, trust your instincts and training (A, B, C, D, E…), listen to the nurses and call for help really quickly if you think you need it. You probably will, and this is fine – medical school basically only prepares you to be good enough to do the basics and call for help. It’s your job to ask for help, watch and learn, which is actually pretty cool. Your seniors shouldn’t mind and if they do, it’s their problem. Again, we much prefer junior doctors who call us every 20 minutes to ones who manage things they aren’t sure about, by themselves, in a quiet corner of the ward.

On the subject of colleagues, value them. Especially the nurses. They’ve been doing their jobs for years, they’ve seen tens if not hundreds of new doctors so they know when you don’t know something, and they can get you out of really sticky situations. If you mess up, which you will at some point, they’ll be there to back you up, but only if you’ve been nice. And despite the fact that they lack a bright, shiny new medical degree, they do actually know a lot about acute management of sick people. When I was half-asleep at 4am on one of my first night shifts as a surgical F1, the high-dependency bay nurse basically talked me through an acute assessment of abdominal pain, while somehow making me feel like I was doing it myself. I remember it to this day and I still owe her a G+T.

There will be times when it all gets too much. You will be stuck in a high-pressure environment for over 50 hours a week, seeing one gravely ill human being after another, some of whom will be very nice, and then die. There will be nothing you can do to help many of them, which is another nasty shock. Some of your colleagues may be cold, demanding and uninterested. It is normal to feel upset and overwhelmed. Crying is okay, but talk it over with your friends and colleagues and make sure it doesn’t turn into anything more serious like depression. Look out for your colleagues too. Try to keep your hobbies going, stay in contact with your family and take all your annual leave. And alcohol might be a fun way to de-stress at medical school, but it’s a dangerous way to cope as a doctor.

Bearing that in mind, there will also be amazingly fun times. Being a junior doctor is still a bit like medical school, in that you get taught a lot and have a close-knit group of peers, but better in some ways as you also get paid and get some respect. This is cool. Patients are incredible people, the things you will see, hear and do will be revelations to you, and you might even help someone in a critical way. And mess parties are fun. Savour this time, because no matter how hard your rota is, you’ll look back on it a few years later and slightly wish you had that time back again.

Finally, more about patients. Medical school may have taught you that patients come into hospital to have one or more well-circumscribed medical problems fixed, at which point their lives will resume normal service. This is rubbish. Patients end up in hospital for many reasons, a lot of which aren’t things like ‘crushing central chest pain’ or ‘right-sided weakness’. They come in because they get a bit dizzy and their carer – the fifth new one in 2 weeks – panics. They come in because their sodium is low due to diuretics and they weren’t confident to get to the GP for monitoring. They come in due to falls in cluttered houses and UTIs from dehydration. The important message is, fixing the acute problem is only half the job. To wholly help someone, ask yourself what the real reasons are for their admission, and tackle those. Furthermore, don’t just treat symptoms but ask the patient what they want from life – it might not be relief from pain but the physical strength and freedom to visit their grandchildren. Facilitating these desires is what being a good doctor is really about.

Good luck, best wishes, and remember – if you’re not sure, just ask. There are generations of former new doctors there to help. We just look a bit older and grumpier than we used to.

Is depression really like diabetes? Yes – in more ways than you think

It’s often said that depression is just like diabetes.

The aim is usually to encourage people to speak up about their mental health problems, by pointing out that they’re no more worthy of shame than other illnesses.

The comparison seems to go down pretty well with most folks. But not with everyone. Some people hate it.


So how much do the two conditions really have in common? A lot, I reckon. Their similarities run deep, but perhaps not in the ways that you’d considered.

To begin with, depression seems to me to compare more closely with Type 2 Diabetes than Type 1, for many reasons.

Whereas Type 1 always involves the same underlying problem – destruction of pancreas cells leading to a lifelong need for insulin – Type 2 is a more variable biological state, just like depression. In Type 2 Diabetes, high sugar levels are primarily caused by the body not being as responsive to insulin as it should be, but insulin levels are often low as well. Other hormones like glucagon and incretin are out of kilter too. This is akin to depression, in which we know that it’s not just serotonin that’s important at the biological level. Other neurotransmitters like noradrenalin and dopamine (and many others) are all involved.

The concept of depression sometimes gets criticised because it’s different for everyone, not like ‘real’ illnesses. But the biological state of any one person with diabetes won’t identically match that of any other any more than one depressed person’s brain will match another. They’re both illnesses with a lot of variation that we treat as one thing because the end results (high blood sugar or low mood) are relatively similar across people and treatments can be developed to tackle them.

Sure, diabetes has an objective test in blood sugar readings, whereas diagnosing depression relies heavily on rating someone’s sadness in at least a partially subjective sense, but just because mood is hard to measure doesn’t mean it’s not a real problem. And both blood sugars and mood ratings are tips of icebergs, the diagnostic variables that we choose to measure in conditions that affect much more. Diabetes will make you feel tired, give you headaches, make you drink lots and pee lots and eventually ruin your eyes and kidneys if left unchecked. Depression affects your sleep, appetite and sex drive and might lead to suicide.

Also, neither Type 2 Diabetes nor depression have one simple cause. Both are caused by a collection of individually small risk factors. With diabetes the big dangers are things like obesity, high cholesterol, poor diet and sedentary lifestyle, whereas with depression it’s things like recent adverse life events, a tough childhood and a lack of social support. Diabetes and depression both have a huge genetic component, but neither has a single-gene cause.

