I'm pretty. Thanks very much for staying on after the end of all the compulsory stuff.
This is an optional extra, but we're delighted that you're here.
I'd like to introduce, though, Sean Evans, who did the.
When did you finish? When did I finish?
When I graduate. Well, that was another story.
You submitted 20 something. I'm 17, I guess five years ago.
And I had the pleasure of supervising and it so I would let.
So my life is quite about until. So, yes, I am sorry.
I'm a serving member of Her Majesty's well Navy.
I am back at the University of Oxford as a as an academic visitor.
I think it's the technical term, but there is a there's the Guy Hudson Memorial Trust.
He sponsored to several naval officers to come to Oxford on time to be members of the academic community and do research on a service related topic.
This isn't it. So this is the research that I conducted on a while.
I was kind of signing your chest in the massive evidence base.
Hellcats vividly remember this module because that's where we came up with this idea because I didn't have it beforehand.
So yeah, when I wrote them and I didn't have the idea by the Friday,
we'd be so feisty right from the beginning we would work it out with more or less so this is what I was going to do.
So little. So what are we going to do?
I haven't got a clicker. I suppose I'm going to be so cool.
So I'm going to talk to you about where the research idea came from.
As you can probably hear, I did not arrive with a free design project.
Talk about what we did to answer the research question, the somewhat tortuous process that was gaining approval to do the study,
having had the good idea and what we what we found when we did the research, but then it was about what happens next.
So I am a consultant, psychiatrist or a medical doctor who specialises in mental health.
I was in my higher psychiatry training as a general adult psychiatrist when I started and started my masters.
And I had one child and I was working full time.
So I did my masters over three years alongside clinical work and shift work within the
NHS and then subsequently working specifically for the well maybe that was watching my,
my training and I've been in the Navy 20 years.
Yeah. So, so I mean technology.
So two big caveats.
This research has not been published or exposed to robust peer review, but it has been through a relatively robust process to become a dissertation.
To become a dissertation. One of the things that I here to do is actually write this study up for some kind of publication.
And while I'm over the next well, now that way, now it's March or the next nine months.
It was 12 months of everything I'm going to say.
These are the opinions of me, as in Charlotte Evans, not the Royal Navy or the UK Ministry of Defence, which I to be.
For example, the slides are not funded. So I.
As I said, I'm a practising Royal Navy psychiatrist.
I was actually doing clinical work until pretty much slightly overlapped with arriving here in January.
I'm also happened to be married and have two children, and we live in the town of Portsmouth.
So I've combined, you know, my clinical work in the NHS and the military along with the academic study back here again.
So. So the research I do essentially is what my patients needed and I didn't know.
And it came from two patients that had sat down with me independently of essentially these roughly tough military men had sat down,
sat down sort of in my consulting room, and it probably burst into tears.
And that's not something that is culturally acceptable, shall we say, in the world in which I work.
And essentially for both of these individuals, there were only two outcomes from having sat down in a room with me,
and this was before I could even introduce myself. So I try not to take it personally.
If they had a mental health problem, either I had a padded cell and I was going to be throwing them in it in the next 10 minutes.
You don't have a working community mental right?
Or that was the end of that career. That was it. The fact that they have just sat down in the room with me, was it.
Now, I cannot imagine to put myself in their shoes how bad things had to be for them
for those two outcomes to two to make it worthwhile coming sitting down with me,
you know, you've got to be pretty sick. You've got to be, you know, the amount that you struggle and the amount that the you know,
the impact it's having on you and those around you to do that, to brave those outcomes is pretty significant.
And the thing that I simply realised was that I had nothing to prove or disprove in terms of research,
in terms of evidence, that assumptions that those are the only two things that could happen.
Now, I've worked in military mental health for, you know, for a few years by this point.
And instinctively, I knew that they were wrong. You know, I knew that we got people better.
I knew that people's careers recovered.
And I knew that we had a big problem, that people that recovered got on with their careers and never spoke about it again.
