Working 9-5: if only! Towards 24/7 healthcare

 

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If you work in healthcare you can’t have missed the recent outrage around government intentions to move the NHS to a ‘7 day service’. Thousands of people have signed a petition calling for a vote of no confidence in health secretary Jeremy Hunt. Mr Hunt hasn’t endeared himself to me, moly sorting from the point where he tried to shut Lewisham Hospital, a recently renovated site that serves a huge population of South Londoners and was noticeably not failing. Following public outrage and months of protest around the legality (not to mention ethics of making hundreds of sick people travel an hour to another busy A&E department when there’s a decent one near by), the plans were reversed and Lewisham H still stands. 

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A 7 day health service is a good idea. People don’t just get sick on working hours and we need to accommodate them, not the other way around. But it’s also not a revolutionary idea. I don’t know if you’ve been to a hospital on a weekend. I have and I can assure you it’s still open. Doctors and nurses work long hospital shifts around the clock every day of the year. It is a fallacy to suggest that they don’t or won’t work weekends – they rarely have a choice. Walk in centres are open weekends, and many GPSs offer a Saturday clinic. Mental health crisis teams cover weekends, keeping people in great distress safe and out of hospital. But Friday night is still not a great time to get ill. Whilst NHS staff do work weekends, it’s usually not the full working force that you’d get on a weekday. Additionally, doctors don’t work in isolation. There work depends on other staff, many of whom do not work weekends. Discharges may face a length delay whilst waiting for assessment from a social worker, occupational therapist or physiotherapist. Scans and tests need to be carried out an analysed. If transferring to another team then liaison is needed, and administrative staff for all the records and associated paperwork. A 7 day service is needed from all staff to keep the operation working.
As a psychologist I have a pretty good deal regarding working hours. I usually work 9-5 Monday to Friday. In my current setting this actually makes sense, I work in rehabilitation and we operate a structured rehab program that mirrors attending a job or course. Therapy sessions occur during the day with breaks, evenings and weekends are left free for leisure activities, family visits and relaxing. The service is residential so clients are available in the daytime for sessions. The unit operates 24/7 and as a senior clinician I also take part in an ‘on call’ system. This isn’t comparable to the kind of on call doctors engage in – I take a phone home about 6 nights a month and am available to give guidance to night staff if needed. Sometimes I’m woken up in the middle of the night but mostly it’s not much hardship. I will work weekends if needed, as sometimes this is the only time family work is possible but most of the time I have pretty ordinary hours, much the envy of my doctor friends. 
I like working 9-5. It’s a predictable, regular routine. It’s sociable – I’m off work when my friends and family are, making weekend plans is pretty easy. It’s comfy and to be honest I’d like to stay working 9-5, it suits my life. But I can see that I need to be flexible and I’m not adverse to it. In training I worked an evening therapy clinic and found it quite peaceful working in the evening. I mostly saw clients who worked and they appreciated the opportunity. Given the push to get people back into work as a marker of ‘good mental health’ it makes no sense that we then disrupt their working day to come to appointments. Mental health obeys no working week and nights and holidays can be times when people particularly need support. 
When I worked in a stroke rehab team we began running a Saturday service in recognition that people coming in to hospital later in the week were getting a worse deal in acute rehab (especially for something like a stroke where early days are very important). It was a briefer service (each staff member worked one Saturday in 7) but it made a difference. Admittedly, with fewer professionals on the ward it was a much calmer atmosphere on a Saturday so it was possible to get a lot done!
Psychologists usually aren’t a crisis service. When someone’s in the midst of a distressing episode they often need containment and support to stay safe, it’s not the time to start exploring things. This kind of support can come from many different professionals. There’s usually not a call for therapy to be provided at 2am (although I believe in some models such as MST the therapist does make themselves available through the night). However psychologists may be needed for assessments (e.g. risk, capacity, cognitive) at all sorts of times, and without them treatment and transfer may be delayed. Additionally, staff support may be needed 24/7 and we need to ensure that staff who work nights don’t miss out on support and also the training that psychologists might provide. It’s also important that we show willingness to adjust our hours as this can be a point of resentment in a team. Everyone has a life and commitments out of work, everyone misses out on something because of their work hours and everyone has an important role to play.
So it’s time to give up our cushy 9-5, as much as we love it. We’re public servants and we’re needed out of hours. We need to stand beside our doctor and nurse colleagues, healthcare should be holistic but that can’t be the case if only part of the MDT are in work. 
Motivation alone won’t be enough to get us to a 24/7 health service. Evening and weekend staff need to be funded. I can do a weekend or evening clinic, but I have a full caseload and I’ll be taking away from the work in do on other days (not to mention missing meetings and other events). I can make my service more accessible but I can’t fit more work into the same number of hours. Hiring more staff to cover ‘out of hours’ times should be cost-effective in the long-run. It should speed up treatment and discharge and limit deterioration as people wait to see a professional. It could support staff by reducing the Monday morning backlog and lengthy weekend handover, as well as hopefully improving patients’ confidence in the healthcare system. Obviously some consideration will need to be given to those with children, care and similar commitments for whom it may be tricky to be flexible. 9-5 is comfy but it ultimately isn’t fair, on patients or the staff who are left behind. Health and wellbeing is a challenge for every hour of the day and we need to rise to that.

