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Issue 1<br />
Summer 2010<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong><br />
<strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
Journal<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online<br />
www.sabp.nhs.uk/journal<br />
in this issue<br />
• Do you ever wonder why you agree to do things?<br />
• New Ways of Working – a three year study of the<br />
practice of a community mental health team<br />
• How can we improve recruitment into psychiatry?<br />
• An interview with Fiona Edwards
Contents<br />
Editorial<br />
Do you ever wonder why you agree to do things? ...........................................PAGE 3<br />
Raja Mukherjee<br />
Let’s do some research.....................................................................................PAGE 4<br />
Raj Persaud<br />
Research <strong>and</strong> Audit<br />
Bipolar Disorder: how effective is our screening in primary care........................PAGE 9<br />
Helena Du Toit et el<br />
Audit of risk assessment documentation in adult inpatients ...........................PAGE 17<br />
Abigail Crutchlow<br />
An evolving service – results of a 3 year follow up study of ...........................PAGE 21<br />
the practice of a community mental health team incorporating<br />
the principles of “New Ways of Working”<br />
Jeremy Mudunkotuwe et al<br />
Commentary <strong>and</strong> Debate<br />
How can we look at improving recruitment into psychiatry? ..........................PAGE 24<br />
Josie Jenkinson<br />
Book Reviews<br />
Psychiatry P.R.N. Principles, Reality, Next steps ...............................................PAGE 28<br />
Josie Jenkinson<br />
Interviews<br />
Interview with Fiona Edwards, ......................................................................PAGE 29<br />
Chief Executive SABP <strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
Abigail Crutchlow<br />
Editorial Board<br />
Raja Mukherjee: Editor<br />
Laurence Church<br />
Philip Hall<br />
Jeremy Mudunkotuwe<br />
Abigail Crutchlow:<br />
Trainee representative<br />
Peer Review Panel<br />
All consultant<br />
psychiatrists unless<br />
otherwise stated<br />
Ruth Alloway<br />
Glen Cornish<br />
Ch<strong>and</strong>u De Alwis<br />
Antonio Fiahlo<br />
Ilenia Pampaloni<br />
Brian Parsons<br />
Raj Persaud<br />
Farida Yousaf<br />
Next edition December 2010: This will be<br />
open to the whole <strong>Trust</strong> <strong>and</strong> all specialities so<br />
please submit any articles you may have.<br />
Editorial guidance <strong>and</strong> st<strong>and</strong>ards as well as<br />
terms of reference can be obtained from the<br />
editor via email:<br />
raja.mukherjee@sabp.nhs.uk.<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal is<br />
published by <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong><br />
<strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
18 Mole Business Park, Leatherhead,<br />
<strong>Surrey</strong> KT22 7AD Tel: 01883 383838<br />
Fax: 01372 203360 www.sabp.nhs.uk<br />
email: communications@sabp.nhs.uk<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong> <strong>NHS</strong><br />
<strong>Foundation</strong> <strong>Trust</strong> © 2010<br />
Reproduction in whole or part without written<br />
permission from the publisher is strictly<br />
prohibited. The views expressed in articles in<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal are those of<br />
the authors, unless otherwise stated.<br />
2 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Do you ever wonder why you agree<br />
to do things?<br />
June 2010 By Raja Mukherjee, Editor<br />
Do you ever wonder why you agree<br />
to do things? The phrase “just say no”<br />
comes to mind, but for those of us of a<br />
certain generation, not in the context it<br />
was widely used back then! When<br />
Malcolm Hawthorne, then in his role as<br />
Medical Director, suggested setting up<br />
this journal, little did I realise I would be<br />
the one running with it. OK, naive I hear<br />
you cry. Maybe even stronger comments<br />
from some, but unfortunately I tend to<br />
agree with them. That phrase comes<br />
back to haunt you from time to time.<br />
The remit of the journal, to begin with at<br />
least, is to allow a space for doctors in<br />
the trust to develop skills at writing to a<br />
peer reviewed level. When I say that, I<br />
mean that it will not simply accept badly<br />
written or poorly thought out pieces. I<br />
will however, with my editorial board,<br />
look to develop the talent <strong>and</strong> skill of<br />
those in the trust who are interested in<br />
publishing. They may as yet not have the<br />
type of data that would interest national<br />
or international journals, but the piece<br />
may still be of interest to us locally.<br />
Primarily, this would initially aim at<br />
medical trainees but that should not<br />
exclusively mean it will be restricted to<br />
this group.<br />
My own experience of publishing is<br />
similar to that reported by Dr Persaud in<br />
his later editorial. It can be brutal out<br />
there. Like him, I think it is important to<br />
not give up <strong>and</strong> keep trying. Not only<br />
does it make you feel great when your<br />
name is in print, but even small new<br />
additions to what is known can be<br />
important. Perseverance can be<br />
important as it is not uncommon to get<br />
initially rejected. There are times I have<br />
wanted to throttle reviewers who have<br />
simply not understood what you were<br />
getting at. Did they actually read what<br />
you said or was it that you simply did not<br />
explain it well enough? Limitations on<br />
what you can present, in terms of word<br />
counts <strong>and</strong> restrictions on references<br />
makes it challenging. In the end though,<br />
establishing something new is never easy.<br />
That is unfortunately the reality of how<br />
things are. As such, better to learn in a<br />
non threatening environment with peers<br />
who you might actually know <strong>and</strong> will<br />
take your piece seriously.<br />
With this journal we have several aims.<br />
Firstly we wanted to allow the<br />
opportunity for people to present <strong>and</strong><br />
share work they are doing but that would<br />
not normally be of interest to those<br />
outside of the trust. Secondly it was an<br />
opportunity to hone skills. We are using<br />
the same set of internationally accepting<br />
st<strong>and</strong>ards for publishing that are adopted<br />
by many journals including the BMJ <strong>and</strong><br />
Lancet. Whilst I suspect we won’t publish<br />
anything of their calibre, we do hope it<br />
will be of a good st<strong>and</strong>ard. The articles<br />
will be placed onto the trust internet site<br />
<strong>and</strong> thus can be accessed by anyone with<br />
web access. This means you can be<br />
quoted in work by others <strong>and</strong> the<br />
information you produce will be<br />
accessible to the wider world. It will also<br />
count as a peer reviewed publication.<br />
In this first edition we present some<br />
audits undertaken by medical teams in<br />
the trust. There is a book review as well<br />
as an interview with our Chief Executive<br />
Fiona Edwards. Ok so it is not expansive<br />
but you have to start somewhere. We<br />
hope this will grow <strong>and</strong> that we can open<br />
it up to the whole trust <strong>and</strong> all specialties.<br />
Eventually we want it to grow into<br />
something we can all be proud of. We<br />
hope you enjoy this first edition. It is a<br />
start <strong>and</strong> will only succeed with your<br />
involvement. Thank you for taking the<br />
time to read <strong>and</strong> hopefully to contribute<br />
in the future.<br />
Editorial<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 3
Editorial<br />
Let’s do some research<br />
June 2010 By Raj Persaud<br />
I was asked to write this by Dr Raja<br />
Mukherjee for our <strong>Trust</strong>’s new<br />
journal. <strong>Here</strong> it is…<br />
If we asked you to predict now whether<br />
you were going to perform some<br />
research <strong>and</strong> publish it, say in the next<br />
year, what would your answer be?<br />
Perhaps, from past experience you might<br />
admit that this is not likely. On the other<br />
h<strong>and</strong>, even if wasn’t particularly likely,<br />
you may also feel that gathering data is<br />
something that you ought to be doing,<br />
<strong>and</strong> given the social pressure <strong>and</strong><br />
management dem<strong>and</strong>s (me asking you<br />
publicly what your research plans are) you<br />
might impulsively declare, that yes<br />
research is something you are planning<br />
<strong>and</strong> intending.<br />
Now, here is the interesting research<br />
question – in merely asking you to<br />
predict the future – do we change it?<br />
Let’s say we ran an experiment where we<br />
divided a sample of the electorate into<br />
two groups, <strong>and</strong> for one, we asked them<br />
to predict whether they were going to<br />
vote or not, while we did nothing<br />
pertinent to the second group; they acted<br />
as a control. Now, if we followed these<br />
two samples up into the future, to<br />
examine what they eventually did in the<br />
privacy of the polling booth; the<br />
astonishing result is that being asked to<br />
predict the future...does change it.<br />
Those who are asked to forecast whether<br />
they are going to vote, tend to confirm<br />
they will, <strong>and</strong> to do so much more than<br />
would be expected from their past<br />
behaviour. They are responding to<br />
external expectation (<strong>and</strong> internal drivers<br />
of a similar nature) so they manage the<br />
impression they want to create of being<br />
responsible citizens, by predicting a<br />
behaviour they were in fact much less<br />
likely to perform in reality. Having<br />
foretold that they will take part in a<br />
ballot, they tend to go ahead <strong>and</strong> actually<br />
vote. Yet if they weren’t asked to predict<br />
the future, they were not particularly<br />
likely to do any casting at all.<br />
We can demonstrate this experimentally<br />
by comparing the group asked to predict<br />
the future with the control group, who<br />
were not asked to make predictions. This<br />
second group vote at the lower baseline<br />
rate of the general population, which is,<br />
not that much.<br />
Why does being asked to predict that<br />
you are going to vote, make it much<br />
more likely that you will?<br />
The short answer is that this particular<br />
psychological phenomenon, like most<br />
others, inspires many theories that<br />
attempt to account for it, but no one is<br />
exactly sure which is the truth. A seminal<br />
paper on this effect in the Journal of<br />
Consumer Psychology by Business<br />
Psychologists Eric Spangenberg of<br />
Washington State University <strong>and</strong> Anthony<br />
Greenwald of the University of<br />
Washington, pointed out that the trend<br />
could be used powerfully to manipulate<br />
large populations into behaviours they<br />
had previously little intention of<br />
performing.<br />
Spangenberg <strong>and</strong> Greenwald are<br />
probably the two world authorities on<br />
this intriguing ‘self-prophecy effect’ <strong>and</strong><br />
their paper entitled ‘Social Influence by<br />
Requesting Self-Prophecy’ showed how<br />
asking people to predict their own<br />
behaviour in the future was associated,<br />
on follow up, with spectacularly less<br />
cheating in tests, significantly more<br />
attendance at health clubs, <strong>and</strong> more<br />
voting.<br />
One theory is that we like to see<br />
ourselves as consistent creatures, <strong>and</strong><br />
having made a prediction of our<br />
behaviour in the future, not to confirm<br />
the prediction by performing the<br />
behaviour, would force us to confront a<br />
rather unpalatable truth; we are<br />
unreliable, inconsistent people who don’t<br />
know our own minds.<br />
4 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
We are not so aware of the hidden forces<br />
at work generated by the social<br />
expectations of being asked about our<br />
plans in front of another, which push us<br />
into making a prediction at variance with<br />
what we would really do in the privacy of<br />
our own un-observed lives.<br />
Having made the prediction, we then<br />
work to fall into line with it.<br />
Another, related, theory is that this is an<br />
example of the power of expectation.<br />
Psychologists have demonstrated for<br />
almost half a century now, that if<br />
teachers are manipulated into expecting<br />
their pupils to be intelligent or stupid,<br />
they then work to render these<br />
expectations self-fulfilling prophecies.<br />
Judges give directions to juries at the<br />
beginnings of trials that appear to bias<br />
the outcome in line with the bench’s<br />
expectation of the future. We also<br />
directly seem to suffer for this effect – if<br />
our expectation of ourselves is<br />
manipulated experimentally, we then<br />
provide later behavioural confirmation of<br />
our expectations of ourselves.<br />
More on Expectations<br />
One of the most famous experiments in<br />
Social Psychology which demonstrated<br />
the power of expectation is a 1977 study<br />
by a team lead by Mark Snyder, now at<br />
the University of Minnesota, in which men<br />
were shown photographs of a woman to<br />
whom they would be talking by phone.<br />
The woman in the pictures was<br />
r<strong>and</strong>omised to being either extremely<br />
physically attractive or unattractive (as<br />
rated by other independent observers).<br />
What the men taking part in the<br />
