Welcome to the Oxford Psychology Podcast series brought to you today by Daniel Mawn, I'm an advance trainee in psychiatry here, the Oxford Dictionary. Today, I've got David Thurston with me. Thank you for coming, David. David is a consultant in general psychiatry and he heads up the assertive outreach team here in Oxford. David, maybe we could begin by talking a bit about how an assertive outreach team differs from a general community mental health team.
Thank you. The fundamental difference is the way of working and the sense of outreach team works as a team and rather than as case management. For instance, in the same H.T., a care coordinator will have that list of patients and basically nobody else in that team will know these patients. On the other hand, in the 30 year average team, given that there is a much less caseload, everybody in the team will have met and will be able to give me a picture of every patient in the team.
So the more we work more of the team than a community mental health team in that we meet every day, we used to meet twice a day as a planning meeting in the morning and a feedback meeting in the evening. But we move to just having a feedback and planning meeting in the evening. So we make every day and every patient, every patient is briefly mentioned during that feedback mission meeting. And anybody who is of concern, we will have a longer discussion about it.
So it really is a team working in the extreme. Everyone knows about every patient. There's a meeting every day and maybe rich discussions of how to bounce back management from the new members of the team. What's the reason for that? That team working? Because this sort of outreach managed quite a different type of patient.
They? Yes, I think so. The I came from the sort of the way people disengaged from normal mental health services and why they disengaged and what it was we could do to try and engage them again. And it in Australia and America and the forerunners have developed this team approach. And we are a tertiary service. We only have referrals from community mental health teams of people who are difficult to engage, who go in and out of hospital.
The old revolving door people, often the people have been admitted many times under the Mental Health Act, then disengaged from services and stopped their medication. There are complex social problems. More often than not, they have what is known as dual diagnosis. That is, they probably use substances in a fairly indiscriminate way. The housing is often problematic and they have difficulty in accessing benefits if anything problems.
So the whole nature of research, which was to do everything in-house so that you might engage with somebody better by helping them with their benefits than banging on about their medication or whatever it was or their symptoms. And so we have a variety of what we used to be able to have a variety of ways of doing this. We might put some of these blinds up in their flat or or something very practical, go for a walk or go downtown or do something that is just different from their usual engagement.
So when you talk about these patients, it seems to me that there the people with high disability and struggle to maybe maintain independent lives. And for that reason, the care delivered by the assertive outreach team is is multifaceted. You don't just think in one dimension application, you actually think of every aspect of their lives. And most important, from my point of view and the philosophy that we've adopted, we think, who is this person?
What is it they want out of their life and what is there in this world? That recovery is used widely now, and recovery is not about me thinking you've recovered. It's about the person reaching a level that they feel that they can manage their lives in a way that they want to. And so the whole whole philosophy is trying to help people find where they want to be in life and where they want to go.
So even though we're aren't we we we manage a high risk population, we're sort of in between adult mental health care and forensics. So we have a number of people who buy into society and sort of criminal justice way and quite high. Obviously, people with serious injury, mental illness have higher risk than other people. So we work in a sort of high risk way with people.
But essentially what we're trying to engage with them is trust that there is something about what we do with them that is different from what the. Done to them before I emphasise the word done. We don't want to do things to people, even though, yes, we do detain people and we do keep people on long term. Section 17, extended Section 17 leave. I'm not a big fan of years, but that's a different issue on a community treatment orders mandated treatment in the community.
My my issue with that is that they're not very honest unless people are still coerced into having treatment. So let's be honest about it. I've never had any problems in managing people this way. And in fact, over the years, we have less people on an extended section, certainly than we used to. Whereas since the community treatment orders have come in, that's been a great increase in the number of people who are coerced into treatment.
Yes, in the recent evidence isn't in favour of community treatment orders. And a randomised controlled trial by Tom Burns did not come to trial. Yes. What I'd like to talk to you about it is, is actually your perspective on mental health care. Because what today's mental health care? Because you've been working in Oxford as a as a psychiatrist for many years. I don't know how many years on and off. I came to Oxford in the 90s for trying this in psychiatry.