Writing and things (less serious edition)

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Lately I’ve been making some more time to write and am finding some new publications and organisations to get involved with. As I’ve moved to having this blog more focused on psychology, sexuality & health I wanted to find some spaces to write about other less serious or just different subjects. Most recently I’ve started contributing to the blog for magazine Things & Ink.

T&I began as a publication celebrating female tattoo culture. They’ve recently increased their remit to all independent tattooing but maintain a feminist slant. To the uninitiated, sexism in the world of tattoos might not seem obvious. Photographing ink naturally requires the display of skin, but all too often women are only featured in magazines as ‘tattooed pin-ups’, in sexualised poses and revealing outfits. Meanwhile male artists and collectors are pictured very differently. There obviously isn’t anything wrong with a tattooed woman enjoying her sexuality and flaunting her body, but it’s problematic if these are the only images of inked women we see. Female tattoos still tend to be culturally linked to promiscuity and a lack of ‘class’ (think of the narrative around ‘tramp stamps’). Visibly tattooed women frequently experience sexual harassment in the street, including uninvited touching of their skin (I could go on but actually I plan on writing something more in depth about this!). I love the magazine as it’s so different and also beautifully out together, with such a range of articles, so it’s great to have the opportunity to be involved. So far I’ve written two pieces, one on white ink tattoos and one on cultural appropriation.

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Another little project I have is a beauty blog focused on pale skin and suncare. I can be a bit of a nerd when it comes to suncream and I’d never been able to find much in terms of blogs and reviews for similarly sun-intolerant people. It’s just a bit of fun and in the works. I’m reviewing higher end suncreams and make-up with SPF in, and plan to do more features related to pale skincare.

“Just a phase”? Freedom to be a little sexually flexible

 Queer women’s sexuality appears to be having something of a media ‘moment’. The new series of Orange is the New Black has got many heterosexual women claiming they’d “go gay” for genderfluid star Ruby Rose and supermodel face-of-everywhere Cara Delevigne is on the cover of Vogue describing her loving relationship with singer Annie Clarke. A comment from journalist Rob Haskell has drawn particular anger “Her parents seem to think girls are just a phase for Cara, and they may be correct.” Having their same-sex attraction written-off as “experimentation” is an experience many queer people can relate to. Photos of Kirsten Stewart sharing intimate moments with her partner Alicia are often naively captioned as “Kirsten and friend”. Bisexuality is often treated as invisible when the individual is in an opposite-sex relationship, as though their past relationships, attractions, preferences and sexual experiences are no longer a part of their identity. People of non-heterosexual identity are keen to stand up and proclaim that their sexuality is not a “phase”, that it’s who they are and it’s here to stay.

