The Responsible Clinician

I’ve got a bit of a theory about multi disciplinary teams. It’s this. The more people in a multi disciplinary team, the smaller the concentration of power. In fact, I believe there’s quite a bit of evidence that shows that although the team may consist of dozens of professionals, the power is often held by just one person. And often that person is the responsible clinician. You hear professionals bang on about “flattened hierarchies” but that’s normally a fog hiding a lethal, centralised power base. I remember the uncomfortable hour in court when the social care manager, armed with four A4 landscaped charts stapled together, trying to explain to Justice Jackson how the decision making process worked. After an incomprehensible narrative, Justice Jackson threw his arms in the air and cried “this is impenetrable”. The Judge voiced what everyone in that courtroom was thinking – the explanation, rather than illuminate, clouded.

A couple of examples. I’ve written recently about the plight of Jack Smith, trapped in an ATU in Birmingham. Jack had been looking forward to some home leave over the Easter weekend. Understandably, his hope carried a huge anxiety and on Wednesday he found that anxiety impossible to contain. The Responsible Clinician, the psychiatrist, immediately cancelled Jack’s home leave. Her rationale? ” To teach him about boundaries”. Eve’s posts became increasingly heartbreaking as she reported how Jack went into a cleaning frenzy, (his room, the communal dining room) in an attempt to win the psychiatrist over. At the time of writing, this hasn’t been successful. Despite the recent support Eve has received from NHSE, everyone shrugged their shoulders and said they couldn’t intervene. The CCG, the LA, the social worker, all bowing to the power of the psychiatrist. I find this incredible. When the 15 odd members of Jack’s multi disciplinary team turn up for the next review meeting, do none of them question the wisdom, or psychological validity of this decision? It would appear not. One person’s decision is final.

I sat in court at LB’s Inquest for the tail end of Dr Valerie Murphy’s evidence. She was the psychiatrist and responsible Clinician. It was Dr Murphy, who had decided that Connor hadn’t been having seizures and she was clinging onto that position in court. Her position led directly to Connor’s death. She was followed in court by another psychiatrist from the MD team, although she didn’t carry the power of Dr Murphy. Despite the obvious coaching she’d received from Southern Health’s consultants, her evidence was both deeply uncomfortable and infuriating. It was clear that she disagreed with the responsible Clinician but didn’t have the bottle to challenge her. Another position that led directly to Connor’s death.

During his time in the ATU, Steven didn’t have a responsible Clinician. It wasn’t run by the NHS. Justice Jackson expressed his constant frustration in not being able to unravel who made the decisions. The Hillingdon witnesses tried to present a united, clouding front. That somehow things moved along with a momentum that had nothing to do with any one individual. I’ve never bought into that presentation. Clearly, decisions were made. Hundreds of them. The two big ones were, (1) Steven must be held in the ATU and not come home, and (2), he would be moved to the hospital in Wales. Somebody, at a MD meeting, must have spoken those words, made those suggestions. One thing is clear from the social care records, is that if anyone in the MD team disagreed with any of the decisions, they were removed from the team. The learning disability nurse, the support agency manager show up in the many minutes as challenging decisions. They then mysteriously disappeared from future meetings. My belief is that all the major decisions were made by the social worker.

But this throws up two different propositions. Dr Valerie Murphy was obviously an egotist, with a terrifying self belief. Plus, in terms of her hierarchal position, she held an enormous power. People speaking up against her would have a lot to lose. She could end careers. It was quite different with Steven’s social worker. She was a long way from being the most senior member of the MD team. But I know other members of that team, both above and below her, and they were very weak individuals. I’m not just talking about people prepared to compromise their integrity. It’s something more basic than that. Fundamental human weakness. You may remember my dream about the social worker on her pink inflatable, sailing down The Thames. Now, a pink inflatable is not exactly the most robust material on which to build your power base, but if your followers are weak, it serves its purpose.

