A Busman’s Holiday

07Aug12

As it’s nearly a year since I arrived in Glasgow, I thought it timely to write about just what I’ve been doing here.

While my appointment as a locum consultant psychiatrist was initially agreed for 12 months, next week I’ll begin a further six month extension. This will be more new territory, as I’ve never been in a post for more than a year and as well as continuity, I’m increasingly appreciating the full range of my caseload. In addition, while juggling clinical roles across two different services, I’m seeing ever more of the local mental health picture.

Community Mental Health Services

Local remedy delivery at our Health Centre

As part of a general adult community mental health team based in a small town 10 miles outside of Glasgow, our catchment area includes parts that are well-known for being well-off with some areas of deprivation. It’s the same as I’ve done before in England and involves assessments of new referrals and reviews of current patients, while working jointly with community psychiatric nurses (CPNs), psychologists, social workers and occupational therapists.

There are two other consultants of a similar age who I get along with well, though we’re pretty busy with our individual caseloads. For my part, I’m here purely in a service delivery role, providing out-patient reviews and consultant support to my colleagues. That’s been enough to be getting on with, particularly as I’ve taken over a caseload that had been managed by a succession of short-term locums. Many of the patients and their carers would say they were pleased that there would now be consistency though I wasn’t so sure that I would stay this long myself. One year later and I’m close to having seen most patients at least twice, which has been a helpful experience, even if they’re not always as keen to see me!

After establishing myself in post, I’ve since gone on to review long-term issues over diagnosis and prescriptions. While there are differing views within psychiatry, I’ve been surprised at how medicalised some patient’s management has been with medication regimes that have increased in quantity and complexity with limited monitoring. That said, there are also strong demands from patient and families for solutions through medication. While I’ve made some in-roads towards reducing doses, there has been some symptom recurrence and withdrawal effects, requiring full dose restoration.

It’s also been notable that although there are some chronically unwell people, some of the diagnoses and prognoses (predicated outcomes for illnesses) are more severe than I would suggest. I’ve since carried out a number of detailed reviews and while accepting that some previous observations were broadly right, I remain concerned about how little indication there is about how that decision was reached.

I’ve also discovered some discrepancies in the prescriptions recorded in the patient’s notes and what they actually receive. This happens because specialists in the NHS, like psychiatrists, make recommendations for GPs to prescribe, though changes made by one service may not be realised by the other. Conversely, there are some patients who have been on the same medication doses for over ten years and thus, even though the service moved into a modern building three years ago, parts of the service have been clinical drifting.

There has also been further changes and cuts in services since I arrived, though staff moral is steady and I’ve had good experiences with all of my new colleagues. I’ve also been particularly fortunate to have a secretary who is super-efficient at organising my clinics, though sometimes I regret my suggested time intervals for follow-up appointments as my recommendations are always followed. Still, with her help, I’ve been able to see nearly 200 individual patients and complete over 500 direct patient contacts. Thus, for all those reasons and more, this role has at times overshadowed what is arguably the more interesting and demanding part of my appointment.

Homeless Mental Health Services

Sunset over Bell Street hostel

Sunset on the former Bell Street hostel

Glasgow’s Homelessness Health and Resource Services began in Glasgow in 1992 as it was recognised that the environment within the East End’s former industrial-sized hostels often perpetuated unhealthy lifestyles for its residents. Thus, the service sought to reach this mostly male population and help individuals take up and maintain more settled accommodation. Now with the large hostels having closed, much of the service’s original purpose has been achieved though at any one time, there are over 1500 people registered as homeless across the city.

While homeless services remain located on the city’s east side (and very close to where I live), the profile of people using services now is somewhat different. As might be expected, there remain many destitute Glaswegians with alcohol and substance abuse issues while others only come to our attention when they’ve been evicted for their disturbed behaviour or non-payment of rents. There’s also a sizeable population of migrants with a dedicated local service for registered asylum seekers, but for those foreign nationals who arrive here independently, homeless services can be a necessary safety-net. Thus, my training in Ghana two years ago remains relevant for seeing people from non-Western cultures, which has included people from Africa, Asia, the Middle East and a few from Europe. Sometimes we even see some English!

Homeless health services are based in its own building, operating as a ‘one-stop shop’ with clinical facilities for General Practice and Addictions care. While I work specifically with the Homeless Mental Health Team, there’s often joint collaboration and some patients may see all three specialties. I’m still picking up on the social issues and themes involved, which includes increased recognition that homelessness in itself is an increased risk for mortality (Morrison, 2009) and that childhood trauma is both predictive and a greater risk for homelessness than childhood poverty (Fitzpatrick, 2011).

End of the Red Road flats

End of the Red Road flats

My main role is overseeing mental health assessments and medication recommendations for our client group, while working with my nursing colleagues. The CPNs here are all veterans of the service and their local knowledge is invaluable for maintaining contacts with patients, some of whom can be hard to engage and may frequently change accommodation. On occasions, I’ll also travel with the CPNs and along the way, I’ve seen a number of hidden locations within the city, including tower blocks flats and b&b’s for the destitute, as well as some purposely designed placements that prepare people for moving into their own tenancies. However, when we visit, there’s often no guarantee that the patients will be there.

Over this past year, I’ve assessed an extreme range of individuals and it’s been enthralling to review their backgrounds while trying to engage them therapeutically. For a few patients we use mental health legislation (Scotland has its own Mental Health Act) to ensure they remain in contact with us and accept medication. Many patients though are resistant to our efforts and will fall back into familiar patterns. Sometimes we’ll conclude that a person’s problematic behaviour is not due to mental illness and our contact will then end, while others have gone on to be imprisoned. Mostly though we try to work steadily towards improving people’s health and functioning, while establishing their own accommodation with some success.

The homeless service has also had to make savings and it was feared that it might even have to close. To some extent, closure is its purpose and would be a successful indicator that homeless people had been incorporated into mainstream services; though for now, the service continues with further streamlining to come.

My own long-term role isn’t so clear as I’ve stepped in to fill a short-term gap for both services. While it has been demanding at times, it’s brought a remarkable exposure to the issues going on, as well as a sustained experience as a consultant psychiatrist. Thus, in the birthplace of R.D. Laing there’s been plenty to consider about the influence of trauma, social opportunities, families and culture; as well as extremes in daylight and weather (it’s not stopped raining this summer!), on the presentation of mental illness. Meanwhile among the other themes going on includes more recession, benefits review anxiety, NHS and pension reforms, Scottish independence, minimum pricing for alcohol, the demise of Rangers FC and the Commonwealth Games to come in 2014. It’s all involving, though I really must get out and have that proper holiday in Scotland soon.

References

Fitzpatrick S, Johnsen S & White M (2011) Multiple exclusion homelessness in the UK: key patterns and intersections. Social Policy & Society, 10 (4): 501-512.

Morrison D (2009) Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology, 38: 877-883.

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