But what’s wrong with having a “phase”? Tastes and preferences vary throughout our lives and experimentation is a way in which we can work out what we like, what we want. The phrase has become imbued with negativity – connotations of inauthenticity. Ideas that sexual experimentation is motivated by ideas of what is “cool”, what is expected at a certain age, being a part of a peer group where such a thing is “expected”. Sexuality is treated as a trend, a fashion. Implicit is the notion that the experience, and any feelings attached to it, are not genuine. In cold hindsight it is rewritten as meaningless.
A particular phase of my own life relates to a period of time where I dated boys in bands. They frequently were dark, brooding and in many ways conformed to the “tortured artist” stereotype. Looking back at this time from my older (wiser?) perspective, some of my choices do a seem a little questionable, it isn’t how I would be now. The experience represents a discrete period of my life, but my feelings were my own and they were real. Although I have different expectations of relationships now the experiences and attraction is still a part of me.
 
 When singer Jessie J reported a same-sex relationship in early interviews, she was labelled by the media as bisexual and quickly featured in lists of prominent LGBT celebrities. Gay media sources responded negatively when at a later date she refuted claims that she was bi and said she now exclusively dates men. But “bisexual” wasn’t how Jessie had labelled her own experience. She had dated women, now she dated men. The later doesn’t detract from the former. It still happened. Sex-positive “agony uncle” Dan Savage often receives calls from gay and lesbian individuals conflicted by suddenly and unexpectedly, after years of out queerness, feeling attraction to someone of the opposite sex.  What does this mean for their identity? Were they bi or even straight all along?
In a word, no. If you find having a label for your sexual orientation empowering and helpful then that’s just dandy. Use it as you wish. But it’s not a straightjacket, it doesn’t preclude you from having any other feelings that fall outside of the box. There’s nothing wrong with feeling an attraction to a particular person at one time in your life, you don’t have to define yourself by it. Maybe it’ll stay with you, maybe it’s this particular person, or this particular time. It’s your feeling and it isn’t for anyone else to judge as “real”. If you’ve previously defined yourself as a “straight” women and now you feel attraction for a woman you don’t need to reevaluate all of your past experiences and adopt a gay/bisexual label. Maybe you like women, maybe it’s this woman, maybe it’s this time. Your life going forward is your own. It’s your choice, enjoy this moment and don’t let other people box in and restrict you. Our teenage tastes are often different from those in our 20s, and 30s and so on. Our experiences shape us and everyone has the possibility of changing. Even within heterosexual sexuality few people have a definitive “type” and often describe feeling attraction to someone “unexpected”. We might state a preference now, but can we be certain of what we’ll want in the future? So let’s stop talking about “just a” phase. All of our sexualities have changed in degrees and varied over time. Evolving, experimenting and developing is all part of the fun.

The more I work in healthcare the more I feel like I’m in someone else’s game of Theme Hospital

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If you never played this simulator game back in the 90s then you surely missed out. The basic premise is that you’re running a hospital. You build walls, stick in different rooms and allocate them different functions (diagnostics, treatment etc), hire staff and design the building to include seating (important), toilets (very important) and an array of vending machines to keep everyone happy. It’s best to design the hospital for a quick in’n’out for patients, to save the staff time. 067741-theme-hospital1

People are points, the more you get through the door and the more you cure, the more money you make and the closer you are to levelling up. Once you’ve got your reception area set up patients start flooding in. They have bizarre conditions such as Bloaty Headedness (an abnormally large head that requires surgical deflating), Slack Tongue (requiring stretching and cutting) and a range of wonderful psychiatric conditions including the King Complex where sufferers believe they are Elvis. Sometimes you have no idea what to do with them so you can chance an experimental cure or throw them out before they make the hospital look bad.

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An advantage the game has over real life is that you can tell people’s mood and how sick they are just by looking at them, which is great as people give you some warning before they complain/die. Waiting lists are easily manipulated by dragging and dropping people in the queue. If something important happens for some reasons people use a fax to tell you.

