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.

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:


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.

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