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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Foreign nurses hold the NHS together – ignore the Daily Mail

The Daily Mail has a lot in common with genital herpes. It’s seemingly permanent, an unacceptable topic in polite conversation, can go several months without causing annoyance but occasionally flares up in repulsive and virulent fashion. And so it did today. Following the (entirely justified) conviction of Victorino Chua, who poisoned at least 22 patients, the Mail saw fit to effectively brand all Filipinos as potential murderers:

Daily_Mail_20_5_2015

Why not just ‘Did The Nurse Murder 11 More?’

In the article itself, the linking of which to my blog makes me physically nauseous, the Mail gives details of their undercover investigation into the hiring practices of NHS organisations in the Philippines. It was possible to cheat on some entrance exams, they say. Forged copies of qualifications can be obtained in Manila, they say (though they found no proof this had happened – but their reporter did get some certificates made and stood outside the shop looking shifty for effect). The insinuations are clear – that the nurses aren’t any good but are gaming the system to steal UK taxpayer’s money and also have sinister intentions.

What a load of crap.

If some entrance exams are too easy, allowing a slim minority of underqualified nurses to gain employment in the UK then fine, look into that. Do make sure you don’t forget about the series of other rigorous process that nurses have to undergo to start and remain in work in the UK when you cast judgement.

But don’t anyone dare conflate this with foreign staff being of generally poor quality with criminal intent. I have worked in the NHS for many years, and met many foreign nurses. I’ve met so many because there are so many. One in seven trained abroad. The vast majority have been hardworking, well trained, caring and kind people who came to the UK not in pursuit of a fortune or an easy ride – who the hell would call £25,000 a year for the ridiculous hours our nurses work that – but because they felt the NHS offered them a chance to be able to care for people without having to live in poverty. Victorino Chua would not have been caught by a more demanding entrance exam or tougher document checks, just like Harold Shipman wouldn’t have been caught by compassion testing. And his crime has nothing to do with his nationality. One bad apple is no excuse to tarnish a whole culture.

Far from taking advantage of our system, foreign nurses actually make the UK money. We didn’t pay for their school or university education, and because they’re able to work they won’t be needing to claim benefits. They help return sick people to work, where they can resume paying tax. Morevoer, they pay income tax themselves.

Without foreign staff the NHS would collapse – almost literally – in a matter of minutes. Stupidly we’ve neglected our own nurse training schemes for years, leaving vast numbers of posts empty and relying on overseas staff to cover for our mistakes, leaving their own countries worse off for it. And trust me, whatever the Daily Mail says, when the inevitable day comes when you feel that twinge of chest pain, your left side going weak, or a loved one collapses, and you reach for the phone to call 999, you’ll be bloody glad they’re still here.

Where does ‘Choosing Wisely’ fit into mental health services?

Last week the Academy of Medical Royal Colleges announced that it would be bringing ‘Choosing Wisely’ to the UK. The US initiative, which has spread to more than 12 countries worldwide, encourages leading medical organisations to list tests, procedures and medications with little evidence behind them and advise doctors to think twice before using them.

This is a good thing. In many areas, medical intervention has expanded way beyond the point of usefulness, resulting in extra risk to patients for little gain.

Though the Patients Association reacted cautiously, fearing it might mark the beginning of ‘rationing’ of interventions, the reception was overwhelmingly positive. No one really buys the ‘rationing’ worry – the ethos of the campaign is openly directed at empowering choice not withholding, and you have to wonder what the harm would be in rationing ineffective treatments in any case. Atul Gawande hit the nail on the head in his utterly readable New Yorker piece ‘Overkill’, saying that these types of intervention aren’t just ‘low-value care’ but no value care.

I’ve been thinking about how this all applies to mental health services in the UK.

The Royal College of Psychiatrists has signed up for Choosing Wisely, as is right and laudable. And there definitely are interventions in psychiatry which could potentially be cut down on. Antidepressants for mild depression, for example, are next to useless but prescriptions continue to rise suspiciously. Antipsychotics for behavioural disturbance in dementia are only temporarily helpful (if at all) but result in a significantly increased risk of stroke. Antipsychotic polypharmacy for schizophrenia is poorly supported by research, associated with increased side-effect burden, but not rare.