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You’re always trying to turn a profit and compete with the glossy rival hospital. Research improves your treatments but it’s expensive. Inspectors and important people turn up out of the blue, causing everyone to panic. Usually you can fool them by building walls to hide the worst bits of the hospital and making the place look nice with some pot plants. It’s best to chuck patients out if they’re looking likely to die on the premises as that isn’t good for the hospital’s reputation or staff’s morale.

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You get applications for staff and get to pick between the more expensive and the more…. professionally dubious. When staff complain you can give them more money or fire them. It’s a good idea to take care of them so they work better, but that takes up time, money and valuable space. Back to work!

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If you do well you’re quickly poached by a rival hospital. If you do badly, the corridors are overflowing with sick people, bodily fluids and rats and all the staff are miserable. Maybe you should cut your losses and just start a new hospital.

Sound familiar?

For reasons I cannot understand they never produced an update of this game. You can download the original here, it’s pretty low-tech by current standards. My computer’s actually too new to play it now.

Luckily for me I work in healthcare so the game never really ended. Now where’s my head-deflater….

Won’t get well: Trying to understand medical non-compliance

How many unfinished prescriptions are left in your medicine box?

How many unfinished prescriptions are left in your medicine box?

This post was born out of discussions with my doctor friends, who frequently struggle with “revolving door” patients. The kind of people you discharge knowing you’ll be seeing them in a few weeks, maybe even a few days. Individuals who  grudgingly accept treatment, as though intent on remaining sick. Those who fail to follow medical advice, despite the pain and risks they then live with. Questions arise as to whether we should treat these patients at all, whether the resources are justified when they seem determined not to look after their own health.

“Non-compliance” has a very punitive ring to it. We comply with authorities, with court orders and sanctions. It suggests the existence of an external control and an absence of choice. The somewhat softer “non-adherence” is perhaps something all of us can relate to. Which amongst us have not been entirely adherent to medical advice? Perhaps we failed to complete a course of medicine, drank whilst on antibiotics or missed a few doses. This kind of non-compliance is one of the highest rated frustrations for doctors, but is very common.

Who is more likely to be non-compliant?

In a review of 102 papers, Jin, Sklar, Oh and Li (2008) found that those who do not comply are more likely to be male, younger, single, to have a lower level of education. Those who have a cognitive impairment (e.g. dementia), a mood disorder or use substances were also found to be more likely to be non-compliant. The complexity of treatment regime, level of medical knowledge, quality of relationship with the prescriber, and stigma attached with the treatment were also highlighted. However, it may not always be as clear “why” an individual is non-compliant, and attention needs to be given to the paradoxical nature of the behaviour.

Beliefs impacting on compliance

Research suggests that cognitive factors may lie behind this “everyday” non-compliance: faulty and inaccurate beliefs that guide behaviour. Patients may believe that the treatment will be ineffective or there will be minimal consequences to non-adherence. They may believe that they are not “truly” ill or that the treatment will impact them negatively. They may believe that the disease is uncontrollable or have religious beliefs regarding illness, or that an alternative method that will help them more.

Readiness to change

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Thinking of the “stages of change” model, many patients may still be at the ‘pre-contemplation’ stage in relation to changing their behaviour. They will need support, education and counselling to progress to a point where they feel capable of change. When medical emergency forces a patient to receive medical treatment, they may still not be ready to engage in change, despite professionals escalating the situation on their behalf.

A good relationship with a professional will be needed to open up a dialogue in which it may become apparent that patients hold these beliefs. In many cases education may be enough to shift the belief, but this will need to be provided in a respectful manner so it can be well received. Motivational interviewing techniques have been used successfully to help a patient to identify discrepancies between their behaviour and their goals.

But what of people with more “severe” forms of non-compliance? Those who seem to actively avoid treatment and seem to exacerbate their condition?

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Trans Visiblity: Rallying, allying and minding your own business

NB – I am open to suggestions and making edits to this piece if anyone feels the language used is inappropriate or inaccurate. Please drop me a message and let me know556cd6644ae56e586e4588d8_caitlyn-jenner-bruce-jenner-july-2015-vf

Here is an extract from a recent conversation I had:

“But the first Matrix is definitely the best Wachowski Brothers’ film”

“They’re actually not called the Wachowski Brothers anymore, as one of them has since transitioned”

“Ah okay, didn’t know that! Good pub quiz knowledge!”

