Robert Howard
@ProfRobHoward
Cautiously pessimistic UCL old age psychiatrist | Improving dementia + mental health treatment | Real critical psychiatry | Layla | Clinical academic training
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Latest posts 5
Makes perfect sense for the patients that neuropsychiatrists see. But that’s probably about it!
November issue of Brain Journal now out with an Editorial by @belin_david and myself on The return of neuropsychiatry: why clinical neuroscience needs neurology and psychiatry reunited
academic.oup.com/brain/article/…View quoted post on X
Not controversial at all. Exactly what has happened within mental health services. Financial cuts from Austerity, shortages of trained and competent multidisciplinary colleagues and (it has to be said) often appalling leadership at individual Trust level have all contributed.
I may say something controversial.View quoted post on X
You can't run mental health services that are overstretched and overwhelmed for years, where clinicians are forced to prioritise high risk, raise the bar for entry and cut anything seen as a "luxury", and then expect junior doctors to develop a high standard of knowledge and skill.
What they learn instead is how to manage risk and reject referrals.
In a system like this, a lot is treated as a “luxury”:
• the therapeutic value of the relationship itself, and of contact with a team (before, it was the status quo. Now patients are not kept open without a clear “intervention”, while the relationship itself can be the intervention)
• psychotherapy skills integrated in practice
• a psychiatrist seeing a patient when there is no medication need
One of the most frustrating phrases I heard in my NHS consultant years was: "I'm not going to prescribe for this patient, so there's no point in seeing them."
At first I thought this came from more biologically oriented colleagues. But when resources are this limited, even caring, formulation-focused psychiatrists end up working the same way.
Trainees learn that this is normal. Few people have time to add: "It shouldn't be like this. It's because of a lack of resources."
So, as generations change, expertise narrows to risk and caseload management.
The RCPsych is clearly aware of this, and the push to bring formulation into training is a good step against the current. My worry is that it becomes another tick-box: something to evidence during training, before trainees go back to copying what they see consultants do on a daily basis.
Psychotherapy training is often treated the same way: do your two cases, attend Balint, get signed off, move on.
For five years I taught psychiatrists in the West Midlands how to integrate psychotherapy and lifestyle skills into everyday practice. The idea is that these skills are not a box to tick, but tools to use in every clinical encounter. Not something to have signed off and forget about. But courses won't change much.
What's needed is less pressure on the system, so that the people who care still have the space to pass on what good care looks like.
P.S. This isn't about any specific trust. It's about a trend across mental health services.
A difficult time of the year for dogs and cats who are anxious about fireworks outside.
Last outing of the year for our old jalopies before they are tucked up for their winter slumber.
