You're listening to Confidence to Thrive, the podcast for ambitious healthcare practitioners and entrepreneurs, brought to you by Our Liddy Advisors. Welcome to Confidence to Thrive, the podcast helping growing practitioners and healthy entrepreneurs navigate the challenges and risks of regulation while building brands that matter. Every episode, Christopher Cloak Brown tackles a different issue facing healthcare practitioners or entrepreneurs, or interviews a guest who is working on the leading edge of private healthcare, building something that matters in their sector or profession. My name is Jodie Rainsford, and on today's episode, I'll be discussing with Christopher how to navigate the risks and regulatory framework around building and growing a mental health practice. Welcome, Christopher. Hi, Jodie. Thanks for having me. Mental health is obviously a huge growth area across healthcare as awareness has grown and funding and solutions are followed. What has been the evolution of mental health in the private sector versus the NHS? This, Jodie, I think it is an area in which the private sector leads. The NHS is notoriously undercapacity in terms of mental health. There was a time when fundamentally, in all but the most dire circumstances, there was nothing available in the NHS. It's improving and it's improving rapidly, but it's improving from a fairly low uh base. So there still isn't a lot of mental health support in the NHS. It's something that fits extremely well with functional medicine, which is looking at mind, body, soul, the whole person. And I think increasingly uh the mind and the body are becoming inseparable in medical thinking, and at least in terms of functional medicine. And you can probably go back pre-NHS to the Victorian hospitals, where that was probably a more common opinion. So everything comes around again, kind of thing. So, yes, I would say the private sector is the leading edge of mental health, and in particular uh the functional medicine area, which looks at the whole body, and even some of these ideas of things like social prescribing, where you're prescribing things like even just going for a walk and stuff like that, which which again my wife would say is straight common sense. And if I'm feeling down or in a bad mood, I get booted out for a walk and not bother her. But on a more serious level, is it is extraordinarily powerful. Such simple things are extraordinarily powerful for people in quite bad situations. And what does this mean in terms of how it is regulated? Because a lot of the areas we've discussed before, there have been years and years of regulation in the public sector, uh, frameworks, uh things put in place to protect patient safety, to reduce risk, and then a lot of the time private practices are cropping up and offering things which are supplementary to that, and then the framework obviously works alongside that. How does this how does the fact that there is so little existing provision affect how regulation works? What are the challenges and what are the gaps? In terms of regulation, it works the same way as all other medicine. I think you've put your finger on it there, Jodie, that the issue is that there isn't this huge body of recorded and consistent NHS practice that sets an absolute standard. And as you can imagine, mental health is a deeply individualistic, deeply personal area. So it's one of those trickier areas to necessarily get a complete body of. It's what makes, to be honest, mental health so difficult and quite a risky area because some people in bad situations are difficult to deal with. I don't want to tell morbid stories at this stage of the podcast, but as my business partner was the head of operations at the NHS litigation authority, and he's dealt with some of the extreme cases and mental health institutions, which are run by the NHS, and it gets it does get pretty bad in the extremes. I think to me, the thing that I notice is that there is probably less of a standard to draw upon, and the big debate at the moment is in terms of ADHD medication. A lot of uh adolescents are being diagnosed with ADHD, rightly, wrongly, what's causing that, what's driving that? There's vast numbers of questions, but you are seeing the amount of ADHD medication being prescribed in this country and many others really skyrocket. And so the question is that a good thing or a bad thing? And without all that NHS data and NHS control, I think nobody quite knows, it's the honest truth. And some of the challenges around that is that that has also coincided with diagnosis online. It used to be, of course, the case that someone would go and visit someone and they'd see them in person, and a lot of the diagnosis for mental health issues, partly caused, I imagine, by COVID and the the fact that that wasn't it, and and and the two things probably uh increased alongside each other. There was probably a you know correlation between them. What are the potential challenges going forward in terms of a lot of people who are now going to be on medication and they are going to be in the in the private sector? Some are moving back to the NHS, they have different pathways as well, and private healthcare is being lent on as well for the right to choose. What are the steps that uh a practice needs to take to make sure they are staying on the right side of the regulation, make sure they're protected against any potential uh shift one way or the other? Yeah, so uh it's really, I think in this one, it's where you're really relying on the practitioners themselves to act ethically, is really where it's at. It is easy to make money as a private mental health practitioner. There's a lot of people who would like to believe that they have some kind of mental health issue, uh will be seeking people to diagnose them or or not, uh and then go on the medication for which you can do that as a private practitioner and charge a fairly chunky amount of money for each prescription, and you're prescribing those every one to three months, probably. Uh, for somebody who is financially focused, who