September 2005

 

 

The Things They Say

 

In the uncertain privacy afforded by the curtained off bay in A&E majors, I see my next patient, Mrs Bellinger. She is a 55 year old lady who’s complaint of indigestion on a Sunday afternoon had worried her husband enough to call an ambulance. He was nowhere to be seen and my patient smiled at me looking disarmingly well. I went through the usual questions as I took the history but noticed a degree of hesitation before she answered me. She did not seem unduly concerned by her symptoms which had now left her and she had no pain at all. As we progressed through the routine of a medical clerking, I asked her whether she was seeing her GP for anything. She replied “do you know doctor, there is something I’m being investigated for at the moment, but I can’t remember what it is.” In a flash of genius, I prompted her “dementia?” She beamed at me, “yes doctor, that’s it, mmmmm” a thoughtful look came across her face. “Alzheimer’s?” I suggested. “Why yes, of course, how silly of me to forget.” I did not know whether to laugh or cry.

 Mrs Bellinger’s smiling face gave me permission to enjoy the moment, but I knew that somewhere deep within I ached for this lady. She seemed far too young to be plagued by this condition, life can be very unfair. Not only that I was wondering why she was here alone. Where was her husband?

 Then I thought of my own father-in-law, a good deal older than my patient but nonetheless walking the same grim path. He seems oblivious to his fate now, but his wife lives on in the battlefield, fighting in the full knowledge that short of a miracle his condition will only get worse. I look on with admiration at her courage. This man whom she married and who has for many years  been her best friend and companion, becomes more child-like by the day. Once he was obsessional in his control of their finance, now she is employed by him as his carer, but he does not even know it. Once he spent most of his time out in the garden pruning his roses and considering what new variety he would next purchase. He fussed over them, tending them with fertiliser and rose feed until the precious flowers emerged to be admired by anyone who should visit the house. Now he sits in his chair looking out on the garden bothered only by the fact that he cannot remember where his glasses are. He calls out desperate not to be alone and holds his wife’s hand, scared by something but he knows not what. He wakes his wife at night, crying out with nightmares or just because he cannot sleep. When he wakes, he clambers out of bed but cannot find the bathroom, let alone the toilet. She knows that incontinence is waiting round the corner and is preparing herself for this eventuality. Still she has her cheerful smile and apologises for the cakes she hasn’t had time to make!

We watch on mindful of our own destinies, wondering whether the same fate awaits us but denying the possibility. Medical advances are being made. Look at the progress over the past few decades. Our life expectancy is longer than it has ever been in the history of our nation. We will even be working longer. Is it so that we will be preserved from years of boring retirement? No, the reality is that our longevity comes at a price. Of course, we are all rejoicing at that. We need to keep our minds productive, play chess, enter competitions, read books. We need to keep our bodies in good shape, a good brusque walk at least five times a week. What about our dignity, how do we preserve that? I haven’t heard of any proscribed solutions. As far as dementia is concerned, all I know is that the only glimmer of hope was for drugs which may delay its relentless progression. They are no longer recommended. They cost too much. The NHS has finite resources you know.

I wonder what Mr Bellinger is doing now. Perhaps he’s at home having a well earned rest, maybe he has his feet up watching the football or maybe he’s gone to bed for a snooze. I call his number and there is no reply. I worry now, concerned about him, maybe he’s become the wanderer walking the streets, tears running down his cheeks as he mourns the slow demise of his dear wife…….

My speculation is brought to a close by the appearance of a hassled looking man accompanied by a young women, his daughter it seems. “Oh doctor, I thought she was having a heart attack, I called the ambulance straight away. I couldn’t let her die, not like that, I would never forgive myself.” I looked at him with incredulity. “Are you Mr Bellinger?” I asked. “Yes doctor, she will be alright, won’t she? She has Alzheimer’s you know.”  At this point he burst into tears, “Betty, my Betty, please don’t die Betty, you’re not ready for that. We have many more years together”.

So where do we go from here I wonder. Suddenly the meandering path of my conscious thought has come to an abrupt halt. I feel uncomfortable not knowing where to go. I cannot comprehend how this broken man can love so much that he would rather care for his wife as she loses her independence, than let her go. It humbles me to be reminded that my wishes and opinions are none other than that. There is no place to impose them on others and I should not assume that they are shared by my patients or their families either. Mrs Bellinger is obviously a lady worth fighting for. She will keep her dignity, but maybe it’s more in the eye of the beholder but just as valuable.

