Leaving Scotland – some thoughts from my final week with a Scottish CMHT
After nearly two years as a locum consultant psychiatrist within a community mental health team (CMHT) serving a small town and semi-rural area outside of Glasgow, I enter my final week with much still to do. While our catchment area boasts some of Scotland’s best life expectancy figures, there are also pockets of impoverishment that are comparable to the most deprived areas in the city. Naturally its been both demanding and rewarding, with a steep learning curve into Scotland’s culture and its health services included.
Earlier in the week, I chat with a social worker before a Mental Health Tribunal where we will jointly argue for continuing our patient’s detention in hospital. While waiting to be called through, the conversation turns to a former asylum-like hospital for learning disabilities that closed some years ago. For me, rather than anything I directly remember, such institutions have distant connotations that I associate more with the era of black & white photographs in which they are usually depicted.
However, sitting with us is a male nurse who reveals that his training and first appointments were at that hospital. Dressed in NHS scrubs, he recalls with despair the conditions when as recently as the 1990s, patients shared communal clothing unless they were inclined to strip off and wore ‘moleskins’ with unreachable fastens at the back. It’s a vivid reminder that the legacy of the asylums provides the foundation for current services while continuing to cast a shadow for many staff and patients.
Fifty year ago, such institutions provided the best available care, as well as a sense of community, purpose and protection for some patients. Yet, this lack of having one’s own personal belongings emphasises how individual’s boundaries can break down within restrictive institutions, particularly within mental health services. Meanwhile the nurse carries his own daily reminder with enduring back pain after lifting patients without hoisting equipment within large, silo-like wards.
After the tribunal, I’m booked to see a patient who’s had several lengthy hospital admissions when his family couldn’t cope with how he was. Now he lives in his own home, supported by family and daily carers from a mental health support service. Joining me for his review is our team’s health care assistant (HCA), who has known him for many years and sees him most weeks. While its been years since his last hospital admission, right now, the patient is unsure about being able to manage.
Had I met with him alone without notice, I may have felt duty bound (for medical and pragmatic reasons) to increase his medication and consider admission. However, before I can act, my HCA colleague reminds him of how much better he is compared to years before. While he may require more support in the short-term, hopefully admission and the personal disruption this would bring can be avoided. It’s a good example of the benefits of having continuity of staff who can provide grounding and containment to patients who are vulnerable to feeling overwhelmed in a world of change and perceived harm.
Later that day, I meet with a man who often has contact with our crisis resolution team; a dedicated service that provides more frequent support at the patient’s home during periods of stress and is an alternative approach to hospital care. While at times our patient functions well and even cares for others, he can quickly become dramatically unwell and stop taking medication, which in turn characterises how he is viewed by services.
This review was arranged by his independent advocate and we meet with his long-term community psychiatric nurse to discuss his management after my appointment ends. Usually due to his currently stability, he wouldn’t have been a priority and indeed, no change in management is advised. Yet afterwards my nursing colleague observes that after a number of previous reviews with me when the patient was in crisis, it was good that our last meeting occurred when he was well, to confirm and reinforce this with him directly.
Whether north or south of the border, such encounters between psychiatrists and patients as their more ‘normal’ self can be a rare occurrence. In recent years in England, the recognition that consultants carried a disproportionate level of responsibility for patients compared to other non-medical staff, led to developing an enhanced role of ‘keyworkers’, where nurses, social workers and occupational therapists took on a more formal role towards individual patients.
While Scotland’s NHS resists the market-driven and service developments seen in England, I found services in Scotland to be more fixed and authoritarian. That certainly was evident when I reviewed earlier medical records for patients whose care had now passed to me. While that may allow for more clinical autonomy, there can also be a ‘doctor knows best’ approach and a distance towards patients for whom medications are directed. Similarly an equivalent gap can arise between medics and non-medical staff, whose duties may feel directed to following doctor’s orders. While that might seem an attractive service model for doctors, I found myself overwhelmed at times as I observed that it wasn’t consultants who demanded they retained their authority but with whom it often remained by default.
For a newly qualified, English-trained consultant who provides direct, typed summaries to patients that are copied to their GPs and seeks a collaborative approach with colleagues, there followed a number of crossed-wire moments. As time went on, I became more aware of these service gaps but also stuck in my mind about how to improve them.
Whether it’s a tightly restricted asylum or a community institution with a fixed mindset, humanity within such organisations can become inhibited and eroded. I return to Sussex believing I made a positive contribution in shifting both the service and for some of our patient’s personal themes.
Patient details have been changed to protect their identity – GN.
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Tags: asylum, CMHT, Community Mental Health Team, Glasgow, NHS, psychiatry, Scotland