The Doctor – issue 5, January 2019

The magazine for BMA members

thedoctor

Issue 5 | January 2019

Homelessness – the victims, the politics that fuel it, and those working to tackle the human cost.

The Doctor investigates a needless epidemic

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thedoctor

The Doctor BMA House Tavistock Square London WC1H 9JP Tel: (020) 7387 4499

Email thedoctor@bma.org.uk

Editor Neil Hallows (020) 7383 6321

Call a BMA adviser

Chief sub-editor Chris Patterson

0300 123 1233 @TheDrMagazine @theBMA The Doctor is published by the British Medical Association. The views expressed in it are not necessarily those of the BMA. It is available on subscription at £160 (UK) or £225 (non-UK) a year from the subscriptions department. All rights reserved. Except as permitted under current legislation, no part of this work may be photocopied, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical or otherwise without the written permission of the editor. Printed by YM Chantry. A copy may be obtained from the publishers on written request.

The Doctor is a supplement of BMJ vol: 364 no: 8183

Senior staff writers Peter Blackburn (020) 7874 7398 Keith Cooper (020) 7383 6390 Staff writer Tim Tonkin (020) 7383 6753 Northern Ireland news email news@bma.org.uk Scotland correspondent Jennifer Trueland 07775 803 795 Wales correspondent Richard Gurner 07786 035 874 Senior production editor Lisa Bott-Hansson Designer Andy Bainbridge

ISSN 2631-6412

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In this issue 4-5

Briefing Why the health service needs to address the basics before meeting ambitious new targets, and doctors’ frustration with the pay review body

Welcome Chaand Nagpaul, BMA council chair Happy New Year and welcome to the latest issue of The Doctor.

Doctors are medical specialists but in truth we are much more than just a profession. In our daily lives we see all parts of society – we are a helping hand to the frail, an advocate for the vulnerable and a comfort to the lonely. We are clinical care but we are also compassion. In a society that can often seem cold and complacent I feel it is important we remember these values.

As I write, temperatures are plummeting and winter night shelters for the homeless are being opened across the country.

In a society as rich as ours it is unthinkable that some should be left with so little. This is a moral tragedy and a financial one.

As The Doctor’s latest investigation reveals, the use of the health service by homeless patients has rocketed in recent years – as numbers of people living, and dying, on the streets have increased. This problem is a direct result of decisions made by successive governments and is having a serious effect on our already-stretched NHS. The recently launched NHS England long-term plan has highlighted the problem, recognising that people affected by homelessness die, on average, around 30 years earlier than the general population.

Politicians are failing the public and our health service. It is time the country’s leaders took action – and I am delighted our voice can play a part in shaping the national debate through this work.

This issue of The Doctor features a fascinating piece on the efforts of a hospital trust to reduce the number of visits by frequent attenders. Emergency-care colleagues across the country will be familiar with this problem – and it is one that rings true to those of us working in general practice, too.

This feature raises many familiar issues – the fragmentation of public services, poor IT systems and frontline staff trying to improve services in a system bursting at the seams.

Thank you for reading and all the best for 2019.

6-13

Streets of shame Our investigation finds a huge increase in homeless people accessing NHS services

14-17

I’ve been expecting you Asking why some patients attend emergency care frequently can save resources and yield valuable insights

18-21 I’m not OK

An impassioned plea for doctors to seek out the help they need

22-23

Dig a little deeper A leading psychoanalyst and his steps for achieving better outcomes for patients with personality disorders

24-25

Beyond parity of esteem A new Mental Health Act could tackle gross disparities in outcomes and give patients more say in their treatment, but proper resourcing is vital

26-30

Life experience Chaperones, gun crime, well-informed relatives and BMA member wins

31

What’s on Keep on top of events

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briefing

TAVABIE: Juniors, debate with your peers

Current issues facing doctors

A chance to break down barriers Back in the days before the internet killed off much of their advertising revenue, there were two magazines produced by the same commercial publisher. Their shtick – without wishing to be horribly unfair to them – was that the one aimed at GPs often blamed hospitals for many of their woes, while the one for hospital doctors pointed the finger at GPs. Inflaming professional rivalries between doctors, much like filling the tabloids with the indiscretions of soap stars, may well be good business but simply playing off one part of the profession against the other – as opposed to exploring the genuine tensions that exist between them – tends to generate more heat than light.

One way in which doctors can counter this is by finding ways to come together but that’s easier said than done. Time pressures, and the artificial barriers set up by the internal market in England, mean that anecdotally there is less direct contact between primary and secondary care.

This is one reason why the BMA junior members forum is a bit special – it’s in the minority of conferences which aren’t confined to one particular branch of practice or specialty. Instead, it’s open to any doctor within 11 years of full, or 12 years of provisional, registration. A number of places are reserved for medical students, too – and applications from grassroots doctors are prioritised. It is usually one of the BMA’s most over-subscribed conferences.

This year’s event, in Brighton later this month, includes eminent speakers on mental health, workshops on topics such as Brexit and bullying and harassment, and a day of wide-ranging debates. At past JMFs, subjects debated have gone on to the BMA’s main policy-making forum, the annual representative meeting, and then to form policies on which the association has campaigned.

It’s also a chance – as Brighton palliative care registrar and this year’s JMF chair Simon Tavabie says – for the association to involve doctors ‘not yet engaged with the BMA, helping them to find a place, and to have an impact’. For many doctors who have gone on to occupy senior roles in the BMA and the profession as a whole, the JMF was their first taste of debating issues with their peers.

‘The JMF is a place where they can hear and be heard,’ says Dr Tavabie, ‘as well as finding out what the association can do for them.’ bma.org.uk/jmf

Prevention or cure – both need proper funding The NHS’s long-term plan will save half a million lives.

That was the front-page message carried by national newspapers on the day prime minister Theresa May finally unveiled the future strategy for the health service – a long-awaited document which must have gathered inches of dust while the Government’s Brexit pantomime repeatedly delayed its release.

The new direction for the NHS, prompted by the Government’s rather delayed – and arguably underwhelming MAY: The future strategy of the NHS unveiled

– funding boost of £20.5bn, is not exactly a revelatory one. Prevention is important and should be front and centre of health service policy, it suggests.

Doctors – and, frankly, anyone with any sense – have known this for some time. Preventing disease is cheaper than treating disease. Preventing social isolation is cheaper than treating the consequences. Preventing homelessness would be cheaper than treating the appalling physical and mental health consequences of people in one of the richest countries on earth having to sleep on freezing streets.

We speak to some of them in this issue of the magazine.

The NHS appears to have fired the

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first warning shots over public health to the Government, too, saying: If you can’t properly run public health, we will. The plan suggests services such as sexual health, health visitors and school nurses could all come back under the care of the NHS, as the funding local councils receive for public health ‘directly affects demand for NHS services’.

As well as preventive measures such as quicker treatment and guidance for people with unhealthy lifestyles and at risk of developing long-term conditions, the new long-term plan promises improvements in areas such as mental health support in schools, support in the community to allow quicker discharge from hospital and digital access to health services.

PA

However, for all the ambition the plan struggles to explain how progress will actually be delivered.

BMA council chair Chaand Nagpaul says: ‘Fundamental to the expansion of cutting-edge treatments and digital consultations is to first get the basics right, such as the workforce.

‘While the Government has highlighted plans to expand capacity and grow the workforce, very little has been offered in the way of detail.’

Keep in touch with the BMA online at

Howard you reward doctors?

Could the doctors’ independent pay review body defend itself in public?

On Newsnight? In an interview, such as Jeremy Paxman (pictured right) vs Michael Howard? Being asked the same question a dozen times for want of a proper response? It’s doubtful.

For doctors, it has been like living that infamous encounter for a decade, making reasonable requests for a decent pay rise, year after year. Our ‘Howard’, the DDRB (Review Body on Doctors’ and Dentists’ Remuneration), has failed to deliver again and again, toeing, too often, the Government’s line, despite overwhelming evidence of the effects of belowinflation settlements on morale and recruitment.

Since 2008, doctors have seen the largest drop in earnings of all professions whose remuneration is set by pay-review bodies. Some have seen a fall of 30 per cent against the retail price index.

In September, the BMA called on the Government to recommit to respecting and implementing DDRB recommendations, for the DDRB to be given back its independence, and for it to focus on pay rather than wider contractual issues.

In the absence of any reassurance from ministers, the BMA has taken a different approach this year. It has cut its evidence to a brief summary, with an accompanying statement saying ‘there seems to be little point in engaging in the process as we usually do’.

The BMA might not have produced reams of data but what it has submitted is stark.

It says: ‘The strength of feeling from our members, who have for years borne the brunt of a cost-cutting agenda from all four governments, was made absolutely clear in a recent BMA survey following the announcement of

instagram.com/thebma

The DDRB wouldn’t last long in a Jeremy Paxman interview

PA

the pay awards.

