RCPsych eNewsletter March 2018

Wendy reflects on our efforts to keep the Five Year Forward View for mental health on track, and recalls a busy month personally.

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The College is urging the Government to add NHS Child and Adolescent Psychiatrists to the shortage occupation list.

The call follows RCPsych analysis of new figures which shows numbers of CAMHS psychiatrists of all grades have fallen by 6.3% in four years.

For consultants alone the decrease was 6.9% over the same period.

What’s the situation in your area?

Across England, the number of NHS Child and Adolescent Psychiatrists per 100,000 children is:

  1. Kent Surrey and Sussex – 3.75
  2. East of England – 4.87
  3. Yorkshire and Humber – 5.40
  4. South West – 5.74
  5. East Midlands – 5.76
  6. Wessex – 6.38
  7. West Midlands – 6.89
  8. North West – 7.92
  9. Thames Valley – 9.29
  10. North West London – 13.42
  11. North East – 14.29
  12. South London – 17.15
  13. North Central and East London – 17.32

Predicted rise in referrals

Ongoing work with Health Education England has highlighted an urgent need to address the shortage – especially in light of the Government’s Children and Young People’s Mental Health Green Paper which predicted a short-term rise in referrals to NHS mental health services. 

In its consultation response to the Green Paper, the RCPsych said recruiting from overseas was crucial to achieve the proposed four-week waiting time against rising demand.

Dr Bernadka Dubicka, Chair of the College’s Child and Adolescent Faculty said: “Earlier this year an Indian child and adolescent psychiatrist had their visa application rejected because the quota for Tier 2 visas had been reached and they did not qualify as a priority on the shortage specialty list.

“Shortstaffing in Child and Adolescent Mental Health Services is no secret. We are already struggling – and the Government’s own Green Paper Impact Assessment predicts a rise in referrals.

“We are now calling for the Child and Adolescent psychiatrists to be added to the shortage occupation list.

“Recruiting from overseas is key to quickly employing more qualified doctors specialising in children’s mental health and will ensure the profession is seen as a priority by the Home Office.”

The HEE mental health workforce plan committed to an extra 100 consultant CAMHS psychiatrists by 2021, but these new roles will not be in community CAMHS teams.

The Home Office shortage occupation list gives specific professions priority for Tier 2 visas to employ non EEA staff because they are struggling to recruit at home. Core psychiatry trainees and old age psychiatrists are on the shortage speciality list, but child and adolescent psychiatrists are not.

Applicants who do not qualify on the shortage specialty list may be rejected for a visa even if they are desperately needed by the service that is trying to employ them.

Clinical services should focus more on the needs of older people as growing numbers of baby-boomers are seeking help for substance misuse, our report out this month has highlighted.

‘Our Invisible Addicts’ highlights the burgeoning problem of substance misuse among older people. The UK now follows other developed countries in having an older population with the highest rises in rates of substance misuse

The report highlights a problem that exists behind closed doors. With most problems going undetected, there remains a pressing need improve the diagnosis, treatment, education, training, service development and policy for all older people with substance misuse.

Deaths related to poisoning from substances in older people have more than doubled over the past decade.

It’s an updated revision of the original 2011 publication, which was an important landmark in recognising the extent of substance related health problems in older people.

The revised edition makes a series of recommendations including the need to enhance training at all levels – including training more addictions psychiatrists and old age psychiatrists to manage the specific needs to older substance misusers.

 

Do male and female mental health patients receive the same treatment in terms of resource allocation?

That’s the question two psychiatrists in Dorset are asking.

Dr Tamsin Peachey and Dr Aneal Sidhu, from Dorset Healthcare University NHS Foundation Trust would love your help to work out if what’s happening at local level is reflected across the UK.

Members are asked to complete the following short survey.

We’re delighted to announce the Call for Entries for the RCPsych Awards 2018.

Now is the time to nominate the outstanding teams and individuals who are making a real difference to mental health services.

The RCPsych Awards mark the highest level of achievement in psychiatry.

Our Awards for 2018 have 17 categories, including Awards for psychiatrists of all grades, as well as for medical students, foundation doctors, and awards to recognise the work being done by teams working in mental health care.

We’ll announce the winners at the RCPsych Awards Ceremony on Wednesday 7 November, at the College’s head office in London.

See the full list of categories and find out more.

Some 82% of you said you thought it was important that psychiatrists won national awards, in a survey in this eNewsletter earlier this year.

Now is your chance to make that happen.

The College is asking you to nominate psychiatrists of all ages who have made a difference to win national honours.

Seven college members were awarded MBEs, OBEs or BEMs in the New Year’s honours list.

Our Nominations Committee – chaired by the President – is keen to increase the number of national honours awarded to both psychiatrists and others who’ve made a significant contribution to mental health.