And then the conversation moved on. Transgender people are arguably more visible now than ever before, and words and phrases such as “transition”, “non-binary”, “female-to-male” and “gender identity” are far more commonplace in general vocabulary and seem to not need the level of explanation that they once did. That isn’t to say that it’s fully entrenched in common knowledge, and many people still don’t know the difference between terms such as “transgender”, “transvestite” and “hermaphrodite” (and think “cis” is some kind of infection), (the BBC published a helpful glossary this week). Awareness is rising, and that’s never been more true than this week, with Caitlyn Jenner’s Vanity Fair cover, quickly becoming the most visible trans person in the world.

Transvisibility has certainly increased in the last couple of years. Openly trans actress and activist Laverne Cox rose to prominence in Orange is the New Black, later gracing the cover of Time magazine and posing nude for Allure. Trans models such as Lea T and Andeja Pejic have been very visible in fashion and beauty campaigns. Popular television shows such as Transparent and Louis Theroux’s “Transgender Kids” have been educational to audiences. Journalist and presenter Paris Lees, once voted top of the “pink list” of influential UK LGBT people, has brought a lot of attention to trans issues. Trans men continue to be less visible, although statistics suggest that they are similar in number.

Prior to this week I was only vaguely aware of Ms Jenner (I’ve never watched her reality shows) but lately my social media has been awash with images of her, celebrating her bravery, openness and the inspiration she gives. But you only need to read the comments posted on this article (or indeed from some celebrities) to see how far we have to go in terms to increasing awareness, acceptance and equality for the transgender and minority gender identity community.

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Trans people experience significant discrimination and abuse. Many trans people, particularly women of colour, are murdered each year. They are rejected by their families, bullyied and the list of those who turn to suicide increases. The stories of Leelah Alcorn and Lucy Meadows are two recent tragic examples that have been publicised. Trans rights were largely ignored in the equal marriage debates, and the issue of “spousal veto” remains – in which a married person applying for a gender recognition certificate must have the approval of their spouse. The UK’s most prominent gay rights charity Stonewall has only recently begun to represent trans people, after lengthy lobbying. Transphobia is pervasive and often slips under the radar, as though seem as a fair topic for fun rather than an undercurrent of prejudice that impacts on the lives of trans people continually. Trans people are often the subject of jokes in the media and derogatory terms such as “tr*nny” are used without thought. If you look out for it you might be surprised the level of offensive language commonly used that refers negatively to trans communities, often slipping in subtly. Trans people are overrepresented in mental health populations, and with a lifetime of discrimination and high incidences of trauma it’s little wonder why. In order to access gender identity services people must jump through considerable hoops that include extensive psychiatric evaluation. The past hashtag #transdocfail exhibited just how uninformed health professionals are about trans issues. Any one of these instances is shocking, but together it’s a pretty horrifying picture of how we treat human beings we see as “different”.

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Tested and found wanting: The experience of completing cognitive assessment 

This piece was originally written as a shorter commentary of a piece in Clinical Psychology Forum. It was scheduled to be published but then got put on hold amidst their various special issues so I thought I’d share it here.

For those unfamiliar, neuropsychological assessment (also referred to as psychometric or cognitive testing) refers  to the process by which professionals (usually but not exclusively by clinical and eductional psychologists) aassess cognitive functioning. This usually involves carrying out a series of tests and tasks with an individual that cover a range of cognitive skills, including memory, concentration, planning, organising, language and visuo-spatial abilities. An IQ test is a form of this testing. Situations in which an assessment might be requested include assessing the impact of a brain injury, asssessing for the presence of dementia, learning disabilitiy or specific learning difficulty. A neuropsychological assessment can provide useful information for gaining a greater understanding of an individual’s difficulties and considering interventions that might help them. 


