‘There was conflict, but this could be creative’

Tom Carnwath (pictured, right) and Hugh Koch (left) have been friends and colleagues for over 35 years, since meeting in the Board room at Tone Vale Hospital, Taunton, in 1986. Tom had been appointed a Consultant Psychiatrist and Hugh the first Unit General Manager, both with Somerset Health Authority.

In their respective roles, they were charged with developing a multidisciplinary community mental health service. 

Over the next few years, they collaborated in the NHS to implement a well-funded and innovative service. Both moved to pastures new in the early 90s, Hugh to Cheltenham to set up a medico legal personal injury business and Tom to Manchester to continue in the NHS developing Drug and Alcohol services. During that time Tom also did medicolegal work, again joining forces with Hugh. In this conversation, Tom and Hugh look back at some of the issues they faced and debated, often over late-night drinks in the Midland Hotel in Manchester.

Hugh: My memory of debates in Taunton at Tone Vale were largely resource-related, with you and your colleagues pushing for more staff resources from a finite pot. You had to represent the needs of psychologist and professions allied to medicine, as well as your own psychiatric colleagues. A difficult job. On my part, I only had a finite budget plus a chance to realign 5 per cent resources each year. We had heated debate but never came to professional blows, I don't think, do you?

Tom: I think these clashes were and are inevitable, but certainly no worse there than other places I have worked. Probably better. I was Medical Director, which at that time gave me some responsibility for arguing the case for allied professions as well. Whereas I disagreed with you at times in your role as manager, I can't remember any heated disagreement with the psychologists. My main source of grief was the Nursing Director. In my recollection this was where the professional power struggle was at its most acute at that time. Perhaps this was just a function of the different personalities of our Nursing Director and our lead psychologist.

Hugh: Somerset didn't have community mental health teams at this time (1986-1990). However, the various clinical teams were multidisciplinary and coordinated by a Consultant Psychiatrist. Clinical responsibility was a frequently debated topic. The nearer the clinical focus was inpatient care and mental illness – schizophrenia, bipolar and unipolar depression – the more the psychiatrist took overall lead and legal responsibility. The relationship between psychiatrist and psychologist here was often heated, wasn't it?

Tom: I don't remember it being heated. We did start forming pioneering community mental health teams at that time with your support. We opened a centre in Taunton where we conducted clinics and therapy sessions. At that time clinical responsibility undoubtedly lay with the psychiatrist to an uncomfortable extent, even with respect to patients they hardly ever saw. It was some time later that New Ways of Working was implemented with more even allocation of responsibility, although it is disputed how far this has in fact happened. 

In practice I had a good relationship with you and with the psychologist in our team. With inpatients I certainly took lead responsibility, but within the community team the opinion of the psychologist was probably more important than mine, whatever the formal arrangement, as was his supervision of therapists. But perhaps as manager you heard angry mutterings from other professions which did not reach my ears!

Hugh: Some mutterings were inevitable bur minor in nature… there were many areas where psychologists and psychiatrists collaborated to good effect, weren't there? I recall conversations about drug and alcohol, especially alcohol, where the combined input by both professionals meant the patient got a more coordinated care plan than a single approach. Throughout the county the service was varied, from inpatient, day patient and outpatient. You took a significant lead on this here in Somerset and again when you moved to Manchester. I always enjoyed our debates and found you very supportive. 

Tom: I very much enjoyed the collaboration between psychologist and psychiatrists at Tone Vale, which I think has unfortunately reduced since then across the country. Drug and alcohol services is an excellent example. Psychological and medical input are both essential, and were available at Tone Vale. More recently I have found that psychologists have been unwilling to work with addiction patients, unless specifically funded for that purpose. For example many heroin users suffer from underlying post-traumatic stress disorder. If they are stabilised on methadone, there is no reason in my view why they should be denied psychological treatment for PTSD, but usually these days they are. This was not the case in Taunton. 

When I was there I was also interested in family therapy, and enjoyed working closely with another psychologist who was somewhat of a pioneer in the field.

Hugh: During this time, we were given the job to build up non-asylum services, closing Tone vale hospital (in Taunton) and Mendip Hospital (in Wells), and developing a series of smaller, modern and more accessible units throughout the county. I felt we had been given significant capital and resources to do this. What did you think?

Tom: I think we did receive sufficient resources to make the initial changes, which in many ways were the right thing to do. You definitely rose effectively to the challenge. I remember, however, the huge anxiety among long-term patients. There was a distressing spate of inpatient suicides. I do not think enough recognition was given by the authorities to the issue of potential new long-stay patients. Another problem had been the subsequent leakage of resources to other specialties. At least before resources were locked up in an institution, but after the changes they were vulnerable to external peculation. At any rate a lot of people who would have been in an asylum are now filling up our prisons, with little hope of appropriate treatment.

Hugh: We also had the staff revenue that was tied up in these two huge hospitals to reconfigure to make the new units run well. It was complicated but there was robust debate between you and your colleagues, who often put forward good arguments for more money and myself and my manager colleagues who only had a finite pot of gold! Do you remember these debates?

Tom: I do.  And certainly some of my consultant colleagues were opposed to the whole process of deinstitutionalisation. In some ways I feel more sympathetic to their arguments now than I did at the time, for the reasons mentioned above. 