As mental health is also a priority area for the current government this is a valuable time to recognise more junior psychiatrists doing great work not necessarily at a national level, but which is making a difference.  College work, which is unpaid, comes under this rubric as it is doing more than you are paid to do.

The Cabinet Office are also keen to promote younger people who are doing things above and beyond the call of duty and are seeking to rebalance the current age profile of holders of UK honours in favour of younger applicants. 

And there’s a new proposed breakdown of honours which will mandate an increased proposition of women and BME.

If you know someone who might be suitable, please send a citation of no more than one side of A4 to membership.operations@rcpsych.ac.uk emphasising your nominated psychiatrist’s

  • impact

  • service to the community

  • service to disadvantaged groups.

Please make clear how the person is going beyond what’s in their job description.

The deadline for nominations is 31 July 2018.  

For further information in the procedure for nominations see https://www.gov.uk/honours.

What is the RCPsych Parliamentary Scholars Scheme?

Since 2012, Baroness Hollins, ex-President of the Royal College of Psychiatrists and a Professor of Learning Disabilities Psychiatry, has taken on a Learning Disabilities trainee for a special interest session to work with her as a parliamentary researcher in the House of Lords.

This is the first year the scheme has been opened to trainees in all psychiatric sub-specialities.

Dr Fiona Taylor is one of the five speciality trainees who spend one day a week treading the floors of Westminster. Each of them is attached to a different peer from across the political spectrum; Conservative, Labour and Cross-Bench.

Dr Taylor is a ST6 in general adult psychiatry, working at Camden and Islington NHS Foundation Trust.

Here are her thoughts on her time so far…

“Valuable experience”

Working for peers has been an incredibly valuable learning experience. The ones that I have come into contact with have all been interesting people who have really worked hard in their fields.

They have often excelled in their career and have always gone the extra mile for other people.

In most cases, it took them a long time to become what they are, and they are appreciated across Parliament for their age and wisdom (although the most common conversation to overhear in the lift is peers talking about who just died...).

Briefing Peers

This month in Parliament, I have been busy preparing briefings for Baroness Tyler to take to the Liberal Democrat Health Team, which consists of six peers who lead on healthcare within the party.

They had invited Prof Sir Simon Wessely to talk to them about the Mental Health Act review and so I had to brief them about the subject.

As well as a briefing the peers about the reasons for the MHA review and issues surrounding it, I prepared a page summarising the opposing views on the MHA, and another briefing about the new fusion mental capacity law in Northern Ireland.

I was also asked to give my comments on a motion for the Lib Dem spring conference about the Mental Health Act and restriction orders, which was then rewritten after I amended it.

Green Paper

As I’m writing this, I have just today written two more briefings about the Green Paper and the CQC report on children and young people’s mental health services.

At the health team meetings, the peers discuss the briefings and from them, decide on questions that they can ask in the chamber.

These questions must be answered by MPs, and generally are used as a nudge to the government so they know they are being scrutinised and held accountable!

Another aspect of my work is making sure I’m up to date with current affairs and reading reports as soon as they are released.

I am often sent embargoed copies of reports and press releases and am asked to think of a response in case Baroness Tyler needs to respond on behalf of the party.

This will often be at very short notice and I am now used to researching something and beginning to write a speech, only for the entire focus of the day to change to something more urgent or topical.

Proud and happy

One week I had to write speeches about poverty and disadvantage, and then also vulnerable children for two different debates on the same day.

Peers do not know how long they will be allowed to speak for until the morning of the debate, so I have to prepare a speech with enough words - generally 150 words per minute, that can be cut at the last minute and still make sense.

Speeches have to be designed to hold the government to account. They must ask difficult questions and demand answers.

Working in Parliament makes me feel proud and happy to be part of British democracy (Brexit notwithstanding!).

The rising tide of obesity and diabetes, the complexity of cases we are seeing in the liaison and primary care setting, and increasing acknowledgement that there are interactions between mind and body in diabetes means it's time for a diabetes and psychiatry working group!

The Liaison Faculty Executive is formally supporting setting up a working group in Diabetes Liaison Psychiatry (DLP). The aims of this group are to:

  1. Build a critical mass of liaison psychiatry experts in diabetes
  2. Synthesize the evidence base for different models of integrated care for diabetes
  3. Generate consensus on key performance indicators of liaison psychiatry in diabetes
  4. Network with Diabetes UK/ABCD/RCPs (London & Edinburgh), NHSE, NHSScotland
  5. Developing proforma for business cases for commissioning liaison mental health models into diabetes pathways
  6. Develop training and educational programmes for diabetes professionals
  7. Identify and promote key areas and gaps in diabetes and mental health research
  8. Foster interest and mentor medical students and trainee doctors

We plan to hold our inaugural meeting at the Liaison Faculty conference on Thursday 17 May 2018 from 12.30 to 1pm.