We didn't have a we still don't really have some of the role models that we need within the armed forces who have been through that that,
you know, who have mental health problems, been through the treatment process. And they on their careers have come out the other side.
That is changing, unfortunately. It is not so much changing for officers.
It is changing for and particularly for senior NCOs and particularly interesting for those who've got deployment experience in.
It is, it is much more acceptable for people to get to whom have deployed to be able to
access mental health care because there is an automatic assumption that it is there.
Warriors deployments for this. The reason why they need to seek mental health care.
It is much more difficult, particularly those in the navy who probably didn't if they did go out to Iraq,
Afghanistan, political it's traditional role that they closing in killing the enemy type role.
See, that's for healthcare. So what did we do?
Yes, I remember. And I remember very I had quite clear mind having decided that this was the research question I wanted to answer.
What did happen to the careers of serving UK armed forces personnel after a period of mental health treatment?
So after they had been, that person sat in the chair with a mental health professional.
What happened to their career next? Okay.
That's why that's what I wanted to find out. That's what my patients needed to know.
Okay. So they could make that decision. Was it worth it? No, because I from my point of view, from my own experience,
those assumptions that it was either a padded cell or, you know, different employment weren't right,
that I didn't have the reason that I didn't have anything other than what I then came to know was called connected to a good start.
So are you going to start somewhere? Unexpected is fine to start off with.
So I knew that there was a, a national database of clinical records for military mental health patients, which could be accessed nationally.
And so we already had the information recorded about what happened to these patients.
We already was already you know, there wasn't necessarily new data.
The question is, how did we legally and ethically access that?
Right. And how do we do that in a meaningful way so that we could get something close to the answer that was looking out for the patients?
So we came up with a closed cohort study so close because once you were in, you were in, and if you were out, you were coming in later.
Okay. It was retrospectively incepted.
So we looked back and the how far we looked back kept changing because the amount of time it took to go through the approvals.
Okay, so we set a period of time and what we looked at is the all of the people who
were assessed in three outpatient departments of community mental health,
a military outpatient department of community mental health over a six month period to everyone who was assessed.
The reason why we chose three different departments was because we've got three single services.
So one obvious point of a navy,
although all three of them see people from all three services say so the countries kind of carved up a geographical basis.
But we know that, you know, most of the Navy were in the vicinity of Portsmouth.
You know, if you were in the vicinity of Bristol, it's probably more relaxed.
And then if it's somewhere near Salisbury Plain will be not only okay, but,
you know, each of those three places will see people from all three services.
So it was wrapped respectively incepted we weren't doing prospective recruits
and we weren't starting at zero and then going right from this point onwards.
We went back to a time that a point that already happened had included the patients then from that point.
Sarah, that it already happens, but it was prospectively analysed.
So we imagined that we had gone back in time and were looking at these patients and progress from the beginning, moving forwards.
And as I say, no one extra came in, no one came out, although there were some people that went out back and again, if that makes sense.
So they were assessed more than once over the time of the study.
Not many, but you'll see that later.
And it was multicentre and actually the initial study design wasn't intending to get a nationally representative sample.
We wanted kind of a reasonable sample, but me being a singleton researcher, doing it on top of a clinical job,
we looked we had to be slightly pragmatic about what was actually going to be capable within the time, within the resources available.
But actually what we ended up with was nationally representative on basic demographics.
We ended up sampling 10% of military mental health patients who were assessed in 2011.
So pre-existing clinical records, three military departments of community mental health over six months,
and we generated an anonymized research dataset from the electronic notes, but the scrutiny was done by clinicians within the departments.
So these were people with a legitimate relationship with the care that had been given.
It went outside researchers. They weren't anyone, anyone different.
And in fact, we went backwards and forwards and forwards and backwards and to the university and to the everyday and somewhere else, I'm sure.
And the Institute of Medicine and Background Round again, the Ministry of Defence,
I hope quite rightly have learned some lessons from doing slightly cavalier research on the people within the UK armed forces and have very,
very stringent rules about any research that is conducted on serving military personnel, both in terms of what is conducted,
who does it, how it's consented, etc., etc. They therefore have three criteria of any studies.
