Older Mind Matters

Old age psychiatry: leadership, role models and taking risks

I’ve just been to the Faculty of Old Age Psychiatry residential conference in Cardiff. There were 262 names on the delegate list but a remarkable dearth of women presenting on the main programme. Posters and new research presentations included women, but I felt that senior women role models were largely invisible. It’s curious. This is something I have observed in the past; see ‘Is the College sexist’ page 3 of the Old Age Psychiatrist in 2001 here. I am not convinced that we are making progress towards gender equality, despite a more evenly balanced consultant body and a serving female College President. What message does this send to trainees?

In a plenary session, Steve Shrubb, Director of the Mental Health Network NHS Confederation, issued a call to old age psychiatrists to stand up and be counted in terms of how to care for older people with complex physical and mental health problems. Refreshingly, he talked about things being morally right not just cost-effective. I’m not sure that the audience showed any signs of rising to the challenge, in terms of talking a lead on behalf of patients and families and ensuring people are treated with dignity. Some of the Mental Health Network’s aims could usefully be adopted by the Faculty of Old Age Psychiatry – see them here.

In the business meeting Dave Jolley drew attention to a letter by Colin Godber, a pioneering old age psychiatrist, published recently in the Guardian (see it online here) which says what many of us are thinking about the politicians and more!

Alistair Burns set an example of leadership and being prepared to take a risk on behalf of what you believe, which contrasted with the inability of the Faculty (the group representing old age psychiatrists) to seize the initiative. The Department of Health dementia portal here give access to information on what he has been doing.

I suppose it’s easier for me having stepped outside the maelstrom that constitutes the NHS at the moment. A number of colleagues said openly that they felt they couldn’t criticise the way things are going from their positions within the system. Maybe those of us outside it could offer a voice?

13 comments (Add your own)

1. Emyr wrote:
Although the fellows of my College, the RCPath, practices at the other end of the physical:mental spectrum to yours, pathology appears to doing better in correcting the historical gender imbalance than psychiatry. My own subspecialty of histopathology has noticed that women are more likely than men to seek consultant posts where they aren't required to perform autopsies, so we have developed a route to FRCPath in Histopathology whereby you needn't take the module in autopsy pathology. Mine is a discipline that is, by tradition, very conservative, in contrast to yours. So why are we doing better than you?

Sat, March 17, 2012 @ 11:00 AM

2. David Jolley wrote:
Thanks for this: we need a vehicle which is capable of responding to Steve Shrubb’s challenge

You have raised a number of issues here:

Gender balance: my belief is that psychiatry still attracts a larger proportion of women doctors than most other specialties http://pb.rcpsych.org/content/30/9/321.full
And Old Age Psychiatry has always been welcoming to women as trainees and consultants (Arie T (1975) BMJ (3) 5984: 641-643

The point is that despite the presence of women in the workforce (balance is roughly 50/50) there was a notable absence of women from the platform in Cardiff: 0/7 on Thursday, 1/5 on Friday. Matters were better balanced in the workshops 50/50 and the trainee presentations (50/50) but not in the split sessions: 1/6, nor the consultant presentations 2/10

Maybe things were better last year – I certainly remember a platform presentation on poetry from Hannah Zelig and Professor Caroline Chew-Graham on depression from a Primary Care perspective.

Other aspects of balance: The dominance of dementia to the virtual exclusion of other mental disorders made me uncomfortable: 22 presentations on dementia: 17 on services – most being skewed to dementia-care and only 3 (all within the trainee presentation session) being devoted to non-organic disorders
This links with the other and most significant point – the passive acceptance by the Faculty of a persona imposed by the views of others: to become a single disorder (dementia) specialty, deserting the needs of older people with other mental health problems which we know are not well-understood or managed by other and yielding our status as psychiatrists with a comprehensive range of skills and abilities which can be applied in any situation and to older people with mixed and complex difficulties.

It was this which moved Steve Shrubb to raise his challenge: the need for a brave, strong, well-informed leadership from our faculty to guide and support development of good services for the numerically and economically most important group of patients presenting for help within health and social car. These are older people with multiple difficulties arising from mixed physical, mental, social and spiritual problems.