Hugh: When it came to taking care of patients who were expressing very low mood and, at times, suicidal thoughts, there was typically more than one professional involved. Psychiatrist, psychologist, community psychiatric nurse, GP. Each valued their own input to try and help and also value the patient's individuality and social circumstance. 

When push came to shove, the main anxiety was ensuring the patients safety. It was at this point that inter professional conflict could and did occur, didn't it?

Tom: There was conflict, but this could be creative. What I found valuable at that time was the continuity of care provided to patients. There may have been differences in the team about individual cases, but our community team was an extension of the hospital team, and many of the same people were involved in inpatient and outpatient care. There was then no fissiparous multiplication of teams, for example into Crisis Care, Early Psychosis etc. I have often had to prepare medicolegal reports on alleged psychiatric negligence. So often the cause of the problem is people falling between holes in the system, and nobody having overall responsibility, or ongoing knowledge about a patient's pattern of behaviour. 

Hugh: Working in the Personal Injury /Expert Witness arena, there weren't any significant conflicts particularly. I remember two issues that cropped up from time to time. The first was how to assess the implications of early vulnerability or personality when considering the effects of a traumatic incident. One expert giving greater credence to early distress, another focusing more on the 6-12 months prior to the index incident. My impression is that psychiatrists are more cognisant of the early history model, but I might be wrong!

The second issue seems to be report length, with some experts finding brevity and logically difficult. What are your thoughts?

Tom: The issue of psychological vulnerability is a difficult one. To some extent it doesn't matter because, as the saying goes, you have to take your victim as you find him. If he has an eggshell skull, it's your bad luck if you strike him and he suffers a brain injury. On the other hand it is important if you think that he probably would have been depressed anyway 'but for' the index injury on the basis of his previous history. I have found that psychologists are more likely than psychiatrists to skip over previous psychiatric history, at times when I have thought it relevant. 

More complex are cases when people are claiming current psychiatric illness as a result of childhood sexual trauma. Psychologists are probably better than us at approaching this debatable issue.

As regards length, I agree with you that some psychiatrists' reports are far too long, and that they seem to be charging by the weight rather than the strength of their opinion! Working with you helped me hone down what I had to say. My economy of style has never been an issue with barristers reviewing the case.

We both have professional bodies looking over our shoulders and quite rightly so, but I find that the GMC guidelines and overview are clearer than the BPS/HCPC. 

Hugh: Difficult to compare and contrast but it is essential that professional organisations support individual professionals as well as monitor inappropriate behaviour. 

What do you think about recent on-line activity for assessment or treatment? I've been surprised at how people have adjusted to Zoom, WhatsApp and telephone calls to discuss their problems. I'm sure we miss some cues, but many patients like it.

Tom: I find it very helpful. The interview is often more productive when a patient is interviewed in the comfort of their home, and without having to travel across the country to meet me. Particularly if they are suffering from travel phobia after a car crash! The main concern is that you are not sure who else might be listening. Occasionally I have had the feeling that people are being watched by an abusive partner, and have felt obliged to terminate the interview. This can be awkward to explain and remedy afterwards. Also some people have technical problems that renders the interview useless.

Hugh: I often get asked 'who's best for treating depression or anxiety?'. What's the best answer? The diagnosis is crucial but so is the personality of the therapist.

Tom: I agree with you. I think that the evidence shows that some people are better at treating these conditions, irrespective of the treatment model they use. Obviously healing skills can be improved by practice and training, but personality strikes me as being really important, particularly factors such as confidence, empathy and optimism. As somebody who is somewhat gloomy and self-questioning by nature, I have always been happy to leave the psychotherapy to psychologists!

Hugh: I found you 'cautious' rather than 'gloomy'. 

How should professionals like us deal with our own 'demons'? I have had brief bouts of mentoring and therapy e.g. as a teenager (about home life), at university (about fitting in) and personal supervision during my training. It's crucial to know what therapy feels like before we try and provide it for our patients.

Tom: I think that some form of supervision is crucial. I am a member of various support groups and also have arranged three-monthly mutual supervision with a colleague. I have never myself been through therapy, but I think I should have been. Probably too late now!

Hugh: Never too late, Tom! You always struck me as very robust and sensible. 

Is the mixed economy for therapy ok? I've often done extra hours for clients wanting to pay for this opportunity, even visiting them at home.

Tom: I have provided private treatment and paid for private treatment (for physical ailments) myself. Having been trained by the NHS, I think I have repaid the debt after 40 years as an NHS consultant. I'm also suspicious of monolithic structures, but that's a whole different debate.

Hugh: We both have had colleagues who have committed suicide during our association with them… this has been very upsetting and very surprising. It illustrated how vulnerable professional carers are to the stress of their work, and also to mental illness.

Tom: This can be very traumatic. One of our colleagues at Tone Vale killed himself shortly after we left, and I have to say that I never realised that he was under stress. Until recently I worked for the GMC supervising colleagues with alcohol and drug problems. It is disturbing how quickly people's worlds can fall apart after for example a bereavement or marital breakdown, and then work pressure which before was stimulating suddenly becomes overbearing. Only recently have services been set up to provide support specifically for doctors with psychiatric or addiction problems. Are there similar services for psychologists?

Hugh: Yes, on an informal basis. There is considerable awareness of how psychologists are not immune to stress and trauma. Access to help is, like with everyone, resource constrained.

Well, Tom, many thanks for 'talking'. I think we have been kind and collaborative in this conversation. I value your friendship, both professional and personal.