One is research, okay, which is hypothesis testing, hypothesis generating and publishable.
That's the kind of highest level. It's the highest standard. It's the highest level of scrutiny.
The next level from that is service evaluation.
Okay. So is looking at what is already being done, is it any good?
And then the level below that is an audit accepted national standards and just a simple does it measure up or not?
Does it matter or not?
Now, what we were looking to do fell absolutely beautifully on the dividing line between service evaluation and ethics and research.
Beautifully on the dividing line. Okay. Which is why we went back to school with same with that was round around the back and the
university were very clear that this was service evaluation that had already been given.
There was no interference with interference with the patient.
The records already existed. This didn't need full university ethical approval.
Myself as a military clinician had a legitimate relationship with the record to generate an anonymized dataset,
which is what the research would be conducted on. The body wanted more reassurance than that.
They wanted to know that they had a full legal and ethical framework.
Because individual patient consent wasn't being sought.
Now, that ultimately feels a bit kind of, you know, sort of is a bit of a jolt, isn't it?
How many people's records of inspiration? I think, you know, 79. Who is doing what is being done?
There are a number of factors that went into that decision. Okay.
One of them was one of the things we wanted to do was include people who would like the other day.
Would you like the. I moved the. Everybody don't know where you got it.
Okay. So getting consent from these patients becomes essentially impossible unless you want to go by financial records.
Seriously, the only people that people that know when they leave the military, if they want to be friends, that would be.
That's that, you know, and that was to seriously skew the research.
If we weren't able to look at the records of people who had left the military for whatever reason,
that was going to seriously skew what we were looking at.
The other one was there was potential harm from going and getting individual patient consent.
Potential harm from doing that. We're talking about mental health care.
But it finished some time. I'd finish sometimes.
Previously it was ongoing. And so you got, you know, so there were risks of a skewed sample.
There were risks of actually causing distress, causing harm by going back to ask for it, to ask for individual patient permission.
And the only people accessing the record were clinicians who had a legitimate reason to access patient care records
within their own departments to look at to look at the care that was being given within their departments to some extent.
The only thing that I as a researcher got was an anonymous dataset.
It was completely untraceable. Back to the record. There was no way I could link what I was given as a researcher back to any patient records.
Even if I recognised, you know, even if as a patient, I looked after my record,
I couldn't couldn't have done it completely in a completely anonymized.
So that was one of the reasons why.
And we had a particularly I don't know what adjective is actually about our experience of physically going to the A.G. Research Ethics Committee.
And we had to go through, I think, the Ministry of Magic, and this is probably the best description and this is a little bit nerve wracking anyway.
Having to get the Gershwin alert to the Ministry of Defence was absolutely terrifying
in like all going through the airlocks to get into the boat like so literally like,
you know, the Harry Potter kind of entrance over at the Ministry of Magic and they go through the
five places we would go in three by looks that was very similar to that in this great big,
great big room. And then once we got there, we would when we got into the committee room, big, very shiny table,
all of the ethics committee at one end was at the exact other end this long table for away literally like a little clue.
And I think unfortunately they weren't terribly supportive when we first sat there were though basically, which was slightly,
as I think we've been through a considerable process with the Royal Navy's
scientific advisory committee to even to be able to get to the Ethics Committee.
So lots of scrutiny of the methodology, lots of scrutiny of the ethical considerations.
And this this kind of again, this borderline of of research versus versus service motivation.
And and we'd always been told, you know, if you get through all of that and this had taken a considerable period of time,
get through all of that, you'll be fine. And Ethics Committee. And they literally sat down.
What we're not sure what legal basis you have to do this that was that became
literally the opening thing we just said sorry for you to fill in saying that.
But actually the conversation that unfolds is and actually it was really
interesting and the different people around the table had different takes on it.
And their parting shot was, we think this is really important. We really want to make sure this happens.
It's like you could have started with I know you're not finished with that.