I had a client who I saw for several years. He was a lovely bloke who had collected several mental health labels over the years. He had an MD team “working” for him. I saw him, first and last, as a survivor. Medicated to the eyeballs, he continued to hold down a full time job. His Responsible Clinician didn’t see him that way at all. She saw him as an “unstable, manipulative man”. From her reports, she obviously didn’t like him. My client was terrified of her. Every encounter he had with her brought on a dreadful threat of being sectioned, of losing his job, of losing his independence. She once told him, ” I have more say than your manager over whether you keep your job”. When it came to his three monthly appointments with the psychiatrist, my client would meet me the day before for some “coaching” (I’d hear myself saying – “You can’t tell her that. She’ll have your guts for garters) and we’d meet the day after for a debriefing. In the end, she won. He swore at her. She doubled his medication. This made driving unsafe. He couldn’t get to work. An example of the Responsible Clinician acting totally irresponsibly.

I don’t know the answer. But as they say, power corrupts. And when all the power is in the hands of one individual, we are in very rocky waters. The Mental Capacity Act is no help in these situations because the Responsible Clinician will be using the full clout of the Mental Health Act to wield power and silence dissenters. And we can’t seem refuge in Carl Rogers and person centred powers.

My client believed in karma. It was one of the things I used to try and dissuade him from discussing with the psychiatrist. Perhaps he was right. Perhaps, we just have karma as our only hope for equalisation.

19 thoughts on “The Responsible Clinician”

  1. This is a good illustration of how patient safety is still not the centre of patient experience outside of acute care hospitals it seems.

    I am reminded of the changes that came because of Martin Bromiley, the man whose wife died while consultants tried to intubate her, even after nurses tried to point out that they should have tried a tracheotomy. In a hierarchical system where the juniors have no voice then patient safety goes out the door, wanders down the corridor and into the morgue.

    However the work of Martin’s group Clinical Human Factors Group as well as others such as Atul Gawande and the surgical checklist, has improved patient safety in acute care. One of the aspects of this is that all members of the team must feel free to speak out.

    This is the same with airline pilots. They found when analysing air accidents a hierarchy in the cabin where those junior to the captain felt they couldn’t point out any potential errors lead to compounding of human error.

    So it isn’t so much that one person has all the power, it is that other people in the team do not feel that they can speak up and be listened to.

    Maybe we need our own checklist manifesto for social care?

  2. The professionals still somehow thinking they wield a scientific precision is so flawed. There’s nothing precise about humans – there are useful indicators but different things work for us and sometimes its really messy – and we all should know that our past experiences influence our present behaviours – so it’s not a surprise to find people panicking, anxious and behaving in difficult ways when they have been at the end of abusive power that doesn’t listen but tells and also when we don’t have the tools that many of us do to express ourselves more “appropriately” (Although ofcourse we also blow it at times but we get angry or swear/shout; someone with a learning disability who expresses their feelings or loses it is “challenging” or “ill”. It’s more and more difficult to see how professionals can spend the time actually getting to know the person in these times of measured intervention too when the pressure down is to save money or in the case of psychiatrists in “units” where they are both invested in their role there, but also have forgotten if they knew what’s possible in the normal world – maybe forgotten what ‘normal’ is. However, that is where the professional should be using their power. They should take the time to really also listen to both families but also caring support workers who actually may well be the advocates who know, and use their professional position to argue for what’s needed irrespective of costs. But when in these cash-strapped times is there going to be a sensible solution to LAs pay in the community but the NHS picks up the (very expensive) cost in ‘units’? It makes for a push towards units where there are difficulties and very expensive costs to move things forward. Putting in the resources early is what’s needed, people who really care with commitment and helped to have the skills to really listen and attend and help to get the things that matter in the person’s life, but be able to stay with it while they learn that they really do care and the person really does matter to them. AND some people have been fortunate enough to land in such services,but it shouldn’t be the luck of the draw! Professional should learn that they alone can’t know and it’s the team of people who do know that will help them know!

  3. Collaboration, Codes of conduct, itinerancy, titles, roles– the bureaucratisation, professionalisation of health and social care, have all been deliberately designed, to avoid any individual blame, to ossify, waste money, and, increase the gravy train of the mental disability industry.

    We have trillions of disparate tools, all ignorant, except for glimpses of standard forms/reports, and meetings about these, all singing from the same hymn sheet, that they are told to sing from.

