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Articles: Helen Killaspy Why do psychiatrists have difficulty disengaging with the out-patient clinic?: INVITED COMMENTARY ON ... WHY DON'T PATIENTS ATTEND THEIR APPOINTMENTS? Adv Psychiatr Treat 2007; 13: 435-437 [Abstract] [Full text] [PDF]

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Engaging with the outpatient clinic: don’t throw the baby out with the bathwater

frank holloway   (7 January 2008)

Engaging with the outpatient clinic: don’t throw the baby out with the bathwater 7 January 2008
frank holloway, Consultant Psychiatrist South London and Maudsley NHS Foundation Trust Send letter to journal: Re: Engaging with the outpatient clinic: don’t throw the baby out with the bathwater f.holloway{at}iop.kcl.ac.uk frank holloway	Letter to the Editor Advances in Psychiatric Treatment Engaging with the outpatient clinic: don’t throw the baby out with the bathwater I could not have been alone amongst the dedicated readers of Advances in Psychiatric Treatment to have returned home after a hard day’s toil in my outpatient clinic to be irritated to read that my patients and I had been wasting our time. Killaspy (2007) makes some bold statements about outpatient psychiatric care, casting doubt about the relevance of outpatient clinics to contemporary psychiatric practice. This theme is taken on and broadened out by Harrison (2007) in a somewhat uncritical review of changes to the role of the Consultant (adult) Psychiatrist over the past decade, particularly in the light of New Ways of Working and the functionalised model of adult mental health services. The argument goes something like this: contemporary services are comprised of multidisciplinary teams whose members have an increasing range of generic competencies that are together providing secondary mental health care to people with severe mental illness under the auspices of the Care Programme Approach. Generic competencies include skills in the assessment and “signposting” of people referred to services who do not have a severe mental illness and risk assessment and care coordination of those taken onto the caseload who do. Non-medical practitioners are increasingly developing traditional medical competencies, including independent prescribing. The Mental Health Act (2007) introduces the “Responsible Clinician” thus breaking the monopoly of the doctor in having charge of the care of the involuntary psychiatric patient that has been effectively in place for 200 years. Within this brave new world the outpatient clinic becomes an irrelevance as, perhaps, will soon be the adult psychiatrist. This scenario has already been played out in slightly different ways within Learning Disability and Child and Adolescent Psychiatry, disciplines that remain in mysteriously good health. There are a few unfortunate facts that get in the way of this, for adult psychiatrists at least, somewhat depressing vision. (1) As Killaspy (2007) notes, whilst the majority of people who are on the current caseload of community mental health services have demonstrable severe mental illnesses (a code-word for psychotic disorders) the majority of referrals for assessment and treatment to secondary services present with other problems that are often conceptually more complex than the psychoses. (The same is true for the inpatient population: there are more admissions of people with non-psychotic disorder although psychosis accounts for more bed days overall.) (2) For many services in inner urban areas the available care coordination capacity cannot manage everyone with a diagnosis of psychosis, let alone those cycling through the system with non-psychotic disorders, many of whom are in fact both disturbed and risky. (3) Current training reliably provides psychiatrists with set of skills that is unique amongst the mental health workforce particularly in terms of assessment, formulation, diagnosis and psychopharmacology. (It is surely unlikely that a brief protocol-driven course on prescribing will allow the nurse prescriber to dabble in the muddy waters of off-label prescribing as described by Baldwin and Kosky (2007)). (4) There is continuing demand from referrers, patients and carers for out-patient services. In my own service I could comfortably run additional clinics, to which patients and carers would turn up (helped by our local practice of telephone reminders which are effective, greatly appreciated by the patients and leave me with distressingly little unstructured time, pace Killaspy) and my work quite appropriately forms part of our Trust’s activity-based contract. Office-based psychiatric practice flourishes throughout the advanced world and (I understand) private practice is alive and well in the UK. This is not to argue against the importance of multidisciplinary team -working, of which I am a strong advocate (Holloway and Chorlton, 2007), nor to suggest that the traditional roles psychiatrists hold are theirs of right. However we need a much more nuanced discussion about the future role of psychiatrists within adult mental health services than offered by Killaspy (2007) and Harrison (2007). This requires both firmer conceptual analysis, particularly in relation to the appropriate care pathways that should be provided for people with suspected mental illness, and a lot more empirical work on a neglected aspect of care. It’s surely premature to throw out the outpatient baby as we modernise the mental health bathwater. References Baldwin D and Kosky N (2007) Off-label prescribing in psychiatric practice. Advances in Psychiatric Treatment, 13, 414-422. Harrison J (2007) The work pattern of consultant psychiatrists. Revisiting: How consultants manage their time. Advances in Psychiatric Treatment, 13, 470-475. Holloway F and Chorlton C (2007) Multidisciplinary Teams. In D Bhugra, S Bell and A Burns (eds) Management for Psychiatrists 3rd Edition. London: RCPsych Publications, pp 99-115. Killaspy H (2007) Why do psychiatrists have difficulty disengaging with the out-patient clinic? Invited commentary on: Why don’t patients attend their appointments? Advances in Psychiatric Treatment, 13, 435-437. Author Dr Frank Holloway Consultant Psychiatrist South London and Maudsley NHS Foundation Trust Bethlem Royal Hospital Monks Orchard Road Beckenham Kent BR3 3BX Declaration of interest: I have throughout my career spent a lot of my time seeing outpatients in clinics