So so actually we took away we took away their concerns, which were mainly about the generation of the dataset.
And rather than myself as a military clinician creating the dataset myself, we use clinicians within each of the individual care teams.
So although we work as a national defence mental health service, they wanted to make sure that that, you know,
it was robustly being, you know, the notes of being scrutinised firmly within the care teams when the care had been delivered.
And so my, my Singleton research project, it wasn't going to bother anyone, it wasn't going to take too long.
That was all, you know, within my experience. Grew arms and legs and mushroomed I think is probably the best one yet again.
So these were the outcome measures that we came down to.
There's a bit of jargon there, but basically it was either you were fully fit to go do your military job, pretty much fit to go do your military job.
So what we call medical limited deploy ability or not fit to go and do your military job.
Right. And we looked at that two years after assessment.
We looked at that five years after assessment. And we also looked at it when you were discharged from care.
And that sentence in itself was a massive lesson in the precision of language,
because discharge was also discharged from the armed forces, as well as discharge from that period of mental health treatment.
Sometimes the Venn diagram overlaps and sometimes it didn't.
So we really had to realise that you lose people along the way to be there, like, well, when was the discharge from your ex?
What was that discharge from? The armed forces were discharged.
Discharged from Cath, discharged from the armed forces because we just took that discharge and switched it on, which won't work best.
So what is it.
That metric, demographic and treatment factors and we use univariate logistic regression as to their association with each of the outcomes.
We had those three outcomes which was the medical capital medical deployed by the team as shown by the medical category that they were in an.
All members of the UK armed forces are in a medical category at all times of the times.
Okay, so that's nice and nice and clear.
There wasn't anyone who we're not sure what category they're in there.
In the last one they were given until someone changes it. That's it, basically.
And then we did univariate logistic regression as the association with the outcomes.
And then we also looked at discharge factors.
So we also then look backwards.
If someone had been discharged from care, we then looked back at what the point was at which they had been discharged from.
All right. So we're looking at it this way. And then in the group that we knew had been discharged from the armed forces,
we were then looking back at the timeline that that had happened and what makes sense,
because we might have missed it if it was between the two and five years point as to exactly what time.
Describing it where we found things were significantly associated with the outcomes that we were looking at.
We then did. Statistics.
But only on those things which we had already found for me for that.
And univariate logistic regression. And we knew that there was something there that was something that that was worth looking more closely with.
And what the multivariate analysis basically means is that you chase down,
is it just the demographic or the treatment factor you're looking at that's making that difference?
Or is it that actually everyone who has medication is that they had seen a doctor?
So if you're looking at whether seeing a doctor impacts, whether you're discharged,
you know, is associated with your body and having medication is associated,
you know, actually the two of the same thing isn't the medication that's that's linked to you not being the services it to you is on its own.
And it's not using a doctor that's linked.
It's associated with you leaving the armed forces at two years because you can't do without without the other.
Does that make sense? I would kind of just checking that.
What we were looking at was the thing that was was the core was that it wasn't cause was associated.
Or was it something else that happened as well at the same time? Does that make sense?
Because it simply took me a long time to get my head around.
So yeah, and we did that using SPSS, which is the software which was most familiar with for the type of research that was being.
So I can't say there would be fancy sort of decisions around that.
That was what was available on the research laptop that we had available to us.
And what I should also say is the study that was done at this point was done jointly with King's College London,
the Academic Department of Defence Mental Health, and he still.
So the approvals process, which I've already spoken, spoken about, if I knew that, I mean, I had no concept this was going to be quite so involved.
It has to be said, this seemed like a really simple idea and, you know, really patient focussed, aimed within my area of expertise.
So the university process was actually really straightforward, really clear guidance,
really clear guidelines and loads of support available within the within the department as to how to do it,
what was required, what, what, what was needed. Loads of experience.
The Mod involved as we've said. I think actually was ultimately helpful.
I can't say I felt that all the way through and I think a particular low point was having to calculate
the sample size by hand because they didn't trust the electronic online calculator or any of them.
