Health Committee One-off session with the Secretary of State

Link to video of debate

Yesterday the Health Committee met with the Secretary of State, Jeremy Hunt. I watched the broadcast and made comments on the Facebook page about my initial impressions. Here you will find a summary of the items related to mental health. It is not intended to be a word for word account but I have attempted to keep the context of the questions and responses. There are a few links in this piece to documents of interest.

To start, below are the members of the committee:

Health Committee

Dr Sarah Wollaston was elected as Chair of the Health Committee on Wednesday 12 July 2017.

The remaining members of the Committee were formally appointed on Monday 11 September 2017.

Member Party
Dr Sarah Wollaston (Chair) Conservative
Luciana Berger Labour (Co-op)
Mr Ben Bradshaw Labour
Dr Lisa Cameron Scottish National Party
Rosie Cooper Labour
Dr Caroline Johnson Conservative
Diana Johnson Labour
Johnny Mercer Conservative
Andrew Selous Conservative
Maggie Throup Conservative
Dr Paul Williams Labour

Overall I found it to be an interesting and constructive meeting. I sensed a few areas where Jeremy Hunt seemed uncomfortable and defensive, but I generally got quite a good impression of him.

To help with some of the acronyms used:

JH = Jeremy Hunt

CQC = Care Quality Commission

CCG = Clinical Commissioning Group

NICE = National Institute for Health and Care Excellence

The mental health questions start about an hour into the video:

Questions from Luciana Berger

Luciana Berger
Luciana Berger

Q According to NHS Workforce statistics there are 5,168 fewer Mental Health nurses and 106 more doctors. In a recent interview JH quoted 4,000 more people.

Response

There are 4,300 more people working in NHS Trusts than 2010 and 2,700 people in Talking Therapies

Q Who are these people?

Response

There is a whole range of skill sets involved in an NHS Mental Health Trust. The reduction of nursing staff is a consequence of the Francis inquiry into Mid Staffs. Nurses were put in to hospitals which had a direct impact on mental health nursing. But the NHS are treating 120,000 more people every year than 3 years ago which equals 1,400 more every day. There has also been an expansion in therapies.

{Later on in the meeting the Chair requested details about the extra mental health staff and the talking therapies}

Q Why are we seeing an increase in children and adults presenting at A&E in mental health crisis. There is a 47% increase in people being detained under the Mental Health Act

Response

Professor Sir Simon Wessely has been asked to review the Mental Health Act, how it works and whether it needs to be changed. {A copy of the details of the independent review can be found here.}

The Health and Social Care Act 2012 legislation regarding Parity of Esteem between physical and mental health requires that a mental health crisis is dealt with as seriously and quickly as that of a physical health crisis. The NHS are rolling out crisis care including liaison psychiatry across the country. Currently half of the total A&E departments have mental health liaison services. This is part of the Core 24 Standards.

Q Why are so many people are turning up to A&E in crisis who are often having to be detained, instead of being dealt with prior to this through prevention or community services

Response

There is a core responsibility to deal with both crisis and prevention. Resources are being put in to place to deal with preventing crisis

Q CQC reports have highlighted many issues at all stages of accessing mental health care. In regard to resources JH has been quoted as saying that there has been an increase in resources by spending over half a billion pounds more on mental health this year. Why is it that many trusts, including Liverpool, are cutting mental health services

Response

Mental health spending is up 1.4 billion in the last 3 years. Last year out of 209 CCGs 177 spent their mental health target and 32 did not. There are discussions going on with those that did not. The overall impact was that an extra half a billion pounds was spent last year.

Q Money comes in to the trust but there is nothing to hold them to account to make sure it reaches the front line. There is not a requirement for every CCG to meet the required investment.

Response

Last years CCG funding went up. There are ongoing discussions to sort out issues. There has been overall expansions but there are still problems.

Q Locked mental health rehabilitation wards. There are 3,500 patients across the country in 248 wards. The majority are in private hospitals. The CQC report has questioned this model of care

Response

There is a concern about people being locked away in expensive high dependency settings for longer than necessary. If they are far from home they may be forgotten about. JH has had a meeting with officials who are coming up with a recommendation. As an example of good practice, JH quoted that Sheffield have eliminated their dependency on locked rehabilitation by providing better community care.

