Finding the light in the dark

In every place I visit, I put the question to the doctors and other professionals I meet, 'What is your role in your patients' lives?' Early on in my journey one replied with Voltaire's quote, 'The role of the doctor is to amuse the patient while nature cures the disease'; when asked the same question a few weeks ago, a community psychiatrist in Norway replied 'Many patients see my role as being able to fix them, I see it as being able to help with the imagined problems whilst having to leave them to deal with real life themselves'.

I'd been curious to spend time with one of the community psychiatrists in Meland Kommune for some time after meeting a few patients in the practice who had been referred and had, fairly quickly, received assessment and treatment. One patient had described his experience of community psychiatric care as 'finding the light in the dark' and very luckily my host GP, Anne, was willing and able to facilitate exposure to the service for me through a community choir connection. B

efore I knew it I found myself smack bang in the middle of the weekly psychosis team briefing trying to keep up with the half Norwegian half English narrative.

The psychiatrist, who had kindly agreed to have me shadow him for the day, told me his story over hot tea following the meeting and it immediately caught my attention. He had grown up and worked for most of his life in the surrounding area and so knew the community well and was, in turn, very well-known to the community. He had originally trained as a GP and had spent twenty years in that very town practising. I was fascinated to hear about his change in direction and keen to explore the reasons behind it.

'I felt like a bad doctor'

The frustrations and issues that had driven the move were all too familiar; not enough time with patients, his list beginning to feel like a 'factory conveyor belt' and yet, for him, had obviously been of particular potency working as a lone GP at a time when secondary care services, especially in terms of mental health, were minimal.

' I couldn't fix peoples' problems and had nowhere to send them'

In the past, without community mental health services in place, patients living on the islands were often reluctant to travel to hospital clinics in Bergen by ferry for psychiatric help. The responsibility for management therefore fell on the GP.

'I was interested in their lives and tried to listen as much as I could within the time I had'

Finding he had an interest in how the psychological health of his patients affected their physical health and aware of the growing need to address these problems, he developed a triage system which allowed him to allot more time to complaints that required a longer conversation. Frustrated by time constraints 'putting him off asking the important questions', he made a point of having free slots of 30-45 minutes available so that if an issue arose during a consultation, he could ask the patient to come back to talk more. He believed that patients suffering with depression and anxiety required more time, but acknowledges now that his system, although effective in theory, in reality consumed his life.

' The GP can be the most important doctor in managing psychological health complaints'

Having grown up and lived for many years in the community he worked in, he found the established relationship he had with many of his patients made caring for them easier. Although, his workload at times was very heavy, he still believes in the importance of this central role being played by GPs as the doctors who often 'know a patient best' and 'can see the whole picture'.

It has been an odd transition for him, and indeed for the population he serves, as he has moved from GP to community psychiatrist. He now sees patients for mental health concerns that he once knew as children or cared for through a pregnancy. However, he now feels more able to offer the care he would like to and is proud of how the service has developed in recent years.

I, too, was impressed on hearing about how things work; government law dictates that referrals to the service need to be answered within ten days and patients seen within thirty days or sooner depending on the level of urgency. They receive approximately ten to fifteen new referrals a week. Like the UK system, services are geared towards preventing admission to hospital and treating patients at home, however funding is allocated a little differently meaning that the crisis team is fully supported and 'always has capacity'. This agenda is not fulfilled through the service itself alone but through better cooperation with local GPs and other services. This was something I'd witnessed firsthand whilst observing at the practice; patients with known mental health diagnoses were regularly discussed in a meeting between their GP and psychiatrist in the community.

I was also interested to hear about plans in the pipeline to have a social worker present in the clinic one day a week. Like I'd seen in the Free clinic in California, the mental health unit in Knarvik believes in the impact of social circumstances on the health of their patients and is proactively working towards providing a more holistic model of care through the support of colleagues. Services working together was a recurrent theme that cropped up throughout my time in Norway. The practice in Frekhaug is special and unusual in that it is owned by the community itself. Whilst this system removes some of the 'business-owning' responsibilities from the GPs, it does dictate a certain amount of communication between the health centre, social services, the local nursing home and school. I had seen a similar model on Hoy which had evolved through necessity and have observed the benefits of this sharing of knowledge, especially in terms of preventative care, in both locations. Seeing this twice now has really made me reflect on why the presence of other services in General practice is not more common in other areas of the UK.

'There are too many doctors'

Moving back to the subject of psychiatry itself, we chatted about Norway's 'healthcare scene'. Interestingly more than 1% of young people in Norway currently become doctors meaning there is often not enough work available. Despite the situation, psychiatry is still an area that is understaffed, but there are hopes that this will improve as demands are rising. This was the point that I really wanted to explore during our day together: just why is demand for mental health services rising in this community?

' The age of patients coming to see me is becoming younger and younger'

A trend that sticks out for him amongst others is the decreasing age of the people he sees. He puts this down in part to an increase in recreational drug use in the area; a fact that opens up the issue of how the community has changed since the completion of a bridge connecting the island to the mainland and Bergen around ten years ago. This transport link has seen the population double in size from 4000 to 8000 over the past years. Many young families who commute are attracted to the area due to the lower cost housing and whilst this has brought new blood into the area, many feel there has been a negative impact on the community from people not living and working in the same place. Easier access to drugs and alcohol, which often go hand in hand with mental health problems, might also be a consequence of the changes.

Another important factor contributing to his workload, he feels, is the reducing stigma of mental health within the community and Norway as a whole, in conjunction with increasing availability of services. Interestingly, it is this last point that concerns him the most . He worries that as his services become more talked about, people become less accepting of 'the normal problems in life' and seek help for concerns that they feel are mental illness, where he feels they are simply the lows that come with being a human being. It is not uncommon, he says, to see a patient requesting counselling 'because they are going through a divorce'.

It's a point I've considered before, especially when meeting many American patients in California. On asking them the question, would they see their GP with a psychological complaint?(put in simpler terms) many replied, 'No, why would I? I would see a psychiatrist'. Whether you agree with his perspective completely or not, they are valid and potentially concerning ideas: Have many psychological stresses, the 'ups and downs of normal life', become too medicalised? and are we, as medical professionals in our efforts to address and manage mental health concerns, encouraging in our patients the inability to cope with life?

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