‘The vast majority (88.1 per cent) of respondents stated that as a result of the pay offer the value they feel working as a doctor in the NHS was reduced, and 88.4 per cent of respondents felt that their level of morale has worsened.’

The evidence tells the profession’s own Howard that it must act now to avert the medical workforce crisis it has already been warned about. Repeatedly.

Is it really unreasonable to expect a pay rise in line with inflation?

The DDRB – in which the BMA’s submission says the ‘profession has lost almost all faith’ – hasn’t needed a Paxman-style savaging in public to damage its reputation. It’s done a good enough job to destroy it on its own.

Read more online ‘Pension rules force consultants to retire early’ ‘Long-term plan to curb competition’ ‘Demand to stamp out bullying’ ‘The consultation: eyes in the sky’ ‘A spectre calls’ ‘It pays to persevere’ Read all the latest stories online at bma.org.uk/news

twitter.com/TheBMA thedoctor | January 2019

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ROUGH TIMES: Samantha Moss and Clayton Bradshaw face eviction

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SHAWN RYAN

Streets of

shame

An investigation by The Doctor has found a huge increase in homeless people accessing NHS services. Peter Blackburn meets those at the heart of an unnecessary epidemic

F

or two and a half years Samantha Moss and her partner Clayton Bradshaw slept under the cold, stone arches of Nottingham’s Trent Bridge.

In the shadow of the wealth of two professional football clubs, on the edge of one of the country’s most well-to-do leafy suburbs, the couple survived ice and snow, witnessing regular criminal acts and abuse – with the wind whipping off the water each and every day.

Wandering through the streets of West Bridgford, where the average house price is more than £330,000, to the homeless drop-in centre that eventually helped find Ms Moss and Mr Bradshaw a home, it is hard to believe such hardship can exist. However, it soon becomes clear that their story is just one chapter in a series of tragedies.

When 44-year-old Ms Moss, a mum of five, speaks to The Doctor at the Friary Drop-in Centre, which sits in the heart of the largely Victorian suburb, the single-storey building – which has the feel of an old temporary school classroom – is busy and bustling.

Volunteers with cups of tea and plates of food duck and dive in every direction, piled-up boxes of clothes and food packages seem to reach the ceiling in one corner.

There are 80 or 90 people in varying levels of

physical and mental distress – some chatting animatedly, some dabbing at wounds on their legs or slumped with head in hands – occupy chairs and tables, waiting for refreshments or much-needed help and advice.

Ms Moss has been one of the luckier of this group in recent years, having been found housing eight years ago but still returning to the drop-in centre for advice and company.

However, today, her eyes are full of the sort of worry most people never experience.

‘I am being evicted out of my house in January,’ she says. ‘My landlord is selling up and we’ve been told we’ve got until then to find somewhere. I’ve been to see housing aid but there’s nothing for us at the moment.’

Mr Bradshaw, her partner since those days under Trent Bridge, who has depression and anxiety, adds: ‘The landlords all want so much money up front – a grand up front, five-hundred quid up front. We’re only on jobseeker’s allowance. We’d got settled. We had been in this place for two and a half years so it’s really stressed us out.’

Ms Moss is warm, chatty and eloquent but can hardly bring herself to recall what life was like in what must seem like a different world, sleeping on streets, in parks and under bridges.

‘It was a long time,’ she says. ‘It wasn’t nice. thedoctor | January 2019 07

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SHAWN RYAN

BREMNER: ‘There is an us-and-them mentality in society’

SHAWN RYAN

SEEN IT ALL: Brendan O’Connor was homeless for 10 and a half years

Emergency departments in England 2010-11

11,305

Patient visits

2017-18

31,924

Patient visits

You see so many dodgy things. You don’t forget – it stays with you.’

And asked to look to an uncertain future, she says: ‘It doesn’t bear thinking about. The streets are getting worse, too. People are getting robbed and stabbed all the time. There’s more people out there by a lot than what there was and they are having a harder time.’

Mr Bradshaw adds: ‘I didn’t get much sleep because she [Samantha] is a woman on the streets so I thought I needed to stay awake to protect her. It was horrible. I was stressing all the time. When it was snowing it was the worst.

It was so cold.’

Every night there are scores of people in Nottingham alone, facing these sorts of realities.

Just a handful of years ago the number of people sleeping rough was in single figures. Now, it’s likely to be dozens.

The ‘us and them’ mentality Brendan O’Connor, another regular user of the Friary, was homeless for 10 and a half years until being found a flat six months ago.

‘You just haven’t got a clue,’ the 49-year-old says when asked what life is like on the streets.

‘I’ve had my head kicked in, I’ve been robbed, I’ve been abused – I could go on about the bad stuff all day. There’s not much I haven’t seen – I’ve seen people I know die.’

These are stories familiar to Ann Bremner, the general manager of the centre, who set up the faith-based service – which provides a GP, food and drink, assistance with administration,

IT support and a warm welcome – 30 years ago when West Bridgford was a deprived area, far from the mecca for young professionals with well-paid jobs it is now.

‘People don’t see them as part of the community,’ Ms Bremner says. ‘They don’t see them as people like I do. Everyone has had a previous life before coming here, and very interesting ones. There is an us-and-them mentality in society.

‘There are lots of professional people here too – it doesn’t matter what abilities you have, you can become homeless or you can turn to addiction, and that is just oblivion. Life is valuable and we always believe that people can change or that we can give them hope.’

Ms Bremner has been to 15 funerals in the last year alone. The number of people sleeping rough, passing between streets and hostels, or vulnerably housed is growing rapidly. And the lives of people such as Brendan, Clayton and Samantha, represent a health epidemic for the UK. New research from The Doctor paints a picture of a society in which homelessness is growing rapidly and the interaction between homeless people and the stretched NHS is soaring. The figures – collected through a series of Freedom of Information requests – reveal that the number of recorded visits to England’s emergency departments by patients classed as having no fixed abode has nearly trebled since 2010/11. During the last financial year, 2017/18, at least 31,924 patient visits were recorded, compared to just 11,305 seven years prior.

In some parts of the country the numbers have risen by five or six times – and at one London hospital trust, King’s College Hospital NHS Foundation Trust, numbers are 15 times higher now than they were.

Recorded admissions from emergency departments to hospital wards have also rocketed, going from 3,378 in 2010/11 to 9,282 in 2017/18.

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Each A&E visit

£148

Estimated NHS cost

‘I was stressing all the time.

When it was snowing it was the worst. It was so cold’

Each visit to emergency care is estimated to cost the NHS around £148, and one day spent in a hospital bed around £400 – meaning these figures alone represent a bill to the NHS of more than £47m over the eight years of collected figures.

The reality is that the true cost to the UK’s hospitals and the NHS will be much higher.

Not only did a significant number of trusts fail to respond to the request for information, but the NHS also has notoriously poor recording mechanisms for homeless patients and most simply fall through the cracks – recorded as having an address: a GP surgery, a night-shelter, a housing aid centre or a friend’s house.

On top of that, on most occasions, homeless patients would spend more than one day in a hospital bed. During days spent meeting experts and homeless people in Nottingham, The Doctor was told a number of stories of homeless patients stuck in hospital beds, even when medically fit, for up to 250 days.

And it’s not just in hospitals where an increased strain on services has been found – and a rising demand from a growing population.

Information was also requested from the country’s 10 ambulance trusts. Most said they did not record data relating to homeless patients or rough sleepers but two did respond with figures, of varying detail.

The South Central Ambulance Service has seen the number of cases relating to homeless patients rocket from 268, in 2014/15, to 1,834.

The South East Coast Ambulance Service reported an increase from 54 in 2013/14 to 339 in 2017/18.

As part of the investigation a survey of GPs was conducted. 28 per cent of GPs – from 178 respondents – said they had seen an increase in homeless patients during the last five years and 18 per cent said their surgery was having to devote greater time and resources to homeless patients than they did five years ago. The statistics are pertinent given many GP surgeries have limited contact with homeless patients.

The numbers are backed up by evidence from elsewhere, too. A 2016 report, Better Than Cure? suggests that people who experience homelessness for three months or longer cost on average £4,298 to the NHS per person plus a further £2,099 to mental health services and £11,991 in contact with the criminal justice system.

Financial waste The total cost of homelessness in England was estimated by the Government in 2012 as up to £1bn a year. This dated estimate is now likely to be considerably higher.

Back in Nottinghamshire – a county covered largely by two hospital trusts, Nottingham University Hospitals and Sherwood Forest Hospitals – The Doctor’s figures show that emergency-department attendances have risen from 542 in 2011/12 to 744 in 2017/18.

Mr O’Connor explains why interaction between the health service and homeless patients is so frequent, through his own experience: ‘I was drinking a lot of whisky. I was collapsing all the time and I went up to Holme Pierrepont [the national watersports centre in Nottinghamshire] where some people have a caravan and a tent – it had rained a lot, there was water all over the land. I was getting trench foot. I collapsed and eventually I was on a life support machine for months. I woke up with a beard so big on my face I couldn’t recognise me.