experiment didn’t know, was that those<br />
sneaky psychologists had told a porky pie,<br />
<strong>and</strong> the photographs were not only<br />
r<strong>and</strong>omly assigned to the men, but they<br />
also did not correspond in any way to the<br />
actual woman with whom they had the<br />
phone conversation.<br />
While it would come as no surprise that<br />
the men behaved differently to the<br />
women during the phone conversation<br />
depending on their (manipulated) beliefs<br />
on her physical appearance, the really<br />
surprising finding was that independent<br />
ratings of the women's segments of the<br />
conversations revealed that females<br />
whose conversational partners believed<br />
them to be less appealing, actually<br />
behaved <strong>and</strong> sounded less attractively (eg<br />
they were rated as sounding less warm<br />
<strong>and</strong> interesting).<br />
The women, just as the men, had also<br />
been kept completely in the dark by the<br />
psychologists about the photograph<br />
manipulation. They were not aware it had<br />
taken place. This effect, therefore, had to<br />
have been mediated in some way through<br />
the men's behavior. One possibility, is that<br />
the men who were talking to someone<br />
they believed to be unattractive, were<br />
themselves less affable than men who<br />
believed they were talking to an attractive<br />
woman. This in turn had an impact on the<br />
way the women responded, <strong>and</strong> then<br />
they way they came over to an<br />
independent observer.<br />
The ‘Pygmalion Effect’ is a special instance<br />
of the self-fulfilling prophecy; where<br />
having an expectation of another, itself<br />
causes that target to modify their<br />
performance so it falls into line with the<br />
expectation of the first party.<br />
Just in case you are starting to think that<br />
Self-Fulfilling Prophecies only inhabit the<br />
obscure world of experimental<br />
Psychology, remember we are living<br />
through a banking crisis <strong>and</strong> suffering its<br />
long term impact, <strong>and</strong> banking crises are<br />
a form of self-fulfilling prophecy.<br />
Because a rumour starts that a bank may<br />
fail, this precipitates a run on that bank,<br />
which in itself inevitably leads to its<br />
collapse. This is why Chancellors of the<br />
Exchequer hot foot it to the nearest TV<br />
studio to ‘steady the markets’ at the<br />
slightest hint of such runs on major<br />
financial institutions. Governments, <strong>and</strong><br />
the whole financial system, live in terror<br />
of the power of the self-fulfilling<br />
prophecy.<br />
It’s so powerful <strong>and</strong> reliable that you can<br />
literally ‘bank’ on it.<br />
Editorial<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 5
Editorial<br />
Expectations <strong>and</strong> You<br />
Consider the continuing controversy<br />
over the benefits or costs of psychiatric<br />
diagnosis. Is it possible that the<br />
expectation set up in the patient <strong>and</strong><br />
their social circle, once a diagnosis of<br />
schizophrenia or depression is made, in<br />
itself serves to make the implicit<br />
prophecy entailed in such a diagnosis<br />
come true? Because of the powerful<br />
self-fulfilling prophecy effect of a<br />
psychiatric diagnosis – is it possible that<br />
users of mental health services would<br />
benefit more from ab<strong>and</strong>oning the use<br />
of such labels?<br />
At the heart of the education system,<br />
psychologists contend, are ever-present<br />
self-fulfilling prophecies. We constantly<br />
stream children <strong>and</strong> students into better<br />
classes or universities, then wonder why<br />
they do better, when the power of<br />
expectation <strong>and</strong> self-fulfilling prophecy<br />
might be the answer, rather than any<br />
inherent benefit of an elite education.<br />
Our <strong>Trust</strong><br />
Is it possible, coming back to research in<br />
our <strong>Trust</strong>, that the expectation of whether<br />
or not you are going to do research<br />
massively influences the outcome? Might<br />
it be of benefit to the <strong>Trust</strong> <strong>and</strong> the<br />
doctors working within it to transform<br />
the expectation so that we ‘become<br />
expected’, by managers, peers <strong>and</strong><br />
ourselves, to generate <strong>and</strong> publish much<br />
more research than we currently do?<br />
And doctors? Why should doctors<br />
bother to do research? Surely doctors’<br />
primary function is to heal the sick, <strong>and</strong><br />
other activities become a distraction?<br />
Can research by used by some as a<br />
‘noble’ from the heaving clinic? How do<br />
eminence <strong>and</strong> academic honour<br />
correlate with clinical acumen? Do<br />
publication lists still appear as a magic<br />
key in unlocking merit awards?<br />
There are some serious obstacles that<br />
will confront any doctor attempting<br />
research. Firstly, finding the time,<br />
support, advice <strong>and</strong> resources to<br />
conduct the study. On top of a<br />
burdensome caseload, anyone in an <strong>NHS</strong><br />
contract who is successful in producing<br />
papers is frequently met with the<br />
suspicion that they cannot be pulling<br />
their weight clinically.<br />
Half way through the study someone<br />
will usually helpfully point out some<br />
methodological consideration that<br />
renders all your meticulous data<br />
collection redundant, so you are faced<br />
with the prospect of starting all over<br />
again.<br />
Most papers hide the key story of the<br />
research project, which is in fact how the<br />
investigators overcame, through adept<br />
improvisation, often on the hoof, various<br />
unexpected impediments tripping them<br />
as they attempted to recruit subjects, or<br />
measure some variable.<br />
Once one nightmare study was over <strong>and</strong><br />
the data was presented at various<br />
conferences, a researcher was asked how<br />
he would do the study differently if he<br />
could start all over again. His response<br />
was that he would not do it at all.<br />
Once you assemble the data, statistics<br />
need to be applied. You visit statisticians<br />
with trepidation, remembering to pack<br />
your calculator. They take one cursory<br />
look at the reams of numbers you had<br />
painstakingly calculated <strong>and</strong> she bursts<br />
out laughing because (a) you measured<br />
the right thing but in the wrong way or<br />
(b) you measured the right way, but<br />
chose the wrong thing to measure or (c)<br />
you didn’t recruit enough subjects or (d)<br />
the measuring instrument you used isn’t<br />
compatible with the statistical test you<br />
hoped to apply…. And so it goes on.<br />
Some people find that, once you have to<br />
start using fancy statistics to illuminate<br />
your hypothesis, the finding isn’t worth<br />
the c<strong>and</strong>le. This should reassure the<br />
statistically naïve that genuine<br />
discoveries are still possible for the<br />
innumerate. Indeed in the world of<br />
research, suspicions mount as the<br />
statistical tests multiply.<br />
Another wonderful revelation was the<br />
(geeky nerdy) joy in just inspecting the<br />
raw data, like graphing it, without<br />
6 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
esorting too soon to complex statistical<br />
tests. This is a real issue in research in<br />
psychiatry – how to measure the elusive<br />
concepts we deal with daily. In the rest of<br />
medicine measuring blood sugar or bone<br />
density levels is much more<br />
straightforward, which is why these<br />
branches lend themselves so much more<br />
easily to research.<br />
So one early tip to the young researcher<br />
is to think very carefully before you start<br />
your study about precisely what you are<br />
evaluating <strong>and</strong> how you are measuring it.<br />
Lean heavily towards using an<br />
instrument, like a questionnaire, that is<br />
widely accepted in the field. Of course,<br />
some of the most gloriously innovative<br />
research in psychiatry involves pioneering<br />
a new measurement device, because the<br />
research community has neglected the<br />
concept you are investigating.<br />
But the problems don’t end there. Let’s say<br />
you dodged the statisticians’ scrutiny <strong>and</strong><br />
colleagues’ criticism. Then you may go on<br />
to long friendships being threatened by<br />
disputes over how to write it up. And,<br />
finally who is going to be first author?<br />
After that jockeying for position come the<br />
editors’ letters of rejection. This happens<br />
even to the most published of us. The<br />
record among people I have known is 10<br />
rejecting letters from editors for one<br />
paper <strong>and</strong> 30 rejections for a book.<br />
So given all these problems – why do<br />
research at all?<br />
I still firmly believe it’s worth it. Much of<br />
what we do as doctors arises because<br />
some researcher somewhere bravely<br />
chose to ask the question – what is the<br />
evidence for this piece of practice? There<br />
is nothing more exciting than pushing<br />
back the frontiers of knowledge <strong>and</strong><br />
discovering something new <strong>and</strong> – the<br />
icing on the ‘cake’ - is that it may alter<br />
clinical practice or improve the outcome<br />
for patients.<br />
Having a research interest keeps us<br />
stimulated <strong>and</strong> interested in our<br />
professional lives. It assists in engaging<br />
with those of similar interests all around<br />
the world <strong>and</strong> at a time when doctors<br />
frequently feel neglected or downtrodden<br />
by the <strong>NHS</strong>; it is great for the self-esteem<br />
<strong>and</strong> earns the respect of colleagues.<br />
I have been impressed at the clinical<br />
acumen <strong>and</strong> lively minds we are<br />
privileged to work alongside. I believe<br />
there would be many benefits, including<br />
raising clinical morale, for the <strong>Trust</strong> to<br />
engage more with a research ethos.<br />
Another advantage for the future is that<br />
rapidly climbing the <strong>NHS</strong> agenda now<br />
comes the issue of providing, proving <strong>and</strong><br />
improving the quality of care we provide<br />
our patients. It would be great for us to<br />
engage in research investigating what the<br />
determinants of high quality care are, in<br />
the eyes of patients as well as clinicians<br />
<strong>and</strong> scrutinize how to improve this. There<br />
may well be some surprising answers. It’s<br />
entirely possible that what doctors<br />
believe is crucial to treatment outcome is<br />
much more peripheral.<br />
Also while we are encouraged to<br />
constantly keep abreast of the latest<br />
research, its only by having done some<br />
yourself, that you are in the best position<br />
to properly evaluate an academic paper.<br />
This is because you will now be aware of<br />
many crucial issues the authors skate<br />
over, but which you know from hard<br />
experience, might be influencing the data<br />
they present.<br />
Its vital not to get pigeonholed – yes I<br />
have done brain scanning research, but I<br />
also got interested in qualitative research<br />
methods – <strong>and</strong> used them to sit <strong>and</strong><br />
observe what goes on in waiting rooms.<br />
These are spaces where our patients<br />
sometimes spend more time than they do<br />
actually seeing us!<br />
Commercial institutions like Banks had<br />
clearly put a lot of thought into<br />
considering <strong>and</strong> influencing the mental<br />
state of its customers, while they wait to<br />
see a member of staff. The <strong>NHS</strong> in<br />
contrast appeared to view the waiting<br />
room as some kind of detainment<br />
compound for undesirables. It was often<br />
at best an afterthought in planning.<br />
Yet by the time any doctor sees a patient<br />
Editorial<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 7
Editorial<br />
– the outcome of that crucial encounter<br />
may have already been partly <strong>and</strong><br />
significantly determined by what the<br />
patient experienced in the waiting room.<br />
Something the doctor may not just be<br />
unaware of, but may be usually beyond<br />
their control.<br />
Qualitative research has a long <strong>and</strong><br />
respectable history in Anthropology <strong>and</strong><br />
Sociology, though it may be sniffed at by<br />
medical colleagues; it’s just an example<br />
that other methodologies are available<br />
to us as research tools. You don’t need a<br />
high tech brain scanner to accomplish<br />
something meaningful. It should not be<br />
forgotten.<br />
<strong>Here</strong> are some possible research<br />
questions that I would be interested in<br />
assisting any staff member with<br />
conducting some kind of project, or<br />
which I believe others in the <strong>Trust</strong> may<br />
want to pick up.<br />
Why do patients complain <strong>and</strong> what is<br />
their experience of the complaints<br />
process? What leads to higher patient<br />
satisfaction after a complaint? What is<br />
the experience of the staff members<br />
who have been the subject of a<br />
complaint? What is the impact on them<br />
psychologically or in terms of the way<br />
they practice medicine afterwards?<br />
What is found most helpful by GPs in<br />
letters from Secondary Care clinics.<br />
What do they dislike the most in our<br />
letters to them? What impact do our<br />
letters have on care? What about a trial<br />
of different kinds of letters?<br />
When a patient first hears that a GP is<br />
thinking of referring them to a<br />