From my own experience, neuropsychologial assessment is often not a favourie activity for psychologists. Some people see it as impersonal and rather arbitary – just running through tests that seem to have little relevance to everyay life in an automated fashion. It can be hard to see the person beyond the list of test scores andpercentiles  generated. I think some of the issue here is the way that neuropsychological assessment is taught and written about. Often there is a lot of foccus on selecting tests, carrying them out in a standardised way (which is of course important), scoring and analysing the data, looking for patterns. What can be left out is how to use neuropsychologial assessment information within a clinical formulation, consideration of ethical issues raised by the testing and how to best use interpersonal and thereputic skills within the assessment.

There has been increasing discussion around separating out clinical neuropsychology from standard clinical psychology training. This isn’t a move I suppport  and I think it’s essential to highlight how the core skills and knowledge of the clinical psychologist are incorporated in neuropsychologial work, including  when carrying out a good quality assessment. If we don’t bring psychology to these assessments, we may as well have clients complete them on a computer. Time pressures and perhaps a lack of professional enthusiasm for neuropsychological tetsing can squeeze out some of the human component. Below I detail a few areas that I believe are  sometimes left out and require attention.

The Stroop Test, one of the best known psychometric tests, is used to measure switching and inhibition (components of executive functioning)


Informed consent

The client’s consent to complete the assessment should always be sought. It is not uncommon for individuals to arrive at their session with little idea of what to expect, and less so the potential implications of the results. We should inform clients of the benefits of the assessment but it is important to also discuss potential negatives. The results may have a far-reaching impact, including contributing to the allocation of a diagnostic label and the potential stigma of this (such as intellectual disability), impact on eligibility for services and associated benefits including fitness to hold a driving liccense. Ideally this is a time for collaborative discussion about the questions the client would like the assessment to answer, and tthis can be used to plan the assessment. Misunderstanding the purpose of the assessment may also impact on the level of effort that clients put in. These converations take time and may be difficult to achieve when there is pressure from referers and other parties to get the assessment ddone quickly or not to “encourage” the client to decline the assessment. 


Creating meaning within the assesment 

In addition to contributing to formulation and intervention planning, there is potential for the assessment itself to be a meaningful and therapeutic experienceThe assessment may be the first time the client has had their difficulties heard and given sufficient attention, and psychometrics may provide a medium for discussing issues that can feel intangible and hard to express to others. IIve been amazed at the relief some clients have flt when I was able to give them words to describe previously nebulous difficulties. AAssessments can be long and stressful, they put people through their paces and can highlight the very things people find most difficult. Rapport needs to be built and maintained throughout the assessment to keep clients engaged, and empathic support provided if the experience triggers anxiety.


Feedback – Concluding the proccess

The provision of feedback brings the assessment results together and maximises the opportunities for the client to understand the outcome of the process and to take away something useful. Providing personalised feedback can enhance clients’ sense of control and engagement in their treatment. It can also be an opportunity to provide psychoeducationand discuss strategies for managing cognitive difficulties. The provision of thoughtful and sensitive feedback is especially important when the results indicate impairment or are suggestive of pathology. Feeding back need not always be a lengthy process and not all clients will wish to have a formal session, but offering this validates the time and effort they have put in to what can be a stressful experience, and also represents a conclusion to the piece of work.


The recent viewpoint article in The Psychologist magazine exemplifies a worst-case scenario where a neuropsychological assessment is experienced as a disjointed process without meaning. 


“The psychologists produced a range of memory, attention and executive function neuropsychological tests without telling me the names of the tests or why it was important for me to complete the assessment. I performed these tests obediently while feeling immense frustration and confusion inside. The results of the tests were never revealed to me. Strangely, the implications of my injury were never highlighted and coping strategies were not discussed. Instead, I spent hours performing these monotonous and challenging neuropsychological tests, while trying to deal with the emotional impact of the car accident and my brain injury alone.”


Experiences like these are regrettable and really an embaressment to the profession. Collaboration is however very possible and can bring the focus back to the client and their needs, helping them to get the most from the process.