19. Queuing like you really mean it.

ImageYork’s new rapid transit system.

After the weather forecast comes the Pollen forecast. For some reason I expect to see it presented by a giant bee, in bee language.

Its pretty difficult to get a GP appointment nowadays, certainly for hay fever. I read in The Times that some GPs are averaging 66 consultations per day. If so, the situation is crying out for a production line system like they use in car factories, where patients move slowly along a conveyor belt in a giant shed.

In fact I see no reason why hospitals shouldn’t operate like this, making so called ‘care pathways’ something of a reality. There would be a faster track through the A and E department, in the same way as East Coast trains fly past First Capital Connect at Potters Bar.

If we have a track for Depression though, lets not make it a tunnel.

Recently I made a GP appointment – I couldn’t really say it was urgently needed, since, like most doctors in fact, I am a bit of a hypochondriac.

Also I made the big mistake of saying ‘its probably nothing’ to the receptionist.

I got an appointment more than 3 weeks later. Of course, like most self-limiting conditions, which is most conditions, it had already got better by the time I got to see the GP. I went in with a grovelling apology and came out in less than a minute. I felt I had blown a bit of credibility though, in case I get a genuine illness one day. Several Cry Wolf points thrown away.

Perhaps there should be a special ‘disloyalty card’ where persistently not attending earns you extra points. Every now and again these could be traded for a free consultation without prejudice.

This set me wondering whether anyone knows how to use the health care system properly. And if so, how can we learn how to do it?

After all, most illness behaviour is determined by social learning.  But no-one ever properly teaches us how to ‘do healthcare’.

We all have a huge stake in the NHS, but, amazingly, the NHS comes with no instruction manual.

Its the kind of thing Michael Gove definitely hasn’t put on the schools’ national curriculum, revealed today. But should he?

At the end of every human interest piece on the news, such as spontaneous combustion in sheep, the damage done by carrier bags or how yogurt can become dangerous under certain circumstances, the answer is always a call for ‘better education’.

This must be hugely irritating to teachers, whose curriculum is already big enough and struggling to cope with constant tinkering.

But along  these lines, instead of say, History, or Geography, why not some basic Medical Sociology?

We could learn about the pernicious effects of the private sector, the inverse care law that affects poor people, how health care systems struggle to constrain costs and how it took the French Revolution to smash the four humour system.

We could learn the difference between Disease, Illness and Sickness, and how the sick-man has disappeared from Medical Cosmology*. Perhaps he will turn up in the cafeteria or X Ray.

We could learn about the sick role and how to play it. We could have a field trip to the Broad Street Pump, where Snow discovered how cholera got transmitted.

Maybe answer the question, why isn’t holistic spelled ‘wholistic’?

We could look at screening programs and learn – very quickly – which ones are worthwhile. Borrowing a few sessions from Science we could look at Causation versus Association and show improving movies like Moneyball. (Subtitle: the art of winning an unfair game.)

If that’s not better than learning the details of World War One peace treaties, I don’t know what is.

We seem to have an insoluble problem in the UK. It is free to go the doctor or see a specialist. Although if we need to get medication it costs £7.85 per item, plus 90p to park. If it involves driving into Nottingham then there’s a £30 charge for getting in the tram lane by accident, and by accident I mean by being careless.

If we try and impose any charge, it looks as though we will discourage the very people who need to see the doctor most often, and the people who most need to drive over tramways. A number of famous studies suggest the most deprived people are those who have the highest rates of illness and shortest life spans.

But being free, the NHS system seems to attract a large number of people whom car dealers would call tyre – kickers.

Perhaps the fairest and most effective way to ration health care would be to create a giant lottery for appointments, or to make them transferable, so that slots could be traded on the open market.

In the GP waiting room, as I cowered in my corner, peering over a 1998 edition of Auto Express magazine, it looked as though the other aspiring patients needed a bit of weeding out, or triage, as it’s called in health care.

With images of Taksim Square in mind, I imagined a military type person coming out with a loud hailer every few minutes:

Anyone whose temperature is 37 or less, please leave.