    If it is under the MCA, it is the social services, that call the shots, if NHS the lead clinician.

    They all do, what these overseers tell them, according to their roles.

    Psychiatrist, psychologist, occupational therapist, speech therapist, mental health nurse, GP, practice nurse, development officer, a ‘person centred’ planner, are all allotted to a mental services ‘client ‘, feed in to his gravy train provision.

    But, do effectively little, but to drug , oversee, hold meeting to communicate with the gang, provide a care plan, which, itinerant zero hour support workers, supposedly implement with the management of a care provider, be the ‘client’ in a mental hospital, supported living ,or, at home.

    As the autistic and learning disabled, are now declared’ incapable’ under the MCA at 18, before adult services will be funded, add on LA, OS, and HSC solicitors and barristers, and a COP judge.

    Huge amounts of money spent, but, the only actual support, relationship, the ‘client’ has is with the itinerant support workers, who are charged to implement all these roles decisions .

    All are Chiefs, who tick boxes, produce reams of standard forms/reports, hold meetings on these, tread water, but, do not perform any of the tasks on their pieces of paper, just oversee, none are, or, want to be, Indians.

  4. Sorry, got so involved in that diatribe, forgot the basic question.

    Why is a psychiatrist, making all the decisions about an autistic, when they are only mental health specialists, and autism is not really anything to do with a mental illness, but, a behavioural problem ?.

    Although in the past 20 years particularly with CAMHS taking over the treatment /drugging of the autistic, they have conspired to find autistic have mental disorders on the basis of observable symptoms only.

    And likewise, if MCA. Why a social worker ?

  5. There should be neurologists involved perhaps, as autism is a neurological disorder. Some psychiatrists have neurology specialisms, but mental health problems do happen alongside autism too, as they’re not mutually exclusive conditions. Just needed to say that.

    In my case, I had a good psychiatrist following a changeover from a bad one (who caused enormous anxiety for me, so how could he have helped my son?). I saw that most decisions were group decisions by the MDT, with RC being legally responsible, so was probably the final decision-maker.
    Others couldn’t however make decisions about medication, as they were not qualified, and I probably was the person discussing that with the RC. The good RC listened, the bad one didn’t.
    The SOAD didn’t really seem independent either. Parents need advocates supporting them as they speak for their child.

    According to the MHA, a whole range of people can be RCs, but I wouldn’t want them, and the MHA is confusing about what constitutes treatment – which is the bit that’s most important in an ATU.
    The bottom line is, to clearly agree what could be useful treatment, consulting family, and asking if the family feel confident in it, and then to carry it out. The good psychiatrist agreed with me that exercise and family input and learning opportunities were needed, but no one helped me find opportunities. The community provider failed more than the ATU with carrying out activities, however.
    Often support workers or nurses in the ATU were not involved in finding activities, but even OTs did nothing much that was useful, and yet they are supposed to be activity-orientated professionals.

    Nurses wrote reactive assessments (not well, as they didn’t address self-harm as much) rather than pro-active, when we needed both. Nurses were generally listened to more than family by the RC, which I always found puzzling as the RCPsychiatrists says that family are partners in care.
    Missing family emotionally was never put into any behavioural analysis by the ATU psychologist, which seems to miss a most important part of understanding a human being.
    I even lived very near the ATU, so my role being sidelined by nearly everyone was such wasted opportunity.

    I can’t believe this has been our experience. It’s horrible to see it in writing.

  6. If this method of teaching about boundaries in people with LD/Austism works, why aren’t they coming out of ATUs better, rather than worse? Or not coming out at all? This is a fairly huge gap between withholding a treat and refusing to let them leave or see their families.

    My daughter has obvious brain damage as the result of birth asphyxia, not autism, but treated that way her behaviour would deteriorate in ways that I can’t even think about. That notion of boundaries would be just about the worst way of dealing with her I can think of. Makes my blood run cold – and, as you know, the harm would take a long time to recitfy. Tragic and brutal. It may or may not work in some forms of mental illness, but different issues with LD

  7. What we need to recognise is that very often the psychs in these places are failed in their profession
    I worked at a large mental health hospital as a non exec
    It was an eye opener
    40 of these people and the hierarchy was such that any psych that dealt with learning disability was the bottom of that tree.
    So the egos when a devalued, failed person gets some power is something we all know about
    The RC I dealt with recently was very young and very arrogant and did far more damage than good. He described himself as a ‘ rare breed’ in public. Shows what he felt about himself it was in the context of being superior. Watch this space because people do need to answer for their actions in all of this.