Questions from Dr Lisa Cameron

Dr Lisa Cameron
Dr Lisa Cameron

Pathway of care from child to adult services. The transition is often fragmented and difficult to streamline. Are you making progress?

Response

This is an area we need to improve. We have a children and young people mental health Green Paper coming out.

Q Access to psychological therapies. How are you monitoring time logged as being access to treatment?

Response

The target is for treatment to start within 18 weeks. This has just started to be measured. Demand is increasing and there is also the implementation of the Mental Health Forward View.

Q Target monitoring and parity of definition

Response

JH will write a detailed response

Q Mental Health in older adults. In the transition from health to social care it is important that psychological issues are addressed. Especially around depression and loneliness in older adults,

Response

This is an important issue which is not always given the importance it deserves. 40% of older people in care homes suffer from depression or anxiety compared to 20% of the older population as a whole. Sometimes mental health needs are clouded by physical health needs. The NHS are planning an expansion in the capacity of psychological therapies in order to meet these needs.

Questions from Dr Paul Williams

Dr Paul Williams
Dr Paul Williams

Q Waiting times for Autism diagnosis in children. NICE guidelines state that a multi agency assessment of a child with suspected Autism should start within 3 months. In some parts of the country families are waiting for up to 4 years. Will you consider a Waiting Time Target for Autism assessment. Diagnosis requires health services to work in partnership with Local Authorities. What can be done.

Response

We need to do better. JH will look in to this and will discuss the issues with the NHS

Follow up question from Dr Lisa Cameron

Q Do you have a map of how many clinicians are trained to diagnose autism and where there are gaps?

Response

JH will find out


The next item to be shown on Parliament TV that I am interested in is on 3 November 2017 when the second reading of the Mental Health Units (Use of Force) Bill will be presented in the House of Commons.
A video link will be available on our Facebook page from 9.25 am.

 

 

 

My research diary – The Citadel by AJ Cronin

20th October 2017

I’ve started reading the eBook I bought earlier. It is cited as being influential in the setting up of the NHS.

Published in 1937, I am hoping it will give me an insight to conditions before the 1940s. AJ Cronin knew what he was talking about:

“Born in Cardross, Scotland, A. J. Cronin studied at the University of Glasgow. In 1916 he served as a surgeon sub-lieutenant in the Royal Navy Volunteers Reserve, and at the war’s end he completed his medical studies and practiced in South Wales. He was later appointed to the Ministry of Mines, studying the medical problems of the mining industry.”

Cronin, A. J.. The Citadel (Bello) (p. 2). Pan Macmillan. Kindle Edition.

I also discovered that there is a 1938 film, so I watched it.

The story begins with a newly qualified doctor (Andrew Manson) arriving for his first assistant post in a mining community in Wales. The doctors’ sister (Blodwen Page) explains that the Mine has 3 doctors on its list, of which her brother is one. The miners have money deducted from their wages to cover medical costs. This money is paid to the doctors according to how many patients they have registered with them. But Andrew discovers that Dr Page is bedridden and he is expected to run the practice alone. The fees from the miners are given to Blodwen Page and Andrew works as a doctor on the salary of an assistant.

Dr Denny, the assistant  of a rival doctor, describes the conditions:

“There’s no hospital, no ambulance, no X-rays, no anything. If you want to operate you use the kitchen table. You wash up afterwards at the scullery bosh. The sanitation won’t bear looking at. In a dry summer the kids die like flies with infantile cholera.”

Cronin, A. J.. The Citadel (Bello) (pp. 13-14). Pan Macmillan. Kindle Edition.

After working for Doctor Page for a month, Andrew discovers the reality of healthcare in Britain:

“Denny at first had aggravated him intensely by his weary contention that all over Britain there were thousands of incompetent doctors distinguished for nothing but their sheer stupidity and an acquired capacity for bluffing their patients. Now he began to question if there were not some truth in what Denny said.”

Cronin, A. J.. The Citadel (Bello) (p. 28). Pan Macmillan. Kindle Edition.

