For Racial Justice the College Was Greatly Saddened to Hear (CCQI) Is Recruiting Peer Reviewers, Whose Registration in Psychiatry

Issue 15 Spring 2021 RCPsych INSIGHT

International Congress goes virtual Contents COLLEGE NEWS IN BRIEF 4–5 Parity across the land Calls for parity between mental Dame Fiona Caldicott Get involved! and physical health in the Welsh and Scottish election campaigns remembered Looking to gain experience by getting under the CESR route and send more involved with the College? Our recommendations to the GMC regarding 6–7 College Centre for Quality Improvement individual applications for specialist Struggle for racial justice The College was greatly saddened to hear (CCQI) is recruiting peer reviewers, whose registration in psychiatry. There are Recognition of the work of of the death of Dame Fiona Caldicott on role is to assess services and help them openings for specialists from old age, eminent psychiatrist Dr Aggrey 15 February. Dame Fiona, who was the first improve the quality of care provided. As a child and adolescent, intellectual disability, Burke female Dean (1990–93) and then the first reviewer, you become part of a network of psychotherapy and forensic psychiatry, but female President of RCPsych (1993–96), was President’s clinicians sharing best practice, innovative applications from general adult 8–9 a “true pioneer”, whose “life was steeped in work and resources. Equality action public service”, says current President psychiatrists would also be welcomed. update Why the College’s Equality Dr Adrian James. There are also slots currently open Action Plan matters Dame Fiona achieved an extraordinary for Certificate of Eligibility of Specialist For further information, search ‘become amount in her career, latterly including her Registration (CESR) evaluators, whose a peer reviewer’ or ‘become a CESR Despite still having some way to 10–11 ground-breaking work on safeguarding patient role is to assess applications received evaluator’ at www.rcpsych.ac.uk go, we have begun the year with a Taking the long view information as the UK’s first National Data sense of optimism – the vaccine roll- Celebrations to mark the 180th Guardian for Health and Social Care. “She out is on track and we are starting to anniversary of the College was a beacon of hope and encouragement see the light at the end of the tunnel. to so very many,” says outgoing Dean Dr As a College, we have launched 12–13 Kate Lovett: “For women of my generation, our Equality Action Plan, the Vaccine preparation she paved the way for so many more of us to product of much reflection and reach our potential.” Practical steps to ensure hard work. This plan wouldn’t have vulnerable patients receive been possible without psychiatrists protection The next issue of Insight will feature a special tribute to Dame Fiona. Dame Fiona Caldicott like Dr Aggrey Burke recognising 14–15 inequalities and paving the way for Caring for the carers future generations to tackle racism Supporting the workforce head on. It is vital that we have clear through the current crisis and actions to help us achieve traction beyond and keep up momentum. It was with great sadness that I 16 heard of the death of Dame Fiona A question of quality Caldicott, a devoted public servant Professor Mike Crawford and the first female President of reflects on the work of CCQI Professor Subodh Dave Professor John Crichton RCPsych. We also recently lost Professor Julian Leff, a pioneer 17 in the treatment of schizophrenia End of term celebrations All change and a wise counsel to many. Reflections on the contributions Both played an important role of the College’s outgoing Dean in psychiatry and will be deeply and Treasurer Congratulations to Professor Subodh Professor Crichton garnered 35.2% in the missed. Dave and Professor John Crichton who first round for the Treasurer election, and Looking forward, we’ve recently 18–19 have been elected as the next Dean and won with 46% in the second round, over Prisons and the pandemic announced that among our keynote Treasurer of the College. Dr Lenny Cornwall, who received 43.6%. speakers at this year’s virtual A vulnerable population being Following the two well-contested elections Dr Anand Ramakrishnan also stood. International Congress are Chief hit hard by measures to control that closed in January, Professor Dave Professor Dave and Professor Crichton Medical Officer, Professor Chris the virus received 43% of votes in the first round will take up their posts in the summer, for the Dean election, finishing with 57% taking over from Dr Kate Lovett and Whitty, author and poet Michael 20 of the ballot once second preferences Dr Jan Falkowski respectively, and will Rosen, and Professor Prabha A Congress like no other were counted. Dr Chris O’Loughlin came serve five-year terms. The enormous Chandra. This will be a great What to expect from RCPsych’s in second with 33% of the vote. Professor contributions of Dr Lovett and opportunity to reflect on the past first virtual International Nandini Chakraborty and Dr John Russell Dr Falkowski are celebrated on page 17 year and I look forward to seeing Congress Celebrating 180 years of the College in all its guises on pages 10–11 also stood. of this issue of Insight. you all there.

Dr Adrian James

Editors: Gemma Mulreany, Tamasin Cave, Rebecca Couper and Kim Catcheside Design: Lee Braithwaite Clinical Editors: Dr Tony Rao and Dr Santosh Mudholkar Illustration: Owen Davey (front cover), Kipper Williams (p2) and Owen Gent (p18–19) Writers: Colin Richardson (p4–5 and 18–19), Dr Samara Linton (p6–7), Tamasin Cave (p8–9, 10–11 and 17), Photography: Grainge Photography, Horst Friedrichs and Harvey Mills 2 Radhika Holmström (p12–13), Claire Read (p14–15), Rebecca Harrington (p16) and Katie Newton (p20) 3 POLICY FEATURE Your Insight

