nhs, Uncategorized

Everybody’s Talking (at me…)


I’m stuck. How to I get people to assess and document mental capacity?

This is something I have been struggling with for a few years now.  I know I’m not alone either.

In last weeks blog I alluded to the fact that part of the Older People in Acute Care inspection focused on mental capacity documentation.  I also spoke about how nursing staff were being held to account for it when it is medical staff who are responsible.

I also came across this tweet by the British Geriatrics Society (@GeriSoc):

‘Some pts in hospital for ages, have multiple procedures, before capacity finally questioned only because they want to go home! #bgsconf‘ 

This is a situation I have been witness to repeatedly.

How can we be striving for person centred care and yet the most fundamental aspect of this is not addressed?

It was therefore fortuitous that I was asked to present to our Clinical Governance Board on this topic.  So with the question twirling in my brain of how to improve it I started with some basic education.

Does this person have capacity?  What about the others….?

Now the first thing I had to do was make an assumption that the people sat in the room had capacity.  That’s how we should approach the assessment of anyone we see in hospital, clinic or at home.  They should have a broad understanding of what is wrong with them, the treatment offered and what would happen if they refused treatment.  They also have to be able to communicate this decision and we should help facilitate this if they are unable.

I quickly ascertained that my audience was full of mentally competent people who were keen to hear what I had to say.

I moved onto what is meant by mental capacity.

Just because you can make bad choices it does not mean you lack mental capacity.  You just have to explore the reasoning behind why they believe what they do.

Mental capacity can also be fluid.  This is true in the case of the person with delirium. As the condition fluctuates there can be times when the person is lucid but at other times they can be confused and/or hallucinating.

Finally mental capacity is task specific.  This is of particular importance in the person with dementia.  They may be able to understand the need for treatment for a chest infection but lack insight regards their own safety at home.

So how can we maximise the decision making ability of the person?  Well first you have to have enough time to go through things, including time to re-assess where necessary.  You need peace and quiet.  The person should have every possible chance to use what capacity they do have. That means put their glasses on, check that hearing aids work, have written information available and allow family members or carers to be present.

Lastly I have spoken about mental capacity in relation to medical treatment.  There is a whole other aspect to it that encompasses decisions pertaining to financial and welfare matters.

With all this to consider is it any wonder that mental capacity is a complex and time consuming process?

So back to my question – how to engage people with it?  I personally think we need a much broader range of people trained in the assessment of mental capacity.  I think our nursing staff have much to offer in this area and I would welcome any thoughts or comments around this.

I also think we need to ensure that medical staff are properly educated.  It is a daunting topic but one that is relatively straight forward to understand if taught well.

Meantime I draw parallels with DNACPR discussions and documentation in terms of importance and the legal aspect.  We would not dream of having a conversation around treatment escalation/resuscitation and not document it.  Why do we not apply the same level of importance to a person’s mental capacity?

It makes no sense….!


It ain’t what you do, it’s the way that you do it…

buriedIt is rare that I get proper mad however this week the red mist descended.

It wasn’t the fact the whole nhs.net crashed on Monday due to some individuals hitting the ‘reply all’ button.  That actually turned out to be a lovely day of respite from the usual gazillion emails.

No, what made me mad was having to watch the total assassination of one of my senior nursing colleagues by external auditors and being unable to do anything about it.

The care of older people in hospital is regularly scrutinised.  It is something I have always fully supported. We’ve seen what happens when such safeguards are not in place (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf )

The care of older people takes a whole team of staff from housekeepers to therapists to doctors to nurses.  However it appeared that virtually none of these people were spoken to about their contribution except nursing staff.

Instead emphasis was placed on the paperwork and documentation.  I have a great deal of sympathy for my nursing colleagues in this respect.  When I do my documentation it is largely confined to one section in the case notes.  Nursing staff have page after page of documentation to complete.  This all to evidence the care they are trying to deliver. And try is the key word here.  Many wards in our hospitals run with nursing vacancies everyday.  I see my colleagues regularly in tears trying to keep up with the documentation which at times is sacrificed in order to deliver the all important care.

A report was published in the summer highlighting the problem of staff shortage. The RCN response made it clear that it is not about to get better anytime soon https://www.rcn.org.uk/news-and-events/news/urgent-action-needed-to-combat-major-uk-nursing-shortage-warns-rcn

Not all legal documentation falls to nurses to complete either.  In Scotland we have the Adults with Incapacity Act which safeguards the most vulnerable people who don’t have capacity to make their own decisions.  We as doctors will assess capacity and complete a certificate along with a treatment plan.  This treatment plan allows, amongst other things,   fundamental healthcare needs to be carried out.  These needs are defined as nutrition, hydration, hygiene, skin care and integrity, elimination, relief of pain and discomfort, mobility, communication, eyesight, hearing and simple oral hygiene.

The assessment and completion of the documentation is not something nurses can do however unless they have completed a module at Napier University (only small numbers have).