psychiatric services – what is their initial<br />
reaction? How does the encounter with<br />
services alter that?<br />
When trainees start psychiatry what are<br />
their expectations? How does doing a<br />
psychiatry placement alter this?<br />
Part of the new <strong>Trust</strong> journal could be<br />
devoted to throwing out research ideas<br />
<strong>and</strong> seeing who wants to collaborate<br />
over conducting. Part of the week could<br />
be set aside for doctors in the <strong>Trust</strong> to<br />
meet in order to discuss <strong>and</strong> assist with<br />
research projects.<br />
Remember as well that publishing<br />
doesn’t have to be restricted to<br />
publishing research – letters to journals<br />
can often be surprisingly influential. A<br />
good place to start in your research<br />
career is by submitting some letters. For<br />
that you must be aware of the literature<br />
<strong>and</strong> eventually dialogues <strong>and</strong><br />
collaborations may develop. before you<br />
critique it <strong>and</strong> then eventually dialogues<br />
<strong>and</strong> collaborations often develop out of<br />
such initial correspondence.<br />
Colleagues could get together <strong>and</strong><br />
submit more letters to journals - drawing<br />
attention to the implications of various<br />
research findings on clinical practice<br />
where we work?<br />
These are just questions – I don’t<br />
pretend to have the answers.<br />
But all great research at least starts with<br />
a good question.<br />
This is not as good a paper as I had<br />
hoped. It was done rather quickly <strong>and</strong><br />
under difficult circumstances. But it<br />
might stimulate you to think of doing<br />
research.<br />
Remember, if you predict you’ll do, you<br />
are more likely to do it.<br />
8 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Bipolar Disorder: how effective is our<br />
screening in primary care<br />
April 2010 By Helena Du Toit, Raja Mukherjee, Rebecca Farrell <strong>and</strong> Sudhir Rastogi<br />
Introduction<br />
Bipolar Affective Disorder (BPD) is a<br />
serious, recurrent psychiatric illness<br />
characterised by periods of mania or<br />
hypomania, <strong>and</strong> depression (ICD-10,<br />
1992). BPD has a global prevalence of<br />
approximately 1-2%, which is stable over<br />
all population groups, however, when all<br />
forms of Bipolar Spectrum Disorder are<br />
included; the global lifetime prevalence<br />
rises to approximately 5% (Kessler RC et<br />
al, 1994; Angst J, 1998).<br />
It is a leading worldwide cause of disability<br />
(Hunter R et al, 2004), is associated with a<br />
high suicide risk (Sachs GS, 2003; Kasper,<br />
2003) <strong>and</strong> costs the UK economy about<br />
£2 billion per annum through active costs<br />
of managing the disorder as well as<br />
through loss of productivity (Das Gupta R<br />
& Guest JF, 2002).<br />
The condition usually presents in<br />
adolescence or early adulthood <strong>and</strong> has a<br />
recurring, often lifelong course, <strong>and</strong><br />
greatly affects the individual’s functioning<br />
in several areas <strong>and</strong> has wide reaching<br />
implications for close family, friends <strong>and</strong><br />
colleagues (Kasper S, 2003; Weissman<br />
MM et al, 1988; Stang P et al, 2007).<br />
In spite of this, it is often several years<br />
from the first presentation of the illness<br />
until the diagnosis is finally established,<br />
sometimes being delayed by as long as<br />
10 years. The under-recognition of BPD is<br />
due to several factors. Firstly, the illness<br />
often first presents with a depressive<br />
episode, <strong>and</strong> there may be several<br />
depressive episodes before the sufferer<br />
experiences a manic/hypomanic episode.<br />
These depressive episodes are often very<br />
difficult to distinguish from unipolar<br />
depression. Equally, the marked shifts in<br />
affect characteristic of emotionally<br />
unstable personality disorder <strong>and</strong><br />
cyclothymia can be mistaken for BPD<br />
(Corona et al, 2007). Additionally,<br />
patients often do not present to medical<br />
services during hypomanic <strong>and</strong><br />
sometimes even manic phases, as they<br />
find their increased energy levels <strong>and</strong><br />
creativity during these periods quite<br />
enjoyable <strong>and</strong> often do not recognize<br />
them as pathological. Furthermore,<br />
clinicians often fail to screen for a past<br />
history of manic/hypomanic symptoms in<br />
patients presenting with a depressive<br />
episode (Brickman et al, 2002). Delayed<br />
diagnosis often leads to inadequate<br />
management of the illness, with<br />
associated recurrent illness, diminished<br />
social <strong>and</strong> occupational functioning <strong>and</strong><br />
significant distress for both the sufferer<br />
<strong>and</strong> his/her family. To make matters<br />
worse, treating bipolar depression with<br />
antidepressant monotherapy is not only<br />
associated with a high rate of treatment<br />
failure, but also with a switch to rapid<br />
cycling BPD, increased mood instability<br />
<strong>and</strong> greater treatment resistance (Wehr<br />
TA & Goodwin FK, 1987).<br />
Conversely, there is good evidence that if<br />
the condition is diagnosed early <strong>and</strong><br />
managed appropriately, it is associated<br />
with a significantly improved outcome<br />
<strong>and</strong> preserved social <strong>and</strong> occupational<br />
functioning (Bauer MS et al, 2006; Perry<br />
A et al, 1999), as well as a significant<br />
decrease in the suicide risk.<br />
The Mood Disorders Questionnaire<br />
(MDQ) is a short, self administered<br />
questionnaire that has been validated in<br />
several countries (including the UK) as<br />
being an appropriate screening tool for<br />
use in the community or a primary care<br />
setting (Hirschfeld RM 2002; de Dois et<br />
al, 2008). It has both acceptable<br />
sensitivity <strong>and</strong> specificity to be used as a<br />
screening tool, <strong>and</strong> although some<br />
studies have suggested that the false<br />
positive rate is unacceptably high, the<br />
Research <strong>and</strong> Audit<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 9
Research <strong>and</strong> Audit<br />
rate of false negatives is consistently low<br />
(Twiss J et al, 2008). It is therefore<br />
recommended that all patients screening<br />
positive for BPD on the MDQ (using a<br />
cut off of 9 positive responses as a<br />
positive test) should be referred for<br />
diagnostic assessment by a professional<br />
mental health worker. Additionally a<br />
large study in a USA health centre with 1<br />
million adult members identified that by<br />
administering one off screening for BPD<br />
to patients presenting with depressive<br />
symptoms, <strong>and</strong> following up positive<br />
screening results with a referral to a<br />
psychiatrist, reduced 5 year health care<br />
costs for that health centre by an<br />
estimated $1.94 million. This reduction<br />
was mostly due the difference in<br />
treatment costs between recognized<br />
versus unrecognized BPD sufferers<br />
(Menzin J et al, 2009).<br />
The importance of screening for<br />
hypomania/mania is that BPD sufferers<br />
are often misdiagnosed as suffering from<br />
unipolar depression, frequently leading<br />
to incorrect treatment. A single episode<br />
of mania constitutes a diagnosis of BPD,<br />
whilst an episode of hypomania should<br />
increase vigilance in looking out for<br />
future episodes of depression.<br />
Aims <strong>and</strong> Objectives of the<br />
Audit<br />
The purpose of the audit was to assess<br />
whether patients presenting to primary<br />
care practices within our catchment area<br />
were being screened for BPD.<br />
Additionally we wanted to establish how<br />
effective our service was at correctly<br />
identifying both true BPD sufferers, <strong>and</strong><br />
those suffering from other mental health<br />
conditions. We intend to examine this<br />
data <strong>and</strong> consider whether further<br />
awareness <strong>and</strong> screening is required.<br />
To summarize, our study aimed to<br />
answer 3 questions: Within the context<br />
of our service-<br />
1. Do primary care physicians <strong>and</strong><br />
Mental Health Nurse Practitioners<br />
(MHNPs), specialist psychiatric nurses<br />
working in both primary <strong>and</strong><br />
secondary care, screen for BPD?<br />
2. Does screening for BPD increase the<br />
likelihood of identifying this<br />
condition?<br />
3. Is there a good correlation between<br />
the diagnosis proposed by GPs <strong>and</strong><br />
MHNPs <strong>and</strong> the final diagnosis made<br />
by the psychiatrist?<br />
St<strong>and</strong>ard<br />
Currently no gold st<strong>and</strong>ard or NICE<br />
guidelines exist regarding screening for<br />
BPD in primary care; therefore we did<br />
not stipulate the use of a specific<br />
screening tool for our study. There are<br />
also no globally agreed cut-off points for<br />
what constitutes an acceptable<br />
screening test, although most<br />
researchers would agree that any good<br />
screening measure should have both a<br />
low false positive rate <strong>and</strong> a low false<br />
negative rate. The actual values that a<br />
researcher may deem acceptable are<br />
related to several variables, such as<br />
prevalence of condition, cost of<br />
screening <strong>and</strong> burden associated with<br />
missing the condition vs. burden<br />
associated with over diagnosing the<br />
condition (Simon S, 2007). For the<br />
purposes of our study, we set 80%<br />
sensitivity <strong>and</strong> 80% specificity as the<br />
st<strong>and</strong>ard, based upon levels set in other<br />
published research (Twiss J et al, 2008).<br />
Although these are arbitrary cut-off<br />
values, they are in line with generally<br />
accepted st<strong>and</strong>ards for psychiatric<br />
screening tests.<br />
Although we did not require the use of a<br />
specific screening tool for this study, we<br />
previously mentioned that a brief <strong>and</strong><br />
acceptable screening tool is available,<br />
<strong>and</strong> we may consider using this tool<br />
routinely in the future.<br />
10 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Research Method<br />
The study was conducted in our local<br />
Primary Mental Health Care Team<br />
(PCMHT) which is a community<br />
psychiatric service that operates both in<br />
GP surgeries <strong>and</strong> secondary care. A<br />
retrospective survey was carried out of all<br />
the patients with affective symptoms that<br />
were referred to the T<strong>and</strong>ridge PCMHT<br />
over a 6 month period between January<br />
<strong>and</strong> June 2008. It was felt that this would<br />
be a sufficiently large sample to accurately<br />
<strong>and</strong> validly assess the efficacy of screening<br />
for BPD in our catchment area.<br />
Table 1: Proforma used to analyse case records<br />
These referrals came from local GP<br />
surgeries, through the Crisis Advisory<br />
service, the Home Treatment Team <strong>and</strong><br />
following discharge from the inpatient<br />
psychiatric unit at Epsom General<br />
Hospital. Some of these referrals also had<br />
a further triage assessment by a Mental<br />
Health Nurse Practitioner (MHNP) before<br />
being referred to the psychiatrist for<br />
confirmation of their diagnosis.<br />
We examined all patients’ records using<br />
an audit proforma that looked at the<br />
following parameters:<br />
GP assessment MHNP assessment Psychiatrist<br />
assessment<br />
Did the<br />
patient have<br />
2/more<br />
episodes of<br />
mental<br />
illness?<br />
Did the GP<br />
screen for<br />
hypomania?<br />
What<br />
diagnosis<br />
did the GP<br />
propose?<br />
Did the<br />
MHNP<br />
screen for<br />
hypomania?<br />
What<br />
diagnosis<br />
did the<br />
MHNP<br />
propose?<br />
Final<br />
Diagnosis<br />
Research <strong>and</strong> Audit<br />
On completion of the proforma’s the data was analysed using the SPSS statistical<br />
package.<br />
The Psychiatrist’s diagnosis was used as the gold st<strong>and</strong>ard next to which the other<br />
proposed diagnoses were measured for accuracy.<br />
Results<br />
Between 01/01/2008 – 30/06/2008 there were 58 patients referred to the T<strong>and</strong>ridge<br />
PCMHT that presented with affective symptoms. Seven records could not be retrieved,<br />
subsequently 51 patients were included in the audit.<br />
The demographics of our study population were as follows:<br />
Table 2: Demographics of study population<br />
Gender<br />
Age<br />
Male, N = 19<br />
Range, 19 – 62 years<br />
Female, N = 32<br />
Mean = 37.6<br />
(normal distribution)<br />
Out of the 38 patients referred by their GPs, 21 (55.3%) had had two or more<br />
episodes of mental illness whilst for 17 patients (44.7%) it was their first episode of<br />
mental illness. 13 patients were referred from other sources. In these cases the initial<br />
referral letter was analyzed in the same way as a GP referral <strong>and</strong> if they were also seen<br />
by a MHNP, this data was also included.<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 11
Research <strong>and</strong> Audit<br />
Table 3: Frequency with which GPs <strong>and</strong> MHNPs screened<br />
for hypomania<br />
%<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
% Yes<br />
% No<br />
GP<br />
MHNP<br />
Screened for hypomania (n) Frequency (n) Percent (%)<br />
GP Yes 8 21.1<br />
No 30 78.9<br />
Total 38 100<br />
MHNP Yes 14 38.9<br />
No 22 61.1<br />
Total 36 100<br />
Table 3 shows the total number (n) of patients that were screened for hypomania by<br />