To send us your insights, email [email protected] or tweet using #RCPsychInsight

Your comments on Insight issue 14: at the heart of their proposals. agenda and I’ve always felt it lost out The Welsh manifesto, entitled to physical health. So, for the whole Good mental health for Wales, calls five years, the health committee has Responding to Centred on jobs, for “a sea change in the way mental insisted that we consider mental an interview with RCPsych health is prioritised and funded in health alongside physical health.” Registrar Dr Trudi Seneviratne on Wales”. Spending on mental health He points to a raft of inquiries unemployment and mental health: services per head of the population carried out by the committee into, in Wales is lower than in the other among other things, loneliness and #RCPsychInsight @TrudiSene1 devolved nations. RCPsych is isolation, suicide prevention and the is clear that she would like to see pressing the Welsh government use of anti-psychotic medication in more focus on public mental health to ensure that spending on mental care homes. The committee’s latest and prevention. Psychiatrists need health and learning disability services report, on the impact of COVID-19 on to be part of conversations around is increased to at least 13% of its mental health, is currently awaiting a prevention. We save life, we can’t overall budget. response from the Welsh government. prevent MH conditions totally, but It is also calling for wellbeing to Both Dr Fergus and Dr Lloyd agree definitely there are things to be done. be “the principal aim of the budget”, that progress has been made in Dr Manal El-Maraghy along the lines of New Zealand’s recent years, with increases in funding Wellbeing Budget introduced in May for mental health services and greater 2019. The idea is that all departments awareness. Last autumn, the Welsh of government make wellbeing their government created a new cabinet top priority when making spending post, that of Minister for Mental Health Responding to the Help at the end decisions. and Wellbeing, a development Dr article on palliative care psychiatry: ”There’s a strong feeling within Fergus welcomes as “very positive Welsh Senedd Health Committee Chair, Dr Dai Lloyd of Plaid Cymru mental health services that a news”. RCPsych recently met with Delighted to see this article on wellbeing budget would work very the minister and had “a very helpful psychiatry at the end of life by well,” says Dr Katie Fergus, a conversation, which, we hope, marks #RCPsychInsight. Some services rehabilitation psychiatrist based in the start of a constructive dialogue.” in England already well established. Cardiff and RCPsych’s policy lead in Dr Lloyd credits the work of his Clear from research that there is a Wales. It’s a view that seems to be committee for the advances that have huge unmet need. How can we start Parity across the land widely shared. “We’ve met with all been made, “though I would say that this conversation in Scotland? the major political parties to discuss wouldn’t I?” He concedes that the @RCPsychScot the manifesto,” says Dr Fergus, “and Health Minister may have played a Dr Darragh Hamilton it’s been very well received.” part, which is high praise from an Insight into RCPsych’s campaign for parity in Wales The manifesto is the latest in a opposition politician. ahead of May’s Senedd and Scottish Parliament long line of interventions made by Dr Fergus pays testament to the RCPsych in Wales. “We enjoy a very work that the College has been doing elections. good relationship with the Welsh in raising its profile and its voice to Responding to the Meeting in Government,” says Dr Fergus, citing advocate for the needs of people Bethlehem article on RCPsych- regular discussions, as well as with mental health problems. She is supported Palestinian trainees: requests for presentations on a wide confident that RCPsych’s influence range of issues. will continue to be felt during the RCPsych Insight features two his is an election year “RCPsych’s manifesto in the Scottish Parliament and The College also works closely with forthcoming election campaign. “We’re exceptionally brave women making like no other. On 6 May, Welsh Senedd are up for grabs in the Senedd’s Health, Social Care certainly anticipating having quite a a difference to the future psychiatry socially distanced voters has been very well May. The devolved nations control and Sport Committee, whose chair high profile over the next few months,” in their country. Proud that the will navigate COVID-19 received by all the their own health budgets, so the for the past five years has been Dr she says. College is involved in their training T to cast their votes in major political parties choices made by voters will directly Dai Lloyd, Plaid Cymru Member of and privileged to be part of it myself. elections across England, Scotland influence future health spending the Senedd for South Wales West. Professor Nandini Chakraborty and Wales. Public health, both in Wales” priorities. RCPsych has launched A former GP, he says he “immensely Both manifestos – Good mental mental and physical, will be front of two manifestos in the run-up to the enjoyed” the six months he spent health for Wales and RCPsych in mind for many. parliamentary elections in Scotland as a psychiatry SHO when he was Scotland’s No Wrong Door – can be There are no elections this year and Wales, both of which put parity training. “Mental health has always accessed from www.rcpsych.ac.uk in Northern Ireland, but all the seats between mental and physical health been high up on my own personal

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A costly struggle for racial justice

Recognition of the work of eminent psychiatrist and academic Dr Aggrey Burke over the past 50 years.