has the right qualifications, there is an easy path to making money. Now, whether they are then acting in the patient's best interests uh becomes questionable and certainly greyer, and so they are exposing themselves to all the discipline complaints and disciplinary issues down that path. So, if you're in that practice, and don't get me wrong, I think there are practitioners there who are very concerned for their patients and do an enormous amount of good, but they are very comfortable in themselves with what they're doing and and why and what treatment they're giving to people and steering very heavily away from that area, which in in GMC parlance would be uh providing treatment for financial gain, which in GMC lands are about as bad an accusation as it gets. So, yeah, it's you have to be, I think it's an area in which you need to be very clear on why you think the treatment is appropriate for your patient, and quite probably be prepared to defend yourself against some quite serious claims, would be my my thought on that. And so is this very similar to uh what we've discussed in other episodes, a clear taste, a rigorous note-taking, clear communication with the patient and monitoring the patient at various points to ensure that the treatment plan is correct. Yeah, absolutely. Uh so it's it's really getting into absolute clarity as to what your diagnosis is and why you're giving certain treatment and why you are you are persisting to give certain treatment. Now, again, interestingly, and I'm picking on ADHD at the moment as being quite a topical issue. Uh you have to be extraordinarily careful there, because again, this is I'm not an expert, so this is information I've gathered from talking to various people over the years, but but the issue you have with the ADHD medication is the side effects of it actually exacerbate some of the negative mental health that is associated with HD. And so as three different main medications, and you have to assess what personality your patient is, yeah, and then pick the medication that clashes least with their own negative thoughts. It's really quite a tightrope that you are uh walking there, and and so clearly it's important to one be very, very careful about which medication you pick, and then even more careful. So it gets into the whole question of repeat prescriptions, which is a huge issue in in medicine overall, and how how much you assess and control repeat prescriptions and how long you just let the repeat prescriptions run without reassessment and so on. And and clearly in this area, it's extremely important you keep a good eye on your patient and don't just chuck out the same prescription every month and then let them get on with it because again it can go badly wrong if you do that. And one of the things that I've uh seen a few times, and I don't know whether it's for anything that's particularly firmed up, but it's certainly part of discussion. Everything's about a class actions at the moment, whether it's for uh cars or exhausts or things like that. But there has been some talk around this area of ADHD, particularly, and over-diagnosis and misdiagnosis being a potential area where there may be a flood of claims coming in the future, simply because of the numbers, and simply because there's a lot of people who are concerned that they were misdiagnosed and they have spent a lot of money in the private system trying to get that right, and and the NHS as well, of course. Is it is that something that is likely to happen? How does how does someone who a practice who has been operating in this area uh look to guard themselves against something like that potentially happening in the future? Yeah, absolutely. I do think it is absolutely that there's something will happen. One of the things that concerns us with uh ensuring clients in the sector, if I were a claimant lawyer looking at all the things that I might get my teeth into, that would definitely be one of them. Uh as you say, it is quite widely talked about, and I'm sure there is bad practice out there, uh, but it is the classic, as we say, there's plenty of good practice, and it would be distressing to see the good practice being thrown out with any class actions. Uh, so it is what we talked about. You want to be the one with a policy with notes to justify these are the people I saw, this is what I did, this is why I did it. Uh, you I'm sure, as the if anybody's putting together a class action or similar, they're going to be wanting to go after big targets. So they will be going after big brand generic practices who might not have rigorous guidelines and might have if you dig into the company on the financial motivations for the practitioners and all sorts of things might emerge. So you want to be the smaller, well, not necessarily the smaller, but the practice that has very clear guidance as to what the criteria are, very clear documentation that you've met and stuck to your criteria, very detailed notes on the individual patients and why they followed the course of treatment they did, and and frankly make it. We always talk about uh when there's a class action or a claim, we want our clients to go on the too difficult pile. So if you think about it in that context, you want your practice to go on the too difficult pile as the claimant lawyers are considering who to go after in that kind of suit. Because that's a very that's a very real way of looking at it. The claimant lawyers are only going to go after easy targets and ones where they're going to be able to prove that element of financial gain over that. And so any I suppose larger businesses, anyone who has uh taken advantage of the fact that the NHS was very quickly outsourcing a lot of these things in order to deal with the overflow, they're gonna be the ones that are gonna be primarily targeted. Yeah, possibly, or or just you can see the attraction of it being a fairly straightforward and and scalable and large business. So anybody who's gone down that path and not taken the medical side seriously enough could could end up with a problem. Yeah. But