I was in an induced coma all that time.

‘It has happened quite a bit yeah [having to go to hospital], of course it does. I’ve had trench foot and pneumonia countless times. You just can’t keep your feet dry and the first opportunity they do get to be dry it cracks – it’s not just a little thing it’s really big and any pressure on it is awful, you’re in so much trouble.

‘You don’t want to go to hospital generally – but eventually you end up passing out and wake up in hospital. You don’t put yourself there because there’s no way of getting money there.’

Little wonder life expectancy for homeless men is 47 – and just 43 for women.

The Doctor asked Stephen Willott, a Nottingham GP who sees homeless patients at the Friary and is clinical lead for drugs and alcohol in the city, what help the patients he works with need.

‘It tends to be a lot of stuff relating to their being homeless – it could be mental health, or they have terrible foot care, a lot of it can be sexual health issues or to do with drugs and alcohol. Sometimes there are things we can do there and then but often it’s about making a plan.

‘If someone is alcohol dependent and living on the streets there’s no medication I can help them with or detox to arrange so it’s working to try and get accommodation and then working out a plan as to how to get them thedoctor | January 2019 09

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their Monday-morning meeting. And if they don’t attend they just get sicker and sicker until they are only attending again at crisis point.’

JO RAYNOR

Lengthy hospital stays

HUNG OUT TO DRY: The belongings of the homeless strewn along the walkways of the Nottingham Canal

£4,298

Cost to the NHS of 3 months of homelessness and

£2,099 on mental health ‘People in their 50s, 60s and 70s are being made homeless’

free of dependency if they want that – in the meantime it’s about getting them some vitamins and things like that.’

Suzey Joseph probably has more interaction with the homeless than any other professional in the area. Ms Joseph is a nurse specialist for the city’s homeless health team, run by NHS community healthcare provider Nottingham CityCare.

In the space of just an hour in her cramped city-centre office, she shares anecdotes which would be enough to upset even the sternest listener: tales of cancer patients who needed palliative care dying on the streets or young people who have left care being sexually and physically abused.

Almost every homeless person Ms Joseph comes into contact with is in need of serious healthcare. Living on the streets, or in and out of hostels, is simply not a healthy existence.

Unfortunately, many people either do not seek help – for a multitude of complex reasons – or it isn’t obviously accessible to them and it will eventually cost them their lives.

‘People just become more chronically unwell as time goes on,’ Ms Joseph says.

‘They get infections, organ failure and get sicker and sicker until they die on the streets.

It can be so difficult. How are they going to get to an appointment?

‘They don’t even know what day it is let alone time, it’s pouring with rain, someone’s urinated on them, they’ve been beaten up – the last thing they are thinking about is making

It is in hospitals where these patients at crisis point are usually treated. For many patients a hospital is the most uncomfortable, unsuitable location in which to be treated at any point up to an acute episode – and hospital care is far more expensive than that which could be provided in the community.

‘We have eight people who are homeless or have housing issues currently within NUH (Nottingham University Hospitals) which runs the Queen’s Medical Centre and City Hospital on the system,’ Kay Parker, who runs NUH’s integrated discharge team, says. ‘The longest length of stay is 242 days.’

She adds: ‘Anecdotally, we are seeing more and more patients coming to the hospital and through our team and there are more complex factors as well – there is partly an increase in the numbers anyway but we are also trying to identify people earlier. And it becomes much worse in the winter. It’s not just young people, these people are in their 50s and 60s. You make the assumption that a lot of homeless people are young people, but we are also finding people in their 50s, 60s and 70s being made homeless.’

But what are the driving forces behind homelessness and the resulting demand on the health service? Ask anyone in this city – or indeed any other in the UK – and the answers are consistent, if unsurprisingly complex: cuts to public health services such as substance and addiction services, lack of mental health provision, inaccessibility of GP services, fragmentation of the health and social care system and rising prominence of (NPS) new psychoactive substances such as mamba or spice. Perhaps most importantly of all, too, are the obvious lack of housing or suitable beds in the community and the over-arching effects of austerity politics.

New psychoactive substances When it comes to substance misuse the problem is two-pronged. Firstly, the difficulties of life on the street means homeless people have always turned to substances but in recent years the rise of NPSs can have even more troubling results. Secondly, support previously

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WILLOTT: Austerity has exacerbated problems around homelessness

‘The drug and alcohol service has had its budget slashed’

SHAWN RYAN

available to people struggling with addiction has been cut to the bone during the austerity era and since the transfer of public health to local authorities from the NHS. Dr Willott says: ‘Everything has become a lot harder in times of austerity, without doubt. There are fewer direct-access beds around, some of that is political and the fault of decisions made by councils, and there are funding cuts – the drug and alcohol service for example has had a quarter of its budget slashed in the county and that has a knock-on effect. Things have got harder. It’s still a case of trying to encourage and educate primary care to be an appropriate response to people with complex needs.’

Nottingham GP Marcus Bicknell, whose surgery welcomes homeless patients and allows them to register with the practice address, cites £7.5m of recent public health cuts in the area as having a devastating effect. Describing the patients he sees, Dr Bicknell adds: ‘There are some incredibly extreme behaviours. In recent times injecting a combination of crack and heroin called a snowball or screwball into the groin is becoming normal behaviour on the streets, which is frightening.

‘And I have a patient who chopped his earlobes off on mamba when he was psychotic.

You see these most bizarre psychotic behaviours unique to these drugs and our knowledge and understanding is still evolving and emerging.’

Dr Bicknell adds: ‘Public health services are so easy to cut – you don’t see such easy decisions being made about cuts to transport or library services, but addiction services have been hit hard, and the impact of that is serious.

All the cuts seem to be in health and social care – that just can’t be right. It has a massive impact upon addiction services and eventually homelessness.’

Sam Crawford, the chief executive of the Friary drop-in centre, sums up the horror of the rise of NPS poignantly. He says: ‘We have been asking people why they use NPS because, generally speaking, people don’t have a good experience, they don’t have a good trip on it.

‘The answer really is that it’s cheap and accessible but most importantly that it completely removes people from reality for two hours – they don’t care if they have a good experience, it’s not about hedonism or enjoyment, it’s about totally removing themselves from society. It’s a thoroughly damning indictment of our society.

‘These people know they will have a period where they are incredibly vulnerable, they have short-term paralysis and at night in particular anything can happen: their possessions will be nicked and they are completely defenceless but they don’t care because reality is so horrible.’

Access to services that mitigate these issues is a real problem. As BMA public health committee chair Peter English says: ‘Homelessness involves a whole constellation thedoctor | January 2019 11

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597

homeless people died in England and Wales in 2017

of problems: poverty, debt, lack of support services in substance addiction and a whole raft of health issues. Cuts to public health services play a part – we see the reports coming through about how the budgets for public health have been spent on other things.

‘We need compassionate arrangements for people rather than punitive attitudes from Government who think people should just take responsibility and then ignore these areas.

The politics of this is important.’

The health and social care system, particularly the structures created by the 2012 Health and Social Care Act, is often the problem when it comes to the experiences of homeless patients – and resulting costs for the NHS and society. A fragmented system – where social care and individual health providers fight for their contracts and protect their own pots of cash – is not conducive to collaboration, finding the best outcomes for vulnerable, or difficult, patients.

Not only that but the NHS is notoriously poor at sharing data and recording patients, and homeless people are liable to fall through the cracks between accessing one part of the service and then needing another.

These are not patients who are always welcome, or comfortable, in reception areas; they may have complex needs that present as being difficult. And as Ms Joseph says: ‘Even in the most caring folk, care can soon turn to contempt.’

The result of all these problems is that homeless people wait on the streets until their need for care is so acute that it can often result in needing very serious care, or that no treatment can be provided. Even if they are able to access the system successfully it is likely they will be either stuck in the wrong place – while arguments over who should foot the bill are had – or they are discharged and forgotten about until the whole process starts again.

Ms Joseph says: ‘It’s causing havoc at the hospital because they are under pressure and they need to get people in who need acute care, beds and therapy but they can’t always

move people on. There are people in there who should be able to go out much more quickly but sometimes there’s no social care available and those discussions are ongoing.

‘People get discharged all over the place to the winter night shelter in July, to housing aid, to a GP surgery. It’s a really good thing for someone to give them a correspondence address and allow them to register but hospitals need to be able to record them better. So many people just fall through the cracks.’

Unmet, complex needs A study into the mental health needs of Nottingham’s homeless population, conducted earlier this year by Sheffield University, found similar conclusions. It showed that a very high proportion of homeless people in Nottingham had multiple, complex needs and that, while political will and empathy seemed to be present in the city, those needs were not being met.