hen in January “I was seeing things 1981 a house fire in New Cross, South that others would London, killed 13 see and ignore, and I young Black people, W would reﬂect” psychiatrist Dr Aggrey Burke was one of few professionals to respond. Working alongside a local community group, Dr Burke established a peripatetic service to support those affected by the fire. “I would Dr Aggrey Burke finish my day job as senior lecturer and consultant psychiatrist in Tooting, and at immediate family. His father, Reverend six o’clock I’d drive down to New Cross,” Dr Eddie Burke, who was involved in correct the consultant. This incident has to conduct pioneering research on the at great cost to Dr Burke’s career. It is anaemia and related disorders. he recalls. “If you have a hurricane, you social reform across the Caribbean, was stayed with Dr Burke ever since. epidemiology of mental illness, suicide striking, for example, that someone with Today, deprivation remains high have to get on with what you have to do.” sent to the UK in 1959 by the Jamaican While Patois was misunderstood and parasuicide in migrant groups; on the his experience and academic profile has among the diverse Black British The lack of response from the police, government after racial conflict and the in the UK, the legacy of colonial rule impact of race and culture in the delivery not received a professorship. population. Racial inequalities are public and government to the tragedy, subsequent killing of Kelso Cochrane and slavery led to it being stigmatised of mental health services; and the mental “I thought we were doing a service to still evident in education, detention, which was widely believed to be a racially in Notting Hill. “People weren’t happy in Jamaica too, where Dr Burke did health of offenders. the medical school and the profession, family courts and the criminal justice motivated attack, led to protest and what about the presence of Caribbean people his foundation training (as well as in In addition to his research and clinical but my colleagues were not happy. The system. Black people have higher was then the largest demonstration by in Britain at the time,” Dr Burke recalls. Trinidad). “It’s a terrible situation back practice, Dr Burke was also a senior lecturer profession as a whole was angry,” he rates of schizophrenia, as well as the Black community in the UK. Dr Burke “It was really quite frightening in that home in the Caribbean, and here and at London’s St George’s Hospital Medical says. “I felt that I wasn’t being seen as a far higher rates of detention among remembers colleagues’ advice at the time: period.” elsewhere,” Dr Burke explains, “that to School. One day, fellow senior lecturer Joe mediator and a diplomat; I was being seen children and adults, and death while “I was told not to get involved,” he says, At medical school in Birmingham, be Black and unsettled and from a rural Collier consulted Dr Burke regarding some as an instigator.” being detained. Yet diagnoses of “but I was involved.” where he excelled in his studies and area and to be unsophisticated as well, it disturbing observations. The system being Around the same time, Dr Burke personality disorders, Dr Burke’s area “Society was scared that something was captain of the athletics team, leaves you as a non-person, and so you used to screen medical school applications published another significant study. After of specialism, are virtually absent would come of it and there would be racial Dr Burke was also cognisant of the strive all your life to be a person.” appeared to be biased against women self-funding a trip to Jamaica to follow in reported samples, a finding he conflict,” he says. “But we’re not in this deprivation among the local Caribbean Still, Dr Burke says of his time there, “it and ethnic minorities. “I couldn’t handle the up 80 people with severe mental illness suggests may be symptomatic of racial business for racial conflict. We’re in it for population. “You could see subjugation,” was a wonderful experience being back material without taking into account that I who had been repatriated from Britain to bias. “Sadly, since the New Cross fire the opposite – racial togetherness. But he says. “There was this sense of a home among one’s peers. To be free is am Black,” says Dr Burke. “I could not under Jamaica, Dr Burke found that repatriation disaster 40 years ago there has been there is resistance to that.” population that’s downtrodden, with the quite a sensation”. any circumstance deny the right or privilege had a negative impact and was not in their little change in the distribution of racial In 2020, Dr Burke was awarded the worst schooling, the worst housing, the He was to encounter challenges, of a group of students to gain entry to any best interests. This research also received injustice and deprivation in urban President’s Medal by former RCPsych worst jobs.” however, on his return to the UK to facility by virtue of race. If I did that, it would little recognition until recently. areas of our country,” he says. “The President Professor Wendy Burn in He also remembers the racial continue his training. “There was be saying that I shouldn’t be around.” Undeterred, Dr Burke continued to profession should not be blind to the recognition of his contribution to psychiatry, inequalities in medicine at the time. While resistance from the place that employed In 1986, Burke and Collier published organise conferences, run working consequences of this tragedy.” particularly his work relating to mental on a clinical rotation as a medical student, me from day one,” he says. “I was not a ground-breaking paper for the Medical groups and research mental illness in Now largely retired, although he illness in Black families. After a long and he recalls challenging a consultant who welcomed, not in a meaningful way.” Dr Education journal that exposed the racist ethnic minorities, racism, deprivation, remains active in the research and pioneering career – and as the UK’s first was assessing a female Jamaican patient. Burke kept going, though. “I wanted to and sexist student selection procedure in repatriation and parasuicide. The latter voluntary sectors, Dr Burke is still Black Caribbean consultant psychiatrist – “She was speaking in the Jamaican learn all the time. I was seeing things London medical schools. The Commission part of his career was spent working concerned with these issues. “There is that recognition was long overdue. language Patois, and he gave an that others would see and ignore, and I for Racial Equality later confirmed their in a personality disorders community much work to be done, and I think we will Dr Burke came to the UK from Jamaica interpretation that was totally inaccurate,” would reflect.” findings which led to reforms of the selection team and as a liaison psychiatrist for need all hands on board,” he says. “There as a teenager along with most of his says Dr Burke, who then stepped in to That reflection would lead Dr Burke process. The exposé, however, came patients with cardiac disorders, sickle cell is hope, but it is an uphill struggle.”

