Somewhere in India a man is having a Skype consultation with a psychiatrist located in a hospital 500 km away. With him in the van is a nurse to help with the consultation and a pharmacist to dispense the medication. In New Zealand’s North Island a woman with depression is logging on to a website for the first of 10 CBT sessions, after completing a screening questionnaire with her GP. E-mental health care was one of many critical topics that I discussed with Professor Dinesh Bhugra, in a conversation that ranged across medical training, practice, and professionalism, and across continents.
Dinesh Bhugra is President of the British Medical Association (BMA), and brings to his position a global experience of psychiatry and mental health. As well as being Professor of Mental Health and Cultural Diversity at the Institute of Psychiatry in London, he has done all the big jobs, including the presidency of his royal college and of the World Psychiatric Association; the first UK-based doctor to be elected to the post. He also has degrees in social science and medicine, and in anthropology.
Bhugra is warm, courteous, and slightly self-effacing, but in agreeing to the BMA’s invitation to become its president he insisted on their support for three projects close to his heart: the rights of people with mental health disorders, the mental health of medical students and doctors, and the need for a new ‘social contract’ between the public, politicians, and medicine. More on this later.
We agreed that the medical profession has never experienced the difficulties it now faces; the extent of dissatisfaction with the job, of oppression by endless, often competing demands, and the consequences for morale and recruitment are new, at least in scale if not in substance.
When Bhugra returned to clinical work after one of his presidential roles he was told by the outpatient clinic staff that he needed to book new patients at 2-hour intervals; one to see the patient and another hour to fill in the paperwork required to achieve 95% Care Quality Commission compliance. He sees medicine and people working in medicine as increasingly mechanical, increasingly wary of taking risks and making their own decisions. Along with the decline in altruism, he also feels that doctors are less willing to take on an advocacy role for their patients. Medical education, he believes, does not prepare students well to become empathic doctors, at least partly because of the focus on the biomedical and, perhaps, the increasing use of simulation.
GENERAL PRACTICE AND PSYCHIATRY
Recognising that general practice and psychiatry have more features in common than differences, he feels strongly that both subjects should be at the forefront of patient contact at the very beginning of the undergraduate curriculum, in which he sees the great value of longitudinal clerkships along Harvard lines. He also believes that much more attention should be paid to the humanities and the arts as integral parts of a medical education. Psychiatric experience for GP trainees should be based in the community, not in hospital settings. He champions the idea of primary care psychiatry, and sees locating community mental health teams more securely in primary care, including consultation liaison or joint consultations with GPs and psychiatrists, as having the capacity to transform access and to smooth the interface between general practice and hospital psychiatry. He recognises that GPs’ knowledge of their patient populations equips them uniquely to target psychiatric services.
World Mental Health Day took place on 10 October and focused on the mental health of young people in a changing world. When I interviewed him, Dinesh Bhugra was planning to launch an initiative championing the human rights of people with mental health problems. A huge multinational survey by the World Psychiatric Association has revealed that basic rights of people with mental health problems, including marrying, voting, inheriting property, and taking employment, are denied to them in almost half of the countries of the world. He is determined to press hard on redressing this shameful statistic.
His second project is to carry out a large survey of the mental health of medical students and doctors, coordinated by the BMA, choosing judicious measures of mental wellbeing and exploring differences in relation to location, specialty, and other variables. The results of this work will provide powerful evidence, he believes, to help design and implement curative and preventive action across the profession. Finally, he is setting up consultations and discussion groups of key individuals and organisations to examine how a new contract between the public, politicians, and the medical profession can be developed, which encourages honesty, open dialogue, and clarity about the way that healthcare funds are being spent, and identifies the changes that need to take place so that the NHS remains fit for purpose.
Dinesh Bhugra is a president who possesses not only vision, but also the clarity of purpose needed to achieve something important. He has a strong moral compass, and the work that he has launched into as BMA president is likely to have significant and beneficial implications for our profession in the future. We should also count ourselves lucky that he recognises the key roles that primary care, general practice, and community-based health services need to play in any healthcare system
- © British Journal of General Practice 2018