  8. Mutual trust and respect between clinician and patient and also the patients parents/guardians is paramount. Clinicians that refuse to discuss the reasoning behind the way they are medicating your son/daughter are being arrogant. It should be a partnership.

  9. […] Mark Neary seems to be having this conflict over his blog posts too. People are asking him to be more ‘balanced’ when he criticises services where oppression of marginalised people happens. He’s basically getting a ‘not all psychiatrists’ argument – which is a silencing and derailing technique, a bad faith argument. Similarly, I’m often told I complain too much, or that I’m too aggressive about disablism/poor access, or that ‘not all non-disabled people’ hate disabled people. If I’m not told it in words, it’s in eye rolls, uncomfortable silences and quiet encouragement to be nicer and less complain-y. (“But you must also have had GOOD experiences with…” *…cue silence from me*) It’s true that ‘not all’ services, facilities and social structures are oppressive and/or inaccessible. It’s true that not all non-disabled people get their thrills from controlling disabled people, as in the example from Mark Neary’s blog. But many are/do. […]

  10. In ’80’s and nineties I worked for an charity that led me to St Andrews and many other mental health and learning disability institutions. I saw and found on close and frequent experience, one very powerful psychiatrist consistently behave as a nasty and self serving despot. I was not alone in this experience and description at the time.

    In another setting over the same period I worked alongside a young psychiatrist who was empathetic, very caring and always alert to other point of view; a joy to work with. A lovely human and highly competent person. He went on to become the CE of a very lucky NHS organisation. Sadly, for very many people, this person retired.

    There are psychiatrists still working in the field of mental health and learning disability that are ‘left overs’ from the old abusive and restrictive ‘bins’. Some may carry with them a ‘god’ complex developed early in their career.

    1. It is now, not a personality thing, there is no autonomy,

      in the private for profit system, they have to do, what their for profits, be they recycled in public or private charitable to management salaries, tell them to do, and that is, to make as much as they can out of the mental services.

      That is why the autistic, and learning disabled, who are not mentally ill per se, but, are made so, but remain often unlabelled as such, by their treatment and drugs, are held for years in these mental institutions.

      The lead clinicians, must make business decisions that lead to the making of more money, and the more drugs they administer, the more money they make, the worse the behaviour, the greater the reason to continue the treatment, which continues the huge incomes ie £4,000 minimum per week these ‘patients’ bring in to the institution.

      Were the leader clinicians, to do anything else, they would be replaced, as most, you will find are now employed probably on a fixed term contract basis..

  11. Poor Jack Smith.,I can imagine the forlorn ,figure cleaning and cleaning, hoping to win his home visit. It is exactly the sort of thing my son would do.
    This was obviously very badly managed. It was extremely likely Jack would be very anxious about going home and extremely likely this would manifest itself in his behaviour.We all know that. So then, how was this anticipated and planned for? If Jack’s family felt able to manage the anxious behaviour,I can’t see the problem.
    Withdrawing a trip home to teach boundaries is a crummy strategy. He has autism. This won’t teach him a damn thing.
    Young people with autism are with CAHMS because there is nowhere else. Of,course you need CAHMS if someone is mentally ill, but often people with ASD are there with no mental illness. CAHMS know that and don’t want people with ASD. They are not set up for it.There is just nowhere else.For years I have imagined that there exists a whole service for people with ASD I haven’t found yet.

  12. THis is the way they broke the spirit of the men in prisoner of war camps. Promise them a meal or a privilege and then at the last minute take it away. It is to break them. This is what they still do. They break them.

  13. Its just all so wrong.
    Denying home visits, over medicating, and playing God with people lives.
    Will they ever listen to the parents? Will they ever learn?