the GP <strong>and</strong> the MHNP respectively as well as their representative frequencies. As<br />
indicated, only 21.1% of all patients were screened by their GP for symptoms of<br />
hypomania whilst 38.9% of patients who saw a MHNP were screened for hypomania.<br />
Table 4: Diagnoses made by GPs <strong>and</strong> MHNPs vs. screening for<br />
hypomania<br />
Combined GP Diagnosis<br />
Combined MHNP Diagnosis<br />
100<br />
100<br />
80<br />
80<br />
60<br />
Screened<br />
60<br />
Screened<br />
40<br />
Not Screened<br />
40<br />
Not Screened<br />
20<br />
20<br />
0<br />
BPD<br />
Total<br />
0<br />
BPD<br />
Total<br />
12 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Screened for Hypomania<br />
Yes No Total<br />
Combined GP Dx BPD 8 1 9<br />
Other 0 29 29<br />
Total 8 30 38<br />
Combined BPD 9 0 9<br />
MHNP Dx Other 1 13 14<br />
Total 10 13 23<br />
Chi-Square Tests<br />
Value df P value<br />
Pearson χ² 32.65 1 .000<br />
Cont.Corr. 27.52 1 .000<br />
Fisher’s Exact Test .000<br />
Pearson χ² 19.22 1 .000<br />
Cont.Corr. 15.63 1 .000<br />
Fisher’s Exact Test .000<br />
Key: (df) degrees of freedom, (χ²) Pearson’s chi-square value, (cont.corr.) continuity<br />
correction – done for 2x2 tables, Fisher’s Exact Test – performed as one or more cells<br />
<strong>and</strong> an expected count of
Research <strong>and</strong> Audit<br />
Table 5 shows how the GPs <strong>and</strong> MHNPs<br />
combined diagnoses (BPD or another<br />
condition) performed against the<br />
psychiatrists final diagnosis, which is used<br />
as the gold st<strong>and</strong>ard in this study.<br />
Thirty-three patients were seen by both<br />
the psychiatrist <strong>and</strong> their GP. Of the 7<br />
patients diagnosed with BPD by the<br />
psychiatrist 5 were correctly identified by<br />
their GP whilst 2 received another<br />
diagnosis. However in 4 patients where<br />
the psychiatrist diagnosed another<br />
condition the GP suggested a diagnosis<br />
of BPD. The corresponding sensitivity <strong>and</strong><br />
specificity of the GPs diagnoses were<br />
71.4% <strong>and</strong> 84.6%. The PPV for the GPs<br />
diagnoses was 55.6% while the NPV was<br />
91.7%. However the LR+ <strong>and</strong> LR- were<br />
4.75 <strong>and</strong> 0.34 respectively which are<br />
outside of the limits of a good diagnostic<br />
test. (Please refer to Fields A, 2009 for a<br />
detailed explanation of these terms.)<br />
Twenty patients were seen by a MHNP<br />
before seeing the psychiatrist. The MHNP<br />
correctly picked up BPD in 2 of the 4<br />
cases diagnosed with BPD by the<br />
psychiatrist. However in 6 out of 16 cases<br />
the MHNP diagnosed BPD whilst the<br />
psychiatrist diagnosed another condition.<br />
The sensitivity, specificity, PPV <strong>and</strong> NPV<br />
for the MHNPs diagnoses were 50%,<br />
62.5%, 25% <strong>and</strong> 80% respectively.<br />
Again the LR+ <strong>and</strong> LR- which are 1.35<br />
<strong>and</strong> 0.8 respectively fall outside of the<br />
limits of an acceptable diagnostic test.<br />
Discussion<br />
There is a growing body of evidence<br />
showing the importance of correctly<br />
identifying <strong>and</strong> treating sufferers of BPD<br />
to improve their quality of life, preserve<br />
their social <strong>and</strong> occupational functioning<br />
<strong>and</strong> to lessen the financial burden of<br />
healthcare costs related to the<br />
mismanagement of this important<br />
condition. Equally, the fact that there is<br />
often a delay of several years before this<br />
condition is correctly identified, highlights<br />
the importance of vigilantly screening for<br />
BPD, especially in the primary care setting.<br />
Our first aim was to establish the<br />
frequency with which our primary care<br />
practitioners screened for BPD. In this<br />
sample of patients presenting with<br />
affective symptoms, only 21.1% of those<br />
referred by their GP showed any evidence<br />
that they had been screened for BPD.<br />
Although this figure rose to 38.9% for<br />
MHNPs, this still represents a rather low<br />
proportion of screening for patients who<br />
are within the at risk category. This is<br />
especially important as tools such as the<br />
MDQ are available, short, <strong>and</strong> easy to<br />
use, <strong>and</strong> could easily be administered in<br />
the context of a primary care assessment.<br />
A potential downfall of this study design<br />
is that it relied on evidence from the<br />
referral letter that the clinician had<br />
screened for BPD <strong>and</strong> therefore it is<br />
possible that where a patient screened<br />
negative, it was not mentioned in the<br />
referral letter. However, a good referral<br />
should mention both positive <strong>and</strong> salient<br />
negative findings <strong>and</strong> routine use of the<br />
MDQ could circumnavigate this issue.<br />
Secondly, we aimed to establish whether<br />
screening for BPD increases the likelihood<br />
of correctly identifying the signs <strong>and</strong><br />
symptoms of this disorder. In our study<br />
both GPs <strong>and</strong> MHNPs almost exclusively<br />
(with the exception of one patient in<br />
each case) only proposed a diagnosis of<br />
BPD when there was evidence that they<br />
had screened for hypomania. These<br />
highly significant results show that it was<br />
highly unlikely that clinicians would<br />
propose a diagnosis of BPD when they<br />
had not screened for the condition. These<br />
results emphasize the great importance<br />
of consistent screening.<br />
Our third question looks at the accuracy<br />
with which GPs <strong>and</strong> MHNPs were able to<br />
rule in or rule out BPD in their patients.<br />
As previously mentioned, a good<br />
screening tool should have both good<br />
sensitivity (low false negatives) <strong>and</strong> good<br />
specificity (low false positives). We also<br />
looked at PPV <strong>and</strong> NPV as well as LR+<br />
<strong>and</strong> LR- as these give additional<br />
information about the quality of a<br />
screening test.<br />
14 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
In our sample the GPs screening method<br />
was very effective at ruling out BPD, but<br />
was less accurate when it came to ruling<br />
the condition in.<br />
The MHNPs’ method was also ineffective<br />
at ruling in BPD <strong>and</strong> although it was<br />
slightly better at ruling out this condition,<br />
only the NPV was above the cut off value.<br />
However for both groups of practitioners<br />
the LR+ <strong>and</strong> LR- of their methods, which<br />
reflects the value of a positive or negative<br />
test result, was well below the accepted<br />
cut off range. This suggests that the<br />
methods used by the primary care<br />
practitioners in our study had little value<br />
in correctly identifying the presence or<br />
absence of BPD.<br />
There are, however, some limitations to<br />
our study. We should note that this study<br />
encompassed relatively small numbers<br />
<strong>and</strong> this makes it difficult to make<br />
predictions about how these methods<br />
would perform in a larger population. In<br />
this study neither the GPs nor the MHNPs<br />
used a st<strong>and</strong>ardized screening tool;<br />
instead we were examining the validity of<br />
the methods they are already using.<br />
Although our results suggest that the GPs<br />
methods were slightly more effective<br />
than the MHNPs’ methods, it is also<br />
possible that the cases seen by the<br />
MHNPs were more complex <strong>and</strong><br />
displayed a less clear cut presentation.<br />
Another limitation of the study is that the<br />
psychiatrist’s diagnosis may not represent<br />
an accurate gold st<strong>and</strong>ard, particularly in<br />
patients suffering a first episode of<br />
affective illness.<br />
In summary, the results of our study show<br />
that within the primary care setting in our<br />
catchment area screening for BPD is<br />
currently unacceptably low. Also it clearly<br />
shows that screening for BPD greatly<br />
enhances the chances of recognising this<br />
condition <strong>and</strong> that current screening<br />
methods used by primary care<br />
practitioners could be improved.<br />
Recommendations<br />
1. Increase awareness of BPD <strong>and</strong> the<br />
importance of screening within our<br />
primary care setting. This could be<br />
achieved by doing a presentation for<br />
GPs <strong>and</strong> MHNPs regarding the findings<br />
of our study.<br />
2. Role out the use of the MDQ as a<br />
st<strong>and</strong>ard screening tool to be<br />
administered to all patients in primary<br />
care presenting with an affective<br />
episode.<br />
3. Improve communication between<br />
primary <strong>and</strong> secondary care<br />
practitioners. This could be through<br />
informal discussions or telephone<br />
advice.<br />
4. Re-audit in 12 months to see the<br />
change in practice.<br />
References<br />
• Angst J. The emerging epidemiology<br />
of hypomania <strong>and</strong> bipolar II disorder.<br />
Journal of Affective Disorders, 1998; 50:<br />
143-51.<br />
• Bauer MS, McBride L, Williford WO et<br />
al. Collaborative Care for Bipolar<br />
Disorder: Part II. Impact on Clinical<br />
Outcome, Function, <strong>and</strong> Costs.<br />
Psychiatric Services, July 2006; 57:937-<br />
945.<br />
• Brickman, Andrew L, LoPiccolo et al.<br />
Screening for bipolar disorder. Psychiatric<br />
Services, March 2002; 53/3(349): 1075-<br />
2730.<br />
• Corona, Rodrigo, Berlanga et al.<br />
Detection of bipolar disorder with a<br />
clinical screening questionnaire: The<br />
Spanish version of the Mood Disorder<br />
Questionnaire. Salud Mental, March<br />
2007; 30(2): 50-57.<br />
• Das Gupta R, Guest JF. Annual cost of<br />
bipolar disorder to UK society. British<br />
Journal of Psychiatry, 2002; 180: 227-33.<br />
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<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 15
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• de Dois, Consuelo, Ezquiaga et al.<br />
Usefulness of the Spanish version of the<br />
Mood Disorder Questionnaire for<br />
screening for bipolar disorder in routine<br />
clinical practice in outpatients with major<br />
depression. Clinical Practice <strong>and</strong><br />
Epidemiology in Mental Health, May<br />
2008; 4:1745-0179.<br />
• Field A. Discovering Statistics using<br />
SPSS, Sage Publications Limited, 2009.<br />
• Hirschfeld RM. The Mood Disorder<br />
Questionnaire: A simple, patient-rated<br />
screening instrument for bipolar<br />
disorder. Primary care companion to the<br />
Journal of Clinical Psychiatry, February<br />
2002; 4(1):9-11.<br />
• Hunter R, Fraser K, Martin M, Hudson<br />
S. Bipolar disorder – aetiology <strong>and</strong><br />
pathophysiology. Hospital Pharmacist,<br />
2004; 11: 129-32.<br />
• Kasper S. Issues in the treatment of<br />
bipolar disorder. European<br />
Neuropsychopharmacology, 2003;<br />
13(Suppl 2): S37-42.<br />
• Kessler RC, McGonagle KA, Zhao S et<br />
al. Lifetime <strong>and</strong> 12-month prevalence of<br />
DSM-III-R psychiatric disorders in the<br />
United States. Results from the National<br />
Comorbidity Survey. Archives of General<br />
Psychiatry, 1994; 51: 8-19.<br />
• Menzin J, Sussman M, Tafesse E et al. A<br />
model of the economic impact of a bipolar<br />
disorder screening program in primary<br />
care. Journal of Clinical Psychiatry,<br />
September 2009; 70(9):1230-6.<br />
• Perry A, Tarrier N, Morriss R et al.<br />
R<strong>and</strong>omized controlled trial of efficacy of<br />
teaching patients with bipolar disorder to<br />
recognized early symptoms of relapse <strong>and</strong><br />
obtain treatment. BMJ, 16 January<br />
1999;318:149-153.<br />
• Sachs GS. Unmet clinical needs in<br />
bipolar disorder. Journal of Clinical<br />
Psychopharmacology, 2003; 23: S2-8.<br />
• Simon S. An introduction to diagnostic<br />
tests. The Children’s Mercy Hospital<br />
2007.<br />
• Stang P, Frank C, Ulcickas Yood M, et<br />
al. Impact of bipolar disorder: Results<br />
from a screening study. Primary care<br />
companion to the Journal of clinical<br />
psychiatry, 2007; vol/is 9/1(142-47),<br />
1523-5998.<br />
• Twiss J, Jones S, Anderson I. Validation<br />
of the Mood Disorder Questionnaire for<br />
screening for bipolar disorder in a UK<br />
sample. Journal of affective disorders,<br />
September 2008; 110(1-2):180-4.<br />
• Wehr TA, Goodwin FK. Can<br />
antidepressants cause mania <strong>and</strong> worse<br />
the course of affective illness? American<br />
Journal of Psychiatry, 1987; 144: 1403-11.<br />
• Weissman MM, Leaf PJ, Tischler GL et<br />
al. Affective disorders in five United<br />
States communities. Psychol Med 1988;<br />
18: 147-53.<br />
• World Health Organization. The ICD-<br />
10 Classification of Mental <strong>and</strong><br />
Behavioural Disorders. Clinical<br />
Descriptions <strong>and</strong> Diagnostic Guidelines.<br />
Geneva: WHO, 1992.<br />
16 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Audit of risk assessment<br />
documentation in adult in-patients -<br />
adherence to <strong>Trust</strong> guidelines <strong>and</strong> how<br />
to improve performance in this area<br />
By Abigail Crutchlow<br />
Acknowledgements: Many thanks to Dr L Church for his help in finalising this document<br />
Background<br />
Current local policy for SABP <strong>NHS</strong><br />
<strong>Foundation</strong> <strong>Trust</strong> states that all adult<br />
patients admitted to an in-patient unit<br />
within the <strong>Trust</strong> should have a<br />
st<strong>and</strong>ardised risk assessment form<br />