And then I was in general practise for quite a long time, but still have the high it was in the days before community care. So I had to hide. As I was known, I had a high mental health caseload and in Section 17, Section 12 work. And so I was set up a day, a day service for people with serious mental illness when I was a GP. So I sort of been involved in in mental health care in Oxford over that long time.
So when I first came to Oxford, I think a little more hospital had about 700, 800, 900 patients from the one field hospital here that I only got three wards has had 250 patients. And it was just a different world and completely different. But I think there's been more change since 2000 or thereabouts when I sort of came back in the last 10 years or for 15, 14, 15 years. And they were in the 20 years before that.
I mean, the whole approach to how we see people with mental health problems, it's more of a process now. It's more of a sort of seeing somebody is a risk. And I find that quite difficult. Seeing somebody is a risk. I wouldn't like to be considered to be a risk if I was a patient. And this emphasis on process and seems to me to be somewhat to the detriment of all of us rather than a lot of things.
People don't think that mental health care please don't get me wrong. I think there's some very, very good mental health care. But it's maybe the sort of the society's change. Maybe that's what it is. And that we the referral rates have gone up a great deal into psychiatric care and patients that in years ago GPS would have managed. But they seem to have the time building or whatever it is, I don't know.
But there's lots of changes there really from for maybe societal attitudes to professional practise and and to to maybe the asylum era coming to an end and community care developing that you've touched on there. But I guess the question I'm interested in specifically looking at your work in assertive outreach is how do you think the care has been has changed with all those developments or changes that you've mentioned?
How do you think that has changed for those with severe and enduring mental illness, those patients you've mentioned with disability, with with comorbid problems? I think that's a very difficult question, because on the one hand, we don't want to go to the world of paternalism and patronage and locking people up in silence.
But there was a sense, certainly for some people that they belong somewhere in the world and that that in that sense they were more felt more secure, whereas asking people to go and share houses with other people with their mental health problems in the middle of nowhere, united nice estate seems to me asking a lot of them that we you know, we will remember when we were students or that we gunshots flatwoods somebody and the
difficulties that arise just in us sharing flats and getting on and dealing with people. But for people with serious mental health, they do have you know, we talk about personality, all that sort of personality disorder and all that stuff. But everybody who has serious mental illness has that effect on their personality and.
The way they relate to themselves and the world, so we ask a lot of them and then they services or whatever we want to call them, community resource is more sort of targeted, that everything has to be measured. Somebody can't just go and be and chat and be and have a cup of tea. They have to go to a group or they have all this has to be measured in terms and the non-statutory services over the centuries it's called I linked into all this tendering and targets.
And so that I think changes the whole sort of emphasis on how we how we help people to find themselves in the world. Certainly from a particular service. We worked without any psychology input for about six months as a part time psychologist. We have had no psychology input at all into people with serious mental illness. It just seems I've tried, tried, I've tried to try, but there is a big gap.
So somebody with an anxiety disorder has no chance of getting psychological therapy them than if you've got serious mental illness. That's not to say we can't do it. That's not to say we haven't developed people who who in our team who have CBT cognitive behavioural therapy skills or that we have counselling skills and all those sort of things, and we try to offer that as well. And from the end of this week, the assertive outreach team is no longer going to be alone in Oxford.
And you might think I'm sad about that. But yes, I am in terms of it was something we built up and I think we've delivered a very good service. But I think we're going to a system that is more accessible to people, more flexible. So we have people on the assertive outreach caseload who don't need us.
They could be managed in the more traditional way. But to transfer somebody on and we don't we don't want to we just, you know, got them better in inverted commas and said we don't want to pass them on. But if we had a bigger system where people were able to, we could meet people's needs more. So somebody came into the service. They might need three contacts a week. Well, let's give them three contacts then. In six weeks, they need one.