There are signs here that a revival movement is called for. As you say Alistair Burns is showing it can be done for the previously unfashionable ‘dementia’. We must move on from that position of strength to accept a wider responsibility

Sat, March 17, 2012 @ 6:39 PM

3. Angela Hill wrote:
I think and have observed that complacency cascades down throughout older adults services whether its old age pyschiatry or health and social care even to grass roots.
To address professionals like Steve Shrubb unforunately I would have to query their intent and interest in Older Adults, is it genuine or just for self gratification.
Grass roots as to cope with lack of funding for services,closure of care/nursing homes, loss of community workers and staff in acute hospital settings.
The loss of experienced old age pyschiatrists through retirement or disillusionment with the NHS unfortunately as left us with their younger versions who have very little practical experience'
I am still convinced that unless grass roots is listened to and there need and wants adhered to all aspects of older persons mental health will hit the bottom of the pile and remain there till mental health history repeats itself
Grass roots experience must be deployed into a scenario full of intent to continue and improve the services required and not to implode into the usual suspects and the old boys network.
Working very much at grass roots level these days I witness the feeling of helplessness from families whos loved ones have dementia and there is nothing there to offer support and comfort.

Bring on the revolution!

Sun, March 18, 2012 @ 5:15 PM

4. Michael wrote:
All very interesting points.

From my experience, the approach taken with psychiatrists is different than with other members of the MDT. Where there are mostly males for example in a community team, managers will try to address the imbalance with more females. This does not seem to be the case with psychiatrists. However, this could be down to numbers available and how attractive these posts are to females.

As a commissioner in mental health, I wrote to several psychiatrists outside of my area for an opinion on the current trend towards splitting old age psychiatry services and creating just dementia teams. Older people with functional mental health issues are being moved over to adult mental health services on the grounds of age inclusion, despite the overwhelming evidence that these services are not age appropriate. It would seem that in some mental health trusts, people do not have dementia and depresison, dementia and schizophrenai or indeed and physical health issues as well as dementia.

Having spoken to psychiatrists, nurses, social workers and psychologists, I have yet to meet someone who agrees with this trend but rarely find anyone who speaks out about it (Benbow and Jolley are the exceptions). It is a lonely place fighting your part of this battle and I do feel it is time for a more collaborative approach.

I heard recently about adult mental health doctors and nurses in another trust writing to their managers and refusing to take older people with functional mental health issues citing the competency card. This is a trump card and more people should consider making use of it. A risk is much less of a risk when shared with others.

Commissioners have a repsonsibility to understand these issues and be prepared to say that mental health providers can do whatever they choose with their services. However, commissioners may choose not to contract them and commission more appropriate services from elswhere!

Mon, March 19, 2012 @ 9:29 AM

5. David Jolley wrote:
It is good to know that technical problems have been addressed and we can be assured that our freely given, non-spam points of view can be received and given air-time

Both Angela and Michael make important and positive suggestions which we ought to consider and turn into an action plan.
What I take from them is
• Older an experienced psychiatrists should be prepared to take a lead
• Psychiatrists should not seek to work alone in lobbying for good services
• We need an organisation which has its roots in the people who really know: patients, family carers, colleagues in other professions as well as Old Age Psychiatry
• We need to be lobbying for better services for Older People with Mental Health problems across the spectrum of diagnoses rather than become divided into diagnosis-specific competitors
• These services need to relate to people who will work with us in an holistic approach to individuals, being competent to provide for the physical, mental, social and spiritual needs of patients and families

Sounds sensible to me

How are we going to do this?

Mon, March 19, 2012 @ 6:23 PM

6. Susan Mary wrote:
Firstly, to reassure Dave I took off the spam filter so comments now go straight onto the blog even if they're from yahoo!

Secondly, thanks for the comments and all the important points raised. I completely agree – we are stronger in partnership.

Angela and I met recently and one of the things we talked about was the possibility of getting together a group of people, combining users, carers, clinicians and academics who are concerned about mental health and older people, and who are prepared to stand up and speak out – lobbying is the right word I suppose and that’s what I hear you suggesting Dave. It sounds as though Michael sees a need for it too.

I also agree that a collaborative holistic initiative would need to encompass, not only a range of diagnoses, but also health, and the positive contributions that older people make in the lives of their families, friends and communities.

Thu, March 22, 2012 @ 6:43 PM

7. David Jolley wrote:
Right - Now how can we progress these good ideas?

Sun, April 1, 2012 @ 5:01 PM

8. Michael wrote:
There are a couple of things I would suggest. In the first instance, there could to be a forum whereby other interested people can join the cause, irrespective of their background; professional or otherwise. One thing that commissioning has taught me, is that there are a large number of people both working in and interested in older people and not just doctors, nurses and academics. The third sector for example.