Anyone with a bad cold or flu, out!.

Anyone with backache, headache, neckache, tennis elbow, golfers’ elbow, or any other kind of elbow – out!.

Anyone with a twinge.

Anyone with insomnia.

Anyone with indigestion.

Out, out, out!

Anyone here for a screening test not based on sound epidemiological evidence?

(Pauses for a moment) It’s 95% certain you should leave.

Now we are seeing a definite thinning in the crowd and a line of people heading for the Cooperative Pharmacy or the alternative practitioners ghetto. No need for the water cannon and rubber bullets after all.

The military style triage is unlikely to prove acceptable in the era of consumerism. Tesco don’t use it, even for the people who turn up at 9pm to get the reduced loaves and then ride around the car park in trolleys.

Instead we have had NHS Direct and 111 – who tend to ‘direct’ you to A and E.

The A and E department have their own filtering system, using time and, to a lesser extent, squalor. More recently they have taken a lead from Heathrow and created a stacking system for ambulances, which circle the hospital, waiting for a landing slot.

I made the mistake of trying to reach Leicester Royal Infirmary by car recently. Like the health care system in microcosm, there is no way in and no way out. I felt like an Apollo space capsule, orbiting the moon, but I had no lunar module to send down.

Those with self limiting conditions have probably got better by the time they are seen. Even those people who are seeking healthcare mainly to meet other people who are seeking healthcare and chat to them, have had enough social contact after 3 hours in a hot little waiting area with a very expensive Coke machine and a silent, armoured television showing volleyball from Belgrade.

Using time as a subtle disincentive is an example of the ‘British’ way of filtering access to healthcare, which is called ‘implicit’ or ‘covert’ rationing. For example, many people who are referred to primary care mental health or substance misuse services receive a letter asking the prospective patient to ring up and make an appointment. Sometimes this also involves filling in some forms and rating scales. A really off-putting one is asking an open question like, ‘what would you say are the aims of this appointment?’

This little change in the Choice Architecture reduces the number of people given appointments significantly. Perhaps these not-very-motivated patients are the right ones to weed out. Or perhaps not. Maybe those who are least forthcoming are most in need.

Because mental health services are very limited, and mental health problems are very common, there is a massive amount of covert rationing for psychological treatments.  Which brings us to the pressing issue. If it’s that difficult to get an appointment for something concrete and medical, like muscle cramps and twitching, oops I gave it away, how much more difficult must it be for a depressed person to enter the system?

Most people with Depression have reduced energy and motivation. Often they are ashamed of seeming weak or useless. Studies have shown that it takes most people a long time to get round to making an appointment. Often it takes a crisis of some kind to bring people into contact with services.

Recently I’ve seen people turned away from blood-doning sessions because they had not made an appointment, even O negative donors, like myself, who should be given the red carpet and chocolate digestives.

I heard would- be donors say things like, ‘I just like to come down here when I’m able to, I just can’t plan that far ahead’. The person in charge assured them that the new appointments system was much more efficient.The Times (10.06.13) reports that the number of blood donors has fallen by 23% in the last ten years.

NHS blood and transport are apparently looking to attract young donors, so perhaps this should also be included in the national curriculum. I’d have given more blood if doning had been offered as an alternative to PE.

It would perhaps make sense to abandon or reduce the system of making appointments in favour of just turning up. We seem to like walk in centres and A and E, where we go when we need to.

In fact I seem to remember GP surgeries used to be like this, before appointments took over. I am sure GPs can produce evidence supporting the idea of appointment systems. And further evidence to support their recent system of the mad telephone rush for slots, jamming the  lines at 8.30 am.

But there has been a massive change recently in the number of things you can do while you wait. This has transformed public transport and it could transform access to healthcare.

If you have a tablet computer, or smart-phone even, you can listen to music, read a book or two, watch a movie and play a few games.

You can skype your relatives and buy a new cardigan online.

This is quite different from even 10 years ago, when you had to be content with old copies of Golf Monthly, collections of curling pucks and a fish tank.