However, we need to keep things in perspective. Unlike most other medical specialties, psychiatry faces the paradox that though we can prune a few treatments back as unhelpful, our main problem is that we’re vastly undertreating most people.

A lot of the time this is fairly convincingly not our fault, due to there not actually being a service in existence to do the treating. Only half of women in the UK have access to perinatal mental health services. Liaison psychiatry provision is so patchy that no official statistics exist, but a recent survey found that even in London only 50% of hospitals have a 24 hour service. Only 25% of people with depression or anxiety access help; the proportion of children with a mental illness in treatment is similar.

But even patients who are lucky enough to find their way to a psychiatrist can somehow avoid being offered effective treatment. Clozapine, the antipsychotic which works significantly better than all others, is meant to be offered after two failed trials of different antipsychotics lasting 6 weeks each. But recent research suggested that the average time to be offered clozapine – which is associated with vastly improved functional and symptomatic outcomes – was 4 years. Similarly, despite the fact that it probably works better than anything else for prophylaxis and suicidal prevention in bipolar disorder, lithium prescribing rates have dropped. Most likely due to the the lack of pharma interest (you can’t patent an ion) and the need for annoying blood test monitoring, patients aren’t getting the best treatment. Moreover, antidepressants aren’t increased to effective doses and aren’t switched in a timely enough fashion if they don’t work. Using an algorithm can help.

And it’s not just medications that are underprovided. According to the National Audit of Schizophrenia less than half of people with schizophrenia who aren’t in remission are offered CBT, just 59% of smokers get offered advice and a measly 25% get counseled on their high blood pressure. Doubtless this is frequently due to clinicians being pressured for time, but the facts remain.

In short, though cutting out pointless and potentially risky interventions is always desirable, in mental health it can hardly be our main focus. We’re way behind the luxurious curve that other specialties find themselves on. Managing to identify and reduce ineffective decisions while introducing effective ones will demand considerable mental dexterity and vigilance of psychiatrists. And of course, they’ll only be able to make those calls if services for them to work in are commissioned in the first place. Choosing wisely is great, but it requires having a choice to start with.

An open letter to Alistair Burt, the new Minister of State for Health

Dear Mr Burt,

Congratulations on your recent appointment as Minister of State for Health and for holding your seat as an MP in North East Bedfordshire.  I must admit, the majority your party obtained last week in the General Election was not the result I had personally wished for, but the result of a fair democratic election is not something to be sniffed at.

Forgive me if I’m wrong here, but a quick trawl of the internet suggests that this is the first time your brief has included mental health. In fact, it seems to be the first time you’ve been tasked with managing health policy of any kind. I was hoping, as a member of the mental health community that includes inordinate numbers of patients, carers and professionals who have spent their lives immersed in this complex area, that I might be able to offer you some advice.

As it turns out, you have big shoes to fill. Norman Lamb was well liked as a politician, which I am sure you’ll recognise as a rare attribute. As one of only a handful of Lib Dem MPs to survive the recent cull, the positive impact of his work over the last 5 years is beyond doubt.

How did he achieve this respect? By having the integrity and compassion to admit that the mental health system he was in charge of was critically inadequate, leading to the needless suffering of countless thousands. His Crisis Care Concordat and the Liberal Democrat’s Closing the Gap report were ample evidence of their commitment to make positive changes in mental health, and they were the only party to give a concrete funding promise (of £3.5bn over 5 years) in their manifesto.

And oh, how we needed that money. Though your colleague Mr Hunt has claimed that mental health funding went up in real terms over the last parliament, no figures in the public domain support that assertion. When corrected for inflation, official figures seem to show a minute fall. But these numbers don’t match our experience of services on the ground – Trusts have recently reported an 8% drop in funding over the last 5 years. Moreover, they expect their funding to keep on falling, by an additional 8% over the next 5 years.