if if you are a a skilled and caring practitioner who has sought to support and help your clients across the years, you should be fairly defensible. And I'll you're the lawyer, not me, but it would seem to me that it's the claimant lawyers would want to avoid anybody who has a strong case because it could contaminate their claim. If you know you could put up the one with the good practice and say, Oh, yes, yeah, well, this is what we do. But a lot of this, a lot of this will have come about by the fact that people are unhappy with the either with the results that they've got, either with the expense that they've they've paid out unnecessarily or otherwise. And so in most cases, any practice that has an effective way of dealing with the claims and complaints quickly and effectively immediately, as well as supporting and providing the kind of the patient support they need, they would never get to this point. Of course, there's always going to be some elements of that, but it it vastly reduces the opportunities for people to be unhappy. It's definitely an area that complaints and claims and by the very nature of the people you're treating is possibly uh it uh possibly doesn't exist. So, yes, you will want to deal with with complaints and claims very quickly and effectively. But yeah, if when it comes to class actions, you can just see the you can see the social media ads where you prescribed ADHD medication in the last 10 years. Exactly. You might have a claim for phone XYZ. And what so what in terms of uh your day-to-day experience of the type of issues that are coming through to you at the end of the phone, what are the what are the common ones in the area of mental health? Yeah, I mean we do I mean range insurance for a reasonable number of practices, and and to date we haven't had too much issue, but then we are we ask a lot of questions up front about their practice. So we're we're fairly confident that we we support what we would see as the decent practitioners. So as yet they they have not had uh they have not had problems. Uh but you can just see out there in the whole environment brewing, as you mentioned previously, it's it's the idea that there is well, it's not even clear, and again, it's even still my understanding debated as to whether overall there is over prescription of ADHD medication or not. Um, and that in itself, I think, is is actually I mean, it depends how deep you want to go. There's a huge societal question on whether ADHD is even a problem to start with. So, do you want to give ADHD medication to people? It maybe makes them more fit a standardized view of society. Uh, but do they want to fit that standardized view? Uh as a complete inside and probably get completely off topic. But I did think was absolutely brilliant, an absolutely brilliant portrayal of the issues of dealing with neurodiversity is there's a Netflix series called The Playlist, which is about how Spotify was built. And there's six episodes, and each episode is basically the same story, the Spotify story, but from the perspective of a different person. And the fifth episode is about a guy called Martin Laurensen, who is basically the investor. So he Daniel Eck was the founder, and he'd already sold one business to Lawrenceon. And Laurenson said, The next thing you do, I'm gonna back. And the next idea he had was Spotify. So he backed it, and he ended up putting all the money he'd made from the first business into it, and then even running out of money and getting other investors and bank debt, and so on. Spotify wasn't profitable until 2024, which blows my mind. But that's uh completely aside. But he is a highly neurodiverse person, Laurenson. So his episode actually starts with him in school, and he's just jumping between the desks, completely out there, touting away, telling a story, jumping between the desks, and then it switches to him and his first company, which is one of the first targeted ad companies, and it's him in his office jumping between the desks, telling the story and all the staff sharing. And there's a man in the corner in a grey suit looking very disapproving. And then the next scene is him and his business partner in a meeting with the stock exchange, and there's a man in the grey suit. They're trying to list the company. So there's a man in the grey suit saying, Oh, we only list serious companies, and this isn't a serious company. And Lawrence's business partner has to say, Well, Martin has special skills, and as best he goes and deals with his special things and tacks him off out of the room while he calms this guy down and says, Yes, yeah, we are a serious company and we can list and so on. And then which is terrible for Lawrence, because he was clearly a massive driving force in his first business, and all his businesses. I mean, his his approach and his neurodiversity of what comes across and all this is is absolutely central to building these massive companies. And uh so then and Spotify, he uh he becomes chairman of Spotify, and the last scene of the episode is when Spotify goes to list, and Daniel Eck has to go and have a very awkward conversation with him about well, we want to list it now, and actually we need you to step down as chairman, which again is utterly heartbreaking. And he takes it again, it's all maybe made for the show, but he takes it enormously well. But to me, it just it's a brilliant portrayal of that balance between the neurodiversity, which brings all this amazing insight and difference and so on, that that builds these businesses, but yet it is completely unacceptable to the man in the grey suit who's there to list the company. Yeah, yeah. So they because it unlike other areas of uh of healthcare that we've talked about, where you've talked, for example, functional medicine, we see a real returning to it's like a certain like that cycle, isn't it, of like non-medication and then begin very medicalized and then going back to it as well. There is no pattern for this. There is no pattern, and so it's almost as though the public discussion and thinking about it is