Austerity, and the resulting effects of the best part of a decade of cuts, have a major part to play – as is the case in so many parts of society, and so many of the changes seen in the country in recent years. Since 2010, the year David Cameron was elected prime minister, the number of people sleeping rough in England each year – not even including those vulnerably, often very vulnerably, housed – rose from 1,768 to 4,751 in 2017, according to estimates.

And figures published by the Office for National Statistics just last month (December) estimate that 597 homeless people died in England and Wales in 2017 – an increase of 24 per cent across five years.

Days spent on the streets, in the homeless shelters and with the experts in Nottingham make it abundantly clear how these numbers have risen. Safety nets no longer exist. It only takes one small piece of bad luck, or one mistake, for people to find themselves among the statistics. No wonder they rise in such exponential fashion. And when the numbers rise the strain on the health service and society’s purse grows rapidly.

Mr Crawford says: ‘I think the austerity

‘The growing numbers of rough sleepers and vulnerably housed people in our society is a continuing tragedy’

4,751 1,768 2010

2017

Sleeping rough in England

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£20k+

Cost of a rough sleeper to society each year

SHELTER: Homeless people often seek refuge under Trent Bridge

measures that hit local authorities have definitely brought about a much more fragmented approach to statutory services which is problematic when you talk about people with multiple and complex needs – everyone tries to address these issues in isolation without recognition for the fact that they interrelate.

‘I can think of at least two people immediately who have long-standing mental health diagnoses who are really chaotic individuals who have magically had their diagnoses removed from them – it feels like mental health services are under pressure to get people off their books and austerity breeds that mentally that it’s budget first and people second.’

The personal stories, the number of those affected, and the costs are equally striking. But perhaps most striking of all is the fact that a serious commitment to addressing homelessness would almost certainly save money.

According to Crisis, if 40,000 people were prevented from becoming homeless for one year in England it would ‘save the public purse £370m’.

A 2015 study, called At What Cost, found that the cost of a rough sleeper to society for 12 months was more than £20,000 – whereas a successful intervention would cost, on average, just £1,426. The clarity of the equation is as striking as society’s unwillingness to act upon it.

Expensive inaction The checklist for solving this problem is as ubiquitous as the causes were when The Doctor asked: a serious house-building programme, investment in community mental health and homelessness outreach services, reversal of public health cuts, genuine collaboration between health and social care and an end to fragmentation in the system. The shopping list might sound expensive – but doing nothing is proving to be much more costly.

Dr English adds: ‘If this was some disease causing all these problems it would be a much higher priority but because victims can be blamed and stigmatised it is easy for Government to ignore. The growing numbers of rough sleepers and vulnerably housed people in our society is a continuing tragedy. To stand by silently as our NHS faces increasing strain and our society becomes increasingly unequal would be unacceptable.’

If anyone needed any further convincing of why action must be taken just think of Samantha Moss – and all those like her – on the brink of having to return to the streets of a society rich enough to help, but which chooses to ignore. As this issue of The Doctor goes to press Samantha and Clayton are deciding where they will sleep when they are evicted from their house: on city-centre streets, in a tent on the embankment or back under the arches of Trent Bridge.

‘It’s just terrible,’ she says. ‘Why can’t they do more for homeless people?’

JO RAYNOR

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CLEAVER: ‘The lack of ability to take clinical risks is paralysing our front door’

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I’ve been expecting you Every emergency department has ‘familiar faces’, people regularly drawn in who receive little medical benefit. Addressing the reasons why doesn’t just save the NHS money, it yields insights into vulnerable patients, finds Keith Cooper

S

tanding, just waiting, in the middle of the emergency department at Charing Cross Hospital, west London, you feel the adrenaline rise.

The snatch of a one-sided phone call, ‘the scan’s done. I understand … come see her?’ This from a nurse in the throes of a hectic shift, ‘I’ve a terrible headache, how can I help?’ That human hum.

We’re here to see Barbara Cleaver, emergency medicine consultant and mental health lead at Imperial College Healthcare NHS Trust. With a spare minute, we’re whisking down corridors to the ‘frequent attenders’ team she wants us to meet.

She introduces us to Emma Schofield, a staff grade in emergency medicine, in an oblong office lit up by PC screens, and then is off, back into the buzz.

It’s from this relative calm that Dr Schofield and Gemma Harper, a mental health support worker, help the trust’s most challenging patients, here and at St Mary’s emergency department, near Paddington Station. ‘“Frequent attenders” is a term likely to go out of fashion, as it’s deemed pejorative,’ says Dr Schofield.

‘Some people refer to them as familiar faces.’ Difficult, troublemaker and source of ‘collective sighs’, are unofficial titles, The Doctor has seen elsewhere.

At Imperial, they’re patients who attend the emergency department more than six times in six months, often by ambulance.

For some patients, it’s much more often than that.

The team’s got spreadsheets, graphs and data galore on

their PCs to prove it. One arrived 50 times in a month, and 200 times in a year, costing £32,000 in ambulance transfers alone.

‘Very often there is no acute pathology for the emergency department to find or treat and the result is a very expensive taxi service,’ Dr Schofield says, ‘to a very expensive day-care centre. In many cases the hospital will have to arrange transport home.’

Underlying issues Many patients ‘get no medical benefit’ from such regular emergency department visits but are drawn here by ‘underlying issues’, what Dr Schofield calls ‘occult drivers’.

‘People come in with physical symptoms, such as chest pain, headaches, dizziness, collapse or seizures,’ she says. ‘On many occasions we find the underlying cause is not physical,’ Dr Schofield adds.

Mental ill health is the most common one, according to her analysis of cases at a previous employer, the West Middlesex University Hospital. It’s followed by social issues, such as loneliness, housing problems, or homelessness.

Others come in with crisis after crisis because of badly managed chronic conditions, such as diabetes. Many cases are hard to unpick, certainly impossible to resolve within the four hours the NHS expects patients to be in emergency care.

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Reducing frequent attendance University Hospitals of North Midlands

University Hospitals of Leicester NHS Trust

FREQUENT USERS 47

FREQUENT USERS 12

ATTENDANCES

ATTENDANCES

ATTENDANCES

ATTENDANCES

2016/17

2017/18

2016/17

2017/18

1,090

640

435

197

The Mid Yorkshire Hospitals NHS Trust

Lewisham and Greenwich NHS Trust

FREQUENT USERS 45

FREQUENT USERS 31

ATTENDANCES

ATTENDANCES

2016/17

2017/18

848

488

Dr Schofield has trialled taking patients on walks with her own two dogs. She has escorted patients to clinics until they attend on their own. Ms Harper sorts housing and benefits out. They’ve trailed around London together, searching for patients at addresses they find are fake.

Much of their work is ‘constant prodding’ until bottlenecks in other public services unstop.

But how’s it a doctor’s job to go dog walking?

‘All of these patients, if you look at their back history, they’ve all had really difficult childhoods,’ Dr Schofield says in response.

‘You can’t even get to some of their childhoods; they’ve had such challenging lives. People who do not attend the emergency department frequently are relieved when informed their chest pains are not life threatening, they don’t want to come to the emergency department in the first place and are happy to have their conditions managed in the community.

‘Often there is no acute pathology for the emergency department to treat and the result is a very expensive taxi service’ ‘You take the medication, see your GP. You know what it’s like to be cared for. A lot of patients we work with have never had anybody care for them. Coming to the emergency department provides them with a form of care and it is open 24/7, every day of the year. It may not be the care that you or I would want but for these patients it is often all they have.’

Ms Harper says the ‘best thing’ to help patients in her work is to go to their home, something she does often. ‘Unless you take the time, you’ll never find out what’s going on or gain their trust. An hour in the

ATTENDANCES

ATTENDANCES

2016/17

2017/18

1,165

953

emergency department is not going to teach you or let them share anything with you.’

She is doughty gold dust with a casual calm, a can-doer.

After more than a decade in Hammersmith and Fulham, she knows how to get things done.

‘I know all the services. I can access the relevant people in housing. I’m plugged into social workers and services people are supposed to be offering,’ Ms Harper adds.

Limiting inappropriate interventions Dr Schofield’s main role is to draw up care plans, working with the liaison psychiatrist if need be, for each frequent attender. The plans guide staff on how best to treat patients and limit inappropriate interventions.

‘People recurrently presenting with “chest pain” several times a week don’t need blood tests and X-rays every time,’ Dr Schofield says. They might want the attention, the atmosphere, a break from an otherwise lonely life. ‘But is this appropriate care? Putting in cannulas?

Irradiating them? No. We’re not making them better.’

Care plans might advise that a known regular attender, arriving by ambulance and presenting with chest pain, can be placed in a chair or the waiting area to wait to see the doctor if their heart trace checks out and their observations are normal.

They do not necessarily need to have a hospital trolley and be connected to a monitor. The plans aim to ease ‘doctor anxiety’ too, if they trust them. Not all of them do straight away. ‘Some people love it, and say, yay!