Andrew and Denny discover an outbreak of Typhoid Fever, and they identify the source as being a well. The two of them advise all of their patients to boil the water before drinking it, and with treatment the epidemic comes under control. But their efforts to deal with the source come to nothing:

“It’s the main sewer that’s to blame. It leaks like the devil and seeps into half the low wells at the bottom of the town. I’ve hammered at Griffiths about it till I’m tired. He’s a lazy, evasive, incompetent, pious swine.”

Cronin, A. J.. The Citadel (Bello) (p. 21). Pan Macmillan. Kindle Edition.

There is an interesting section of the book which didn’t make the film. It is about a suspected case of madness. One of the miners had been:

“acting strangely lately, getting into trouble at the mine, losing his memory. He had turned quarrelsome and violent. ‘I don’t like it, Manson.’ Bramwell nodded sagely. ‘I’ve seen mental trouble before. And this looks uncommonly like it.’”

Cronin, A. J.. The Citadel (Bello) (p. 58). Pan Macmillan. Kindle Edition.

The patient had set upon his wife with a bread knife and Andrew receives a note asking him to attend as two signatures were needed to “certify a lunatic”. Andrew attends the patient and examines him:

“He went over to Emlyn and at first he hardly recognised him. The change was not gross, it was Emlyn true enough, but a blurred and altered Emlyn, his features coarsened in some subtle way. His face seemed swollen, the nostrils thickened, the skin waxy, except for a faint reddish patch that spread across the nose. His whole appearance was heavy, apathetic. Andrew spoke to him. He muttered an unintelligible reply. Then, clenching his hands, he came out with a tirade of aggressive nonsense, which, added to Bramwell’s account, made the case for his removal only too conclusive. A silence followed. Andrew felt that he ought to be convinced. Yet inexplicably, he was not satisfied. Why, why, he kept asking himself, why should Hughes talk like this? Supposing the man had gone out of his mind, what was the cause of it all. He had always been a happy contented man – no worries, easy going, amicable. Why, without apparent reason, had he changed to this!”

Cronin, A. J.. The Citadel (Bello) (p. 60). Pan Macmillan. Kindle Edition.

Andrew diagnoses thyroid deficiency and after successful treatment the patient is returned to his former self.

After a while Andrew has an argument with Miss Page over money. His frustrations about his assistant status lead him to give notice and leave the practice. He finds a post as a qualified doctor and applies for it. He is interviewed by a committee which is made up of medical experts and miners:

“About thirty miners filled the room, seated, and all of them smoking, gazing at him, with blunt, but not unfriendly curiosity. At the small side-table was a pale quiet man with a sensitive, intelligent face who looked, from his blue pitted features, as if he had once been a miner. He was Owen, the secretary. Lounging on the edge of the table, smiling good naturedly at Andrew, was Doctor Llewellyn. The interview began. Owen, in a quiet voice, explained the conditions of the post. ‘It’s like this you see, doctor. Under our scheme, the workers in Aberalaw – there are two anthracite mines here, a steel works and one coal mine in the district – pay over a certain amount to the Society out of their wages every week. Out of this the Society administers the necessary medical services, provides a nice little hospital, surgeries, medicines, splints, etcetera. In addition the Society engages doctors, Doctor Llewellyn, the head physician and surgeon, and four assistants, together with a surgeon dentist, and pays them a capitation fee – so much per head according to the number on their list. I believe Doctor Leslie was making something like five hundred pounds a year when he left us.’ He paused. ‘Altogether we find it a good scheme.’ There was a mutter of approval from the thirty committee men.’”

Cronin, A. J.. The Citadel (Bello) (pp. 96-97). Pan Macmillan. Kindle Edition.

Andrew accepts the job offer and the house that goes with it, on the understanding that he is engaged to be married. The miners prefer a married man attending their wives and daughters. Andrew proposes to his girlfriend and is able to take up the position of GP with immediate effect.

To be continued………….

