Month: October 2014

On paying doctors to diagnose dementia

Being paid by outcomes is no new thing in the NHS. In physical health, good outcomes are relatively easy to distinguish. In mental health, it’s more complex. Often, outcomes look at symptoms or daily functioning (often defined as ability to work, travel alone, etc), but these are blunt instruments for complex and often nuanced problems. It’s a fundamental truth that not all health is quantifiable and that not al treatment is quantifiable. It is perhaps as great a truth that the people who decide how health services should be commissioned and run don’t really get that.

Thus it was that I read with horror that GPs are to be paid up to £200 to diagnose dementia. There will be no ‘second opinion’ in this case – no one will verify the diagnosis, but there it will sit, on your medical records, colouring the way you are treated and interacted with for the rest of your life. The government says that this will increase the number of diagnoses of dementia made, which it doubtless will, if it will earn the diagnosers a small fortune. But a diagnosis which is incorrect is worse than useless; it is actively harmful.

Not that I am accusing all GPs of being mercenary. Far from it. Most GPs are dedicated to their patients and, I am pretty sure, have an ethical code which would stop them diagnosing for the sake of it. But some are less scrupulous. I am currently working in learning disabilities. People with learning disabilities tend to have poorer health than the rest of us and, when they become ill, they are more likely to die. Partly, this is because people with an LD often lack the knowledge most people have about the ways their bodies should look or feel and partly it is because they may have trouble communicating it. As such, tumours, abscesses and ulcers can grow and grow without anyone knowing until they become fatal. GPs are paid £100 to do an annual health check for someone with a learning disability – diabetes, breast, prostate and thyroid checks are all par for the course. Yesterday I was told that there are some GPs who have been found to pocket the £100 whilst palming off the health checks to unqualified care home staff. The parallels are clear. The acquisition of money can do terrible things to our sense of professionalism and it takes quite something to resist the lure of it..

But there’s a more fundamental point here. GPs have a breadth of skills and knowledge, but the clue is in the title, they are ‘general’ practitioners. They tend not to diagnose severe and enduring conditions; they, rightly, send you to a specialist. During training, I have spent six months working with older people, diagnosing dementia. I spent six months working in a specialist neuropsychology placement assessing people with stroke, multiple sclerosis, Huntingdon’s chorea, epilepsy, Parkinson’s and so on. Typically, an assessment, a thorough, robust, clinically-defensible assessment would take some four or five hours. With older people, it often takes longer because they fatigue more easily. Writing a report, up to nine pages long, takes hours if it is done well. To be sure, with practice, you can do it more quickly, but there is no substitute for a detailed clinical interview and a well-selected test battery. Neuropsychological assessments show what brain scans can miss and virtually always add real clinical value. That value is then translated into help for the person. I have written reports detailing a dozen recommendations to help the person manage better. It’s time-consuming, but it’s my job and it’s the right way to do it. The wrong way is to have a ten-minute appointment with your GP, be asked some crude questions to estimate your cognitive functioning and receive a diagnosis on the spot.

But, you might say, if the person gets a diagnosis, they will get treatment. Well, perhaps. But if the diagnosis is incorrect I question the point of treatment. And, unfortunately, they blunt truth is that we can’t do a lot for many dementias. There are tablets that work for some people, but they are only prescribed for very specific types of dementia, of which there are many. Thousands of people have dementias which cannot be treated by medication. There are ways to support such people, but a diagnosis is not always helpful and not everyone who has an assessment wants to know the outcome of it. Knowing can affect your ability to drive, your perceived ability to work and retain control of your legal and financial matters. It can make you pitied by your family and friends. It can make you terrified of the future. It cannot be easily undone and the effects cannot be avoided. There is no magic cure and, truth be told, having an assessment, even a good one, is something that people often think about very carefully. Now imagine all those consequences based on a poor assessment and a diagnosis of dubious nature, made in the context of £200 in someone’s back pocket, and think whether you would want your parent to be in that position.

On Nick Clegg’s promises of extra funding for mental health

This piece was originally written for the press and is due to be published later this month.

With a little over seven months until the General Election, all parties are gearing up to charm the electorate. A repeat of the hung parliament of 2010 is unlikely to be the ambition of any of the main parties, and it certainly doesn’t seem to have been terribly popular amongst the electorate.