completed on admission <strong>and</strong> this should<br />
be updated regularly at every ward round<br />
or if a significant change in risk occurs.<br />
The aim of this audit is to provide an<br />
overview of performance <strong>and</strong> whether<br />
these guidelines are being met <strong>and</strong>, if<br />
not, to implement methods to improve<br />
performance. Through re-audit, the<br />
benefit <strong>and</strong> impact of such interventions<br />
<strong>and</strong> their role in the future will also be<br />
assessed. Formal ethical approval was not<br />
required for this audit as all data were<br />
anonymous <strong>and</strong> patients were not<br />
directly approached or involved in the<br />
audit. The audit was registered <strong>and</strong><br />
approved by the <strong>Trust</strong> audit department.<br />
Method<br />
Initial audit<br />
The initial audit included all current adult<br />
in-patients on general adult wards at the<br />
Abraham Cowley Unit, Chertsey. The<br />
PICU unit was not included due to<br />
altered level of risk for these patients.<br />
Their notes were identified <strong>and</strong> their risk<br />
assessment on admission <strong>and</strong> its<br />
subsequent updates examined.<br />
The following questions were asked:<br />
1. Was a complete risk assessment<br />
recorded on admission?<br />
• This included a completed<br />
comprehensive risk assessment<br />
within 24h of admission<br />
2. Has the risk assessment been updated<br />
regularly /at each ward round?<br />
• Occasional or irregular updates<br />
were not considered satisfactory<br />
• If the patient had been an in-patient<br />
for a very short time <strong>and</strong> not yet<br />
been seen on a ward round<br />
(meaning regular updates may not<br />
yet have commenced) then this was<br />
noted <strong>and</strong> they were excluded from<br />
question 2<br />
3. Is the risk assessment accessible to<br />
staff?<br />
• Information needed to be clearly<br />
visible in the appropriate section of<br />
the notes<br />
It was recorded whether all, some or<br />
none of these three criteria were met for<br />
each set of notes reviewed. The length of<br />
stay, regularity with which the patient<br />
was seen on a consultant ward round<br />
<strong>and</strong> the team they were under were also<br />
recorded, as these were identified as<br />
possible factors that could influence the<br />
results.<br />
In order to meet the st<strong>and</strong>ard guidelines,<br />
all three criteria needed to be met. The<br />
data was then analysed <strong>and</strong> results<br />
identified as below.<br />
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Research <strong>and</strong> Audit<br />
Based on the results of the initial audit,<br />
strategies to improve performance were<br />
implemented. An e-mail was circulated to<br />
all consultants <strong>and</strong> junior doctors<br />
involved in risk assessment for adult inpatients<br />
highlighting the outcomes <strong>and</strong><br />
raising awareness of the need for<br />
adequate risk assessment. The three<br />
questions <strong>and</strong> the need to fulfill these<br />
were documented in the e-mail along<br />
with the intent to re-audit in 2 months’<br />
time. As the changeover for junior<br />
doctors occurred shortly after the audit,<br />
this e-mail was circulated to both those<br />
doctors completing their post <strong>and</strong> those<br />
taking over from them.<br />
Re-audit<br />
A re-audit was undertaken in May 2009.<br />
23 sets of notes were r<strong>and</strong>omly selected<br />
from all the in-patients currently on ACU<br />
(split equally across Blake <strong>and</strong> Clare<br />
wards). The 23 notes selected were then<br />
examined using the method <strong>and</strong> analysis<br />
outlined in the initial audit. Results were<br />
obtained for an overall view of the<br />
different criteria being assessed. There<br />
was no breakdown of results by<br />
consultant or regularity of ward round as<br />
this showed no impact in the initial audit.<br />
Results were analysed depending on<br />
length of stay, as this was identified as<br />
having an impact. These results were then<br />
compared with those of the initial audit to<br />
see if the heightened awareness had<br />
altered the recording of risk assessment<br />
Based on the results of the first re-audit<br />
<strong>and</strong> the possible areas of bias, further<br />
strategies to improve performance were<br />
implemented <strong>and</strong> second re-audit<br />
conducted in November 2009, which was<br />
towards the end of the post for the<br />
cohort of doctors included. The second<br />
re-audit followed the same method <strong>and</strong><br />
structure as the earlier re-audit in May<br />
2009. This ensured that there had been<br />
consistency in the doctors completing the<br />
documentation over the last four months<br />
<strong>and</strong> also a long enough time period to<br />
ensure no notes had been included in the<br />
previous audit cycle. Formal teaching on<br />
risk assessment was delivered to the new<br />
cohort doctors at the beginning of their<br />
post in psychiatry at the ACU, Chertsey.<br />
This included an explanation of the risk<br />
assessment form <strong>and</strong> its importance, <strong>and</strong><br />
was conducted by one of the in-patient<br />
consultants.<br />
Results<br />
Fig.1 Initial audit – distribution overall<br />
100<br />
90<br />
80<br />
70<br />
60<br />
% 50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Criteria<br />
Initial RA<br />
Initial complete RA<br />
Regular updates<br />
RA accessible to staff<br />
Meets st<strong>and</strong>ard guidelines<br />
18 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Fig. 2 Re-audit May 2009 – distribution overall<br />
100<br />
90<br />
80<br />
70<br />
Initial RA<br />
60<br />
% 50<br />
40<br />
30<br />
20<br />
Initial complete RA<br />
Regular updates<br />
RA accessible to staff<br />
Meets st<strong>and</strong>ard guidelines<br />
10<br />
0<br />
Criteria<br />
Fig. 3 Re-audit November 2009 – distribution overall<br />
100<br />
90<br />
80<br />
70<br />
Initial RA<br />
60<br />
% 50<br />
40<br />
30<br />
20<br />
Initial complete RA<br />
Regular updates<br />
RA accessible to staff<br />
Meets st<strong>and</strong>ard guidelines<br />
10<br />
0<br />
Criteria<br />
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Research <strong>and</strong> Audit<br />
Discussion<br />
When considering the results of the initial<br />
audit, the numbers in several categories<br />
are too small to be of value when<br />
analysing the data by the different factors<br />
felt to be possible influences on the<br />
results. Results should be interpreted with<br />
this in mind. There was no clear variation<br />
of results by consultant or regularity of<br />
ward round. There does however appear<br />
to be a link between increasing length of<br />
stay <strong>and</strong> decreasing fulfillment of criteria.<br />
This may be due to becoming less aware<br />
of a patient’s risk the longer they stay <strong>and</strong><br />
an assumption that the risk is stable <strong>and</strong><br />
therefore the update is not completed as<br />
frequently <strong>and</strong> is more likely to be<br />
forgotten. The achievement of the<br />
recommended targets actually<br />
deteriorated when re-audited. This was<br />
mainly due to a reduction in completed<br />
risk assessments on admission <strong>and</strong> also a<br />
smaller percentage of risk assessments<br />
were updated regularly. There was also<br />
less evidence on re-auditing that length<br />
of stay impacted on achievement of<br />
recommended targets.<br />
Heightened awareness by e mail appears<br />
to have been ineffective therefore in<br />
improving st<strong>and</strong>ards. However, various<br />
factors could have impacted upon this.<br />
As a large number of junior doctors<br />
changed between the two data collection<br />
points, this could have affected the<br />
results as new doctors were less likely to<br />
have experience <strong>and</strong> remember to<br />
complete risk assessment forms than<br />
those who had been doing the job a few<br />
months. Also some notes would have<br />
been included in the data collection on<br />
both occasions, <strong>and</strong> this may have also<br />
altered results. Notes which had not met<br />
st<strong>and</strong>ards initially were unlikely to meet<br />
st<strong>and</strong>ards in the re-audit, which would<br />
have led to a disproportionately larger<br />
amount of notes not meeting st<strong>and</strong>ards<br />
in the re-audit compared to the initial<br />
audit. It was therefore beneficial to<br />
repeat the audit at a later stage towards<br />
the end of one group of junior doctors’<br />
employment (i.e. November/December<br />
2009). This allowed a long enough time<br />
period to ensure that no notes audited in<br />
earlier cycles are audited for a second<br />
time, which was a source of bias in the<br />
initial re-audit. This also allowed for<br />
consistency in documentation completion<br />
<strong>and</strong> had the advantage of identifying if<br />
time spent working in psychiatry helped<br />
increase awareness <strong>and</strong> completion of<br />
risk assessments <strong>and</strong> gave a more<br />
accurate picture of the benefit of any<br />
interventions that were implemented.<br />
Formal teaching on risk assessment was<br />
recommended during induction or in an<br />
early teaching session for this cohort of<br />
doctors as this has not been included in<br />
previous years. An improvement in<br />
meeting the recommened guidelines was<br />
evident from the re-audit in all areas, <strong>and</strong><br />
length of stay appeared to have less<br />
impact than in the previous cycles.<br />
It appears from the second re-audit that<br />
structured interventions <strong>and</strong> formal<br />
teaching that heighten awareness of the<br />
importance of risk assessment <strong>and</strong> how<br />
to complete the relevant paperwork have<br />
led to improvements in meeting the<br />
recommended guidelines. With the<br />
introduction to the ACU of the new<br />
computer system, RIO, such interventions<br />
will become all the more important in<br />
order to ensure risk continues to be<br />
documented to the highest st<strong>and</strong>ard. The<br />
overall outcome of this audit suggests<br />
that formal face to face teaching along<br />
with time spent working in psychiatry<br />
<strong>and</strong> heightened awareness on the ward<br />
of risk documentation are all necessary to<br />
optimise meeting the guidelines <strong>and</strong> such<br />
interventions should be regularly<br />
employed by the <strong>Trust</strong> for doctors, both<br />
at induction <strong>and</strong> throughout their<br />
rotation.<br />
20 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
An evolving service – results of a 3<br />
year follow up study of the practice of<br />
a community mental health team<br />
incorporating the principles of “New<br />
Ways of Working”<br />
June 2010 By Jeremy Mudunkotuwe, Farida Yousaf<br />
Acknowledgements: Helena DuToit, Dipesh Naik<br />
Introduction<br />
In 2005 the National Steering Group<br />
published “New Ways of Working for<br />
Psychiatrists”1. This document outlined<br />
the way in which teams could change in<br />
order to facilitate the time spent by the<br />
psychiatrist with the team considering<br />
their training <strong>and</strong> skill set. The<br />
requirements for this change necessitated<br />
a major change in service at the<br />
community psychiatry level. The changes<br />
were principally to enhance patients care,<br />
but were also planning for a perceived<br />
lack of psychiatrists in the future, due to<br />
increased retirement <strong>and</strong> inadequate<br />
numbers of doctors in training. Services<br />
around the country made changes in-line<br />
with the National Service Framework, <strong>and</strong><br />
the authors sort a way to monitor the<br />
changes within our team with regards to<br />
psychiatrists’ practice.<br />
Aim<br />
To assess over time the nature of<br />
psychiatrists’ appointments in the Mole<br />
Valley Primary Care Mental Health Team<br />
with regard to the changes as outlined in<br />
the “New Ways of Working” document<br />
published in 2005.<br />
Method<br />
An audit tool listing 15 reasons for<br />
psychiatric doctor appointments has been<br />
adapted from an audit tool described in<br />
the NWW report of 2005 “The Bromley<br />
<strong>and</strong> Greenwich Medical Staff Outpatient<br />
Clinic Audit Tool”1(see table 1). Each year<br />
from 2005 to 2008, for a 2 month period<br />
the psychiatrists within the team were<br />
asked to complete the audit tool for each<br />
patient they saw, either in their<br />
outpatients’ clinic, home visit or any<br />
other planned or emergency<br />
appointment. After each 2 month data<br />
collection period the results were collated<br />
<strong>and</strong> in 2009 the results for the 3 periods<br />
of assessment were compared.<br />
Table 1: The audit tool<br />
Reasons for assessment<br />
• DNA<br />
• New Assessment<br />
• Carer / family education / support<br />
• Court report preparation<br />
• CPA, or planning for CPA<br />
• Crisis planning / resolution<br />
• Discharge appointment<br />
• Medication review / prescribing<br />
• Mental state exam / diagnostic<br />
assessment<br />
• Physical health care check<br />
• Reassurance & support<br />
• Risk assessment / monitoring<br />
• Reports / benefits<br />
• Session of therapy as part of on-going<br />
course of therapy<br />
• Support than only a consultant can<br />
give due to complexity<br />
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Research <strong>and</strong> Audit<br />