Even though I said, Well, I've checked it for it.
I think we've put it through like five in the end, just in case someone was using a different calculation and they were like,
No, we want to see it, we want to see it works through my ordinary A-level maths is now coming in, coming out in full.
That is not typical. That is not a typical experience at all.
But I have to say one of the things that did come out of it was a [INAUDIBLE] of a network.
Basically, the number of people that had to have contact with, the number of people that had to.
Then I had said, you know, my elevator pitch for this research was homes only because of a number of people.
I had to do a really quick explanation of so that I could get the very precise, you know, agreement and yes no out of them.
And so that, you know, yeah, the soft skills definitely helped enormously with it with the Ethics Committee process.
Definitely. And it did it did take longer than I thought.
But the trouble is, at the beginning I didn't think I'd need it. So that's a difficult thing.
It was a difficult thing to predict, to be honest with you. I am.
I had the reason why I started matters in the first place was because I had a gaping hole.
That was where research was supposed to be in my CV. And as I was approaching the end of my psychiatry training,
this whole was getting more and more apparent and definitely needed something in it basically.
So I'd got no background, you know, as an undergraduate or in the early days, my technical career as a researcher at.
At all. So I think it's safe to say that the the Masters definitely feel the end.
And the fact that I'm back here again probably says something about that as well.
So for, you know, normal people that plan early, but also, you know, sort of expect the unexpected sometimes if it's just university stuff.
Actually, I, you know, like kind of a bit jealous. It's like, you know, can they not say that it needs to go through that?
But then, you know. So what do we actually find?
So. Tick.
Tick. This continues to haunt me. I spent hours, if not days, trying to get a out of this box.
It does like this. It just. It.
It doesn't exist when you go in anyway. So you become obsessed about things like this would be dissertation.
Like trying to get the page numbers on the on the on the right side.
They found it with the page numbers in the inside. And again, you know, things even, you know, this consumes your life.
So. So the data is the defence analysis and statistics agencies that they were the ones who did the speaking
of the electronics system to create the list of patients if you like but it wasn't a list of patients.
It was an it was a coded list of patient identifying numbers which only exist within the electronic recordkeeping system.
If you don't have access to the identity record system, the list means nothing to you at all.
Leave them both not going to you know, not going to know about it.
So these were two identified, the three departments for Community Mental Health, so that these match were all shopped, Brize Norton and Portsmouth.
And they were two ways at the beginning of the period of research, which is again another complication.
And the departments were asked to send in an Excel spreadsheet with the numbers of the patients that they'd seen at the beginning of the sort of time,
at the beginning of the six months. But by the end of the six months it was all done by electronic searching.
They were in a period of transition and that in itself we had to kind of paint.
I was like, what? You know, where the you know, where the why, the numbers look so different.
So we had to chase that down. 19 patients confinement or no idea where they were displayed on the site, how they how they ended up in here.
So they were probably typos within the Excel spreadsheet that was generated probably.
But we had absolutely no way of knowing what the number was on the system.
Nothing that we could do. Nothing we could do about that. So we ended up with 670 and there were 45 patients who didn't meet the inclusion criteria.
That was usually due to inputting error that a template had been completed about CAD had happened outside of the cohort inception period
or patients had been coded as having a fresh case that hadn't actually happened either because they didn't attend or it was interrupted.
Or there was some reason why that didn't happen, which left us with 572 patients who we knew definitely belonged within the cohort.
One data collection form was just not that one patient number,
just didn't have a data collection form, didn't arrive, don't think you got lost, just didn't exist.
And on 20 forms weren't complete, they filled in.
Nothing we can do, you know, nothing we can do about that, unfortunately.
They were unfortunately from two of the three sites, but there was again, because there was no information on them,
there's no way that we could tell whether this was skewing the data or whether they were specific or what have you.
And because by this point, I was very much relying on the goodwill of colleagues, there was no way that I was going to be able to go back.
Would you point out that you can't take all boxes but you months going back?