The sad thing is, our services were on the ropes even before these cuts. Mental health problems account for 23% of the illness burden in the UK, but receive only 13% of the funding, an approximate annual shortfall from CCGs of £6.5bn. And during the cuts of the last 5 years, referrals to community teams actually rose by 17%, stretching us further. This pressure had to tell, and the result was agonising. We lost over 2,100 inpatient psychiatric beds. Community teams, the development of which is usually touted as an excuse for reductions in bed numbers, were cut too. Patients continue to be shipped up and down the country, away from their friends and family, just for the sake of finding a bed. Sometimes, even worse, they are sent home when a bed cannot be found or admitted to a ward but without a bed (!). At least seven patients have ended their lives by suicide as a result, just the tip of an iceberg shrouded by confidentiality and incomplete reporting. Those who somehow manage to stay alive receive a grossly and shamefully lower standard of care than their counterparts with physical health disorders. Despite the touting of increased overall nursing numbers in the pre-election period, here in mental health we’ve actually lost 3,300 nurses over the last 5 years.

As if this wasn’t hard enough to bear, the deep cuts to social care have hit people with mental health problems harder than any other group, with a staggering 48% fewer people claiming help in 2013 than they did in 2006. Because recovery in terms of mental health encompasses the whole person, this only serves to heighten the risk of needing more intensive input from mental health services, wasting money in one area by pinching pennies in another.

I could go on, detailing the desperate state of our services in detail. But that wouldn’t be as productive as telling you how to help. You see, you may have inherited nothing short of a national human rights issue, but it is a national human rights issue that you can go a seriously long way to fixing. Our services aren’t that complicated and they’re not even expensive in comparison to interventions in the rest of medicine – but the results can be incredible. Early intervention services, for example, were recently shown to be capable of saving £15 for every £1 invested. Similarly, though perinatal mental health problems costs society £8bn a year, over half the women in the UK don’t have access to a specialist perinatal mental health service. Providing cost-effective care consistent with NICE guidelines to the whole UK would set you back just £337m a year in comparison. I believe economists call this ‘low hanging fruit’. Instead of cutting your outgoings now, cut them in the future by funding these services, and save some lives to boot.

Here’s another tip. Listen to people who have lived experience of using the services that you are in charge of. Listen to them more than you listen to statistics or advisors. When they say that there is a problem, then trust me, there’s a problem. Mental health is fascinatingly complex and learning all its nuances takes years – I still learn something new every day. Genuinely hearing what these people have to say will win you supporters for life, but assumption and hubris will turn this crowd against you like no other.

As well as individuals, listen to the major organisations. They talk a lot of sense and are driven solely by wanting the best for people with mental health problems. Mind, Rethink and the Mental Health Foundation are just about as informed and influential as charities get. My own affiliation, the Royal College of Psychiatrists, regularly turns out lucid documents on topics like Parity of Esteem. They also asked for 6 things from the incoming government, including investment in (again, unbelievably cost-effective) parenting interventions and liaison psychiatry services.

As an additional note, could I implore you to bring a halt to the government’s flirtations both with putting online CBT into Job Centres and sanctioning people who refuse treatment for long term conditions. Both policies are in direct contradiction to the most basic principles of medical ethics (i.e. free consent), underestimate how difficult recovery is for people with these difficulties, discriminate against people with mental health problems and risk a dangerous conflation of unemployment with illness. The goal of recovering from a mental illness should be recovery itself, not employment. To be honest, in a general sense, I do not feel that the further fragmentation of our health services through privatisation, which brings with it the added clash of ideologies between profit and care, and a cumbersome and expensive tendering process, has any place in the NHS. But this is an issue for another day.

In summary, your new job may have more in store for you than you may have expected. You quite literally have the power to do more good, and to win more plaudits, than any other politician in the UK today. We will help you in any way we can, but only if you are eager to listen. I genuinely look forward to working with you in future.

Yours in collaboration,

Alex

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