Results<br />
The results were entered into a database<br />
<strong>and</strong> simple comparisons were made<br />
between the results for each category<br />
over the 3 periods of data collection. The<br />
Chart 1 Comparison of results from 2005-2008<br />
50<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
DNA<br />
New<br />
Assessment<br />
Discharge<br />
appointment<br />
psychiatrists were allowed to select,<br />
none, one, or more than one of the<br />
fifteen categories for each case that they<br />
saw. Eight of the categories registered<br />
any results over the assessment periods.<br />
The results are shown in Chart 1 below.<br />
Medication<br />
review/prescribing<br />
Mental state<br />
examination/diagnosic<br />
assessment<br />
Reassurance<br />
<strong>and</strong> support<br />
Assessments 2005/2006<br />
Assessments 2007<br />
Assessments 2008<br />
Risk assessment/<br />
risk montoring<br />
Some notable trends were seen in the data collected over the 3 years.<br />
Crisis planning/<br />
crisis resolution<br />
The percentage of medication review <strong>and</strong> prescribing increased year on year, from<br />
27% in 2005/06, to 34% in 2007, <strong>and</strong> then to 46% in 2008.<br />
There was a marked increase in mental state examination <strong>and</strong> diagnostic<br />
appointments in the 2008 period (43%) compared to the years before, 18% in 2007<br />
<strong>and</strong> 20% in 2005/06.<br />
The percentage of appointments for reassurance <strong>and</strong> support remained at a similar<br />
level in each of the assessment periods.<br />
Risk assessment/monitoring appointments initially decreased in 2007 (1%) from<br />
the previous period but then markedly increased in the 2008 (14%) period.<br />
Discussion<br />
The authors felt that some really<br />
encouraging results were collected over<br />
the past 3 years indicating one aspect of<br />
the NWW movement that had greatly<br />
altered practice.<br />
We believe that the increase in the<br />
proportion of medication review <strong>and</strong><br />
prescribing is a result of the appointments<br />
with the psychiatrists utilising their skills<br />
appropriately. Team members have seemly<br />
felt more able to arrange for the patients<br />
they care coordinate to attend for this<br />
specific advice.<br />
Mental state examination <strong>and</strong> diagnostic<br />
should a substantial increase in the last<br />
period <strong>and</strong> again the authors believe that<br />
this is an appropriate use of time for the<br />
psychiatrist in the team <strong>and</strong> would<br />
benefit patient care. Also with increased<br />
need for coding <strong>and</strong> monitoring of<br />
service this allowed accurate accounting<br />
of illnesses treated within the team.<br />
Risk assessments have increased markedly<br />
increased in the past year <strong>and</strong> is perhaps<br />
a marker of the increased concern in the<br />
present climate about serious incidents<br />
related to mental health. This could be<br />
seen as a retrograde step towards doctors<br />
22 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
having clinical responsibility for all of the<br />
patients within the team, instead of this<br />
being devolved to the respective care<br />
coordinator. Further research could<br />
establish what happens with the<br />
information gathered at this time to<br />
establish whether risk information adds<br />
to the care coordinators management<br />
plan in an appropriate manner.<br />
Appointments offering reassurance <strong>and</strong><br />
support have remained at a low level<br />
throughout the assessment period this<br />
shows that despite changes to the service<br />
there is an appropriate level of this that<br />
should be offered by the psychiatrists.<br />
The authors believe that were this to be<br />
eliminated from their role then this would<br />
be to the detriment of patient care <strong>and</strong><br />
job satisfaction.<br />
A reduction in the DNA rate over the 3<br />
periods of assessment could be seen to<br />
be a sign that patients appreciate the<br />
change in the nature of appointments<br />
that has occurred over time. The authors<br />
recognise that this surrogate marker for<br />
patient satisfaction may not be a true<br />
reflection of patients’ views. Future audits<br />
of this nature within the team will include<br />
more direct measures of patient<br />
satisfaction.<br />
Changes within the team that have<br />
facilitated this evolution are sometimes<br />
hard to pinpoint. As the population<br />
covered by the team have not changed<br />
<strong>and</strong> neither has the demographics of the<br />
people living in the area so the change<br />
has been within the team. The authors<br />
believe that increased <strong>and</strong> more effective<br />
supervision of the MDT has been a major<br />
factor <strong>and</strong> resulted in requests for fewer<br />
outpatient appointments.<br />
Conclusion<br />
Debate in the psychiatric literature<br />
continues about how the NWW<br />
movement impacts upon the<br />
psychiatrists’ role, job satisfaction <strong>and</strong><br />
even recruitment 2,3,4,5 This literature has<br />
undoubtedly uncovered strong feelings<br />
that the majority feel that this process<br />
acts to the detriment of the psychiatrists’<br />
practice. The authors believe that the<br />
audit shows that an evolutionary change<br />
in the service need not be a tremendous<br />
upheaval if managed well, <strong>and</strong> could<br />
improve psychiatrists’ working practices.<br />
The authors recognise that the process of<br />
change can only be attempted if others in<br />
the team are willing to take on new<br />
responsibilities. We believe that more<br />
effective <strong>and</strong> regular supervision from<br />
medical staff to non medical staff in the<br />
team has facilitated this change within<br />
our team. We are aware that our audit<br />
does not take into respect their view<br />
points <strong>and</strong> further work will address this<br />
as well as more direct measures of<br />
patient satisfaction.<br />
References<br />
1. Department of Health; Final report<br />
from the National Steering Group. New<br />
ways of working for psychiatrists:<br />
Enhancing effective, person-centred<br />
services through new ways of working in<br />
multidisciplinary <strong>and</strong> multiagency<br />
contexts. Department of Health;<br />
31 October 2005 67.<br />
2. Craddock N, Antebi D, Attenburrow<br />
M-J, et al. Wake-up call for British<br />
psychiatry. The British Journal of<br />
Psychiatry 2008 July 1, 2008;193(1):6-9.<br />
3. Dale J, Milner G. New Ways not<br />
working? Psychiatrists' attitudes.<br />
Psychiatr Bull 2009 June 1,<br />
2009;33(6):204-7.<br />
4. St John-Smith P, McQueen D, Michael<br />
A, et al. The trouble with <strong>NHS</strong> psychiatry<br />
in Engl<strong>and</strong>. Psychiatr Bull 2009 June 1,<br />
2009;33(6):219-25.<br />
5. Vize C, Humphries S, Br<strong>and</strong>ling J, et al.<br />
New Ways of Working: time to get off<br />
the fence. Psychiatr Bull 2008 February 1,<br />
2008;32(2):44-5.<br />
Research <strong>and</strong> Audit<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 23
Commentary <strong>and</strong> Debate<br />
How can we look at improving<br />
recruitment into psychiatry?<br />
January 2009<br />
By Josie Jenkinson<br />
If recent figures are to be believed, fewer<br />
UK graduates are entering higher<br />
specialist training in psychiatry than ever<br />
before. Just 6% of c<strong>and</strong>idates sitting<br />
Paper 1 of the MRCPsych in diet one of<br />
2008 were UK graduates (Oxtoby, 2008),<br />
<strong>and</strong> this is likely to be a national indicator<br />
of recruitment trends (Brown et al, 2009).<br />
This has lead to widespread attention<br />
being focused on potential ways of<br />
improving recruitment into psychiatry,<br />
<strong>and</strong> the Royal College of Psychiatrists<br />
having taken specific steps to address the<br />
issue (Royal College of Psychiatrists,<br />
2009).<br />
The current recruitment crisis is by no<br />
means a new problem. In fact, concerns<br />
regarding poor recruitment into<br />
psychiatry have been discussed since the<br />
1970’s <strong>and</strong> there have been similar issues<br />
in other countries, most notably in the<br />
USA (Brockington, 2002). As a result,<br />
there has been a substantial amount<br />
written on the subject of recruitment into<br />
psychiatry. Much of the literature has<br />
been concerned with identifying the<br />
factors influencing the choice of<br />
psychiatry as a career as well as<br />
suggesting strategies that might be<br />
adopted to improve recruitment based on<br />
these factors. However, in the light of<br />
ongoing change within the <strong>NHS</strong> <strong>and</strong><br />
medical education, as well as a current<br />
climate of doubt <strong>and</strong> uncertainty as to<br />
the future role of the psychiatrist this is a<br />
very real <strong>and</strong> current issue facing the<br />
profession. Increasing reliance on<br />
international medical graduates to<br />
support <strong>and</strong> maintain delivery of<br />
psychiatric care increases the pressure to<br />
improve the current situation even<br />
further, given the possible impact of<br />
Home Office immigration policy changes<br />
(Brown et al, 2009).<br />
Any strategy aimed at improving<br />
recruitment into psychiatry would need<br />
to take into account the possible reasons<br />
why people choose psychiatry as a career,<br />
as well as what might deter them. This<br />
may be difficult as processes which<br />
influence doctors in their choice of career<br />
have been described as “subtle <strong>and</strong><br />
complex” (Eagles 2007), however I shall<br />
outline some of the possibilities below.<br />
Prior to entering medical school, many<br />
specialties including psychiatry are rated<br />
as a very attractive option (Maidment et<br />
al, 2003). However, this attitude is not<br />
maintained throughout the years of<br />
undergraduate training, with medical<br />
students tending to develop more<br />
negative attitudes about the specialty<br />
(Brockington, 2002). This may in part be<br />
due to the negative attitudes towards the<br />
profession from non-psychiatrists <strong>and</strong><br />
even psychiatrists themselves, for<br />
example describing psychiatrists as ‘not<br />
proper doctors’ (Craddock, 2008 p70).<br />
This is confounded by the sadly ever<br />
present stigma surrounding those with<br />
mental health problems <strong>and</strong> those who<br />
treat them, which medical students are<br />
exposed to both inside <strong>and</strong> outside of<br />
their training (Brockington, 2002). Four<br />
broad categories of negative opinions<br />
surrounding psychiatry as a specialty have<br />
been identified amongst medical<br />
students. These are related to the<br />
assumption that psychiatry lacks<br />
objectivity <strong>and</strong> is unscientific, that<br />
treatments are ineffective, that<br />
psychiatrists are ‘emotionally unstable’<br />
<strong>and</strong> ‘second rate’ doctors, <strong>and</strong> a dislike of<br />
the patient population treated by<br />
psychiatrists (Scott, 1986 p99).<br />
However, undergraduate exposure to<br />
psychiatry seems to be particularly<br />
important as a potentially positive<br />
influence, with consultants in psychiatry<br />
citing a lasting influence of medical<br />
24 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
school exposure to psychiatry as an<br />
influence on their ultimate choice of<br />
specialty, even if their career choice was<br />
made after leaving medical school (Dein<br />
et al, 2007). Several studies have found<br />
that intentions of students to pursue<br />
psychiatry as a career were increased<br />
following exposure to a psychiatric<br />
attachment during their years at medical<br />
school. Specific factors are likely to be<br />
associated with a greater intention to<br />
pursue psychiatry as a career following a<br />
psychiatric attachment; namely receiving<br />
encouragement from consultants, seeing<br />
patients respond to treatment <strong>and</strong> having<br />
direct involvement in patient care<br />
(McParl<strong>and</strong>, 2003).<br />
Positive elements of career in psychiatry<br />
which have been identified as appealing<br />
to prospective trainees are empathy for<br />
patients with a mental disorder, better<br />
working conditions, <strong>and</strong> the interface of<br />
psychiatry with neuroscience <strong>and</strong> the<br />
social sciences (Dein et al, 2007). Other<br />
factors identified as being important<br />
when choosing psychiatry as a specialty<br />
are enthusiasm <strong>and</strong> commitment for the<br />
specialty, <strong>and</strong> self appraisal of one’s own<br />
skills <strong>and</strong> aptitudes (Goldacre, 2005).<br />
In the light of the above, it would seem<br />
that focusing on the undergraduate<br />
experience of psychiatry as a target for<br />
increasing recruitment is paramount.<br />
Historically, this has been the reaction to<br />
the recruitment problem, <strong>and</strong> as a result<br />
pre-clinical teaching in psychology, social<br />
science <strong>and</strong> behavioural science now has<br />
a much greater emphasis. Inclusion of a<br />
psychiatry placement is now universal,<br />
however unfortunately it would seem<br />
that in recent years with the ever<br />
exp<strong>and</strong>ing dem<strong>and</strong>s placed on the<br />
curriculum, placements have decreased in<br />
length (Brown et al 2009). As such it is<br />
increasingly important that the best use is<br />
made of these placements, with students<br />