Observations

If this is based in truth, it seems that the system is inadequate. The miners, or shall we say the end users, seem to have too much influence in the running of the practice. Andrews employer, Dr Page, is kept on as a GP despite the fact that he is unable to perform his duties. This is the result of his patients loyalty allowing him to stay on the company books. This in turn affects the status and pay of Andrew who is running the practice alone but not receiving the financial reward or professional recognition for doing so. There is also the possibility that Dr Page and his sister rely on the fees from the mining company and would not have the financial means to retire.

There are a lot of examples of incompetence by doctors and Public Health representatives. I have also picked up a sense that most of the GPs either don’t know or don’t care about the symptoms of their patients and are happy to fob them off with ineffectual remedies. There seems to be an attitude of “things have always been done this way, why change now?”. This distrust of new methods becomes more apparent later in the book.

Till next time.


As a footnote, the father in law of my Great Aunt was a doctor and surgeon from the late 1880s. He died in 1938. So I’ll see what I can find out about his career. The information I have at the moment suggests that he had a surgery in Yorkshire and also worked at the hospital. He left £21, 267 12s 11d to his daughter. The equivalent value is about £610,000. They were wealthy enough to have a governess, a cook and a private nurse (I’m not sure if she was just for the family or whether she also worked in the practice) and they could afford to go to Australia for a holiday (I think there were relatives there).

 

 

 

How to get help in a crisis

There seems to be a lot of coverage of mental health issues and talking about emotions. Which is brilliant.

But how easy is it to actually get help if you are in crisis?

The first step should always be your GP. A GP can listen to your symptoms, prescribe medication, order tests and refer you to more specialist services. The first two, listening and prescribing, are relatively quick. Medication can take a while to start working effectively, but often the knowledge that something is being done can make a huge difference. I know this because the last time I increased my dose I went back for a follow-up appointment a few weeks later. The doctor asked how I was feeling and I told her how wonderful everything was. She then told me that the increased dose won’t actually kick in for another couple of weeks!

Further tests, usually blood tests, can help to diagnose if it is depression or another condition that has similar symptoms. So it is important to follow this up.

Referral to specialist services is something that takes time. On the Transparency Indicators for NHS Trusts there are indicators for:

  • People waiting less than 6 weeks to start treatment
  • People waiting less than 18 weeks to start treatment

If you’re anything like I was and you’ve struggled for years without knowing what’s wrong or what can be done about it, when you need help it is urgent. Six weeks are an eternity if you struggle to get through one day.

So this is why you should seek help as soon as you think you have a problem. This is easier said than done. I struggled for 2 years, probably more, before I sought help of any kind. And when I did get help I was sent to hospital.

If you are in crisis, you can only access the crisis support team if you have already been referred by your GP. Local charities may only help if you have been referred by your GP.

Once you are in the system you can access other services. Referral to a Mental Health team, access to psychiatrists and therapy and access to a crisis support team. These all come with a waiting period. So the trick is to get in the system before you need help. Which doesn’t make sense. To me.

However, there are options open to you if you don’t have a referral: 

Listening and emotional support services via telephone or internet.

Emergency or Out of hours GP appointments

Accident and Emergency

Support Group

Counselling (fee paying)

See our How to get help A-Z page for details. Please tell us of any other services that you are aware of or that have worked well for you.

My research diary

9th October 2017

 

 

It’s been a while since I felt able to do research. I have tried to get other people involved in helping by joining Helpfulpeeps, a website that puts people in touch with each other with the aim of helping each other. No cash involved. I have had a little interest and am still hopeful that help will arrive.

I think I have discovered that researching the services on offer in the UK is not my strong point. So I have decided to concentrate on the things I find easier to do, writing blogs and reporting on news items.

I have decided to turn my attention to researching the history of the NHS and how it was before the NHS came into being.

This sounds like a project more suited to my strengths as it involves history. I have already found a useful article in Wikipedia which I will use to guide me through my research, and I have bought 2 books (another love of mine) which I am hoping will provide some information. The first book is The Citadel by AJ Cronin, which I have downloaded as an eBook. Apparently, this novel published in 1937 instigated criticism about health care in England and it is cited as being  important in laying the foundation for the NHS.