 

Dr Cathy Wield

Primhe Trustee

 

Cognitive behavioural therapy skills can be applied in general practice consultations

In the 3 September issue of BMJ Career Focus there is an informative article Cognitive behavioural therapy in general practice by Satwant Singh, nurse consultant in cognitive behavioural therapy from London, UK. “The word cognitive implies thoughts, and it is our thoughts that affect our behaviour. The theory of CBT is that emotional difficulties arise as a result of the way information is interpreted or misinterpreted according to the beliefs and assumptions that stem from our experiences in life, and that deep rooted beliefs stem from our early childhood experiences. Assumptions arise as a means of stopping negative emotions from being activated; for example, "If I please others, they will like me." Assumptions are adaptive mechanisms that are helpful in conducting our lives but become maladaptive when they become rigid and turn into a rule for living. CBT involves teaching patients to identify their negative automatic thoughts, which perpetuate the way they feel. These negative automatic thoughts can help to identify underlying beliefs and assumptions and help to develop a shared understanding of problems. The patient is taught to identify the thinking errors that are responsible for the misinterpretation of information and can then correct these errors by disputing their negative automatic thoughts; patients can then be taught how to have a more balanced view of the situations that disturb them. Behavioural experiments are carried out to test underlying assumptions and beliefs, which help to make these assumptions more adaptive. The process of therapy is collaborative and involves the active participation of the patient; the aim of therapy is to enable the patient to become their own therapist and deal with their psychological problems as they arise.”

“Cognitive behavioural therapy (CBT) is the most researched form of short-term psychotherapy, and treatment usually lasts for 12-16 sessions. Its efficacy is demonstrated by its application in a wide range of psychological disorders, including psychosis and bipolar disorder. In the UK, the recent National Institute for Clinical Excellence (NICE) guidelines recommend CBT as the first line of treatment for depression, anxiety, post-traumatic stress disorder, and as an adjunct treatment option for schizophrenia. General practice remains the first point of contact for the majority of patients who need to access help and treatment, and the demand and pressures for psychological services remain high. The use of basic CBT skills can enhance consultations, empower clinicians, and reduce the sense of hopelessness that sometimes comes when dealing with patients with psychological problems. In addition, the use of these skills will gradually enable patients to start dealing with their problems in a different way.

”Aspects of CBT relevant to general practice include:
- Can be used in all consultations
- Socratic dialogue allows shared understanding between patient and GP
- Helps to identify thinking errors
- Disputes patients' negative thinking
- Activity scheduling helps patients to plan their time in a more efficient way
- Suitable for a variety of psychological problems
- Therapist and patient work together to understand ongoing problems."

The writer concludes: “Using these skills does not mean that the clinician is acting as a therapist, but it improves the consultation so that there is more patient involvement, autonomy, and increased concordance; it is a positive experience for both the clinician and patient. These skills are easy to develop and improve with increased practice.”

BMJ Career Focus 2005;331:gp99. 3 September 2005. © 2005 by BMJ Publishing Group Ltd
Cognitive behavioural therapy in general practice, Satwant Singh. Correspondence to

Category P. Psychological, HSR. Health Services Research, PT. Professional Training. Keywords: CBT, cognitive behavioural therapy, general practice
Synopsis edited by Dr Stephen Wilkinson, Melbourne. Posted on Global Family Doctor 28 September 2005

 

 

 

Elizabeth Armstrong, a non-executive director at Northampton PCT, is so incandescent about the planned reconfiguration of PCTs that she has penned this letter to the Secretary of State.

 

“From:    Ms M E Armstrong

Email:

 

Rt Hon Patricia Hewitt MP

Secretary of State for Health

House of Commons

London SW1A 0AA                                                                                                           20 August 2005

 

 

Dear Ms Hewitt,

 

Reconfiguration of Primary Care Trusts

 

It would be an understatement to say that the recent letter from the Chief Executive of the NHS about the reconfiguration of Primary Care Trusts is unwelcome. It is unnecessary, damaging to staff morale and will only serve to distract senior executives and managers from other, more important, changes currently underway, such as Choose and Book, Payment by Results and self assessment against the new Healthcare Standards.