#RCPsychInsight #RCPsychInsight 6 7 COLLEGE FEATURE

being detained under a section of the “I want to make sure that when a Mental Health Act. Urgency is needed patient is involved in mental health too to tackle the discrimination faced services, they know that they can by LGBTQ+ individuals in accessing trust that organisation. Whether it’s healthcare, as well as the higher risk of a psychiatrist or someone else, you suicidality they face. Inequality is still a need to know that you can trust that reality for disabled people, particularly person to help you.” This is especially those with intellectual disability, that true on wards, where patients can be has an impact on their life expectancy. very vulnerable, she says. “Patients Women today also face inequality in need to feel that they’re in a safe too many areas of life. space and taken care of.” The roundtables sought to learn For Ms Joseph, of the 29 key actions from people who had experienced in the Equality Action Plan, three areas prejudice in the mental health system. stand out, all of which the College “Sometimes it was heartbreaking,” has committed to achieve in the first says Ms Joseph who listened to their year. The first is the establishment of stories, “but, unfortunately, it wasn’t a Quality Improvement Collaborative a surprise. I don’t want that to be the to promote the implementation of the case,” she adds. It became clear that, Advancing Mental Health Equality while RCPsych has made strides in (AMHE) resource methodology, which upholding the College value of respect, she believes “is really going to help much more needs to be done to with how patients are treated on ensure equality and diversity is front wards”. Second is the commitment Michelle Joseph, patient representative and centre of everything it does. to champion and support the Besides the roundtables, Ms Joseph implementation of NHS England and and other members of the Taskforce NHS Improvement’s Patient and Carer “ hat makes this undertook a thorough appraisal Race Equality Framework. Finally, Taskforce different Launching the plan, RCPsych of previous recommendations on she supports the proposed review of from any other?” President Dr Adrian James was clear achieving equality from multiple CCQI’s Core Standards for mental That was one of about its purpose: “Discrimination organisations. “We had a lot of health services to ensure that they W the first questions Equality action and prejudice, based on any of the reading to do,” she says. Having promote equitable access, experience RCPsych patient representative, protected characteristics, is inherently combed through them all from the and outcomes for patients and carers. Michelle Joseph, asked before wrong and can lead to profound patient’s perspective, she was asked “Patient experience is so important, joining the team charged with Patient representative Michelle Joseph explains why distress and unhappiness, which for her views as to which of them she but so too is access,” she says. creating the College’s Equality Action the College’s Equality Action Plan matters. negatively affects mental wellbeing,” felt were most important. “I looked “People are having to wait potentially Plan. “It’s clear that these issues he said. “To promote equality, we for a whole range of things,” she a year to be seen. We are losing have been identified before, and it’s need to implement a process and a explains, from barriers to action to the people because of this. People are clear change is not happening on system that puts these goals centre systems that are needed to ensure losing their lives because they are anything like the scale needed,” stage at every turn. We need clear progress can be measured. despairing, or families are having she adds. actions that help us achieve traction “I was very focused on issues to take the strain and they are not Assurance came from Dr Rajesh “Patient experience carer representatives, like Ms Joseph, and momentum.” around duty of care and flagged equipped.” Mohan, who was appointed last alongside College staff – to hold a The document sets out why action up areas that I knew were really “For me now, it’s about making year as one of two Presidential is so important, but series of roundtable discussions with is needed now. Profound inequalities important because of my own sure I continue to make the College Leads on Race Equality, alongside so too is access” experts, including those with experience still exist for Black, Asian and Minority experience,” she says. While Ms accountable for what it says it will Dr Shubulade Smith. “It is all of mental health services. Published Ethnic people in access to treatment, Joseph now sees herself as a achieve in year one,” Ms Joseph about action, is what he said,” in January this year, the Equality experiences of care and outcomes. success story, thanks in large part adds. “Change will take time, but if it Ms Joseph explains. “They didn’t Action Plan they created sets out how The unmet needs of Black African to a mental health professional who works towards better mental health for want there to be a huge number of the College will promote equality and and Caribbean people is leading was “amazing”, she has “been on the patients, then it’ll be worth it.” recommendations, but instead a plan Last autumn, RCPsych brought equitable outcomes for members, to an over-representation of these receiving end of mental health care that was smart and set to a realistic together an Equality Taskforce – College staff, the mental health communities in detention and a that hasn’t been at all good”. The Equality Action Plan can be timeframe.” made up of doctors and patient and workforce, and patients and carers. greater likelihood of Black adults “I know that trust is key,” she says. downloaded from www.rcpsych.ac.uk

#RCPsychInsight #RCPsychInsight 8 9 COLLEGE FEATURE

Coming together The earliest predecessor of the College, the Association of Medical Officers of Asylums and Hospitals for the Insane, was the first national psychiatric body anywhere in the world. In 1841, Dr Samuel Hitch of Gloucester asylum wrote to colleagues around the country that they “should be better known to each other”. There was a need, he wrote, to share their experience, collate data and help each other improve s we come through this treatment for mentally ill people. Forty- challenging period full five asylum doctors answered his call, of questions as to what 11 of whom attended the very first comes next, the College annual meeting. Subs at the time were A is taking time to celebrate one guinea. its history. Since 1841, RCPsych and From the outset, founder members its predecessor bodies have advocated sought to shift perceptions of mental for people with mental illness and the illness. Recognising the role that profession, and this year provides us language plays in reinforcing attitudes with an opportunity to reflect on where and stigma, they proposed replacing the we have come from and how we have word ‘asylum’ with ‘hospital’ in a bid to adapted and changed over the past reframe the treatment of mental illness 180 years. from a site of detention to a place for “We can learn much from considering treatment and recovery. It marked the the past, both the good and the bad Belgrave Square, home to the College from 1974 to 2013 beginning of the long journey to parity of bits,” says College historian Dr Claire esteem with physical health. Hilton. “How our forebears strived with Today, the College shares much with challenges can give us ideas about the Association formed some 180 years how we might respond today in similar ago, albeit on a very different scale. circumstances.” Thousands now attend RCPsych’s The anniversary is being marked in annual International Congress, which various ways throughout this year. A this year, for the first time, is an entirely wide-ranging series of online webinars, Taking the virtual event. But the impulse that led to for instance, has been curated to open the Association’s creation is unchanged: up the College’s history to members, that psychiatrists come to better know covering topics such as: the part played and learn from each other’s work by Jewish doctors in the development through membership of the College for of psychiatry, how the patient’s voice long view the benefit of those with mental illness. has grown over the last 180 years, and the best and worst of Henry Maudsley. Included with an issue of Insight We take a look at some of the celebrations to mark the later this year, there will be a special supplement commemorating the 180th anniversary of the College in all its guises. anniversary. It charts the College’s journey from the very first meeting of RCPsych’s earliest predecessor body, Virtual Congress 2021 the Association of Medical Officers of Asylums and Hospitals for the Insane “How our forebears In addition, this year’s celebrations “History is like a jigsaw,” says most serious mental illnesses are often at Nottingham asylum in November include an opportunity for psychiatrists Dr Hilton. “It lets you see how the neglected,” says Dr Hilton. “When the 1841, right up to the present day. strived with today to contribute to the College’s whole picture came together: public economy begins to recover, physical A particularly turbulent period of the challenges can give collective history. Members, as well perceptions, the patient’s voice, health services tend to get priority over College’s history has also been captured us ideas” as other medical staff, patients and legalities, economics, politics, the mental health services, and the ‘parity on film. In 1968, as political movements campaigners, are invited to contribute media, science, medicine, professional gap’ widens. We must do our best not ignited around the world, the Royal their views – which could be in the roles and rivalries, buildings and to let this happen by working with all Medico Psychological Association form of a piece of prose or poem, film facilities. They all coexisted in the past those other parts of the ‘jigsaw’.” (as the organisation was then known) or music – to create a ‘Future Archive’ like they coexist today, even though the experienced its own uprising. Junior documenting how services are delivered shapes of the pieces vary.” To find out more about RCPsych’s psychiatrists seeking to modernise and experienced now. The deadline for “In the context of a prolonged disaster 180th anniversary events, including training and standards clashed with many months. The short film captures submissions is 30 April and RCPsych is – this certainly includes both world details of the webinar series, visit: Dr Samuel Hitch: Founder of the Association of Medical the establishment of the RMPA in an the testimonies of those that fought for keen to encourage a diversity of views wars, but also to an extent what we are www.rcpsych.ac.uk/about-us/ O cers of Asylums and Hospitals of the Insane, the acrimonious and public row that lasted change during this period. on mental health services. experiencing today – people with the celebrating-our-history ﬁrst predecessor body of the College in 1841