Somehow we have created a system where people’s time is felt to be incredibly important and they can’t be released from work. Did planners fondly imagine that people would pop out of work during their lunch break to have a quick endoscopy?

It looks as though ill people will seek help, providing they know which queue to join and where it starts. All they need is a sign saying, ‘Stagger this Way’.

The biggest crime in the NHS is to make covert rationing ‘explicit’. It’s a bit like a magician showing how the tricks are done.

Perhaps there’s something more honest and straightforward about a queue. A bit like Stargate, we’d call it a ‘Portal into Care’.

Take your iphone. And the charger. Food and drink also. And if you see the sick-man, please send him back to Medical Cosmology*.

*The disappearance of the sickman from medical cosmology, by Nick Jewson,  Sociology May 1976 vol. 10 no. 2 225-244

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4. Getting over the mind brain problem

Image

What it looks like inside your mind.

One of the biggest barriers to tackling Depression is getting hung up on the Mind / Body, or more specifically the Mind / Brain problem. Its the mind part that’s the issue. As soon as the word ‘mental’ comes into play, people get all upset.

Its hard to adjust to the fact that we may be nothing more, or nothing less, than very clever machines. Its also hard to believe that consciousness can emerge gradually from a wiring network, providing that network is large enough.

Surely, if all you needed for consciousness was a massive wiring system, then British Telecom would be a god like super-creature bent on world domination. Hmm…

So can consciousness, or the mind, be considered a separate entity from the body? This argument still hangs heavily for many when they think about mental health problems.

The mind / brain issue did preoccupy philosophers for many centuries and still occupies a large section of Wikipedia. Some philosophers thought that mind and body were entirely separate devices. This idea is called ‘dualism’ and tends to persist in the way people think about the human control system.

If mind and body were different ‘dual’ entities altogether, like sound and light, then how could they interact? Some kind of transducer device, as proposed in the pineal gland by Descartes? Or simply, (cheating really) bringing God into it to solve the problem, God acting as a cosmic DJ, operating the twin turntables of mind and brain, making sure they were synchronised properly at all times?

(This school of thought was termed ‘occasionalism’ and probably did not influence the Faithless song ‘God is a DJ’ nor even Pink’s cover version. Pink was yet unknown in ninth century Iraq).

Glossing over Philosophy and Religion for a short moment, there is a lot to support the argument that the brain is a very sophisticated computer system.

For instance, nerve cells which make up the brain are long and thin and transmit electrical charge, just like wiring. The nerve pathways in the brain look a lot like the wiring loom in your Honda Civic. Damage to part of the wiring system, such as after a stroke, can clearly bring about symptoms, like loss of movement to a limb.

Higher up the brain, the nerve networks get more complicated and seem to provide for various different types of mental activity. There is the completely automatic type that controls basic physical functions like the operations of the lungs, heart and gut. Then there’s the largely automatic thinking system that does things like drive you to work and make toast. And then there is the reflective part of the mind that chooses what to think and do, or thinks it does, or you think it does.

Computer speak has given us a new ‘dualist’ model to consider, the division between hardware and software. Sometimes it can be helpful to think of the brain as the computer and the mind as the operating system. As an analogy it is both helpful and unhelpful.

The plus points are that factors such as social learning and experiences and memory can be seen as software, running within the brains basic wiring network, which starts off as a largely empty system and gradually fills up. The mind’s ability to process information and store it, or create actions, are similar to an operating system.

There is also a nice computer analogy to be made between the mind’s two main memory systems, long term and short term. Stored memory can be seen as similar to a computer’s hard drive, whereas short term or ‘working memory’ has features similar to RAM. Working memory is far more limited than long term and easily exceeded by multiple or complex tasks, such as chewing gum and walking at the same time.

Many memory problems, such as those found in Depression, occur within the process of moving memory between the two systems. Depression very often reduces the power of concentration, which is needed to retrieve information from the storage system, and also to file memories away.