 

Moreover, the way it has been initiated, in the holiday season with totally unreasonable deadlines and no opportunity for Parliamentary debate, is extremely worrying. It is yet another ‘top down’ directive on top of many others the NHS has suffered over the past 20 years or so.

 

I have been involved in health care for over 45 years, as clinician, researcher, writer and teacher, and have lived through all of these. In my experience they cause dismay and cynicism amongst staff who feel that yet again they haven’t been consulted or considered. The resultant low morale can only adversely affect patient care, which is after all what we are here for. I believe that it is in the models of delivery of care, which are often outdated and do need change, that we should be focussing our efforts – and that is certainly what we are trying to do in Northamptonshire.

 

We do not need further tinkering with structures. The very fact that this has been done so often seems to suggest that it doesn’t work!

 

Furthermore, I do not believe that reconfiguration saves money. (I think there is recent private sector research evidence to back this contention). We are being asked to ensure that this new initiative saves 15% in management costs. In this area that is tantamount to an insult. As a Leicester MP you must be aware that Leicestershire, Northamptonshire and Rutland Strategic Health Authority is already the worst funded in the country, well below capitation. Northamptonshire is part of the South Midlands growth area and is already experiencing population increase every year. We struggle to keep up but we are achieving real improvements in health as our latest public health figures demonstrate. We should like to have some encouragement from the Centre to continue our work, not be distracted by what often seems to us to be an out of touch London-centric bureaucracy.

 

One aspect of this new reconfiguration is that PCTs should become solely commissioning organisations. What effect do you think that this idea will have (is having) on the community nurses, health visitors and school nurses we employ? And who do you suggest will provide these essential services if PCTs don’t? The private sector?  I suggest that would be totally unacceptable to both patients and nurses themselves.

 

Finally, this really is unnecessary! Reconfiguration of PCTs would probably have happened anyway. We already work very closely wit our local partners. But it would have happened organically, with consent and in tune with local needs and conditions.

 

Please reconsider this unwise and potentially disastrous intervention.

 

Yours sincerely,

Elizabeth Armstrong

Non Executive Director

Northampton Primary Care Trust

 

cc. Phillip Hollobone MP”

 

 

 

 

12/09/05 Healthcare Commission mental health patient survey

 

Users of mental health services have praised the care they get from NHS doctors, nurses and other specialist staff, including psychologists and social workers, in a major national survey published by the Healthcare Commission.  However, the survey also highlights a number of areas where care could be improved, including better emergency support and better information on the side effects of medication.

The survey of 26,500 users of outpatient and community mental health services, found that 77% rated their overall care as excellent, very good or good.  Less than one in ten rated their care as poor or very poor.

The need for better access to crisis care was highlighted by the survey, with 52% saying that they did not have the phone number of someone from local mental health services to contact in an emergency, despite guidelines in the National Service Framework (NSF) for Mental Health saying that they should.

The survey also found that only 40% had been given access to “talking therapies” such as counselling or psychotherapy in the last 12 months. This is despite strong evidence that a combination of drugs and psychological treatments can provide real benefits to people with mental health problems.

Questions are also raised by the survey about continuity of care. The majority (75%) of service users saw the same psychiatrist at their last two visits; one in four did not. Those who had seen the same psychiatrist on consecutive visits reported that they felt they were treated with more respect and dignity than those who were seen by different psychiatrists. Nearly half (44%) have had at least one appointment with a psychiatrist cancelled in the last 12 months.

Healthcare Commission press release, 12 September 2005

 

 

Ezine News

 

Issue 32 of NIMHE West Midland’s E Bulletin is now available from their website and can be accessed using the following link.

NIMHE West Midlands E bulletin Issue 32 link

 

To view London Development Centre Bulletin September 2005 please go

http://www.londondevelopmentcentre.org/index.php?topic=29

 

We noted two very interesting reports from the WHO:

 1) Mental Health Promotion - www.who.int/mental_health/evidence/en/promoting_mhh.pdf  

 2) Prevention of Mental Disorders - www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf