Big Brother

We had a letter about a patient.

Nothing too unusual about that.

The patient was on a ward, having been there for a goodly length of time, detained under the Mental Health Act 1983 for treatment of delusions and hallucinations and passivity. It was the patient's first psychotic episode, the delusions had been managed in the community with the patient's family providing rich support, but the effects on work and relationships and health and risk to self resulted in police bringing him to hospital for assessment and care.

The patient felt that a secret military experiment with satellites was affecting her. She wrote to civil servants, her Member of Parliament and the Prime Minister. She was convinced that her experiences were through technological processes the military were developing and she wanted the experiment on her to stop.

We had a letter from FTAC.

Have you heard of them? I hadn't. The Fixated Threat Assessment Centre (FTAC) was apparently set up in October 2006, according to The Times, and consists of police and mental health workers who "identify suspects." Our patient came to light from their 2 or 3 letters to politicians.

Did you know police screened mail to "identify suspects" and then direct mental health services to intervene? Parliamentary questions have been posed, apparently Mr McNulty had "security, counter terrorism and police" within his portfolio, yet he was the chap explaining FTAC to parliament.

Hmmm. It seems that Big Brother is indeed watching us. And Big Brother's mate is a mental health worker . . .

Legal matters

No sooner had I posted on laws on Friday, then Dr Grumble posted about legal matters on Saturday. Odd how themes pop up.

It got me thinking.

How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.

The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.

Laws

The political parties have had their get togethers and rattled sabres muchly. They've talked of "vision" and "character" and "challenge" with little detail of content. Except the Conservatives, to their enormous credit, who've shared specific policy details. Having endured Thatcher's Britain I'd never have imagined I'd see anything the Conservatives did as laudable; plus ca change.

I still think that the likes of the UK Libertarian Party have the right notion.

Government govern through making laws. We have lots of laws. About time someone, instead of just generating loads of edicts, starting doing away with 'em and pulling back to what's necessary.

In this notion of laws, and the desire to be explicit about laws (rather than just posture and waffle) and to have the minimum amount of law that's necessary, how does that translate to mental health? Well, I'm glad you asked. In 1978 we gratefully received the work of Shem, The House of God, a book dressed with humour as a vehicle for the grim themes explored, which sadly resonates with an awful lot of truth in it. The tale is of a keen junior doctor, who's first year as a doctor is damaging to both him and his colleagues and his patients. Having finished medical school and entered hospital practice, his up beat mentor schools his to survive in the really real world through breaking rules and instead using his own rules.

The House of God gave us 13 laws.

In his sequel, Shem offers us insight into progress as a trainee in psychiatry. With the book come new laws. The 13 laws of psychiatry in Mount Misery are as follows :
I. There are no laws in psychiatry.
II. Psychiatrists specialise in their own defects.
III. At a psychiatric emergency, the first procedure is to check your own mental status.
IV. The patient is not the only one with the disease, or without it.
V. In psychiatry, first comes treatment, then comes diagnosis.
VI. The worst psychiatrists charge the most, and world experts are the worst.
VII. Medical school is a liability in becoming a psycho therapist.
VIII. Your colleagues will hurt you more than your patients.
IX. You can learn everything about a person by the way he or she plays a sport.
X. Medical patients don't take their medication fifty percent of the time, and psychiatric patients don't take their medication much at all.
XI. Therapy is part of life, and vice versa.
XII. Healing in psychotherapy has nothing to do with psychology; connection, not self, heals.
XIII. The delivery of psychiatric care is to know as little as possible, and to understand as much as possible, about living through sorrows with others.

What do you think of these laws? Better than HMG suggest, worse than the opposition are proposing, relevant to mental health work? Discuss.

Cash

I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.

The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.

The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.

We gave our views to her medical team. She went in to permanent care.

It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.

Her family visit daily and are very happy with things, too.

She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.

A dismal consequence of the MCA 2005, methinks.

Doctors' work

I find myself increasingly reliant on good nursing colleagues, with investment in our service over the last 5 years involving reducing medical staff numbers whilst increasing nursing staff, OT and social work staff numbers substantially. Still fretting that I don't have enough pharmacy time, but that's a battle for another day.

My junior doctor does very little work. It's not a criticism. He's there in a training post, to learn. Gone are the days when junior doctors worked every hour and were the cheapest resource; I was paid less than porters, student nurses and domestics for my work out of hours and on bank holidays. Come to think of it, I still am. But my junior doctor's hours are scrutinised and all have to be purposeful in progressing his training needs.

Also, all junior doctors in psychiatry now have to do Old Age Psychiatry in their first year. This mean my junior doctor has done his medical training at university, then his Foundation training as a doctor, then started in psychiatry with me last month. He had an induction so he's being doing psychiatry for all of, oooh, about 4 weeks. Clearly he's not in a position to give meaningful input, on his own, in out-patient clinics or the like.

The Royal College of Psychiatrists recognise this and define what it's reasonable/desirable for junior doctors to do at different stages of their training. In their first year, as mine is, they're to learn core skills. It's even called Core Training, so if after a year he thinks psychiatry's a terrible mistake and he want instead to be, say, a gynaecologist, off he can go and his year in psychiatry is useful and translates into a year of gynae training through teaching him consultation skills, approach to examinations, documentation, governance frameworks, evidencing rational prescribing practice, undertaking clinical audit and other such skills a medic is expected to develop.

As such, he can't do clinics on his own. Or skip off and see new referrals in the community. Or do liaison psychiatry, seeing folk on medical/surgical wards.

It's genuinely a training role which has the advantage that the service ticks along quite nicely whether he's here or not, it gives him time to read and study and shadow loads of folk to get a good understanding of practice, and it's hardly a stressful post. It also means patients get medical psychiatric input from a Consultant Psychiatrist, not a junior doctor.

As well as junior medical staff having a training (rather than a service commitment) role, as a Consultant Psychiatrist I input into other peoples' work. Mornings and afternoons our teams meet up and discuss the work to do/work done and consider what needs to be changed. As such, every patient has both this informal discussion when a Consultant can think if specific investigations need to be done, or psychiatric/other medication reviewed, or physical health symptoms unpicked or whatever. Every patient has formulation and care planning discussed with a Consultant Psychiatrist. Equally, all mine are discussed with nurses, OT, support work, pharmacy and social workers so they can chirp up with their thoughts on input into care.

The consequence of this is that all medical decisions within our service are through a Consultant Psychiatrist, and through both formal and informal forums there're mechanisms for medical input into every patient's care, every day.

At least when someone's stuck and refers in to our service, the diagnosis is made by a Consultant Psychiatrist (for good or bad, in my corner, nobody else does diagnosis) and medical dimensions are considered by the Consultant. I think this is of value, enabling non-medics to work at the top of their game doing what they do best, with medics contributing their bit, and the whole working synergistically.

I have seen a gentleman with mild cognitive deficits. He's in his 40s. He's unfortunately got dementia. He had a jerky tremor and poor balance/coordination. He said his mouth wouldn't work; he often chomped down and chewed his cheek, sometimes he couldn't swallow solid things easily. I thought he had something other than Alzheimer's disease or another neurodegenerative dementia unfolding, it looked like he'd neurological deficits. Huntington's disease sprang to mind, or p'raps normal pressure hydrocephalus. More sleuthing by clever physicians was in order.

I wrote back to his GP giving the results of his assessment, mental state examination, cognitive testing and brain imaging, suggesting that an assessment and neurology opinion would be helpful.

A few weeks later, I got a copy of my own letter back, as part of a referral to me, with a covering letter asking if I could give an opinion on this gentleman who had been invited into the GP's surgery and seen and discussed referral, so could I please see and advise. A mistake had been made. It should have gone to a neurologist, not back to me. It happens. The mistake had been made by a First Contact Practitioner. It rang bells because this is not the first time she's made a mistake.

I shouldn't, but I do feel somewhat piqued if I spend 2 hours assessing and investigating a patient, identify organic disease that merits more sophisticated assessment than I can do (it's many years since I worked in GP land, now), but the history and examination and formulation and care planning is undertaken by someone who consistently doesn't seem to be doing a brilliant job. Maybe it's bias and prejudice, maybe it is factual, maybe it's idealistic but unfounded, but I do reckon it all worked better (for our patients) when GPs did this work.

I'm all for clinical teams doing work that they do best, but inadequate assessment/management of neurological deficit, trying to gain tighter glycaemic control of a diabetic patient and making things worse, review of a patient's use of triptans with a poor outcome, and stopping someone's lithium (that had kept them stable for decades) are all recent undertakings of a First Contact Practitioner that perturbed me.

Most GPs in my area are really, really good. I'm fearful that in the future most Primary Care won't be. Much badness.

Benzodiazepines

I've differing views on the use of lorazepam and other benzodiazepines (here and here).

The Jobbing Doctor has quite rightly highlighted how mental health can be overly zealous in dishing out lorazepam. Got me thinking.

Bit of a delay in getting an answer to this one since it got me hassling a pharmacist to suss things out for me.

The outcomes were rather heartening.

Most patients prescribed lorazepam within my corner receive it as part of an adjunct to their dementia care. By "most patients" I in fact mean all of them. I have two patients who are prescribed a benzodiazepine for anxiety states. Every other patient on a benzodiazepine is taking it as a part of their package of dementia care.

One lady has anxiety which necessitated hospital in-patient care over many months, she relocated to my corner a few years ago to be near to family and now is on oxazepam 5mg as required. The tablets are 10mg, so it's half a tablet a time. The dose range in older adults is 10mg to 20mg, 3 or 4 times a day. 30mg to 80mg a day, then (which is what she was taking when we first met). She now takes 5mg a couple times a week. At such a tiny dose there's no risk of pharmacological dependence, no problems of side effects. Okay okay, it's homeopathy in all but name, yet for her it's invaluable. She finds that when she's anxious she can take half a tablet, she's in control, it's a key tool for her in her toolbox as part of her anxiety management. Developing an internal locus of control, patient choice, an empowered patient, person centred care, frame it how you will. For her, being able to have a bottle of tablets with just one tablet used up each week is incredibly effective in enabling her to manage her mood state and functional level.

Another lady's had a major adjustment disorder and is currently taking diazepam 2mg half to one tablet once a day. Again, a dose that doesn't cause pharmacological dependence (or side effects for her) but a dose which gives her feelings of relief that she finds necessary to help her cope. And cope she does, now managing activities of daily living that six months ago eluded her. Sure, her CBT and SNRI and twice weekly CPN input are far more meaningful than a sniff of diazepam, but for her the choice of taking a dose (or not) when she wishes is a choice that she feels she needs, a choice that puts her back in control, a choice that enables her to feel she's better equipped to cope.

Other than these two patients, every other prescription for a benzodiazepine since April has been purely as an aid in the management of dementia care. It's not used a lot, at all. We've specialist teams to support care in my corner so if there're problems then the team looks at causes and understanding and interventions, I look at physical comorbidity and concurrent medication, our commonest intervention is stopping drugs not starting them.

I still find it amazing how much medication is used for the right reasons at the right time, but then when dementia progresses the medication's side effect profile and tolerability generate treatment emergent adverse events (e.g. wailing, sobbing, battering carers) which a GP and I can improve upon through review and rationalising a drug regimen.

But if you've dementia, and this advances to cause the inevitable cognitive decline but also non-cognitive changes (i.e. behavioural and psychological symptoms of dementia, BPSD), and these are intense (e.g. battering your wife), and these are pervasive (happening in most situations or most of the time or in a repeatable fashion such as each time personal care's delivered), and there's distress to the patient and carer through this, and practical changes haven't improved things, and behavioural changes haven't helped, then I'll consider medication too. I'm not keen on antipsychotics in the first instance since they ramp up risk of serious things (like strokes and death) significantly and invariably the patient's not psychotic (so an antipsychotic's use is contentious). The evidence base increasingly shows that an acetylcholinesterase inhibitor is more effective with less side effects in the management of BPSD than an antipsychotic. If you've Alzheimer's disease. What if you've vascular dementia, or you've Alzheimer's and the drug doesn't work?

Increasingly the evidence suggests that in this patient population (of dementia and BPSD) that a benzodiazepine is a safer and more effective agent than an antipsychotic. Makes sense, too. It's an anxiolytic, it reduces anxiety, it's a "minor tranquilliser" and if someone's distraught through poor memory, or frustration, or through misperception of situations, or misinterpretation of activities/events, or losses, or fears, it helps reduce the anxiety and distress.

On using a benzodiazepine, it's then reviewed by a nurse or myself to see if it works. If it does, huzzah! If not, can it be increased to have a therapeutic trial at a decent dose for a decent duration? Still no benefit? Then it's stopped. We have to do this otherwise I end up writing FP10s forever (which I've not the inclination to do) and my nursing colleagues are locked in to reviewing outcomes forever, which they've neither the capacity nor the need to do. Hence a desire to robustly evaluate effectiveness then determine whether to continue or stop the drug.

A less distraught patient's a good thing, since they feel better and have a lower symptom burden. Too, they're then more likely to accept the reassaurance, reality orientation, personal care or other interventions from carers more successfully, more of the time.

Overall, I'm with the Jobbing Doctor that the NHS can be keen to dish out benzodiazepines too readily, some of the time. But, babies an' bath water, I'd not want to unhelpfully simplify the discussion into use of benzodiazepines is bad, since that's not true. Inappropriate use of benzodiazepines is bad. Rational prescribing practice is not bad. On that basis, within such a framework, I'm far more enthusiastic about a bit of lorazepam than haloperidol/more noxious agents.