Some medical staff are more, ooh, I’m not sure,’ says Dr Schofield. ‘But then they slowly come around to it.’

Patients’ reactions to them also vary. They’ve seen attendance spike when medical attention is curbed. They miss it. They miss the staff. There’s plenty of emergency-

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room reality shows, reminding them what it was like.

‘When they’re here, they’re important for 30 minutes to an hour, and that is very comforting,’ Dr Schofield adds.

It can take six months to a year for behaviour to change.

However, the team’s stats and graphs show that spikes are followed by drops in the number of tests and attendances, as care plans take effect. They can’t stop patients calling and coming in by ambulance but they can and are influencing what happens once they’re through the front door.

Imperial, as with all trusts in England, tracks efforts to reduce frequent attenders for an NHS England ‘quality and innovation’ temporary target. This expects a 20 per cent annual reduction in ‘presentations’. It’s to improve care for people with mental ill health, who scholars claim have 3.6 times more preventable emergency admissions than those without.

‘People recurrently presenting with “chest pain” several times a week don’t need blood tests and X-rays every time’ Last year, Charing Cross reduced its attendances by 21 per cent for a dozen patients (it has 200 on its books, trust-wide). We asked NHS England and trusts with the 20 busiest emergency departments for similar figures.

NHS England declined and just four trusts responded.

Lewisham and Greenwich NHS Trust, south London, last year reduced attendances for 31 patients by 19 per cent in emergency departments at University Hospital Lewisham, and Queen Elizabeth Hospital. It’s seen further reductions this year, working with more patients.

‘There is a culture of frequent attendance at both our hospitals,’ the trust says.

‘Patients feel safe in the emergency department and may have nowhere else to go,’ it adds. It’s setting up a ‘mental health crisis café’ in the emergency department for people with no ‘safe spaces’ to go to.

Joined-up care University Hospitals of Leicester NHS Trust has reduced attendances by 55 per cent last year for 12 patients and is working with 42 this year.

Back at Imperial, Dr Schofield reflects that stopping people attending the emergency department should not be considered a ‘win’ if you haven’t improved their lives and care somehow.

And in a (relatively) quieter moment, a week later, Dr Cleaver says the trust has learned much from its years of helping frequent attenders. It’s thrown up issues which doctors, the NHS and politicians might mull over.

Its efforts have been frustrated by curbs on data sharing and poor IT links between public sector players, including those in the NHS.

WELCOMING PARTY: (From left) Barbara Cleaver, Gemma Harper and Emma Schofield believe in handling ‘frequent attenders’ more appropriately

‘We can’t see what the GP is writing or what the mental health team is writing or what the London Ambulance Service is doing,’ Dr Cleaver says.

‘Our IT systems make things very difficult. There are massively important concerns about data protection, but they don’t half make things difficult.’

Lewisham and Greenwich faced similar barriers.

It means emergency departments across London can’t share how they treat patients, so they can just jump from one to another, where access to medical attention is less restricted.

Dr Cleaver says the frequent attenders work also raises some moral questions for the NHS. ‘Do we need someone to say that this isn’t an acceptable use of national health services? We are going to hold you to account. You are an adult, you have mental capacity.’

Some health professionals, such as ambulance crews, have become too wary of taking clinical risks.

‘When did we stop letting patients take responsibility?’

Dr Cleaver asks. ‘Someone comes in over and over again for years and years, saying they have chest pain. What do we do? It’s worth having a debate about. The lack of ability to take clinical risk is paralysing our front door.’ thedoctor | January 2019 17

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I’m not OK Facing bereavement, money problems and exam stress, Ayesha Shahid’s answer when asked how she was coping was always the same – I’m OK. She wasn’t, and, in a piece which was a runner-up in this year’s BMA writing competition, she makes an impassioned plea for doctors to seek out the help they need

Monogram

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BMA writing competition 2018

I

f I could change one thing, it would be a small thing. So insignificant, one would hardly think it needed to change. My small change would be to answer the question ‘how are you?’ truthfully.

For you to understand this request, I must tell you my story from the start. At medical school I was a self-funding student without financial support from family and being a graduate meant paying my own fees. I was committed and driven but I was keeping afloat.

Yes, my boat had leaks but they were small. So, when anyone asked, ‘how are you?’ my response was always ‘OK’.

Then a storm struck in the winter of my third year. My youngest and most beloved sister died. It was a shock and after six weeks in ITU she lost the fight. I didn’t cry. I didn’t break my resolve. Every family has its issues and mine is no exception. I needed to be a pillar of strength for them.

My leaky boat had taken on water but I survived. When my mother asked, ‘how are you?’

I answered ‘OK’.

I continued medical school but all was not well. I struggled to earn money and my focus was gone. I followed the GMC Good Medical Practice and sought help from my GP who supplied me with beta blockers for anxiety. I wanted to tell him how I felt, I really did, but I was afraid of being seen as weak, unable to cope with the pressures of medical school.

Worried somebody would find out. My boat had gone under but I was keeping afloat. So, when he asked, ‘how are you?’

I just said, ‘OK’.

The medical school noted my attendance was dropping

‘I started to drink. That summer was spent in a stupor.

When medical school restarted I couldn’t stop drinking’

and called a meeting. I met with the dean who suggested I ‘take time out’ for the remainder of the year. I tried to explain that money was a problem but it didn’t seem to register.

My options were to drop out and face financial difficulty or complete the end-of-year exams without submitting extenuating circumstances.

What could I do? I continued to tread water just about coping.

When the dean asked, ‘how are you?’ I said ‘OK’.

I started to drink. It felt good. At university everyone drinks so no one noticed. That summer was spent in a stupor.

When medical school restarted I couldn’t stop drinking. The next two years were spent pretending everything was OK. I hadn’t dealt with my sister’s death, I had money problems, I had exams and the only coping mechanism I had was alcohol. I was beginning to tire but there was some hope.

I met my husband. Together we made it through medical school. When he asked, ‘how are you?’, I said, ‘OK’.

On graduation my husband and I got jobs in different deaneries. My only support was taken from me. Although I passed my exams, I didn’t make it through medical school. I was drowning. I tried to move jobs to be closer to my husband, but I did not meet inter-deanery transfer requirements. So, I commuted two hours each way, so we could live together. Needless to say, it took a toll on our relationship. I wasn’t sure we would survive. Work was hard. Home life was harder.

I was unhappy, lonely, angry, irritable. I was drowning, yet I never took a day off work.

No one knew. When my

‘I rejected the offer against everyone’s advice. I started seeing a therapist’ colleagues asked, ‘how are you?’ I knew no other answer apart from ‘OK’.

I was offered a core medical training post but it meant long commutes for another two years. I was starting to unravel but finally did something.

I rejected the offer against everyone’s advice. I started seeing a therapist. I took a trust-grade job and started to evaluate my options. All of this was a little too late. I had had enough. I had the intention of ending my life. I just couldn’t cope any more. No one knew, and when any one asked ‘how are you?’ I just said, ‘OK’.

I got lucky. My trustgrade job was a wonderfully supportive environment.

My supervisor was more like a mentor. He spent time with me. Made it clear my needs are important. When he asked me ‘how are you?’ The truth came out. For the first time in a long time I could breathe.

Like me, I know there are many in the medical profession who feel they must be invincible, who do not get the right help at the right time, who live away from their support networks because of the nature of the job. Those who know me will not believe this is my story, but I share it because being vulnerable is not a flaw. Saying you are not OK, is OK. Ayesha Shahid is a staff grade in general medicine and dermatology in Surrey.

She was one of three runners-up in this year’s BMA writing competition thedoctor | January 2019 19

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An opt-out too far Parents who decide to forego vaccinating their children place others at risk, says BMA writing competition runner-up Susannah George

Monogram

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BMA writing competition 2018

‘V

accinations all done?’ I ask, casually. Just another routine question in the paediatric history.

‘No, he hasn’t had any.’

‘Do you mind me asking why not?’

‘Just personal choice, I don’t believe in vaccinations.’

‘Not even tetanus?’ I ask.

‘No, none of them.’

And now I am stuck. I can’t spend the next 17 minutes arguing my point. The parents have made the decision and so far, I don’t think I have ever managed to convince any one to change their minds.

‘No childhood vaccinations given,’ I write in the notes.

I’ve heard every reason – natural immunity is better, it’s the right thing for my child, no one dies of measles any more, they might react to the vaccination, they might get autism.

As a dermatologist, my patients often have rashes, a viral infection may be in the differential diagnosis. It’s also relevant if I need to immunosuppress someone. There are a small number of systemic medications I can use for a severe inflammatory dermatosis and I need to make sure that they’re immune. Until recently I only asked this question of parents, I now ask my adult patients if they were vaccinated. There is a cohort of young adults who never received their childhood immunisations. They are alone in the clinic, the person who made the decision for them 20 years ago is not there to tell me.