Thus it was that I followed Nick Clegg’s speech on mental health provision at the Liberal Democrat Party Conference with interest. Having spent several years working in a range of mental health services, I applaud the fact that it is clambering up the political agenda, if rather more slowly than I would like. On the face of it, then, the content of his speech was positive: 75% of people referred for difficulties such as low mood and anxiety will be seen within six weeks; all those referred for psychosis will be seen within two weeks, funded with £120m over two years. Mental health charities were enthusiastic, but a closer look reveals rather more.

Nick Clegg’s party has been in government for over four years. In those four years it has privatised healthcare, including vast swathes of mental health. It has drastically reduced funding for social care and support services. It has slashed Housing Benefit and, courtesy of Workplace Capability Assessments, terrorised those on benefits. Its policies have led to the poor and the disabled being demonised by the media and the public at large. It has cut the number of beds available for people with mental health problems by 10%. It has presided over people being ferried halfway across the country for acute admissions because inpatient units are at breaking point. It has cut funding to such an extent that recruitment has been frozen. In my own profession of clinical psychology, this is especially evident: I know of services in which the waiting time for an assessment is nine months. Austerity is bad for our mental health: our waiting lists are increasing at exactly the point at which our capacity is reducing. Nick Clegg’s government has been implicated in every bit of this wretched tale. In short, it has decimated the mental health system and ridden roughshod over those who require it.

Having spent four years watching this sustained assault on mental health services, I see no reason to be enthused. Clegg’s proposals relate to waiting times; nothing has been said about how clinicians are meant to meet those targets without a sustained recruitment drive. We have limited capacity; we can’t simply see more people because Mr Clegg tells us we ought to. We can’t do more, with less. Mr Clegg is no fool: he is well aware of this. But he is also leader of a party which is likely to be decimated at the coming election. One can hardly blame him for trying to appeal to the electorate. I just wish he wouldn’t make promises which he will break to a group he and his peers have systematically persecuted over the past four years.

On the relative irrelevance of sex offender demographics

This piece was originally written for the press and published in September 2014. The delay in posting it here has been my own.

From Jimmy Savile to Rochdale: sometimes, it feels as though the news over the past couple of years has been about little other than the sexual abuse and rape of children. Major institutions have been charged with failing to investigate accusations of impropriety and of covering up the ‘open secret’ of celebrities having sex with minors. More recently, there have been the Rotherham scandals, involving gangs of men grooming and sexually assaulting young girls subject to the care system – a system which, quite obviously, failed to care for them adequately. It’s certainly not the case that everyone in care is preyed upon and exploited but a cursory glance at the facts suggests that care sometimes falls short: children in care have poorer educational outcomes, are more likely to have poorer emotional and behavioural health and to use substances than their peers who are not cared for by the State. Rates of criminality, mental health problems, teenage pregnancy and homelessness in adulthood are also higher. Frequently, children in care will have experienced early adversity, be it parental substance use, domestic violence or a history of abuse or neglect. These are often vulnerable individuals and they are likely to require enhanced support compared to other children their own age.

But all that has been forgotten. The press is busy describing the Rotherham offenders as ‘Muslim’ or ‘Pakistani’ or ‘of Pakistani origin’ or something similarly designed to tarnish all members of one or other community with the same brush. Cue counter-pieces stating, rightly, that not all paedophiles are Muslim, Pakistani or of Pakistani origin. The overwhelming majority of sex offenders in prison are white, though it would be incorrect to assume that the rates of reporting and conviction are the same across ethnic groups. Ethnic minorities, particularly those from Asian backgrounds, are less likely to report abuse because the dual burdens of shame and stigma continue to act as a deterrent. The effect is that ever-increasing numbers of children are raped and that rapists get away with it.

Personally, I have no interest in the demographics of paedophiles. You don’t violate a child because of your ethnic background, nor because you notionally subscribe to a particular faith. You violate a child because you disregard the rights of that child to only engage in consensual sex. It’s not about being Asian, or Muslim, or white, or Church of England. It’s simply about being a rapist.

As for the girls? Who knows? What we do know is this. Children who are sexually assaulted are more likely to experience mental health problems, including eating disorders, and to self-harm. They are more likely to misuse drugs and alcohol and to attempt suicide. They are more likely to have difficulties in forming and maintaining relationships and to be in violent, emotionally abusive relationships. The impact is often devastating, and may be life-long. But, what with all our hand-wringing over our religious and cultural identity, we have forgotten that there are children, violated children, at the centre of this.