The forum could literally be an Internet forum where people could contribute at any time and from anywhere until the lobbying group is identified and established. I agree entirely that, "older experienced psychiatrists should be prepared to take a lead."

Secondly, I see a need for education on the issues at hand. Without knowing the background arguments, it is easy to see why people will argue the point, that it is only correct that older people with functional issues be sent off to join their younger peers by removing the age limitation. We would not argue against this, except for when those services were never designed for older people with complex co-morbidities and then those specialist services cease to exist.

Mon, April 2, 2012 @ 2:57 PM

9. David Jolley wrote:
Thanks Michael. This is sound. Can we assume we have a membership of four right now? We should draft a manifesto, or something like that, in agreement and make this available.
Will thi sblog provide a suitable site for such a forum or do we need something different - self-standing?

Letters to key newspapers and journals could be used to point others to the site and offers of presentations at meetings

Sat, April 7, 2012 @ 8:05 AM

10. Angela Hill wrote:
I think David its a constitution we need not a manifesto, sounds to much like a political party and i am not ready to become prime minister just yet. A virtual group comes into mind, we have a core group and of couse Susan and I will be the founder members and the group uses the internet where it can access organisations and people who have an interest in dementia and older adults in general. A constituted group can put in tenders for various pieces of relevant work, perhaps Michael can clarify that for us,once we start looking in this area I feel certain that we will very quickly move forward

Tue, April 10, 2012 @ 10:33 PM

11. Susan Mary wrote:
Angela and I met recently and came up with a possible outline plan which seems to fit the thrust of our discussions: to get together a group of like-minded people, combining users, carers, academics and clinicians who are concerned about mental health and older people, and who are prepared to speak out. We thought this might be best described as a Think Tank. Angela’s colleague suggested the name ‘Mindset’ and I wondered about the strapline – Stand up and be counted!

Dave suggests we need a manifesto and Angela says we need a constitution. I looked up a definition of ‘manifesto’ – ‘a public declaration of principles, policies, or intentions’. Maybe then we need both, but, if we go ahead with this developing idea, I think we need to be, above all, an action group. The possible actions I have heard suggested so far include: education; lobbying; connecting with others perhaps using an online forum; writing to newspapers, journals etc; presentations.

As to founder members we might have angela, dave, me, maybe michael... and there are a few others we could approach. Does anyone else out there want to come on board?

Wed, April 11, 2012 @ 2:35 PM

12. Angela Hill wrote:
On Thursday afternoon I attended a meeting that was intended to discuss the community representative who wouls sit on the board of the Clincal Commissioning Group,of course everyone was representing their own group and everyone had their own ideas.

What was of interest to me was that a local GP who sat on the commissioning group and had the lead for dementia and that it was causing him problems due to the lack of interest from Dudley and Walsall Mental Health Partnership Trust and that Walsall seems to be the area that as been commissioned by Dudley and Walsall and Dudley for its memory clinics is contracted out to South Staffs.

I know from the information that I collate no one actually knows what goes on with Dementia services in Dudley, the funding was only given to Walsall, the Dudley side of the partnership say Walsall get everything not only in dementia but in all mental health services, infact i envisage a civil war before much longer, I shall take the option of leading from behind

How could we influence such stupid attitudes when the illness is pushed to one side and funding becomes the main issue,what about the users and their carers,family,loved ones how must they feel-unwanted,on their own.How can we in a sensible way use our influence to highlight this before they give up and slip through the safety net,that is if that net still exists.

Sun, April 22, 2012 @ 9:06 PM

13. Susan Mary wrote:
Everyone is trying to improve services with limited funding. This is a national problem and not just one affecting the Black Country. However, both areas mentioned above by Angela have an historical issue with low rates of diagnosis of dementia and both, in their own ways, are trying hard to address this.

As I understand it Walsall has technically been the lead commissioning body for both areas but this has not had any effect as far as dementia provision goes. Dudley has its own commissioners, receives its own funding and decides how to utilise it. Walsall does not have any say in this!

With regard to how much Dudley or Walsall has spent on dementia, a FOI request could be put in for that information (let’s do that angela).

Walsall has a full time Dementia Care Programme Manager to implement the strategy in Walsall. This person is known to me personally and intends to make a difference. Dudley’s commissioner has long term conditions also to consider. Perhaps this is why Walsall is viewed as having more than Dudley? Maybe Dudley needs a similar person to lead for them too?

Wed, August 1, 2012 @ 4:00 PM

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