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Vaccine preparation

With the vaccine roll-out at full tilt, what practical steps can psychiatrists take to ensure vulnerable patients receive protection?

he vaccination programme help address these issues among to protect people against their patients, especially those who COVID-19 is arguably may find the information hard to follow the one real public health or may lack capacity altogether? Krishnan, who is the Chair of the This group of people have died from Mental capacity is a crucial issue that person should be consulted to T success in the UK over the The most important point emphasised Faculty of Old Age Psychiatry at COVID-19 at a far greater rate, and here and capacity, importantly, is make the decision. If not, it’s up to a course of the pandemic. By lobbying to by those with experience of RCPsych. “Give visual aids, assess younger, than the average population. ‘decision specific’. The assessment, multidisciplinary team, which consults include people with mental as well as delivering vaccination programmes their capacity and choose your “People with intellectual disabilities are in this case, is whether someone everyone concerned including any physical vulnerabilities in the higher- is that people’s concerns need to be moment,” he suggests. highly vulnerable, and mortality rates is able to understand the issue of relatives who know the patient best. priority groups, the College can claim taken seriously, whether these are One example he gives is in trying to confirm this,” says Dr Ken Courtenay, vaccination and make a decision Importantly, though, they are thinking to have played a role in its success. worries about side-effects or the Bill get past doubts over the seriousness Chair of the Faculty of the Psychiatry of about it. In the case of older people, Dr about the decision that the person At the end of last year, the Gates microchip conspiracy theory. of the virus. “Explain that you’re not Intellectual Disability. Krishnan explains, it’s about assuming without capacity would have taken, guidance from the Joint Committee scaremongering, but that it is very Dr Courtenay echoes the importance everyone has capacity until proven considering both the risk and benefits on Vaccination and Immunisation different from flu. That explanation of preparation and assessment for otherwise: “Just because we have associated with having or not having was updated to include RCPsych’s takes time, but it’s very important,” people who aren’t sure about the given a diagnosis of dementia, doesn’t the vaccine, and also the patient’s recommendation that adults under “Give visual aids, he says. With older people, it is vaccine. “The big challenge for us is mean we automatically assume they previous wishes. “I have a couple 65 years of age with severe mental assess their capacity often particularly important to also in ensuring that families and support don’t have capacity. We will ask if they of patients who won’t even take illness, severe and profound learning include families and carers in these staff are actually preparing people understand about the pandemic, as paracetamol for pain. Those are the disability and Down syndrome should and choose your discussions, he adds. “I do have some for the vaccination programme,” he that will be the key. Then we talk about ones whose best interests we look be included in the cohort of individuals moment” families who don’t want their loved says. “Consent forms are available the vaccine and what it will do to fight at,” says Dr Krishnan. The point is to with underlying health conditions one vaccinated,” but by educating on NHS England’s website for people against the virus. Nine out of 10 times, understand and fill in the views of the (group 4). At the end of February, this them too, he says they “generally to complete, and we are encouraging as you work through these questions, person and what decision this person cohort was extended to include all come to an agreement.” The situation support staff to do this.” it will not be too complex for them,” he would have taken. adults with intellectual disabilities, after is not helped by people being unable For people who have capacity, there says. If someone with capacity has Vaccination cannot and should pressure from a number of different to visit their GP surgery, according to are ‘easy-read’ and accessible materials made an informed choice to refuse the not be forced, everyone agrees. But organisations, including the College. Simply dismissing these feelings Dr Krishnan, which is where they are developed by groups such as Learning vaccine, he adds, it must be recorded with the death toll in the UK among Vaccine take-up has been very and beliefs doesn’t work and, in fact, used to accessing health information Disability England and Mencap. “In more and their wish respected, even if others the worst in the world, continued good in the UK overall. Yet, some can be counterproductive, given from pamphlets and leaflets. “It means difficult situations, where it’s harder to consider this an unwise decision. efforts need to be made – including people, including those who are the persuasive volume of anti-vax the information they have is mostly obtain consent, the local community When someone is judged not to be better information, preparation and more vulnerable to COVID-19, are misinformation out there, including from the TV news,” which he says teams should consider completing able to understand what’s involved, assessment – to protect those most at proving harder to reach, whether targeted misinformation through social has led to some patients experiencing capacity assessments on people,” however, the decision needs to risk. As RCPsych President, Dr Adrian that’s because they have concerns media. concerns. Dr Courtenay says. “This is about equity be taken in their best interests. If James says: “We hear a lot about over safety, lack awareness, or they Instead, what’s needed to allay For those with intellectual and equal access to healthcare. We do they have formally designated a numbers, but behind those numbers experience other barriers to accessing concerns is “preparation, negotiation disabilities, the issues are slightly have mechanisms and it’s really important power of attorney for health and are real people. There are going to the jab. What can psychiatrists do to and clear information,” says Dr Mani different, but just as important. to protect people from this disease.” welfare and now have no capacity, be real gaps in our lives.”