2018 will be remembered for the heatwave and the best result in the World Cup for 28 years but we have also seen another measles outbreak in Europe. So far there have been 37 deaths – 37 preventable deaths.

‘Is vaccination compulsory?’ I remember asking the nursery manager before my daughter started.

‘No, we can’t make parents vaccinate their children, it’s their choice,’ she replied.

‘We can’t make parents vaccinate their children. It’s their choice’ In the next few months, with one nursery-derived infection after another, her MMR vaccine was postponed not once, but twice. She finally had her vaccination aged 15 months, but by then it was too late. The cough, temperature and sore eyes, I assumed were probably a reaction to the vaccine.

‘I think it’s a viral infection,’ said my GP. The next day the spots appeared behind her ears – tiny erythematous macules, spreading to her forehead, becoming papular, coalescent, covering her whole body. She refused food, she vomited, I couldn’t get her temperature below 39 degrees. My tiny little daughter – born off the bottom of the centile chart – was becoming thinner and thinner until her ribs stuck out and I was crying on the phone to the out-of-hours GP.

‘If we can educate people to recognise this disease, we can try to minimise its spread’ Friends told me that natural immunity was a gift, better that than having been vaccinated. I contacted the local public health department, did the mouth swab myself and reported her – another case in the 2009 outbreak.

This was the second case of measles I’d seen in my life. The first time was in 1983, when I looked in the mirror one night and saw the same red rash, dappled on my face.

I had had one dose of a measles-containing vaccine, but with a history of febrile convulsions, the doctor made the decision not to give me a second.

By the 1980s, with an effective vaccine available for more than a decade, cases of measles had fallen rapidly.

Our new GP was worried – he visited every day.

I photographed every stage of my daughter’s rash, from the tiny macules behind her ears to when the rash became purpuric in places and then the brown post-inflammatory pigmentation. I’ve used them in my own lectures, published them in medical journals and lent them to colleagues. If we can educate people to recognise this disease, we can try to minimise spread from suspected cases.

But if I could change one small thing, I would make vaccination compulsory. Other countries have set a precedence yet the British Government cowers in fear of being labelled ‘the nanny state’. We are just not good enough at educating the public on the benefits of vaccinations. A choice of doing nothing is perceived as the better than accepting a vaccination that might cause harm.

After all, if children catch the infection, it is not their fault, it is just one of those things. Seventeen minutes is not long enough to finish my consultation, let alone change someone’s perspective.

In the last 20 years, we’ve paid more attention to the discredited work of Andrew Wakefield, than the reality that these illnesses still cause significant morbidity and mortality. Perhaps the person who argues the case for vaccination best of all is Roald Dahl in his moving tribute to his daughter Olivia, who died of measles when she was seven, in a time when an effective vaccine was not available.

If public perception cannot be changed, then immunisations must be compulsory. Vaccination is a privilege, not a choice.

Susannah George is a cconsultant dermatologist from Brighton Editor’s note: The BMA has a longstanding position in support of a voluntary approach to vaccination – the BMA’s medical ethics committee considered the arguments for different forms of compulsory vaccination in 2009, in light of the high numbers of measles cases attributed to the fall in uptake of the MMR vaccine, and affirmed its support for a voluntary approach backed by educational and promotional campaigns.

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Dig a little deeper When a patient has a personality disorder, it can seem easier to worsen their condition than to treat it. Leading psychoanalyst Peter Fonagy tells Keith Cooper the steps he believes can help achieve better outcomes

A

fter an hour of quiet conversation, Peter Fonagy slams his hand on the table. Bang.

‘I’m fed up,’ he barks. ‘You’re here for the third time. You just want attention. You’re wasting NHS resources. There’s nothing wrong with you. Why are you darkening my door again?’

It’s his response to this: how could you make someone worse?

The someone we are talking about has a personality disorder. His response is an imagined outburst of frustration at a patient who just happened to fall down a flight of stairs. He

FONAGY: ‘They are not trying to manipulate you’

or she had left the phone at the bottom and the front door open, so emergency services could let themselves in.

‘It’s a little bit planned,’ he says. ‘You could say, they’re being manipulative. But if you try to understand, they are just trying to survive.’

Personality disorders are a subject on which Professor Fonagy is a well-known expert in some circles, particularly for his work with London

‘You could say, they’re being manipulative. But if you try to understand, they are just trying to survive’

consultant psychiatrist and fellow psychotherapist Anthony Bateman.

They trained together as psychoanalysts and developed the theory of ‘mentalisation’.

It aims to help doctors and other health workers better understand and interact with patients rather than making things worse, as handslamming frustration does.

Their book, Mentalizationbased treatment for personality disorders: a practical guide, was highly commended in the psychiatry category in the 2017 BMA Medical Book Awards.

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Desperate state Professor Fonagy is an NHS England adviser, professor of psychoanalysis and development science at University College London and heads the Anna Freud National Centre for Children and Families, to which Professor Bateman is also attached. He returns to a more soothing tone to elaborate on the emergency department scenario.

‘You know, there was something wrong with that patient at the top of the stairs,’ he says. ‘There was. They were in a desperate, desperate state. The world was closing in on them. This was the best way they had to open a little crack. They opened that little crack, so they could get some contact with humanity again. They are just trying to survive, they are not trying to manipulate you.’

According to the theory, the apparently ‘manipulative’ behaviour is explained by their ‘teleological thinking’, one of three things which hampers profoundly their ability to mentalise.

Mentalising is the normal thought process we use to reflect and make sense of ourselves and each other.

But people with personality disorders struggle to do this, making social interactions hard. Like any skill we struggle with, it worsens under stress.

‘When interpersonal relationships are difficult, they give rise to very intense emotions. This makes it even more difficult … and they just blow up,’ Professor Fonagy says.

‘They have a catastrophic explosion of emotion, which

FONAGY: People with personality disorders need physical care ‘to feel somebody cares for them’

then gives rise to desperation.

It’s like walking around with raw skin, after a burn.’

With teleological thinking, so the theory goes, people with personality disorders don’t ‘believe’ things until they ‘see’ them. ‘They need physical care in order to feel somebody cares for them,’ Professor Fonagy says. This brings them frequently to GPs, emergency departments, and the 24/7 access to care which it offers.

The second is pretend mode, a term he admits is ‘really bad’. It means they can ‘talk and talk’ about feelings which don’t connect with ‘reality’. So many conventional psychological therapies don’t work. They don’t touch the sides.

The third is ‘psychic equivalence’, where people equate what is in their mind with what is in the world, to the extent that no alternative perspectives on reality exist and the contents of the mind become unbearably real.

Step by step BOOKED UP: Dr Fonagy’s publication was highly commended by the BMA Medical Book Awards

Using this analysis, Professors Fonagy and Bateman came up with a series of steps to help health professionals help people with personality disorders to start ‘mentalising’ again.

The first step he demonstrates by raising his hands to a stop sign.

‘These are my mentalising hands,’ he says. ‘You’ve stopped. You’ve noticed you are going this way, and they’re going that way. You say, look we’ve got a problem.’

Then you must validate and empathise with their position.

‘This is what helps them downregulate their emotions.’

It can be hard and requires broad shoulders.

‘You accept that you are quite likely a party to a failure to mentalise,’ he adds. ‘You are not an innocent party. You can say, I was manipulated into it. Yeah, fine. But it doesn’t matter how we got here. We got here. We’ve just got to get ourselves out of it.’

‘When interpersonal relationships are difficult, they give rise to very intense emotions’ The next stage of ‘clarification’ can get mentalising going again.

The last is to offer an alternative perspective.

He gives an example: ‘Maybe he wasn’t trying to screw you; maybe he was trying to help but misunderstood where you were.’

It all feels like a good way to solve an argument and Professor Fonagy agrees there are similarities.

‘You don’t need a brilliant set of new techniques,’ he says. ‘This isn’t rocket science.’

Emergency medicine staff tend to learn the techniques with experience.

He’s keen to downplay the level of sophistication.

‘You just need to be a human being. But you need to be a human being under unusual circumstances,’ he adds. thedoctor | January 2019

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iStock

Beyond parity of esteem A new Mental Health Act could tackle gross disparities in outcomes and give patients more say in their treatment, but proper resourcing is vital, writes BMA consultants committee mental health lead Andrew Molodynski

F

ew will argue against the need to rebuild our mental health services after more than a decade of poor investment and limited political interest. None, except perhaps some politicians, believe it will be easy.

The first part of that process reached a crucial stage with the publication of Modernising the Mental Health Act: increasing choice, reducing compulsion.

It follows a review led by the immediate past president of the Royal College of Psychiatrists Professor Sir Simon Wessely, and has included the views of scores of patients, carers, lawyers, and experts, including the BMA. Fairly major restructuring of mental health laws is proposed, with significant shifts in our relationships and interactions

‘Different outcomes, inevitably worse for those from black minority groups, have no place in a modern health service’

with patients. They’re changes which will affect us all, and hopefully for the better.

