SOADs and electroconvulsive therapy

Yesterday the BBC ran a news item about the large sums that consultants in the NHS can earn by doing overtime. Psychiatrists did not get a mention, but there is a way for consultant psychiatrists or retired psychiatrists to supplement their income and that is by becoming “second opinion appointed doctors” (SOADs) for the Care Quality Commission (CQC).

In the last financial year the Care Quality Commission paid out nearly two-and-a-half million pounds (£2,399,000)  in fees and expenses to SOADs. I am confused about exactly how many SOAD visits were made in 2009/10. According to the CQC annual report (on page 46) it was 15,288; according to their Mental Health Act annual report it was 13,736. Whatever the total number, most were for the use of medication after 3 months (for the first 3 months of detention psychiatrists can give medication to a non-consenting patient without approval from the CQC) and over 3,000 for patients subject to community treatment orders. 1,339 visits were to authorize the use of electroconvulsive therapy (ECT). The system has become overloaded, with many visits not being completed within the target times. This is partly due to the unexpectedly widespread use of community treatment orders. In their annual report the CQC says they have increased the number of SOADs from 90 to 115 (the last Mental Health Act Commission report for 2008/09 listed 99 SOADs). So the nearly two and half million figure works out, on average, to over £20,000 per SOAD, although some may do more visits and receive more fees than others.

The fee for an individual visit to a patient is £180. There are also half-day rates (£270) and whole-day rates (£540). The fees have risen considerably over the past few years: in 2002, according to an answer in Parliament, it was £102.50 per visit. At that time, there were 156 SOADs covering about 9,000 visits.

According to the Care Quality Commission guidance: “The SOAD service safeguards the rights of patients detained under the Mental Health Act who either refuse the treatment prescribed to them or are deemed incapable of consenting”. (Since November 2008, SOADs can only authorise the use of ECT on patients considered incapable, rather than refusing). It has always seemed a little odd to me that you can talk about safeguarding rights when a person is being treated against their wishes.  The CQC information for SOADs says that “the role of the SOAD is not to give a second clinical opinion in the conventionally understood medical form of the expression, but to decide whether the treatment recommended is clinically defensible and whether due consideration has been given to the views and rights of the patient”, which makes you wonder why they are called second opinion doctors. And why doctors, rather than psychiatrists? There is no appeal against a SOAD’s decision (which as far as ECT is concerned is almost always to agree to treatment) and it is only since a court case in 2002 (concerning medication) that SOAD’s have to give any reasons for their decision. Perhaps this bit of extra paperwork accounts for the large increase in fees since 2002.

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