So let's do that in a much more flexible way. Let's respond to patients needs rather than here's our system. Where can we fit you in? So I'm quite excited by the changes, even though I'm losing something. And I'm so within these larger teams, we can develop more specialist skills that, as I mentioned, cognitive behavioural therapy for people with psychosis. We can develop motivational interviewing with people who who have substance misuse problems and and other problems.
And we can develop each individual in the teams skills that they have. So that potentially is coming out. They're not just fixed into whatever care coordination. Well, it is I'm not very keen on this generic mental health professional working. I, I would love occupational therapists to do to do what they were trained to do. I would love social workers to be more involved in in the sort of wider societal aspects of what we use rather than being fixed into this role that I have a moment.
So I think it's exciting and I think it's better for everybody. But obviously the transition is extremely difficult. OK, thank you, David. Well, it seems that when you when you're talking about services and how they've changed, it seems that those things have become more formalised.
There's been less. And in that you're concerned that some of the care or the the ability for service to really meet the patient's needs is lost, potential potentially lost if we become too focussed on on process and systems. And actually the focus needs to be on the patient and meeting the needs of the patient and that actually there needs to be a certain degree of informality in that care provision because because of that very. And and with their carers and has anybody else involved in them.
And why sadly, why has the carers why is the carers movement there? Because we didn't talk to parents and they're about for some reasons that I find, except I just don't understand it.
Why are the things like think family come in, which is a sort of service of patients or surely that's a role for social workers within our team is to and for all of us to think, oh, we just sort of blinded by just the sort of biomedical model that here's somebody with depression, let's give them answers to questions. Here's somebody with bipolar. Let's put them to the bipolar treatment. Here's somebody with a psychotic schizophrenic illness. Let's give them the list.
Everybody is the same as us. Everybody has the same feelings and the same emotions that we do is sitting here and let us recognise that they're sort of blind people out of that because he's got schizophrenia. So. And that's because of this and that. And it's not because they're human beings. And we have to try and find that way of being and be a bit more informal about it and maybe spend a bit more time listening.
Listening is something that is just so vital in our work and maybe it gets forgotten. People are already thinking about what they're going to do at the beginning of the consultation, how they're going to go on from it, rather than just letting the person be and be listened to. And sometimes we don't need to do anything. And I spent many years in practise where maybe I just that people wait for 10 minutes or turn around and saw them again and and didn't actually do anything,
but they were glad to have that. Yeah, that's that's really good to hear the fact that, you know, actually that there's something about the time spent with a patient as a as a psychiatrist, which is of value in itself without needing something to be done to the patient necessarily. What I like to ask you about, if it if it's okay, because in your work with any sort of outreach, you deal with a lot of risk.
You deal with patients who are often very unwell and often very unwell with having taken substances, not sometimes in a very high risk category. And I was just wondering about your thoughts on managing that risk in the community and how how you go about doing that, what your thoughts on on that are. I suppose I'm seen as somebody who's a positive risk taker. What does that mean really?
From my point of view, it means that I want to give people another chance, another opportunity, another one and another one and another one. That's a bit like a set of philosophy, which we just hang in there. Nothing will deter us from. Somebody doesn't turn up. Then we'll find ways of finding them. So what positive risk taking?
For one thing, most people with mental health problems don't have an enormously greater risk than the rest of the population or certain areas of the rest of the population. For me, it's more risky to walk down George Street in Oxford on a Friday or Saturday night and see all my patients. So we all do risk assessments all the time. That's what we do in life. We will cross the road if we see some people we think might be healthy.
And so we'll just look in that short window and let them go past that. Yes, we do all the time. So every time I see a patient, I'm doing a risk assessment. I don't need a better form to to look at it, to remind me that sometimes people become more risk and usually the times for that of their meds may be or they're drinking more or they're using stimulant drugs. And one has to sort of balance that. And I think be honest with people that fundamentally I think what you need to be is honest and not.
Patients don't want you to be frightened. They don't regard if you went to see a doctor and you thought he was anxious about what you want to say, you'd run a mile, wouldn't you? I would. So patients do not want to see fear and anxiety, even though we are dealing with things that may turn out badly. But most people we see have choices in life. It's their choice.