#RCPsychInsight #RCPsychInsight 12 13 NEWS FEATURE

Caring for the carers Evidence shows healthcare sta are experiencing understandable mental distress caused by the pandemic. But it also shows how to eectively support the workforce through the current crisis and beyond.

uring 23 years as a “Most people don’t Professor Neil Greenberg medical officer in the UK armed forces, Professor go and seek help Neil Greenberg learnt a lot from professionals, D about helping an under- but they do speak to pressure workforce deal with traumatic in military veterans who have served partly down to a moral prerogative. Professor Greenberg echoes the a battle you can’t say: ‘Well, if you’re events. In hostile environments their colleagues” in combat.” But there is also a practical impetus, need for this sort of reflective practice. distressed, off you go.’ You have to including Afghanistan and Iraq, he But there is a crucial way in which she says: “If you want to keep services He also stresses the value of formal make this judgement about how you helped individuals find ways to carry on research on COVID-19’s impact running and provide good quality care, peer support, because “we know that can get someone back to duty. in the face of horror, allowing them to diverges from much other study of then you require a well-looked after most people don’t go and seek help “You might think that sounds cruel, contribute to the vital work of a service trauma. “Most research looks at workforce.” from professionals, but they do speak but when you look at the long-term that simply could not stop. the impact of the trauma after it has Indeed, research shows that any to their colleagues”. evidence, the more effective you are at Today – a year into a pandemic happened,” says Professor Greenberg. mental health issues relating to trauma And he believes everyone in a getting people back to duty, the better which has already claimed more than “But these people are still doing the – not just diagnosable mental illness – supervisory position should be their mental health is 20 years later.” 100,000 lives in the UK – these are traumatic work.” impact on someone’s ability to do their equipped to have conversations about This isn’t the only aspect of military lessons he’s applying to the health and What that means, he says, is job. In safety-critical jobs, this so-called mental health. response to trauma that Professor social care workforce. that it is very difficult to know the functional impairment can have serious “The evidence is that if you have a Greenberg hopes will be applied to Greenberg, now Professor of likely longer-term mental health consequences. supervisor who’s able to have what the NHS. He speaks of the Armed Defence Mental Health at King’s impact. Some healthcare staff will “If you’re functionally impaired we call a ‘psychologically savvy’ chat, Forces Covenant, which entitles College London and the College’s entirely recover once the pandemic in Afghanistan, you might miss an that can lead to a 90% reduction in the veterans to special access to mental lead for trauma and the military, says ends or eases, perhaps even improvised explosive device,” explains likelihood that someone will become healthcare. the need to support these workers is experiencing post-traumatic growth. Professor Greenberg. “In intensive unwell, and it can reduce sickness “Why should you not do the same clear. A study of intensive care unit But a proportion will prove to be care, you might miss someone’s absence by 90% again.” for healthcare staff who have given staff, which he is leading, shows nearly symptomatic in a way that requires changing physiology.” The importance of enabling people to their all during this crisis? This needs half are currently likely to meet the clinical care. So, what can organisations do manage their feelings so that they can to come about politically.” threshold for post-traumatic stress Regardless of the ultimate level of right now to help those experiencing continue working, even during a very The potential for that sort of disorder (PTSD), severe anxiety or clinical need, action is required now. distress? Dr Dave points to the traumatic time, is something Professor progress is, he suggests, a reason problem drinking. For Dr Ananta Dave – who is Medical importance of creating strong teams. Greenberg emphasises frequently – for optimism. “One of the hopeful “What we’ve found is that the levels Director and a consultant psychiatrist “Supporting initiatives like Schwartz and it’s a view again informed by his post-pandemic things is that our of reported symptoms of distress are at Lincolnshire Partnership NHS Rounds [in which all staff can discuss experience in the armed forces. learning about how to deal with really high,” he explains. “They are Foundation Trust, and who works to the emotional impact of their work] is “The military deals with a lot of highly these traumatic instances in a more much, much higher than we would see Dr Ananta Dave prevent suicide in doctors – that’s very important.” distressed soldiers, but in the middle of effective way will increase.”