being actively involved in clinical care,<br />
being taught enthusiastically with an<br />
emphasis on evidence based medicine<br />
<strong>and</strong> patient recovery. Psychiatric trainees<br />
may be ideally placed to provide<br />
additional teaching <strong>and</strong> support to<br />
medical students, <strong>and</strong> should be<br />
encouraged to do so by their supervising<br />
consultants. Liaison psychiatry<br />
placements have been identified as being<br />
of particular appeal to medical students<br />
<strong>and</strong> may have special value in aiding<br />
recruitment in the future (Brockington,<br />
2002). Medical students who show an<br />
interest in pursuing psychiatry as a career<br />
should be encouraged <strong>and</strong> given ongoing<br />
support <strong>and</strong> careers advice (Eagles et al,<br />
2007).<br />
Another potential target for recruitment<br />
are those who have not yet entered<br />
medical school. It has been found that<br />
the type of person likely to pursue<br />
psychiatry as a career tends to have an<br />
interest in more psychological,<br />
sociological <strong>and</strong> artistic subjects, with<br />
many tending to have one A-level in a<br />
non-science subject (Brockington, 2002).<br />
They are also more likely to be from a<br />
lower social class, come from cities <strong>and</strong><br />
be politically liberal (Eagle <strong>and</strong> Marcos,<br />
1980). It may be that development of<br />
widening participation schemes <strong>and</strong><br />
graduate entry programmes may result in<br />
a greater number of students with these<br />
interests <strong>and</strong> attributes entering medical<br />
school <strong>and</strong> hence moving into psychiatry,<br />
although the effect of these<br />
developments has yet to be evaluated.<br />
Greater public awareness of mental<br />
health issues <strong>and</strong> the ongoing challenge<br />
of tackling stigma, possibly by<br />
improvement in public education <strong>and</strong><br />
covering of mental health issues as part<br />
of the primary <strong>and</strong> secondary school<br />
curriculum may in time raise the profile of<br />
psychiatry <strong>and</strong> lead to greater<br />
underst<strong>and</strong>ing <strong>and</strong> appeal of the<br />
specialty, however this is unlikely to yield<br />
results in the short term.<br />
Several surveys have identified that the<br />
majority of people choose psychiatry as a<br />
career after graduation rather than<br />
during the undergraduate years<br />
(Brockington, 2002). With this in mind,<br />
increasing positive exposure to psychiatry<br />
during the foundation years may well<br />
have a positive effect on recruitment. By<br />
the end of their first year of work post<br />
Commentary <strong>and</strong> Debate<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 25
Commentary <strong>and</strong> Debate<br />
qualification, doctors surveyed reported<br />
work experience as being a more<br />
important determinant of career choice<br />
when choosing psychiatry than with<br />
other specialties (Goldacre 2005). This<br />
would indicate that foundation posts in<br />
psychiatry may have a positive effect on<br />
recruitment, <strong>and</strong> this has been borne out<br />
to some extent (Boyle et al, 2009). Even<br />
where a doctor is unable to work in a<br />
foundation post, tasters in psychiatry can<br />
be organized as part of the foundation<br />
programme in order to give the<br />
foundation some additional experience<br />
of psychiatry.<br />
Unfortunately, doctors’ experiences of<br />
psychiatry if they are not doing a<br />
foundation post may be limited to<br />
occasional acute presentations, which if<br />
they do not have access to a psychiatric<br />
liaison service may be very difficult <strong>and</strong><br />
frustrating to manage. Liaison psychiatry<br />
services, where they exist, may present<br />
valuable opportunities for psychiatrists to<br />
demonstrate the relevance of the specialty<br />
across all branches of medicine, to portray<br />
a positive image of psychiatry to our nonpsychiatric<br />
colleagues as well as to<br />
educate <strong>and</strong> motivate those doctors who<br />
are as yet undecided in their career choice<br />
towards considering psychiatry as a career.<br />
In summary, the major possible targets for<br />
recruitment into psychiatry would appear<br />
to be improving undergraduate experience<br />
in a variety of ways, maximising positive<br />
exposure to psychiatry during the<br />
foundation years, <strong>and</strong> supporting those<br />
who show an interest in psychiatry early<br />
on. Ideally any strategy should be coupled<br />
with an overarching aim to increase the<br />
profile <strong>and</strong> awareness of the importance<br />
<strong>and</strong> validity of psychiatry as a profession<br />
amongst the lay population as well as the<br />
medical community.<br />
So what has been done to address the<br />
problem? The Royal College of<br />
Psychiatrists has taken urgent steps by<br />
means of a Scoping Group on<br />
Undergraduate Education in Psychiatry,<br />
which has helped to develop a core<br />
curriculum for undergraduate psychiatry.<br />
Work is also being done with the<br />
Academic Faculty <strong>and</strong> the Association of<br />
University Teachers of Psychiatry to address<br />
issues within the undergraduate<br />
experience that adversely affect the image<br />
of psychiatry (Brown et al, 2009).<br />
The Royal College has also prioritised a<br />
process of engaging more closely with<br />
medical students. A student associate<br />
grade has been introduced, whereby<br />
interested students can sign up to the<br />
Royal College for free <strong>and</strong> gain access to<br />
various resources, such as electronic<br />
versions of the Royal College’s<br />
publications, a dedicated section of the<br />
Royal College website, reduced prices for<br />
college events <strong>and</strong> a variety of other<br />
benefits. An annual summer school has<br />
been organised in collaboration with the<br />
Institute of Psychiatry <strong>and</strong> South London<br />
<strong>and</strong> the Maudsley <strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong>.<br />
A lot of this work has been done with the<br />
help of the Psychiatric Trainees<br />
Committee, who have also embarked on a<br />
project of developing student psychiatry<br />
societies in each medical school across the<br />
UK. These societies, with the support of<br />
local consultants, academic departments<br />
<strong>and</strong> trainees, aim to foster interest <strong>and</strong><br />
raise the profile of psychiatry within<br />
medical schools by means of talks, careers<br />
events <strong>and</strong> educational meetings (Royal<br />
College of Psychiatrists, 2008).<br />
There is an additional aim to exp<strong>and</strong> the<br />
numbers of foundation posts available<br />
within psychiatry, however this will require<br />
extensive negotiation <strong>and</strong> planning with<br />
the <strong>Foundation</strong> Schools <strong>and</strong> is an ongoing<br />
project. The Psychiatric Trainees<br />
Committee is also developing an e-<br />
learning project to enable foundation<br />
doctors to develop psychiatry<br />
competencies, which will be mapped to<br />
the new foundation curriculum, <strong>and</strong> with<br />
an emphasis on the overlap of psychiatric<br />
problems <strong>and</strong> physical health problems.<br />
This project endeavours to increase the<br />
resources available for foundation doctors<br />
to further their underst<strong>and</strong>ing of the<br />
relevance of psychiatry to the medical<br />
profession as a whole.<br />
26 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
The measures outlined above will<br />
hopefully go some way to addressing the<br />
current issues surrounding recruitment<br />
into psychiatry, however it seems clear<br />
these measures will require the support<br />
of the profession as a whole. Portraying a<br />
positive image of psychiatry, by means of<br />
emphasis on academia, use of evidence<br />
based treatments, enthusiastic <strong>and</strong> active<br />
involvement in teaching of medical<br />
students <strong>and</strong> foundation doctors requires<br />
the help of all psychiatrists (of any grade)<br />
who may encounter them. Medical<br />
students <strong>and</strong> foundation doctors are our<br />
potential colleagues of the future, <strong>and</strong><br />
we owe it to our patients to try to recruit<br />
the very best.<br />
References<br />
Boyle A.M. et al (2009) ‘Recruitment<br />
from <strong>Foundation</strong> year 2 posts into<br />
specialty training: a potential success<br />
story?’ Psychiatric Bulletin 33: 306-308<br />
Brockington I., Mumford D. (2002)<br />
‘Recruitment into Psychiatry’ Br J<br />
Psychiatry 180: 307-12<br />
Brown N., Vassilas C. A., Oakley, C.<br />
(2009) ‘Recruiting Psychiatrists – A<br />
Sisyphean task?’ Psychiatric Bulletin 33:<br />
390 - 392<br />
Craddock N. et al (2008) ‘Wake-up call<br />
for British Psychiatry’ Br J Psychiatry 193:<br />
6-9<br />
Eagles J. M., Wilson S., Murdoch J. M.,<br />
Brown T. (2007) ‘What impact do<br />
undergraduate experiences have upon<br />
recruitment into psychiatry?’ Psychiatric<br />
Bulletin 31: 70-2<br />
Maidment R., Livingston G., Katona M.,<br />
et al (2004) ‘Changes in attitudes to<br />
psychiatry <strong>and</strong> intention to pursue<br />
psychiatry as a career in newly qualified<br />
doctors: a follow up of two cohorts of<br />
medical students’ Medical Teacher 26:<br />
565 - 569<br />
McParl<strong>and</strong> M., Noble L. M., Livingston G.,<br />
&McManus, C. (2003) ‘The effect of a<br />
psychiatric attachment on students’<br />
attitudes to <strong>and</strong> intention to pursue<br />
psychiatry as a career’ Medical Education<br />
37 (5): 447-454<br />
Oxtoby K. (2008) ‘Psychiatry in Crisis’<br />
British Medical Journal classified<br />
supplement 27/8<br />
Royal College of Psychiatrists (2008)<br />
Tackling psychiatry’s recruitment crisis<br />
head on RCPSych News 2010 Jan<br />
(http//www.rcpsych.ac.uk/member/rcpsyc<br />
hnews/november2008)<br />
Royal College of Psychiatrists (2009)<br />
Dean’s newsletter Royal College of<br />
Psychiatrists website 2010 Jan<br />
(http://www.rcpsych.ac.uk/specialtytrainin<br />
g.aspx)<br />
Scott, J. (1986) ‘What puts medical<br />
students off psychiatry?’ Bulletin of the<br />
Royal College of Psychiatrists 10<br />
Commentary <strong>and</strong> Debate<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 27
Book Reviews<br />
Psychiatry P.R.N.<br />
Principles, Reality, Next steps<br />
June 2010<br />
By Jose Jenkinson<br />
Edited by Sarah Stringer, Laurence<br />
Church, Susan Davison, Maurice<br />
Lipsedge<br />
Publisher Oxford University Press<br />
ISBN 978-0-19-956198-8<br />
Price £24.99<br />
Psychiatry PRN is a new textbook<br />
primarily aimed at medical students,<br />
which introduces the specialty in a very<br />
practical <strong>and</strong> unique way. It offers a<br />
different approach to the majority of<br />
psychiatry texts by means of focussing on<br />
the key aspects of psychiatry from a<br />
clinical point of view rather than a purely<br />
academic one, whilst covering most of<br />
the subject matter needed by<br />
undergraduates to get the most out of<br />
their placements <strong>and</strong> to equip them for<br />
the OSCEs.<br />
Part one of the book gives an overview of<br />
psychiatry, including classification,<br />
interviewing skills, safety, mental health<br />
law <strong>and</strong> the basics of assessment. Part<br />
two consists of 20 chapters which cover<br />
the major areas of psychiatry including<br />
mood disorders, schizophrenia,<br />
personality disorder, addictions <strong>and</strong> old<br />
age psychiatry. Topics are covered in 3<br />
stages, as per the title. Each chapter<br />
starts with outlining the ‘principles’ of the<br />
subject in question, followed by taking<br />
the reader through the ‘reality’ of how<br />
such patients present, by means of case<br />
histories, <strong>and</strong> practice OSCE stations.<br />
‘Next steps’ then focuses on<br />
management <strong>and</strong> specific issues relevant<br />
to the subject, eg capacity issues in<br />
relation to dementia. This pattern is<br />
followed throughout the chapters <strong>and</strong><br />
the format makes it a very easy book to<br />
dip in <strong>and</strong> out of as the need arises.<br />
The book is beautifully illustrated, with<br />
many of the pictures serving as an aide<br />
memoire for major conditions. Use of film<br />
<strong>and</strong> book quotes to illustrate topics <strong>and</strong><br />
lists of books <strong>and</strong> films alongside books<br />
<strong>and</strong> papers for further reading bring the<br />
subject alive <strong>and</strong> further increase the<br />
accessibility <strong>and</strong> subjective relevance of<br />
psychiatry in the eyes of the reader.<br />
Additional online resources are also<br />
included, with video clips of assessments,<br />
downloadable OSCE mark sheets, an<br />
MMSE outline as well as all the artwork<br />
in the book which can be downloaded<br />
for use in teaching sessions.<br />
Overall: This book is very much focussed<br />
on practical ins <strong>and</strong> outs of assessing<br />
psychiatric patients, <strong>and</strong> the importance<br />
of communication <strong>and</strong> empathy, rather<br />
than purely focussing on diagnostic<br />
categorisation, psychotropics <strong>and</strong> exam<br />
questions. As a result this is an extremely<br />
useful aide for students, <strong>and</strong> very<br />
different from other undergraduate<br />
textbooks available. Read in conjunction<br />