You point out those choices to them. And so as long as you share these risks and talk to your colleagues about patients, that's what's so good about teamwork that we can talk about somebody every day if we're worried about them. And then we can all have you know, some people might say, oh, I think you need a mental health assessment now or we might discuss. Let's see what we can do over the next couple of days. And so I think this sort of risk thing generates fear in people.
And I think fear is not a great way to standpoint, to work from. And yes, if things happen, they need to be investigated because they do. But if you allow this sort of wave for myself, if I behave honourably. I mean, it is sort of in the way it's meant, and I've written down everything and I have discussed it with all the people, I have nothing to fear, nothing.
I really good to hear you talking about that. The positive risk taking approach and being honest with patients and and seeing the patient in that context rather than the tick tick on on a risk assessment form. And having that that that rich focus allows you to really think about the whole risk assessment business is there's no evidence. We all go on about evidence based medicine. There isn't any evidence. My guess is as good as a scare.
I take box and my you know, it's a sort of I think the thing that's gone away from is the art of medicine. People don't really talk about the art of medicine anymore, but it is it's a way of how your experience and your and your knowledge and combines and your knowledge of the person in your relationship combines for you to have a sort of wider picture of how to manage them. In the same way we might think of one medication is good for one patient.
I couldn't explain to you why exactly, but somehow it is. So it's it is a bit of a mystery and it can't really be measured, sadly. But I do think if we could all try to be a bit more reflective about what we do and try and see the person as as an individual, the world would be in all sorts of ways with their. There is so good to hear your thoughts and your reflections and some of your great experience has been it's been really good to spend time with you here today.
Before we go, I'd just like to ask you a question about the fact that you were GP and now you're a psychiatrist. And I know in my experience, there are quite a number of junior doctors who are debating about whether to go into the general practise or psychiatry. What would you say to people who are taking that choice and what would you say psychiatrist, given years in your career? I love being oh, I've always loved being a doctor. I think it's a fantastically privileged job.
And I think it's amazing that people just sit down and trust me and talk to me and then I help them and try to make a difference to them. So being in general practise where you didn't know, you might know the person who is coming in the door, you didn't really know why they come. And I, I only recently I've discovered that the way I love being a doctor is that I like being a detective. And when I was a boy, I wanted to be a detective. And it is a sort of detective thing.
You're trying to piece out the evidence that is put in front of you. However that's presented. So I love being a GP, but it was it became somewhat remorseless. It was relentless. Yes. And the whole business side of it didn't really attract me greatly. And I become more and more doing more and more mental health work. So I think of experience in general practise is great for everybody. Hmm. I love psychiatry basically because I wanted to try being a proper doctor, whatever that was.
And I did discover what being a proper doctor was, the sort of experience of knowing that the parameters of normal are so wide as to be just immeasurable that people are so completely different. But the scale in general practise is to have that tweak of thing. That's a bit unusual. That's a bit strange. We better look at that more and helping people through terminal illnesses. I love doing that.
And people with chronic diseases that how one person with rheumatoid arthritis is different from another person terms that is a bit older. But those people don't realise in general practise is a very lonely job. You go to where you do see your 30 percent, whatever it is, and you got your visits, you come back to your apartment and see another 20 or 30 and you don't really meet your partners in any sort of clinical way.
And the and the refreshing thing I find about returning to psychiatry was this openness, this conversation with. North of some of the best chemical discussions I had may be in the corridor or maybe over a cup of coffee or at the end of a meeting, we've gone on chatting and this constant flow of meeting all sorts of different people and having a real multidisciplinary view of things and and that sort of so, yeah, it's not a lonely job at all. And that's all. And so that's what I love.
Coming back to psychology in some ways, I think I should have come back years ago. Yes. Yes. Ago, just a little bit as an apprentice. And that as some people have done. It really I think it's a fantastic career. David, it's been so good to speak to you today, so interesting to hear your views and thank you for tuning in to another episode of the Oxford Psychiatry podcast. I you listen to some more. Thank you and goodbye.