Taking things further, the treatment for both Type 2 Diabetes and depression is almost uncannily similar. The first step for both – and people never seem to know this – is not medication, unless the problem is severe. For diabetes it’s a change to a healthier lifestyle, whereas with depression it’s self-help and perhaps talking therapy. Both conditions can fully remit with those kinds of interventions, or partially remit, or remain a problem for life. When medication is needed it comes in the form of artificial chemicals that try to assist the body in doing what it does when it’s healthy. Drugs like metformin are first choice in Type 2 diabetes, and they certainly aren’t ‘natural’, but even injectable insulins aren’t the same as insulin produced by a real pancreas. Just like depression we don’t know who will respond to a particular diabetes treatment, how much, or why.

It’s ironic that some people think depression is something sufferers are to blame for and can fix for themselves (‘pull yourself together!’) when in reality it might be Type 2 diabetes with the risk factors and treatments that are most controllable by the person with the illness. It’s probably easier to shift your Type 2 diabetes by avoiding junk food, exercising and losing weight than it is to ease your depression by taking away life stressors like a busy job and magically undoing an abusive childhood.

So depression certainly isn’t identical to diabetes, but they do share a lot of common ground. They’re both illnesses with variable and complex biological states, tests which don’t show how widespread the problems can be, ranges of risk factors and treatments and unpredictable outcomes. Next time you hear someone say that ‘depression is just like diabetes’, you can agree with them – perhaps more than they’ll realise.

Smoking in psychiatric hospitals

Last week the Mental Elf reviewed a research paper on the effects of smoke-free policies in psychiatric hospitals. It looks like some smokers manage to stay clear of cigarettes after being admitted to a hospital with a ban.

The debate about whether such bans are fair is complex and often heated, but can usually be boiled down to an argument between freedom (to smoke) and health (of the smoker and others). Contrary to my usual mindset, which is very freedom-orientated, I actually support smoking bans in psychiatric hospitals. I’d like to discuss why, not because I’m particularly ardent in my stance (in fact I used to be against them) but because it’s a tricky area in which I value both points of view. And before you ask, yes, I’ve been a smoker.

Firstly, let’s not forget – smoking is really, really dangerous. It wrecks the human body like nothing else, with smokers dying at least ten years before non-smokers on average. Furthermore, over a third of cigarettes are sold to people with mental illness, unfairly targeting a group that are already having a hard enough time.

Second, despite how many people feel, smoking doesn’t improve mental health conditions, it makes them worse. Smoking might appear to soothe naturally occurring anxiety but in reality it probably only relieves anxiety caused by needing a cigarette (if I had a cigarette now as a non-smoker, would I feel less anxious?). Moreover, quitting smoking while being treated for a mental health problem does not appear to make it worse if you get the right help – in fact, it seems to lead to a decrease in anxiety.

So from a health perspective, smoking is something we don’t want people to be doing for any reason. But should we be able to insist that they stop when in hospital?

Informal patients should be able to nip off the ward for a fag any time they like, but patients held under section aren’t free to leave. This is the most contentious area of the debate. I see both sides of the argument, but overall I think that if someone has been sectioned for the benefit of their health, it seems farcical to facilitate their hugely harmful addiction. Plenty of other behaviours and habits are seen as unacceptable in hospital, without such fierce criticism – drinking alcohol, using illegal drugs, gambling. Even though they can be a normal part of life when well, they’re not allowed in hospital because they aren’t helpful when unwell and it certainly isn’t within the remit of staff to spend time helping patients undertake them.  As a correlate, do we insist that patients have leave from hospital to be escorted to the local betting shop or off license?

Furthermore, facilitating smoking – which often involves nurses wasting hours of each day escorting people back and forth to smoking gardens or the front gate – sends out a bad message about mental health services, I think. When someone is admitted to a general hospital, they accept that the aim of the staff is to improve their health and that although they can smoke if they can make it outside, staff aren’t going to bend over backwards to help them. Plenty of people with physical health problems can’t leave hospital, just like people under section, because they’re too unwell but they don’t tend to feel like that’s unreasonable.

On the topic of rights, non-smoking patients have a right to nurses that aren’t spending their time facilitating the addictive and harmful behaviour of other patients, who then come back onto the ward covered in dangerous chemicals. Most of us have met patients who started smoking on psychiatric wards as a result of exposure to a cigarette-friendly environment, which has to stop.

I’ve worked in psychiatric hospitals both with and without bans. In places without bans, throngs of patient spent literally all day crowding around the nursing station, asking for smoking breaks. It consumed the nurses’ time, so they couldn’t do a range of other caring tasks, and led to a number of incidents of aggression when demands couldn’t be met. In psychological terms such ‘variable reinforcement’ regimes (i.e. only letting someone have something they ask for every so often in an unpredictable way) is a recipe for frustration.

However, in places with bans, in my experience patients are usually a bit annoyed when they’re admitted but usually accept fairly quickly that it doesn’t make sense for a hospital to be condoning smoking, they accept nicotine replacement therapy (which works pretty well), and do just fine. Counter to what you might expect, violence is not increased with total bans, and in at least one instance in the UK a smoke-free policy has halved it.

In summary, there is no perfect solution. We can either help very ill people harm themselves by smoking in the name of freedom, or restrict something they want to do in the name of health. The key for me is that the freedom to smoke isn’t as simple as just letting people smoke – it’s a freedom which has to be actively supported but has negative knock-on effects on patient health and mental state, staff time (including time with other patients), the image of mental health services as pro-health, and ultimately parity. And I haven’t lost any sleep because my patients don’t have access to something that will kill them when I’m meant to be looking after them.


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