Against the software / hardware model however is the following problem; the brain is not a fixed system like your PC or Mac. It can create, remove or change its physical structure as it goes along. The changes are not just electrical, as in hardware, or even just chemical – the brain is continually creating new connections. This is why the brain is called ‘Plastic’ – the term is used to mean flexible and open to structural change.

In babies and children there is a huge and continuous rebuilding program of nerve cells. In adults there is a much more limited program of nerve cell slum clearance but sadly not much in the way of inner city regeneration. Depressed people may lose their ability to generate new nerve connections in certain parts of the brain. In fact an attractive theory of antidepressant therapy (both drugs and psychological therapy) is that these may work by stimulating nerve cell growth in certain key areas.

And this brings us, a little early, to the punch line. Which is that structure and function are inseparable features of our control system. They are so interactive that it make no sense to identify two entities called Mind and Brain.

In practical thinking this dilemma presents itself frequently in thinking about mental disorders. For instance in thinking of some illnesses as either mind based or brain based. In particular illnesses that were once considered to be ‘psychosomatic’ such as bowel or fatigue syndromes. Within Fatigue Syndrome there have been heated arguments by some sufferers that they should not be regarded as mental health patients, even though CBT may well be very helpful, as it can be in ‘physical’ illnesses like chronic pain.

The law has frequently got itself into a pickle by trying to separate what is due to the mind and what is due to the brain. We have seen concepts such as ‘non insane automatism’ invented to illustrate this area. The newish Mental Capacity Act speaks of a disorder of ‘mind or brain’, to get over the possible argument about which one was disordered. Could one ever be disordered without affecting the other?

Within Education, we have seen concepts such as ‘Brain Based Learning’, or ‘Mind Brain Constructivism’ as it is more properly known. Here again the proponents are careful to use the term mind/brain as a portmanteau concept. Strangely, educators have been rather uncritical about the supposed ‘Brain’ aspects, such as improving food and water consumption for students. The ‘healthy mind in a healthy body’ notion has been about for a long time in schools. Before Michael Gove, and in fact before even Socrates, neither of whom would have seen the mind as a wiring loom.

One of the more interesting findings from Brain Imaging has been the recognition that psychotherapy may bring about structural brain changes. For instance, changes have been found to the mid-brain serotonin transporter system, after psycho-dynamic psychotherapy. A much larger number of studies have shown changes to nerve cell functioning during and after therapy.

It could be argued that these sorts of changes are not actually ‘causal’ but rather just a secondary indicator of mood change. Nevertheless, there is clearly a mood control system in the brain that is represented in physical structures.

So we have the Fatigue Syndrome lobby who resent being considered as having a mental health problem, and we have the ‘anti-psychiatry’ lobby who hate the so called ‘biological’ model of Depression.

The fatigue lobby would be delighted if one day a clear biological cause is shown for the illness – presumably then it becomes like MS or any other ‘proper’ illness?

And the anti- psychiatrists would be delighted if absolutely no biological change could be found in the brains of depressed people. They have been similarly delighted by the findings that antidepressants are not as effective as people used to think. Their response is not at all to suggest finding a more effective antidepressant, but rather to debunk the whole concept of Depression.

If you need to ask how can simple chemicals substances change the way people think and behave, then you have (wisely) not visited Nottingham city centre at 11pm. If you doubt that faults can occur in complicated electronic control systems, and that such faults are impossible to diagnose and treat, try using a 10 year old Beko washing machine. It has a mind of its own.

It seems the learning point is never to try and assign a problem to mind / or body, and always to recognise that the two are one. If that makes us just a brilliant machine or merely thirty nine dollars worth of chemicals dressed in a suit of similar value, so what?

Well, for one thing, less stigma, and less guilt. If we have defective mood control systems, whatever the basis, then this is a health problem and not shameful.

I was taught by Irish Nuns that ‘man thou art dust and to dust you will return’. (Its the kind of thing Rugby Forwards say to each other before a game). The dust cost less than thirty nine dollars in those days.

And if God is really acting as DJ, is he playing enough soul?