Medication

I work full time. If patients problems through the working week, I am keen to sort them out with them. Sometimes, problems can be around the use of medication. Maybe it isn't working. Last week I had a patient 'phone because they'd been prescribed something else and wanted to know if she could take both tablets together. Maybe it's side effects (a patient last week had his rivastigmine patches stopped and a yellow card filled out after they caused ghastly rashes beneath each patch). Often it's because something destabilised the otherwise manageable situation (such as a patient last week with a chest infection who's otherwise manageable confusion/dementia became unmanageable and another lady who's daughter was going on holiday so couldn't give mum her tablets for that week).

My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.

Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.

Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.

Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.

The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.

He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.

The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.

The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."

No ECG was done for this gentleman before starting haloperidol or during it's use.

Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).

Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).

The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.

Grrr.

Time for more thought on how to solve that one.

Absence

We're not absent, a lot.

I've not had a day off sick, this year. Or last year, come to that. On working through an annual appraisal with one of my Consultant colleagues, we pulled his sickness record for the last 16 years. He'd had just one day off sick.

I know some colleagues who don't use all their annual leave entitlement. Instead of going on holiday or having time off at home or whatever, they stay at work instead.

Gets you thinking.

No, it's not that all my Consultant colleagues are workaholics and passionately addicted to saving lives and making the world a better place. No, it's not that there's any financial advantage to working more (indeed, none of the extra hours or overtime or worked leave is paid). No, it's not that they've dysfunctional lives or grim home settings so would rather be at work.

The issue that one of my Consultants shared at appraisal was this. A holiday was less relaxing and more stressful than being at work. When we're away from work, nobody does our job. Our teams have discussed this. CPNs cover for each other. Ward staff cover shifts. Our OTs and social workers cross cover. Even our secretaries cover each other. This cover is substantial, involving sorting out work, doing depots, reviewing patients, typing letters, getting the work done.

With Consultant Psychiatrist cover, it's just cover for emergencies and specific problems. Nobody does my clinics whilst I'm away. Nobody does my home visits. Nobody does my reports. Nobody does my CPA reviews. Nobody sorts all the GP and solicitors' queries.

We've less Consultant Psychiatrist time than the Royal College say we should have, for our population. We've markedly less Staff Grade and junior doctor time than any other mental health unit I know. We've no Associate Specialist of Hospital Practitioner sessions. We don't have capacity to do the work of anyone else whilst they're on leave.

Through this, when we come back after leave, we've that week's work to do, plus the work of the last week when we were away. All the letters, emails, 'phone call messages, supervision, care home reviews, meetings, teaching, out-patient clinics, home visits you didn't do last week you somehow have to fit in to the week or two when you return, on top of everything else.

The stress some colleagues feel from this is such that they simply feel they can't be off for more than a week, or would give up their holiday entitlement and not go on leave at all.

Can't be healthy.

Must think on how to manage this differently . . .

Private Psychiatry

People dabble in private practice, within the mental health arena. Patients seek solutions outside of NHS care, especially if care's shabby in their corner. Practitioners ply their trades, cross their palm with silver to receive whatever benedicition you desire.

Mostly it's innocuous stuff. A nurse charmingly nailed it when she said it's all a bit like internet porn, everyone knows it's going on and is somewhat unwholesome, it's pervasive and there in the background, but it doesn't change day to day life that much.

I don't do any private work. Partly it's because I simply don't have the time to do so. Mostly it's because the NHS can do it better.

A lady with a bereavement had input from us a few weeks ago. I saw her 3 times in one week, my nursing colleague saw her every day, for an hour, doing CBT. A support worker's since got her out, shopping and swimming and baking and doing again. She had a few days as an in-patient, under my care, when things were bleak. For 5 years she's been housebound. She's had a fair investment of care, over a couple of months.
- I got the referral from a GP on a Friday afternoon, rightly worried she was suicidal. She was seen by me, a Consultant Psychiatrist, at home, that afternoon.
- I saw her twice the next week, visiting to talk with her and her husband, whilst fiddling with tablets, formulating with them and looking at what she wanted to do to cope better
- She's been seen by an OT, looking at getting out to do more, in a purposeful and meaningful and pleasureable way, rather than just doing more
- She's been seen by our support worker who takes her out and goes with her to tea rooms, filled out forms with her, got her back to feeling okay in practical day to day tasks
- She's had input from a Consultant Psychologist who's not seen her but has given advice on her care and CBT that's undertaken
- She's had indirect input from our pharmacist too, discussing her medication with me
- She's seen by a CPN a lot, from subsequent joint visits with me to daily input for CBT to weekly input

Two months on she's strikingly better, will it last? Time will tell.