This is during the lunch break. There will be time to get your lunch and bring it to the meeting. As you can see from the conference programme, Dr Partha Kar, NHSE Associate Director for Diabetes will be presenting early in the morning and taking questions and answers during his talk.

Please email Stephanie.Whitehead@rcpsych.ac.uk if you are interested and please forward to colleagues who are or want to work in this field.

Do contact Professor Khalida Ismail or Dr Luke Solomon if you want to have an informal chat.
Otherwise in the meantime, we look forward to seeing you in Liverpool with your 'diabetes hats'.

Professor Khalida Ismail

Professor of Psychiatry and Medicine

Institute of Psychiatry, Psychology and Neuroscience

King's College London

khalida.2.ismail@kcl.ac.uk

Dr Luke Solomons

Consultant in Psychological Medicine/ Psychooncology

Oxford University Hospitals NHS Foundation Trust

luke.solomons@ouh.nhs.uk


We aim for seriousness and science, not frivolity and #fakenews in Kaleidoscope, but an aligning of the stars meant we could entertain ourselves by getting an old rhyme into the start of every piece this month: you’ll have to look at the full article to see if you’re as amused as we are – we’re simple people. But back to the science, and the column reports on an incredible piece on adolescent antisocial behaviour: individuals with this condition have a tenfold increase in public sector costs due to various issues such as involvement with the criminal justice system and social care, not to mention the human toll it puts on them and those around them.

The need to help change their trajectory at a critical stage in their lives, and to nudge those outcomes, is enormous. Lots of interventions have been tried, but they were often marked by small trial sizes. Multisystemic therapy has shown promise, and Fonagy et al randomised 684 families to either 3-5 months of this, or treatment as usual.

The intervention was intensive, with three meetings per week for the family, and contact available 24 hours a day. Astonishingly, those receiving this did no better in terms of the primary outcome of subsequent out-of-home placements, also showing no gains in terms of behaviour, mental health, social care, or educational attainment.

Indeed it was worse than placebo in terms of reducing offending. It’s hard to square this, though the authors are to be praised for their openness with their negative trial data – these also advance our knowledge by telling us what doesn’t work. The question of how best to help these vulnerable young people remains.

Stimulant medication for mania: just a crazy enough idea to work? It sounds counter-intuitive, but then so does stimulant medication for attention deficit in children. In fact, there could be an overarching principle in both cases: the ‘vigilance regulation model’ proposes that unstable regulation of vigilance with disrupted wakefulness is aetiological for both ADHD and mania.

This leads to homeostatic responses of hyperactivity and sensation-seeking to auto-regulate through a stimulating environment. Following on from this (as is seen in ADHD), stimulant medication would therein putatively help re-regulate this, and be of therapeutic benefit in bipolar affective disorder.

Kaleidoscope notes a recent trial where forty-two patients with acute mania were randomised to methylphenidate or placebo before the trial was terminated because of an interim futility analysis; the active compound showing no benefit over placebo at 2.5 days.

The authors note their relatively small sample size, short trial duration and a medication dose below that typically used in adult ADHD. So, a nice hypothesis, but a clinical failure. Once again, negative trial data is useful.

Finally, does money make you happy? You want to be idealistic and say no - at least if other people are in earshot and you can #virtuesignal (we’re #hashtaghappy this month) - but…mebbe it does a little…? It’s been debated since ancient times, but they didn’t have Gallup polls, and left it to philosophers and poets to decide – but they’re just #experts and #snowflakes, and we’ve all given up listening to people like that, apparently. Anyway, Kaleidoscope reports on a piece of work that encompassed poll data from over 1.7 million people across 164 nations looking for ‘income saturation’ – the point at which further increases in salary led to no further happiness.

There were interesting variations between countries – those from richer nations being greedier and wanting more.

What’s your hypothesis on the differences between men and women – who needs more to be happy? – and what is your prediction for the optimal income required for maximum happiness? Read the final piece to find out...

Quiz

  1. Gallup poll data of almost two million people across 164 countries has shown that ‘income satiation’ – the point at which more money no longer leads to happiness – requires an average annual household income of almost £200,000.

    Answer: False; it’s £70,000, if that makes you feel any better.

  2. Half of all scientific articles remain uncited five years after publication.

    Answer: False; that was the oft-recanted figure, but more recent data suggest it’s under 10%..

  3. Based on the ‘vigilance regulation model’, novel work has shown promise for stimulant medication in treating mania.

    Answer: False; the study had to be discontinued following an interim futility analysis.

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