The other book I have ordered is The Dawn of the Health Age by Dr Benjamin Moore. It was published in 1910. This synopsis is a quote from Amazon:

“written by an Englishman, it applies to conditions in the United States as well as in Great Britain. The author endeavors to demonstrate the necessity for an entire remodeling of the present system of medical service in the interest of the whole community, by showing that thousands of lives and millions of money can be saved every year if disease is attacked on scientific principles “instead of being dallied with as at present.” Dr. Moore advocates a system of state medicine by which competent physicians are made officers of the state for the suppression of disease…”

This sounds quite interesting and useful as a reference point. I just hope that it is easy to read as I often find my attention wandering.

That’s where I’m up to at the moment. I shall try to keep you posted as to my progress.

 

 

Disability Benefits

If you’re aged 16 to 64 you could get between £22 and £141.10 a week by claiming Personal Independence Payment (PIP).

The amount you get depends on how your condition affects you, not the condition itself.

You’ll be assessed by a health professional to work out the level of help you can get. Your rate will be regularly reviewed to make sure you’re getting the right support.

PIP is made up of 2 parts. Whether you get one or both of these and how much you’ll get depends on how severely your condition affects you.

Daily living part

The weekly rate for the daily living part of PIP is either £55.65 or £83.10.

Mobility part

The weekly rate for the mobility part of PIP is either £22 or £58.

Terminal illness

You’ll get the higher daily living part if you’re not expected to live more than 6 months. The rate of the mobility part depends on your needs.

How you’re paid

All benefits, pension and allowances are paid into an account, for example your bank account.

I worked until 2013 when anxiety made it impossible. I receive PIP, but it’s a horrendous and scary process. The last time I went for an assessment there was a man in tears. He was having a panic attack. He just couldn’t cope. I was quietly panicking inside too. This is a phenomenon that is normal for me: when I see a GP about my mental health I always worry that they won’t believe me. Because it’s not always visible. I always feel under pressure to prove to them that something is wrong. I get anxious and clammy and prone to tears. It is a recurring fear even after all these years.

We are lucky that in the UK we have access to financial help from the Government if we are unable to support ourselves financially. Unfortunately, receiving that help is not always straightforward.

I get that the Government do not have a bottomless pit of cash available and need to know that it is being given to the right people. And I understand that there need to be rules to minimise the chances of giving money to people who are able to earn money for themselves. This is not in doubt.

What concerns me is the increasing number of horror stories I have come across. A lady in a support group I’m in posted about how her PIP has been stopped because she appears to be able to cope. She suffers from a mental illness. She has probably spent her entire life “appearing to be ok”. That doesn’t mean she is. She is distraught.

So I’ve taken another look at the form you have to fill in. This is a specimen copy.

This form is geared towards physical health. It is very difficult to explain your state of mind by simply answering these questions. For example, question 3 is about preparing food:

pip
What I want to say to this is:

“I don’t need any special aids but due to my food disorder I struggle to feed myself. I am able to cook but I often find that I can’t be bothered, or I forget, or sometimes my head will say that although I’m feeling hungry I don’t actually need to eat.” So a and b will both be NO, and then a long rambling explanation goes in the any further comments section. And so it goes on with questions like “Are you able to wash yourself”, “Yes, but I often can’t be bothered and I’m only going to put my nightie on again at bedtime so what’s the point?”

There is an area on the form where you have to list your medication and health professionals. Surely this in itself is an indication of your levels of fitness to work? It seems that nobody follows this up. At least, I don’t have any evidence from my own experience that this happens.

This is a Last Leg Correspondents report that covers PIP from the point of view of someone with cerebral palsy:

I have a solution which will work for the physically ill and the mentally ill. It is a simple idea. This is for people with an ongoing condition, ongoing meaning, a specified number of  years. Let’s say 2. The initial form could have a box asking how long you have suffered with your illness or condition. There could be another box to give the DWP consent to contact your GP. If you have a genuine ongoing condition there will be copious notes and letters in your medical file which support your claim. These notes can then be given to a neutral GP/specialist to read. This is to get a 2nd opinion. If there is any doubt, a medical assessment can be arranged. If the 2nd opinion concurs with the GP notes, you are automatically entitled to financial support. That’s it. No assessment, no trying to prove you are ill. The trick here is for the DWP to liaise with the medical profession and it is down to the DWP to prove that a person is NOT ill. Yes, there is probably extra work for the DWP going to hundreds of GPs for information and then reading the opinion of the doctor who has conducted the 2nd opinion. But the pay off is that the DWP can then concentrate on the people who are actually trying to cheat the system. So in my mind this is a win-win situation.