Could she have received better care, privately? No. Could she have received comparable care within the private sector? Not within my patch, or within the adjacent cities or counties. Episodic input titrated to need, indirect care contributing to the team working, flexible care across in-patients/community, care in clinics/at home (depending on what she wanted her family to hear), joint working, daily input from different qualified/unqualified professionals, rich and meaningfuly input from numerous individuals all effecting change in her care, collaborative working without a medical or nursing or psychological model dominating.

Community Mental Health Teams get a lot of stick. Sometimes rightly so, I'd not want to be a working age adult in receipt of our Trust's services. But when they get it right, it's in incomparable.

The NHS then far outstrips other provision of care.

It's good.

Work

The Girl asked about managing someone with suicidal risk.

It's a contentious area because how ever you deliver care for these patients, you get it wrong.

If you want no risk, you're overly draconian and coercive and admit everyone. To assess if there's mental disorder and risk to self, you recommend they're admitted under a section of the Mental Health Act 1983 for assessment, if they decline. Why not? A few days assessment to save lives, a fair price to pay, no?

If you want to preserve patient liberty, autonomy and their ownership/control of their problems, choice, collaborative therapeuric working then you'd not detain or admit many at all. So some folk would be suicidal out in the community, with some going on to completed suicide. Whether in-patient care would prevent all that is another issue.

So you admit everyone, thus notionally reducing suicidal risk. Or you don't admit everyone, thus accepting patients (and not Secondary Care) are managing a lot of the risk themselves.

Clearly, not everyone's going to be happy all the time.

It's telling that the first theme that came to me on this issue is risk managament. That's how management of suicidality is taught, reported, framed, documented, written about. The Department of Health and Royal College aren't in the habit of sending me helpful letters about clinical elements and therapeutic elements of care, it's invariably about risk. The Trust doesn't look at quality of care or constituents of care of patient pathways, it looks principally at governance and risk.

I can see that risk management is part of the equation because if the decision's wrong then someone could die. Unlike other areas of medicine, in psychiatry this patient death often could be seen as preventable. Getting the risk management right is therefore vital (in the true sense of the word) since it's about a life.

My first evening on call as an SHO involved section 136 assessments (it was in an age when the SHO did them . . . now I'm a Consultant it's Consultants who do them) and liaison assessments in A&E (again, SHO's did those, now it's not something junior doctors are allowed to do, so it's Consultant work) and GP referrals for assessment (again, this now falls to Consultants). I'd trained as a GP before going in to psychiatry, so prior work in A&E then in GP gave me some confidence in triage, risk management and safety netting, but not the clinical competence to manage acute mental health presentations.

My first night on call involved assessing a lady in her 20's who cut herself. I took took a psychiatric history, went through mental state examination, checked we had a bed for her, 'phoned the on-call Consultant to be told to send her home. I couldn't quite get it. Her self injurious behaviour was seen by the Consultant as a sign of distress, of not being well, of poorly coping, but guessed it was part of her way of coping. I was told to send her home and arrange for her team to see her in the morning.

As time moved on this started to make more sense because what the Consultant had been sifting through was information to suggest whether there was evidence of acute psychiatric illness (necessitating acute care) or whether it was more of a psychological problem (which psychiatry couldn't fix by acute admission).

That really is what an assessment of someone feeling suicidal should be about. It should be about a clinical assessment (rather than an assessment skewed by political drivers) to look at patient need, then consequent care necessary to address that need.

Taken back to basics, this makes assessment of a suicidal patient no more fraught than assessments of someone with a chest infection.

Free will. People have free will. If someone's wishing to hurt or kill themselves and have capacity to make that decision, support can be offered but ultimately it's their choice. We can't use the Mental Health Act 1983 or Mental Capacity Act 2005 if someone's capacitated, with no mental disorder. The harsh reality is therefore that it's likely that someone could elect to kill themselves after being assessed. But if they weren't mentally ill and were offered appropriate support, surely mental health services have done their job.

Believing this has resulted in significant positive risk taking, including sending a gentleman on his way with police who was covered in petrol and threatening to immolate himself. But he wasn't mentally ill.

That's how I personally manage the assessment of suicidality without finding it too scary and being risk averse, I pull back to look at the clinical presentation and consequent need, then simply go from there . . .