Health and social care

Many of our patients need both healthcare and social care, rather than one or other. Attempting to split care needs may feel counterintuitive to clinicians: for example, how should services for problem gambling be categorised (George & Copello, pp. 318–322)? Even so, it has been argued that there is a health and social care divide – a ‘Berlin Wall’, contributed to by a series of barriers, including structural, financial and procedural (Glasby 2003). In addition, it is difficult to achieve effective partnership working between health and social care, particularly in the context of huge differences in power and culture between different occupational groups (Lymbery 2006). In some areas, such as implementation of Section 136 of the Mental Health Act 1983, psychiatrists have a clear leadership role, with involvement in setting standards (Hampson, pp. 365–371). In other areas, such as problem gambling, our involvement might at best be as part of ‘a coalition of the willing’ (George & Copello, pp. 318–322).

Two-thirds of people in Britain’s care homes have dementia, a disease that is ‘one of the greatest health and social care challenges facing the world today’ (Burns 2011). Agitation is a common and distressing symptom in the care home population. It is associated with behavioural disturbance, including aggression. Treatment with antipsychotics may be neither safe nor effective, but no other drugs have been shown to be of value in reducing agitation – although effective pain management may help. However, there is increasing evidence of the efficacy of systematic non-drug-based interventions (Rosenberg 2011). Hence, the importance of psychiatrists contributing to developing the skills of the care workers who provide day-to-day care could hardly be overstated (Mason & Adeshina, pp. 372–380).

Improving care workers’ skills

Evidence-based medicine ‘essentially involves integrating individual clinical expertise with the best available evidence from current research’ (Wallace, pp. 389–395). Thus, clinicians might contribute to the ‘bottom-up development of a “what works and how” literature base which can inform others’ (Sarkar & di Lustro, pp. 323–331). My Editor’s pick this month, by Mason & Adeshina (pp. 372–380), is an exemplar of this approach. The authors distil weak (level 4) evidence into a clear set of pragmatic principles emphasising the importance of three stages of effective training: predisposing, enabling and reinforcing. Thus, knowledge and attitudes are informed through small-group interactive sessions; changes in the working environment allow workers to implement their new skills; motivational approaches, support, advice and feedback facilitate implementation. The authors suggest that these principles apply to dementia care in all settings. I think that the principles are more generally applicable for all psychiatrists who work across the health and social care divide.