There are calls for greater weight to be given to patients’ preferences for treatment even when it is compulsory, greater transparency about how compulsion is justified, and steps to address the gross disparities in Mental Health Act use according to ethnicity.

Different outcomes, inevitably worse for those from black minority groups, have no place in a modern health service, and it is to be hoped the review will show teeth as it goes forwards. We (doctors, patients, carers and others) will need a believable and bold blueprint moving forwards.

Crucially, it will need to be backed by an equally believable

plan from government to support these reforms and provide the better-resourced services needed to make words become reality. There has been enough tinkering around the edges. It is time for meaningful and transformational change.

‘Excellent to abusive’ The BMA, on behalf of its members, welcomes the review’s ambition to improve patients’ experience of mental healthcare. Kate King, a patient who spoke at the review launch described the care she received in detention as ranging from ‘the excellent to the abusive’.

We need to have much more of the former and progressively less of the latter, with patient experiences improving steadily year on year.

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MOLODYNSKI: The restructuring of the Mental Health Act will affect us all

The Government has pledged to consider the report and its recommendations in detail and has restated its intention to reform mental health laws.

It has already accepted two, which should strengthen a person’s say over his or her care: the creation of legally enforceable ‘advanced-choice documents’ and the role of ‘nominated person’ – someone a patient can nominate to be informed of and involved in decisions about care. It will seem odd to many that this is not already the case and indeed it is time for change.

Sir Simon hopes his reforms will help to create mental healthcare which is fairer and which doesn’t rob patients of their voices once sectioned. He

‘The review group hopes its reforms will reduce inpatient detentions by 15 per cent’

rightly recognises that it’s not fair for patients to be detained for weeks or months without treatment as can happen at present. Or that black people are eight times more likely to be put on CTOs (community treatment orders).

‘Mental health and mental illness has come out of the shadows and so should the Mental Health Act,’ he said.

Mental health law is only part of the picture, however – albeit an important one. Many people already get excellent treatment from caring and humane practitioners in a system fit for bursting.

Improved mental health law, as Sir Simon, acknowledges, will do nothing about that: ‘You can hardly have a modern mental health system without a modern estate,’ he said.

He wants dilapidated wards improved and has placed faith in NHS England’s forthcoming LTP (long-term plan) for improvements. We all want these building works, and have for years. We hope that the mental health review and the LTP will fit together to enhance each other’s potential.

The review group hopes its reforms will halve the number of CTOs and reduce inpatient detentions by 15 per cent.

These are conservative aims given the lack of evidence for the former and the 50 per cent rise of the latter in recent years. Surely, we can do more Sir Simon?

If a drug with side effects did not work and was used eight times more frequently in black people I don’t think we would be looking for a 15 per cent reduction – it would be out of the formulary.

Surely, we should regard legal remedies such as CTOs with

the same objectiveness as their pharmaceutical and therapeutic equivalents?

Funding squeeze To make real the promise in this review – that of a fairer, less coercive, and more patientcentred system – will require the Government to put its money where its mouth is. Our general mental health services strive hard to look after people and usually do so well but they are progressively deteriorating with increased demand and squeezes on funding.

Billions of pounds of investment and real (not pie in the sky) plans will be needed to allow for proper care for ordinary people such as you and I if we get ill.

Funding needs to be fairer and clearer with less of the ridiculous inequalities in commissioning that exist.

We need a bold vision for how we will staff our services now not in a decade or more.

None of these things are easy. Not one, however, is impossible. The stakes are high. Doctors, nurses, and others deserve to work in a system that allows them to care properly and humanely for patients and their families.

To be able to provide long-term care and work on prevention rather than being entirely crisis driven owing to shortages as we are now.

Those patients and families deserve that too, at the very least. The stakes are high; the chance is there. But will the Government take it?

The era of parity of esteem is dead (it never really meant anything). It is time for parity of resource, parity of access, and parity of outcome. Anything less is morally unacceptable. thedoctor | January 2019 do 25

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on the ground Highlighting practical help given to BMA members in difficulty

Recouping expenses claims, a fair deal for locums and working out daily pay rates – all quandaries the BMA has tackled and resolved for members

Pound for pound

No time to chase pay

Completing expenses claims is rarely a doctor’s favourite job, and the chore is often compounded by systems so complex that it’s almost like your employer doesn’t really want you to have the money.

A junior doctor knew she should have claimed some money back but was busy and found the system cumbersome and so let it go. However, her employer started trying to claim historic sums back. A payroll error on transferring to a new contract had led to an overpayment of around £1,200.

While talking to a BMA employment adviser about the trust’s claim, the doctor happened to mention the problem with expenses.

The employment adviser got to work. It took many emails during 18 months but the adviser persuaded the trust to offset the salary overpayment against the unclaimed expenses.

Many of the expenses were far beyond the date when claims were usually allowed. Yet if the doctor was showing willing with the salary problems, the BMA reckoned the trust should show the same spirit with the expenses. The offset meant the junior doctor’s bill was cut from £1,200 to less than £400, which she described as an ‘excellent outcome’.

Imagine being owed thousands of pounds for work done but being so frustrated by the slowly grinding wheels of NHS bureaucracy that you almost give up on the chase. You probably don’t need to imagine it.

That was the situation a junior doctor found herself in, when she had helped her hospital out with some locum shifts at a time of need. She was owed more than £10,000.

There was no dispute that the money was owing but paperwork kept floating around different parts of the organisation, each time missing internal deadlines and finding itself on the bottom of the pile.

The doctor felt she was being ignored and called in the BMA. The employment adviser was able to bring the necessary persistence and focus – something doctors find difficult when balanced with the demands of their day jobs.

After about five months of chasing, the money was finally paid.

The doctor wrote to the employment adviser to say: ‘I had just about given up and you helped me finally get paid what I was owed.’

It shouldn’t be so difficult, but it often is – and the BMA is there to help.

All in a day’s work A month might seem a solid and tangible thing – although that doesn’t explain why January always seems twice as long as December. And it was an employer’s definition of a month that almost had serious pay consequences for a junior doctor.

The trainee had a large amount of leave she was unable to take as a result of sickness absence, and so her employer was paying her in lieu for that time. To do this, it needed to establish her daily pay rate.

The employer worked it out by dividing her monthly salary by the number of calendar days in a month.

The BMA disagreed, and said it should be calculated instead based on the average number of working days.

The implications of this are significant. It is the difference between dividing a monthly salary by 30 or 31 or by approximately 20. The latter approach, which the BMA insisted was correct, gives a daily rate around 50 per cent higher.

The problem was that the national terms and conditions allowed for an open-ended interpretation of how the rate should be calculated. However, having heard the strong arguments put forward by our solicitors and employment adviser, the employer agreed with the BMA and the junior doctor was paid at the higher rate. She thanked the BMA for its time and expertise.

26 thedoctor | January 2019

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the secret doctor

The writing’s on the wall E

very doctor has patients and families – or types of patients and families – they find particularly tricky to work with.

Some struggle with the medical-school-drop-out nephew who insists on a level of medical detail he clearly can’t follow; some are flummoxed by the submissive older person who insists on saying, ‘whatever you advise, doctor’, regardless of the question; some get wound up by assertive people who know their rights and demand them loudly in all circumstances.

To balance this, though, some kinds of people are a particular pleasure to work with – and, like pet hates, this varies very much from doctor to doctor.

My personal favourite variety of family member are those who are totally un-medical but are trained in some quantitative, technical discipline which makes them ready to understand how medical treatment works – or sometimes doesn’t. Physicists and engineers are good for this, but so too are plumbers and electricians.

There’s one disadvantage with these people, though;

sometimes a clear understanding of what’s happening isn’t an unmixed blessing. We’re no longer allowed to withhold information for someone’s ‘own good’, but many doctors still try to soften or at least pace the information they’re giving when it is particularly devastating. If the patient or relative is ahead of you, this is impossible.

I recall a father – an analytical chemist – whose two-year-old daughter developed a degenerative condition. It took us some months to diagnose her but long before we did, it was clear that her outlook was very bad indeed. This father had drawn a graph to keep track of how his daughter’s condition changed over time.

The x axis showed months; the y axis showed abilities: walking, standing, crawling.

The line showing the little girl’s progress wavered to begin with but as time went on it trended inexorably down.

The father had had to add new milestones on the lowest part of the y axis: reaching out.

Raising head. Swallowing.

If you did history at school, you’ll probably have seen the famous picture of Guy Fawkes’s signatures,

before and after he was tortured into confessing to the Gunpowder Plot. The first signature is in a firm, looping hand; the second is so tremulous and fragmented as to be barely recognisable.

This father’s writing, neat and technical to begin with, in the newest, lowest parts of his graph became scarcely legible.

Handwriting, as with Guy Fawkes’s, distorted by pain.