happening as the diagnosis happens, as everything happens. Because everything I think in mental health is crisis to crisis, isn't it? There's a there's an ADHD crisis, then there's a not enough psychiatrist to diagnose ADH crisis, and then now there's a over-diagnosis, it's all playing out in real time. And so I imagine that firstly massively heightens the the risks for anyone operating in those areas. It is an opportunity as well, of course, but it also massively increases the risks, but it also it's it it it also means that things can change very quickly if if if if public policy on it changes quickly and public discourse changes on it very quickly, as for exactly those reasons. What you're finally settling on, do we actually want to treat it in this way, or do we want to build better systems, build better jobs, create spaces where that neurodiversity doesn't have to be uh medicated, for example. Yeah, no, absolutely, Jodie, and uh and I think you're right, and and and and possibly one or of your risk mitigations is to keep up to date with public and policy perception. Because are you over-medicating how do you measure that? You kind of can't. So the view on whether or not you're being over-medicated or whether or not there's over-medication will depend on the view of whether ADHD requires medication or not, and that that's a public perception. But say but say something like that comes out, say something like uh there all of a sudden there are there's an increasing body of not necessarily even evidence, but uh discourse around is there is there over medication? Would one way of showing that you are keeping in touch with that would be to a review of all the cases you've got, a review of who you currently got on medication to see whether they're you see whether all of those things are in the in the same way that you would with other policies as as potential public policy changes. Yeah, no, I I would agree, but all that is if you if you're a big busy practice reviewing all your cases for the uh it would be quite the task. So so maybe it's more a case of it comes down to that repeat prescription question, doesn't it? You should actually be assessing each case uh on the current thinking environment, no doubt, as you renew each prescription, which there isn't a resource there to do, to be blunt, but that is is technically probably what should be happening. Yeah, but yeah, because as it as it as a as controlled drugs, they can't be prescribed more than sort what 28 days at a time. Therefore, uh how likely is that review going to happen every every 28 days? It's not it's not, yeah. It's if we're realistic about it, but certainly people should be whatever the time frame is, three months, six months, they should be scheduling to say, I actually need to need to think about this case versus current thinking. Again, thinking in the environment developed very, very quickly. And so for anyone who is growing the mental health practice, what are the key pieces of advice you'd take away just to make sure that you are adhering to everything that needs to be adhered to and to prevent any of those potential class actions in the future if that ever emerges? It's the area where you really need to, I think, to be really clear as to what's in the patient's best interests, and probably an area where your fine your own financial interests and the patient's best interests are possibly most at odds. Because certainly a lot of mental health could even almost should be treated with uh without medication. Yeah. Uh and and diet, exercise, lifestyle, social prescribing, all these all these things are are are actually enormously powerful. Even again, I don't want to be critical because it's absolutely brilliant, but it's it doesn't it doesn't seem like a massive step forward. Though I don't know if you saw in the news the other day, there's the they've put the intensive care unit, there's is it a hospital in Cambridge, is it? I can't remember where it is, but they've they've built this roof garden for the intensive care unit where they can actually and amazing and they've built lifts and they can get all the intensive care beds up there, and they've got all the things where they can connect all the intensive care equipment, but they can actually get these people out of the ward, onto the roof, into the fresh air, into the sunshine, and they're now starting to monitor and track uh whether that speeds up the speeds up recovery and uh and all these things, which which is is highly likely. And and I'm I'm sure they'll get positive results from it, but it's it's what infirmaries were doing in at the turn of the century. Yeah, exactly. It's like it is it's not critical of them doing it, but it's just presented as this amazing new thing that they're doing, and it's like, no, no, we know that works. Maybe there's some interesting measurements to how much it works and what it can do, but and so on. So I think that's that's the thing that you really need to think about here, is really there is a whole range of options, and and medication is is one small part of that. And so is that medication necessary versus the other options and and what's really best for the patient. I think we have covered that in sufficient detail. Uh, I'm sure we're going to be coming back to the issue of mental health in various ways as we push on with the episodes of Confidence to Thrive. But in the meantime, thank you very much, Christopher, and I'll see you on the next episode. Thank you for listening to Confidence to Thrive. Before you go, please rate, review, and subscribe to Confidence to Thrive on your preferred podcast platform and help us spread our message to others who are making a difference in private healthcare. This podcast was brought to you by Our Litity, insurance advisors who support your business ambitions. Our literity advises practitioners, owners and entrepreneurs of healthcare practices on mitigating risks so your business can thrive. Learn more about how OurLitity can support you by finding the link in the show notes or visiting our litertity.co.uk