I realise that I haven’t covered the financial side, I haven’t thought of a solution for that yet. But does this sound like a workable solution? What are your thoughts?

 

My research diary

22nd September 2017

I have decided to start using dates instead of a day count. My research is sporadic, some days I’m just not up for it. And anyway, I keep losing count!

Yesterday I was quite excited. I watched a video about the German Healthcare system. I have not corroborated the facts yet, but I found some similarities and a few differences. The point that intrigued me most was that the German General Practice system has a maximum patient limit. It also scored very highly on patients getting appointments either the same day or the next day.

I hate making appointments to see my GP.

The phone lines open at 8.30 am.  Everybody tries to phone as soon as the practice is open for business because everyone knows that everybody else is doing the same thing and they need to be quick to get an appointment. Then the line is constantly engaged because everyone is phoning……

When you get a ringtone (oh joy) it doesn’t necessarily mean you will get to speak to someone. Sometimes you just have to wait for the phone to be answered (the poor receptionist is trying to answer the phone and help patients who are in the surgery and get medical notes for the doctor….etc), or you might get put through to another receptionist who tells you that your call is on hold, please wait.

Eventually, you speak to someone. They offer available times, take your details and you’re in. Or not. “Sorry, there are no appointments for today, phone again at 8.30 tomorrow”. WHAT??!!

I can’t decide which is worse. Going through this when you are also trying to get ready for work or maybe are on speakerphone and automatic redial because you’re driving to work, or you’re at home with small children who are refusing to eat breakfast; or going through this when you are crippled with anxiety, not sleeping properly and have hauled yourself out of bed because you need to phone at a specific time. In all cases anxiety levels are bound to be high. Tempers will flare. You may start shouting at the receptionist because you are so frustrated and have lots of more important things to do and don’t have time for this but need to see a doctor. Today. You wouldn’t be phoning otherwise.

How do receptionists stay sane in this environment?

Writing this has given me an idea. (And I’ve noticed that I have deviated from my main point a little.) In my surgery, if you get told to phone again the next day, there is no guarantee that after going through the same process the next day you will be given an appointment. My idea is that a system be created to give priority to people who have phoned previously. This might get complicated and involve urgency ratings (because there have to be appointments available each day). I haven’t thought it through yet.

This is why I either don’t make the appointment at all (I’m fine, really, I don’t need to go) or if I’m desperate I use the electronic appointment system. (I have been using the electronic repeat prescription services for a few years now because getting an appointment to see a doctor to say I need more tablets was way too stressful – I suffer from anxiety). Electronic appointments are much easier, but there are only advance bookings, and sometimes advance means a few weeks away.

I think you can safely say that I don’t like the system as it is.

So in Germany a practice has a maximum number of patients. This initially excited me because the easy access to appointments appeared to be a direct consequence.

Looking in to how it would work over here, I’m not so sure now. We have a GP system where we are free to register with whichever practice we think suits us best. The practice is legally bound to accept your registration unless there are reasonable grounds not to, which must be explained. I like this, freedom of choice. This is to help people who want a GP nearer to the place they work, someone who has moved but wants to keep their family GP, or someone who feels they are not getting their needs met at their current practice.

But this freedom of choice means that practices can get oversubscribed. Which is why I can never get an appointment and when I do I have to regularly wait half an hour after the appointment time to actually get seen. And this must also have a huge impact on doctors and nurses and receptionists……..

Do we need more doctors for the growing population? Where will they come from? How long will it take to get them trained? Who is going to pay for them?

The Royal College of General Practitioners (the body which regulates family doctors in the UK) produced a report on patient access in 2015. It has some interesting arguments and can be downloaded here.

Lots of questions, not many answers. Yet.

 

 

 

 

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