  14. I now know several parents, myself included , who would hesitate, no matter what, to take our young people in to emergency services,either via calling the police or , assuming this is possible, taking our sons or daughters in to A and E ourselves.Why? Because we know that there will probably be nothing that helps and we risk becoming drawn in to the sort of ATU nighmare described. CAHMS ,although flourished as an acute service is not an acute service. It has no after hours provision and even during opening hours cannot cope with an emergency and you are told to go to A and E. Most acute services have day and night teams and designated crisis workers. Or had.

    If there is a hospital mental health crisis/outreach team, they are only involved at the A and E crisis.CAHMS do not involve them earlier. “Go to A and E” is intoned. Occasionally I call their bluff. “And what will happen then? ” “Um, he will be assessed by a psych registrar” ” And what then?””Well he or she will look at treatment options” ,”What might they be?” Usually they have no idea and no interest.
    So after a terribly distressing trip to A and E with or without the police, we are likely to be greeted by a tired psych registrar, who will not know what on earth to do. Usually if somebody is mentally ill and cannot be safe at home they are looking at an admission, but this government has slashed inpatient beds. There are so, so few.And here they have somebody with autism, who many not be mentally ill but still really needs help to help things settle down, assess the crisis and have breathing space to line up the help needed. Ideally a skilled clinical assessment would result in an actual plan for assistance by a team.. This is meant to be put together quickly. This is what an ATU is meant to to do.
    Nobody should be left struggling with behaviour which is distressing and dangerous but frightened to ask for help.When I worked in a crisis line for parents of autistic people this was a common scenario. Either the young person’s behaviour was worse with adolescence or was the same but they were bigger and stronger and the parents were becoming frail.But the parents didn’t want to call for help.
    The current and looming cuts to services are going to make things much worse. There will be fewer and fewer beds of any sort. No crisis services. CAHMS hollowed out and useless. Less things for the young people to do after leaving school.No drop in, no sheltered employment no good housing.
    So here I am with my son coping with what comes and terrified about the day coming when it gets dangerous for him or me.
    I would have so much more respect for services if they were able to be honest about the cuts. “Yes, he needs X ,but we can’t give that because management sacked all the X clinicians” “I am afraid funding cuts mean that we have half a behaviour therapist with the clinical qualifications of Mickey Mouse to cover the Borough instead of a clinical team. She will give you a star chart. We know this won’t help”
    Instead we are told that what is in place is superb, is just what is needed, although we mustn’t be greedy. That there are no cuts only efficiencies.
    I feel like we are going back in time to the 1950s. Desperate parents coping alone fearing their children being sent away forever if they involve services.

    1. Sally all you say here is so spot on accurate.

      My son, born in1966. He was lucky and his parents fortunate.

      He was just a bonny little boy, who looked a little bit different from his brother, but seen seen outside the family as a genetic mistake to be discarded. I /we loved him. And he grew up easily – plus pneumonias and slight delays in development. He was lucky, he was fortunate because we refused the options pushed at us on his birth; there were two options one was Normansfield institution and another huge bin the name of which escapes me. At four my pushing shoving and shouting and a fanatstic headmaster, he went to school. But only option available to him was a training centre at 7.

      He was lucky again for when we refused the put away option, (apart an annual ‘health’ check up that son and I soon learned to manage) we were left alone.

      He was lucky. No one to take our sons and daughters away unless we asked. I saw many heart rending family situations. The five year old tied to a toilet because he was a danger to himself. A 15 year old girl whose parents took turns to lie on her each evening till sedative kicked, and many autistic children who were named their ‘mothers fault’.. But in the fifties and sixties families were more terrified of their children being taken away, tipped into into huge bins far away from home.. For two decades families drove the new forms of support. Saw beginnings of the new professionals who believed they were born an oracle in special needs care, and who thought parents were all oppressive monsters. NHS was becoming a dangerous place for people with learning disability, Parents increasingly excluded. But compared to now, the two decades till the mid nineties were so bloomin’ good.

      Now families are waking each day in a nightmare where the institution has jaws as wide as a valley and the budget, dogma and care managers rule. And the bin is back.

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