It therefore irked me even more to hear that our senior nursing staff were being held to account for this particular aspect of care without speaking to medical staff.

The visit did highlight many positives, in particular the care experienced by patients and relatives.

Afterwards I looked to remind myself of the definition of team work:

‘cooperative or coordinated effort on the part of a group of persons acting together as a team or in the interests of a common cause…’

Our common cause is excellent care for all our older people.  We do however need to reach a balance between written evidence and the kind of evidence that shines through just by looking at and talking to our patients.



It’s the end of the world as we know it….

The Scream by Edvard Munch, 1893What a week!

For months I’ve been aware of a low grade anxiety bubbling away at the back of my brain.  It would usually come to the fore whenever there was mention of the US election.  Saying that it wasn’t something I gave a great deal of thought to until election day. Sure I had a very visceral response to the news that Donald Trump had been elected.  It also seemed that the universe was conspiring to make it the worst day ever (sprained my ankle, train was cancelled, late to work and snow).

What was interesting to watch was the response on social media especially amongst healthcare professionals. We are well used to dealing with sudden and at times surprising change of events.  It’s what we’re trained to do.  However this week there was a sense that while we were prepared to expect the unexpected, no one was very sure what to do when it actually happened.

There was a great deal of ‘we’re all doomed’ tweets and Facebook posts (admittedly some of which were quite funny). There were also a few ‘I’m only focusing on the things that I can control’

I came across this article which I think does a good job of summarising the past week for many people:


The word ‘acceptance’ has been scored through which I don’t agree with though.  That doesn’t help anyone.

No, by the time Friday rolled around my main feeling was of optimism.  This whole thing was inevitable.  While I don’t think that Trump is the best person to be President I think he is part of a bigger process that will even overshadow him in the end.  Things had to change and I’m not just talking about the USA – look at what has happened the world over in recent years…

So as always there is a choice to be made.  Be paralysed by fear, have a temper tantrum at the injustice of it all.  Or as that well known phrase says ‘Keep calm and carry on’

And carry on we will because there is much to be done.

I returned from the European Delirium Conference focused on making delirium education a priority for all healthcare professionals. However before I could start on that I had an on call to do which also happened to be day one of our frailty pilot.  Instead of seeing every person >75yrs we decided to focus on those we could have the biggest impact on – those with frailty.

More education followed on Tuesday with the ‘Managing Stroke 2016’ event at the RCPSG.

The week finished with a positive meeting with colleagues about the use of Patient Opinion in our Directorate.  Plus my blog was published in the BMJ which not only prompted discussion but encouraged a few to small acts of bravery;


I am naturally an optimistic person.  I will try to see the positive in every situation but I am realistic enough to have plans A – Z in case things don’t work out.  The coming months and years will be at times unpleasant there may even be trouble ahead but as Mr Cole said;

‘…while there’s music and moonlight and love and romance

Let’s face the music and dance’


It’s all a matter of perspective….

img_5134Following on from last weeks blog (and a day later) I decided to write this from 37,000 feet in the air.  No I’m not speaking metaphorically after a couple of gin and tonics.  I am literally flying in the clouds as I type. Oooooooo!

I’ve been on call all weekend and in the usual way of trying to get everything done my brain objected to the additional pressure of writing a blog as well.  The only thought I had was to ‘get done and get home’.  Not exactly a riveting read.

So this morning I took off from a beautiful sunny Glasgow bound for Faro, Portugal.  I had managed to get a window seat too.  Now I’m not going to spend the rest of the time waxing lyrical about the stunning scenery as we flew past Loch Lomond, over Arran and down the Irish coastline.  What struck me though was that although I had been to all of these places, it felt like I was seeing them for the first time.  By merely going a few thousand feet in the air I was seeing a familiar landscape from a new perspective and that’s really what my week has been like.

I had been invited to a Patient Opinion event earlier in the week (more of that in a future blog).  Most of what was discussed was around perspectives.  Not just ours but those of patients, families and other staff members.

Sometimes we get so caught up in the throes of work that we forget what it looks like though the eyes of those we care for. Now, we may know how things work but all to often I have been witness to unnecessary friction between staff and patients/families purely because we do not stop to see it from their perspective.  When in fact we do stop we are often not surprised by what they are saying.  Most of the time we find ourselves agreeing.

This week in clinic I had this exact conversation with one of my stroke survivors.  This person had done exceptionally well post treatment and I was bringing them back to see how things were.  Now while I do not expect everything to be perfect I was a little unprepared to hear how negative an experience it had been for them.  It wasn’t that anyone had done anything wrong per say but there was a sense that despite what we thought were our best efforts we somehow fell short…

So I decided to try something I haven’t done before, I invited them back to the ward.  I want us to have an opportunity to talk though the experience.  More than that though, I want to hear how we could do better.  My hope is that by looking at our world from a different perspective we can make things better for people in the future.

While going 37,000 feet in the air can help to see things differently sometimes  it’s as easy as stopping to listen…..