#RCPsychInsight #RCPsychInsight 14 15 COLLEGE FEATURE COLLEGE FEATURE

1,600 teams participate in programmes. One of its many success stories is sustained improvements for people with psychosis by increasing access to psychological treatments, securing safe prescribing and delivering better physical healthcare. Professor Crawford says: “Before the Accreditation for Inpatient Mental Health Services Programme, most people in inpatient wards did not have access to Dr Kate Lovett psychological therapies, but now most do. Ten years ago, many patients were receiving medication at doses that caused more side-effects than benefits. The Prescribing Observatory for Mental Health has greatly End of term reduced the use of high-dose prescribing.” celebrations CCQI pays close attention to the way data is collected, used and presented. Local As their tenures as Dean and Treasurer come to an end in late June, we reﬂect on the inspiring reports are tailored to teams. “Rather than contributions of Dr Kate Lovett and Dr Jan Falkowski. trust-wide findings, we report information at a granular level – at a level that actually matters to psychiatrists and the people they work with,” Professor Crawford says. Over the next 10 years, he would like to see an expansion in the mental health travelled to China and India to advocate for College headquarters for £2.4m, another the College’s international ambitions, share initiative led by Dr Falkowski. The same year, Professor Mike Crawford audit programme. At present, only one of the 27 national audits is specifically on experience and of course talk to students in he also spearheaded changes to how the mental health compared with seven on these countries. College publishes journals and books, striking cardiology. One of the reasons for this is Raising standards at home and ensuring a deal with Cambridge University Press. As a the challenge that mental health services that the College’s output is fit for purpose result of these and other actions, Dr Falkowski have in measuring outcomes. Most quality has also been a major focus of her work. As ensured that the College came through this A question improvement programmes in mental health Dean, she helped lead the migration of the challenging year with a projected surplus. focus on the process of care – if the right MRCPsych exam online, which has led to Perhaps his most significant contribution, treatments are being delivered at the right 3,600 candidates taking the exam virtually in however, has been leading on change to time – and that’s important. But service what President Dr Adrian James described the College’s investment strategy. In 2020, of quality quality is ultimately about improving the as one the largest achievements in the RCPsych removed fossil fuels from its £12m lives of patients. “We need to find ways to College’s history. portfolio and committed to only investing integrate the collection of patient outcomes The College is immensely grateful to in responsible companies. Not only does As he steps down as clinical lead for the College Centre for into clinical practice, so that we can work Dr Lovett for the five years of hard work and this better reflect RCPsych’s values and Quality Improvement, Professor Mike Crawford reﬂects on out how and why some services are able Dr Kate Lovett energy she has brought to the role of Dean. responsibilities, but it is estimated that the CCQI’s work and its goal of helping teams improve their to deliver more effective care,” he says. College would be £1.5–2m worse off were it to quality of care. He believes that greater focus on patient Dr Kate Lovett Dr Jan Falkowski have stuck with its previous investment policy. outcomes in the next 10 years will help RCPsych wholeheartedly thanks Dr increase the impact of audits, accreditation When Dr Lovett began her tenure as As Treasurer overseeing the financial Falkowski for all his hard work. The College services and other improvement initiatives. College Dean, nearly a third of psychiatry health of the College for five years, Dr would be poorer, in both senses of the word, Work at CCQI has had to change since places in England remained unfilled. After Falkowski has shown something of a sixth without his many inspired contributions. s a psychiatrist, how do you “We report the start of the pandemic – accreditation five years, the increase in applicants for core sense, implementing changes that have know you are providing the information at a level and peer networks have moved online and training meant 100% of the posts available seen RCPsych not just survive, but thrive best care for your patients? its virtual events have helped staff continue were filled. throughout the challenges of the past 12 The College Centre for Quality that actually matters to share good practice and maintain high- Dr Lovett, who has been responsible months. A Improvement (CCQI) helps to psychiatrists” quality care despite the increased demand for training, education, recruitment and In 2018, Dr Falkowski authorised a major make this easier for mental health teams for services. retention, played a pivotal role in this investment in IT at RCPsych to improve both through quality networks, accreditation Professor Mike Crawford became director success. She was the driving force behind the resilience of the College’s systems and programmes, national audits and research. on a 5-year secondment but has stayed for RCPsych’s Choose Psychiatry campaign, the quality of services for members and staff. “It helps people share learning and 10. He is keen to stress the strength of the did much to raise the profile of psychiatry in Less than two years later, the wisdom of this spread good practice,” explains CCQI’s CCQI team and its overriding goal to ‘support the national press, including appearances on decision was made abundantly clear when outgoing director, Professor Mike Crawford. the programmes are voluntary. As Professor teams in assessing and improving the quality the BBC’s red sofas, and built an impressive the pandemic mandated remote working “This is important because there is a lot of Crawford says: “It is a testament to the of care they provide’. What could be more following on social media. But it is perhaps and a shift to online services. The investment unwarranted variation in the quality of care expertise and hard work of the CCQI staff central to RCPsych’s goals than that? her journeys around the UK, meeting meant that the College was equipped to that patients currently receive.” that membership levels are so high.” countless trainees and students face to face, stage its first ever fully remote CASC last CCQI’s remit is vast as is its reach He is proud of the expansion achieved If you would like to apply to be the next that have done the most to persuade record year and ensured that members could stay throughout the NHS, with every mental by the team in the past decade. There are Clinical and Strategic Director of CCQI, numbers to enter the profession. connected by tuning into the College’s many health trust in England and health board now 27 networks that cover mental health please email CCQI Senior Associate Dr Lovett’s energy and commitment to online conferences, events and webinars. in Wales participating, as well as some in services ranging from community CAMHS Director Peter Thompson at the profession has taken her beyond our The investment in IT was enabled by teams to inpatient forensic units, and over Scotland, Ireland and further afield. Most of [email protected]. borders as well. During her tenure, she has the sale in 2017 of unused land behind the Dr Jan Falkowski

#RCPsychInsight #RCPsychInsight 16 17 PRACTICE FEATURE

Prisons and the pandemic

An already vulnerable population is being hit hard by measures to control the virus.