When we eventually came to break the news of the child’s diagnosis, it was clear that he was only waiting for us to put a name to his fears.

A lack of false hopes and self-deception on the part of relatives may possibly make the clinicians’ lives easier, but does it make the relatives’ own lives harder?

By the Secret Doctor bma.org.uk/ thesecretdoctor @TheSecretDr thedoctor | January 2019

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the consultation

More people are killed by guns in a single day in the USA than in a whole year in the UK. Rhode Island emergency medicine physician Megan Ranney leads research into widespread firearms violence – despite pressure from gun lobbyists to stay clear

The number of firearm injuries and deaths are increasing, across the USA. And the numbers ignore the huge ripple effect of each firearm injury and death on our society.

People with gunshot wounds are less likely to make it to emergency departments in the first place, compared to patients with any other type of injury.

And if they do make it to my emergency department alive, I am less likely to be able to save them. Recent studies suggest that 25 to 35 per cent of patients with firearm injuries die after hospital arrival, versus only 5 to 10 per cent of patients injured in other ways.

Gunshot wounds are also scarier, for patients and their families, than other types of injury. The sheer terror in

the eyes of my patients who have been shot is, frankly, unforgettable.

We cannot stay silent. It’s unconscionable for us as healthcare professionals – or for the public at large – to stand by. This epidemic is decimating our country not just physically, but also emotionally.

The science of firearm injury prevention has stalled. A law passed in 1996 prevents the Centers for Disease Control and Prevention from advocating gun control.

It does not forbid federal funding of firearm-injury prevention but nonetheless it has had a chilling effect on the field. There has been a dramatic decrease in funding, researchers, publications and the quality of the science.

iStock

The Doctor will see you now

ENOUGH IS ENOUGH: The shooting of 20 children at Sandy Hook Elementary School in Newtown, Connecticut turned the debate into a public health issue

28 thedoctor | January 2019

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iStock

who was part of a grant (based at University of Michigan) from the National Institute of Child Health and Human Development to restart the science of paediatric firearm-injury prevention. It’s a terrific first step.

RANNEY: ‘This epidemic is decimating our country’

So we have committed to finding other ways forward.

This was the motivation for the creation of AFFIRM Research (the American Foundation for Firearm Injury Reduction in Medicine). It is non-partisan, nimble, and committed to doing what healthcare does best: saving lives through evidence and action. Also, recently, I was one of a number of researchers across the USA

WHAT THE PAPERS SAID: US newspapers in the days immediately following the school shooting at Sandy Hook in 2012

I have spent my career researching the overlap between violence and mental health, particularly as it intersects with technology.

Some of my projects include automated text-message programmes to reduce fights and depression among youths with histories of fights; to evaluate social-media predictors of post-traumatic stress among youth exposed to school shootings; and to develop solutions to the cycle of bullying, physical fights, and gun violence that plague our youth.

What strikes me most about my work is the degree to which our youth feel lonely and scared. They are desperate for meaningful social connections. I’m honoured to get to provide some innovative solutions for these youth through my funded research.

iStock

I was warned by mentors to ‘stay away’ from the issue because it would doom my career. This attitude started to shift after Sandy Hook [the school shooting in 2012 in which 20 children were murdered], when many of us began to say ‘enough – it’s time to treat gun violence like the public health issue that it is’. This momentum has grown, year after year and tragedy after tragedy.

The #ThisIsOurLane Twitter response [to the National Rifle Association of America saying last November that ‘someone should tell self-important antigun doctors to stay in their lane’, after which emergency physicians tweeted pictures of the effect of treating firearms violence] occurred because of the long, hard work that many physicians and other healthcare professionals have been doing for years: this issue is about human lives, not political debates.

Approximately 40 per cent of American physicians are gun owners. Being a gun owner doesn’t negate a doctor’s commitment to public health and injury prevention. We are collaborating across the political spectrum to promote gun safety and common sense.

I predict that in five years, it will no longer be debated: the American public will fully accept that gun violence is a public health issue, and we will be well on our way to creating solutions.

The public already sees gun violence as the core issue of our time. It is destroying communities across the USA, physically and psychologically.

As healthcare professionals, within and outside AFFIRM, we know there is hope.

Megan Ranney is an associate professor of emergency medicine at Brown University, Rhode Island, and chief research officer of AFFIRM Research thedoctor | January 2019 29

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it happened to me Doctors’ experiences in their working lives

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Out of touch As the burly 60-year-old man lumbered on to the couch, my eye caught the laminated notice on the wall.

‘Would you like a chaperone?’ I asked.

He looked startled. ‘I’m a big lad, love!’

‘I think we’ll be alright with each other,’ I agreed.

We laughed nervously.

I regretted the introduction of bizarre, slightly distasteful innuendo into a relaxed consultation.

Before the GMC and Care Quality Commission issued guidance, I had never considered I needed a chaperone. When a trainee informed a middle-aged man that she wasn’t prepared to examine him alone, I was surprised.

Apparently, a witness was not only supposed to prevent doctors mistreating patients, but also deter them from molesting us. A mundane aspect of my job had become fraught with the possibility of actual, or falsely alleged, sexual assault.

By the time I’ve defined the quaint word, outlined to the erstwhile trusting patient the hazards of being examined by me, and recorded everything and got consent, there is barely time to give the genitalia the thorough drubbing required.

There are sporadic, depressing instances when medics abuse the trust implicit in the doctorpatient relationship. Mostly their motives are bleak and manipulative. But sometimes,

they are just inexcusably crass.

Long ago we were taught, ‘if you don’t put your finger in it, you’ll put your foot in it’.

A conscientious doctor was expected to perform rectal examinations ‘just in case’ at every clerking.

Only patients fortunate enough to have had a recent myocardial infarction, in whom rectal stimulation was purported to risk arrhythmia and sudden death, were excused.

I recall one student who decided he lacked experience of the art. Without informing anyone, he spent an afternoon drawing the curtains around each bed in succession on the ward, and slipping behind to perform a rectal examination on every patient. Nobody remonstrated, and the tea trolley rattled along behind.

As doctors we invade our patients’ personal space many times a day. It is easy to become blasé, and forget the flux of power and vulnerability. I remember the first patient I ever touched: a frail, jaundiced man during a ward round.

Encased in my oversized starched white coat, which somehow absolved us from the strange intimacy, I tentatively kneaded his knobbly liver edge. Although he smiled encouragingly, I struggled to overcome an instinctive reluctance and my fear of hurting him.

These days, I must make a conscious effort

not to grab my patients, tug at their clothes and position their body parts for my convenience. Just as a plumber cannot do his job without enthusiastic deployment of the plunger, we cannot do ours without touch. We can diagnose the wince of the fibromyalgia patient and the flinch of the trauma victim. We reach out to establish rapport.

Yet I feel constrained to hug the bereft with the warmth that once felt natural.

Instead, I suffice with a pat on the hand, and push the tissue box across the desk. As a small, increasingly raddled female GP, I know I am less likely to be accused of assault than differently endowed doctors.

Still, I deplore the insidious effects of another example of over-regulation, which encourages patients to be wary of their doctors, and us to be terrified of them.

Jo Cannon is a GP in Derbyshire

thedoctor | January 2019

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what’s on

January 26-27 BMA junior members forum, 10am, Brighton 30 Practical skills ... for effective communication, 9am, Glasgow 31 Self care, self aware: your health matters, 9.30am to 1pm, Acton Trussell, Staffordshire

February 02 Clinical academic trainees conference, 10am, London 04 Appraisal training for consultants and SAS doctors, 6pm, Belfast 05 Pride in Care: Improving the healthcare of older LGBT+ patients, 6.30pm, BMA House, London. Call BMA London regional

coordinator Andrew Barton on 020 8655 8863 for more details 08 Planning for retirement seminar – delivered by the BMA, 9.15am, Edinburgh 11 CESR seminars for SAS doctors, 1.30pm to 4.45pm, London 13 Disciplinary and grievance procedures, 9.30am to 4.30pm, Edinburgh 20 Disciplinary and grievance procedures, 9.30am to 4.30pm, Glasgow

25 Job planning workshop, 6pm, Belfast

19-20 LMC conference UK 2019, Lanyon Place, Belfast

27 Consultants conference, 9am, London

29 Conference of medical academic representatives, 9am, London

March 05 Practical skills ... time management and taking control, 9am, London 05 Public health medicine conference, 9.30am, London 15 BMA retired members conference, London

April 02 Practical skills... leadership and management for doctors, 9am, Birmingham 09 Introduction to critical appraisal workshop, 9am to 4pm, London

Visit bma.org.uk/events for full details Download the BMA events app at bma.org.uk/events/events-app

Leadership and management for doctors Time management and taking control Effective communication

Non-clinical masterclasses Develop your career with new skills you can use immediately bma.org.uk/masterclass

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20% off Use discount code JAN2019

This offer is available until 27 January 2019

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