with one of the other weightier texts this<br />
should provide students with sound<br />
knowledge <strong>and</strong> practical ability, as well as<br />
being useful for any doctor starting their<br />
first psychiatry post or wanting to refresh<br />
their basic knowledge of the subject. It<br />
will also be highly relevant for anyone<br />
who teaches medical students as a basis<br />
for structuring teaching sessions, running<br />
practice osces <strong>and</strong> providing useful<br />
h<strong>and</strong>outs. It is fairly lightweight (<strong>and</strong> very<br />
portable) <strong>and</strong> offers good value for<br />
money given the amount of materials<br />
included in the price.<br />
Highly recommended<br />
28 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Interview with Fiona Edwards, Chief<br />
Executive SABP <strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
June 2010 By Abigail Crutchlow (supervised by Raja Mukherjee)<br />
Fiona Edwards is the Chief Executive of<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong> <strong>NHS</strong><br />
<strong>Foundation</strong> <strong>Trust</strong> <strong>and</strong> I met with her<br />
recently to interview her about some of<br />
the current issues <strong>and</strong> her views <strong>and</strong><br />
opinions on her role <strong>and</strong> how the <strong>Trust</strong><br />
can progress:<br />
Q. Many people working in the <strong>Trust</strong><br />
may not know that much about you.<br />
Can you tell me a bit about your<br />
background <strong>and</strong> interests?<br />
“My background is human resources<br />
professional, originally in industry, before<br />
working for the <strong>NHS</strong>. I achieved seniority<br />
fairly early on in my career, <strong>and</strong> initially I<br />
was very focussed on that, <strong>and</strong> then<br />
thought “what’s next? What does my<br />
career look like?” I was interested in<br />
exposure to an industry that I thought<br />
would be more people based. I became<br />
HR director in a Community Mental<br />
Health <strong>and</strong> Learning Disability <strong>Trust</strong> in<br />
Berkshire <strong>and</strong> after about six years<br />
became very focused in wanting to move<br />
into general management <strong>and</strong> a Chief<br />
Executive role, largely because I felt my<br />
professional background <strong>and</strong> the nature<br />
of the services <strong>and</strong> the work would match<br />
well in terms of what I consider needed to<br />
be sorted in the Health Service, which is<br />
people management. In my spare time I<br />
do a lot of running; physical exercise is<br />
important to me, it is my personal <strong>and</strong><br />
switching off time. I am competing in the<br />
London ASICS 10k race”.<br />
Q. We have now been a <strong>Foundation</strong><br />
<strong>Trust</strong> for about two years. What do<br />
you feel has gone well so far?<br />
“I am pleased to have achieved<br />
foundation trust status in a struggling<br />
health <strong>and</strong> social care economy. <strong>Surrey</strong><br />
has never had a good reputation from a<br />
financial management point of view, <strong>and</strong><br />
given that one of the main issues for a<br />
foundation trust is competence in<br />
running the organisation <strong>and</strong> being<br />
focussed, that has been a big<br />
achievement. Key factors in this include a<br />
strong executive <strong>and</strong> board team working<br />
ethos. We have invested a lot of time at a<br />
senior level concentrating on how we<br />
work as a multidisciplinary team. The<br />
other bit is optimism - rather than<br />
spending all our time focussing on what<br />
is going wrong <strong>and</strong> what is worrying us.<br />
One example would be when we were<br />
thrown by a negative visit by the Health<br />
Commission where it did expose some<br />
genuine criticisms. You could then go<br />
into immediate disaster scenario,<br />
thinking: “Is this what all our Services are<br />
like?” which is what we did. But what we<br />
then did, to get ourselves into a positive<br />
frame of mind, was to then systematically<br />
look at all the issues, but also why we, as<br />
a board <strong>and</strong> executive team, were not on<br />
the alert to this. It meant we had a much<br />
more comprehensive view of things,<br />
which some people might think is quite<br />
bureaucratic <strong>and</strong> audit based, but has<br />
helped me <strong>and</strong> the board to really focus<br />
on the importance of local team<br />
leadership”.<br />
Q. What are your visions for the<br />
future <strong>and</strong> can you outline any<br />
particular challenges faced,<br />
particularly running a geographically<br />
large <strong>Trust</strong>?<br />
“Over the last year we have put a huge<br />
amount of effort into our Staff Survey,<br />
getting a high level of response, <strong>and</strong><br />
involving all of our staff. This is to<br />
demonstrate to staff that we really want<br />
to underst<strong>and</strong> where they are at, <strong>and</strong><br />
through managing that process via local<br />
managers <strong>and</strong> leaders it will help me to<br />
underst<strong>and</strong> <strong>and</strong> manage individuals<br />
better as well as the organisation. With<br />
Interview<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 29
Interview<br />
regard to challenges I don’t see the<br />
geography as such a problem as the<br />
clinicians on the ground, because I have<br />
worked in a multinational organisation<br />
with places in different countries <strong>and</strong><br />
actually this <strong>Trust</strong> is not that big in the<br />
terms of geographical spread, although<br />
admittedly it is not like a hospital in that<br />
we are not all on one site. For the<br />
clinicians on the ground I think it is about<br />
really working at our IT infrastructure<br />
better <strong>and</strong> realising that we do not all<br />
have to be in one place. If you can get<br />
the IT infrastructure connected then the<br />
organisation will feel more connected in<br />
a different way, rather than in the<br />
traditional way of all being in one<br />
hospital. The IT strategy includes a<br />
Blackberry pilot which is now beginning<br />
to take off <strong>and</strong> one very basic, simple<br />
thing that M<strong>and</strong>y Stevens, Director of<br />
Quality Performance, has (she comes<br />
from the Priory, which has sites across the<br />
country) is doing telephone<br />
conferencing”.<br />
Q. I suppose the other issue is having<br />
sufficient funding <strong>and</strong> resources there<br />
for rolling out the Blackberries, <strong>and</strong><br />
other more financially draining<br />
aspects of communications?<br />
“They are actually reasonably easy to<br />
deliver; we just need to make sure we are<br />
managing it at a decent pace, because<br />
we do have a lot of people (not least<br />
myself) who are not over confident with<br />
technology!”<br />
Q. That leads on to discussing money<br />
<strong>and</strong> other opportunities. If money<br />
was no object, as a hypothetical<br />
question, what other services would<br />
you like to bring in?<br />
“Well I would object to that question<br />
because that is not the real world. I think<br />
as an organisation we have to help<br />
people underst<strong>and</strong> that limited resources<br />
<strong>and</strong> service development go h<strong>and</strong> in<br />
h<strong>and</strong>. My particular interest is around<br />
having a much greater focus on<br />
wellbeing. I am very interested in the<br />
nature of the <strong>Surrey</strong> population <strong>and</strong> why<br />
<strong>Surrey</strong> has such a high usage of general<br />
hospitals acute care, when it is technically<br />
supposed to be one of the healthiest,<br />
wealthiest counties in the nation. I think<br />
we have some fantastic opportunities as<br />
a Mental Health <strong>and</strong> Learning Disability<br />
<strong>Trust</strong> to move away from looking at<br />
individual specialties <strong>and</strong> to try to use the<br />
expertise we have in our clinicians to start<br />
answering those questions for a bigger<br />
population. I think that getting people to<br />
underst<strong>and</strong> <strong>and</strong> think of the connection<br />
between mental <strong>and</strong> physical health, in<br />
the way Services are commissioned, is a<br />
real challenge”.<br />
Q. There have been some difficult<br />
decisions recently that have had to be<br />
made across the <strong>Trust</strong> regarding bed<br />
closures <strong>and</strong> reconfiguration. Do you<br />
think there are any particular lessons<br />
that came out of that?<br />
“I think one of the lessons is that there<br />
has been no reduction in the number of<br />
people that are being seen <strong>and</strong> the<br />
reason we have been able to close beds is<br />
because the system in the community is<br />
up <strong>and</strong> running well. Admittedly there<br />
has been some discontent around it, but<br />
not as much as there may have been<br />
elsewhere. The readiness of people to<br />
work with it <strong>and</strong> try it out is a<br />
phenomenal testimony to the sound<br />
clinical practice <strong>and</strong> teamwork in those<br />
systems. The best way to manage such<br />
issues is to have a strong multidisciplinary<br />
team locally, with strong confident<br />
clinicians, who are able to work<br />
collaboratively. My job is to make sure we<br />
have the right people in the senior<br />
leadership positions <strong>and</strong> the competence,<br />
confidence <strong>and</strong> climate so that people<br />
have the challenge <strong>and</strong> discussion before,<br />
rather than after, the event”.<br />
30 <strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal
Q. Very topical to that is the<br />
appointment of a new Medical<br />
Director of the <strong>Trust</strong>. How do you<br />
view the role of medical director? I<br />
underst<strong>and</strong> that there has been some<br />
discussion of the role changing in<br />
some respects. How do you envisage<br />
that role <strong>and</strong> how will you ensure you<br />
seek out <strong>and</strong> engage the right<br />
person?<br />
“I view the Medical Director as being the<br />
clinical leader of the organisation. What I<br />
really want to see is someone who brings<br />
a vision for the clinical tasks of the <strong>Trust</strong><br />
overall <strong>and</strong> pulling the whole thing<br />
together. This is someone who can talk to<br />
all clinicians, not just doctors, who can<br />
underst<strong>and</strong> where everyone is at <strong>and</strong><br />
someone who is excited by the thought<br />
of taking the leadership, rather than<br />
doing it out of evil necessity”.<br />
Q. How do view the role of medics<br />
<strong>and</strong> clinicians within the <strong>Trust</strong>? How<br />
do you feel they should be working<br />
with management to get a<br />
collaborative approach?<br />
“I think they should be part of the<br />
management team, not see themselves<br />
as separate from it. They should be<br />
confident leaders. I would like to see a<br />
little bit more pressure from the clinicians<br />
in the organisation, a bit more testing<br />
<strong>and</strong> more questioning <strong>and</strong> confidence in<br />
admitting what they don’t know, <strong>and</strong><br />
what they need in help in underst<strong>and</strong>ing<br />
about how a foundation trust <strong>and</strong> the<br />
finances work. I do see some really good<br />
examples where clinicians are very clear<br />
on their ambition for theirs services, for<br />
example a liaison service in one part of<br />
the <strong>Trust</strong> got up <strong>and</strong> running from the<br />
vision of the medical lead”.<br />
Q. Do you have any final comments<br />
that you would like to make?<br />
“The other area that I am really interested<br />
in for this organisation, going back to<br />
your question about what I get excited<br />
about, is research <strong>and</strong> education. I think<br />
we have more opportunities emerging in<br />
the sense of research for patient benefit.<br />
It is something we could build our<br />
reputation around in partnership with the<br />
service user community <strong>and</strong> also with the<br />
universities”.<br />
Q. That was one of the areas that the<br />
Care Quality Commission mentioned<br />
as lacking on their recent visit to the<br />
<strong>Trust</strong> so it is an important area. So<br />
again that is something quite<br />
important.<br />
“I wasn’t aware of that specific issue so<br />
much, but it doesn’t surprise me. What<br />
we are doing with the role of the Medical<br />
Director <strong>and</strong> the fact that we want to<br />
elevate the research <strong>and</strong> development<br />
directorate function, to have it more<br />
closely overseen by the Board, dovetails<br />
with seeking to address that concern. I<br />
am very clear as Chief Executive that we<br />
need to get it right, for the kind of<br />
organisation we are, but also pay much<br />
more strategic attention to it”.<br />
Interview<br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> Online Journal www.sabp.nhs.uk/journal 31
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong><br />
<strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
<strong>Surrey</strong> <strong>and</strong> <strong>Borders</strong> <strong>Partnership</strong> <strong>NHS</strong> <strong>Foundation</strong> <strong>Trust</strong><br />
<strong>Trust</strong> Headquarters, 18 Mole Business Park<br />
Leatherhead, <strong>Surrey</strong> KT22 7AD<br />
Tel: 01883 383838 www.sabp.nhs.uk