ith little fanfare at the end “There are big barriers of January, a programme to the transfer of of vaccinating prisoners began, thanks, in part, prisoners into the W to lobbying by RCPsych health service” President Dr Adrian James. While receiving far less attention than the Illustration: Owen Gent enormous rollout of vaccines to the old and sick, protecting those in custody against COVID-19 is no less urgent. More than 10,000 prisoners tested While many prisoners have pre-existing what happens to prisoners discharged of courts for many months. As a result, the These trends may simply be a positive for the virus from the start of mental disorders – the prevalence of into the community. Half of them will have remand population increased by 24% in consequence of the limits placed on the pandemic to January this year, psychosis among male prisoners, for no fixed abode when they leave prison, a the year to December. The prevalence of prisoners’ freedom of movement. As both fuelled in part by a 70% surge in cases example, is up to 20 times that of the situation Dr Holloway describes as “tragic” mental ill-health among remand prisoners Dr Holloway and Dr Mudholkar point out, in December. In a prison population general population – others become and one that contributes to a vicious circle. is significantly higher than among those prisoners confined to their cells for 23 of 78,000 this equates to roughly one ill following, and often as a result of, “We are seeing prisoners being released, serving time following a conviction. hours a day are less likely to be able to in eight adults and children in custody incarceration. It is feared that the not getting adequate follow-up, experiencing There are some brighter spots in this access instruments or substances with being infected. pandemic – and measures designed mental state deterioration, perhaps picture. Self-inflicted deaths in prisons in which to self-harm, and opportunities to By the end of December, the virus was to control it – will lead to an increase reoffending because of this, and then going England and Wales were down 21% last assault anyone have been few. Both say suspected or confirmed to be the cause in mental illness across the board at a back to prison or to hospital. And the whole year and the number of incidents of assault it is difficult to draw any firm conclusions of death of 51 prisoners and 28 probation time when the ability of psychiatrists and cycle goes round and round again.” Her fell by slightly more (27%), before ticking up at this point. service users in England and Wales. mental health services to treat people is faculty is looking to work with colleagues again in the last quarter. Assaults on staff Prison psychiatrists have also managed Anxieties about COVID-19 transmission severely hampered. in the College’s General Adult Psychiatry were also down last year (16%). to adapt to a world where face-to-face are understandably very real among When a prisoner develops a severe and Addictions faculties to address some of contact is limited through the use of prisoners. It is the strict measures put in mental disorder, they are generally these issues. telephone and video consultations. Dr place to control the spread, however, that Dr Santosh Mudholkar transferred to a secure psychiatric facility Then there is the fact that some people Holloway can see a positive in this in that has contributed most to a deterioration in for treatment. Even before COVID-19, are being released into a world that is it has made communication easier. “If you the mental health of the prison population, depression, self-harm and, in some it was a complicated process involving very different from the one they left when were assessing somebody for admission, with prisoners being confined to their cells cases, florid acute psychosis not seen several different agencies, which often incarcerated, with stay-at-home orders for example, and had to arrange to go for up to 23 hours a day and curbs on to this degree during day-to-day prison led to big delays. Now, in the midst of and new rules around social distancing. to the prison, that would probably take family visits and rehabilitation services. clinical work in the pre-COVID era,” he the pandemic, Dr Mudholkar is finding Protective social networks, such as half a day for a local prison. If you can The effect of such restrictions is causing says. that he’s having to work “maybe twice or family and friends, may not be able to do some of that online, you can devote great concern among psychiatrists. “We There is some research to support three times as hard to get those who are meet prisoners when they are released; more time to the interview and less to the have seen an unusually high number of his observations. The number of severely ill into secure facilities”. restrictions are in place on face-to-face bureaucracy and difficulty of getting in and referrals to the prison Mental Health In- self-harm incidents among prisoners, “There are big barriers to the transfer of clinical contact by community mental out of the prison.” Reach Team and more acute psychiatric which saw a small decline last year, prisoners into the health service,” agrees health services; and as Dr Mudholkar As with the population at large, presentations during the pandemic,” suddenly shot up by 9% in the last Dr Josanne Holloway, Chair of RCPsych’s points out, many ex-prisoners may have the vaccine offers the best hope to says Dr Santosh Mudholkar, a consultant quarter of 2020, perhaps mirroring the Forensic Faculty. Reforms of the Mental little or no access to IT and are likely to prisoners. Until then, and with it the forensic psychiatrist who works in offender second wave of COVID-19 infections. Health Act are currently under way to remain isolated. easing of measures to control the virus, health in the East Midlands. Self-harm among the female prison help address this, but in the meantime it There are also serious problems faced psychiatrists will continue to find ways “There seems to be an escalation in population saw a much steeper rise of remains a complicated transfer process. by the remand system, which has become to look after this already fragile and anxiety and stress, sleep disturbance, 24% in the same period. Dr Holloway is also concerned about a pinch-point due to the prior forced closure Dr Josanne Holloway vulnerable group of people.

#RCPsychInsight 18 19 A Congress like no other

For four days in June, RCPsych will stage its rst ever virtual International Congress. Here’s what members can expect. Keynotes from: • Professor Chris Whitty, Chief Medical Officer for England • Dr Fiona Godlee, BMJ editor in chief • Michael Rosen, author and poet • Professor Prabha Chandra, National Institute of Mental Health and Neurosciences, Bangalore • Professor Sir Michael Marmot, Institute of Health Equity • Professor Prabha Chandra Professor Chris Whitty Michael Rosen • Dr Huda Zoghbi, winner of the 2020 Brain Prize for her fundamental and pioneering work on Rett Syndrome. A taste of what’s on offer: he pandemic may be preventing Congress is not just about learning. So, to • How to make friends and influence us from meeting in person at this fulfil delegates’ need to discuss and debate people: Tune in for a psychiatrist’s guide year’s International Congress, but topics, the online conference will feature a to lobbying and campaigning. It can be it hasn’t curtailed our ambitions new Congress Lounge. This will host more hard for politicians to understand what’s T for the event. When delegates in-depth interactive sessions, including really happening on the ground and so, dive into the immersive and interactive extended Q&A sessions with our keynote this session is a crash course on making platform that will host the conference, it will speakers. your voice heard. feel very different from RCPsych’s online International Congress has always been events to date. an important social occasion too. As a • Disorders at the interface of This full-day The most important, practical difference result, another innovation introduced this neurology and psychiatry: training course returns to explore the from previous Congresses is that members year will be the cultural Congress Fringe. disorders at the interface of neurology won’t have to miss any sessions due to a Designed to give attendees the chance and psychiatry. Topics this year include: clash in the schedule. All the content will be to explore and unwind – with wellbeing how to search for biomarkers, COVID-19 available through the Congress platform, sessions, music, theatre, poetry and film and the nervous system, and diagnosing allowing attendees to view over 120 hours – it will also include social sessions where delirium and dementia in a general of educational activity in their own time. members will be able to network and hospital setting. Given the quality of the speakers, this interact with fellow psychiatrists from across is good news. Sessions range from high- the world. • Activist psychiatrists and the profile international keynotes, including Chief Finally, engaging with RCPsych posters climate and ecological emergency: Medical Officer, Professor Chris Whitty, and will be an altogether different experience in Learn about the mental health and popular author and poet Michael Rosen, to 2021. Being both online and interactive, the psychological impacts of the climate five concurrent streams featuring world- posters will include dynamic content that crisis, the intersection of social, racial and class academics and clinicians, people will bring the work to life. The number of climate justice, the reasons we choose with lived experience and opinion leaders slots for the popular quick-fire rapid poster to take action, and the important role from the social and political sphere. This sessions has also doubled this year, with psychiatrists can play in the crisis. year’s Congress will also feature sessions the creators of the top-scoring posters and masterclasses covering the gamut of being given the chance to pitch their work psychopharmacology, new science, clinical to a live audience. And for the first time, all RCPsych International Congress 2021 runs practice, policy and media, education and presented abstracts will be published in a from 21–24 June. Book your place now at: training, and more. special supplement of BJPsych Open. www.rcpsych.ac.uk/events/congress

#RCPsychInsight 20