So we ended up with 543 patients on which to base the study, the basis of the the research on.
So what did we find? So I do have the numbers for this, but there is a painful little sliver of missing.
Very, very painful for me as a researcher, a little sliver of missing data.
But so at two years after assessment,
basically the easiest way of looking at it this is to work is to work your way round to bearing in mind that my patients assumed
that their career was disappearing so back home that they were destined for essentially what it was leaving the padded cell.
But, you know, so medical limited deploy ability, a medical full deploy ability.
So this white [INAUDIBLE] isn't actually white. Okay? This is the full deploy abilities.
These people who were who at two years after they were sexed were fully fit to do their job.
And this and this coat was it. They were doing the job. They just might be some limitations on what to do.
Now, that might be, for example, if they're in the Navy, their ship can't go they can't go on a ship that goes to say,
but they can be on a ship that's alongside in the UK, for example.
Or it might be that they can't do shift work. Okay.
But what we don't know is whether that medical lack of deploy ability was actually due to their mental health.
It could have been to sunk due to something else. It could have been a twisted ankle.
It could have been a broken arm. Okay. Okay.
And then in addition to that, we've got those people who are medically non deployable and then we've got these people who have left the armed forces,
but not through medical discharge. They've gone because they've applied to leave.
And then we've got this war which has left the services on medical grounds.
So if we're looking for this for, you know, if the purpose of this research is looking at stigma and that.
Right. That's it. You know, the end of my career.
Well, you would expect if they were correct, that's the non deployable and the medically discharged would have been the majority of this growth.
Right. And they're certainly not have got the numbers.
But to be honest, giving them the numbers as meaningful as that is the big what is essentially on that on the graph.
Okay. So we are certainly not saying, you know, setting clinical instinct, the kind of data that two years obsolete supported it.
Now we can go on and probably talk for a long time about what?
About this lack of services. Non-medical. Right.
Was that really non-medical? Was there something else going on?
And, you know, that that so that could have been the most of that would have been people who just let, you know, some responders left.
Some may have failed drugs tests. Some may have been thrown out on disciplinary grounds.
But that is never a huge number of people in the armed forces effort every year and is probably in the region of the list of them.
And if we look at the whole armed forces. So in five years.
So the left, the services, non-medical is looked even, is even bigger now.
One of the big flaws of this is we don't know what you what the so-called natural wastage would you would expect in,
you know, what's the turnover, if you like,
the personnel, how many how many of these people would you expect to have left the armed forces and having an assessment individual to help,
you know, kind of his thinking. Okay.
But you can see that that the wedge of full deploy ability and limited deploy ability, it's time to go five years after assessment.
But actually, these two still aren't looking massive. Right.
People have left the game. They've not left because they've been medically discharged or or they're not hanging around,
not able to do they're not able to do their job, said she.
Under threat of this potentially, depending on what they, you know, what their skills, their expertise and think, you know, what they're doing.
But this one, which is the point of discharge from care, I'd bear in mind again, this graph includes known mental health reasons.
It is not mental health reasons, but this is at the point that we discharged them.
Okay. This is the point at which they were discharged from clinical care.
Something sorry, positive social and clinical care. So actually we've got full deploy ability, limited deploy ability.
You've got a better chance of being in one of those two categories than you have in. And that in itself challenges the stigma.
From the get go.
And this has actually been essentially the most useful the the, you know, the most satisfying, for want of a better word statistic that we found.
And we did also remember I said we looked at how long did that take?
So we looked at two years, minutes at five years. But that's a nice kind of, you know, individual lives.
How long did it take? And again, it pains me the fact that because it's up to 2000, the nought 200 bit, which is where it was,
I never found a way of getting the computer to do this because it's done within SPSS.
So but what you've basically got there is a very bad box and whisker plot.
Okay. Where you've got the median, the most common time between the assessments and discharge from care is 83 days for everybody.
If you're deployable at discharge, it's slightly shortening.
It's shortened at 71 days. And if you're not too horrible at discharge, it's slightly longer.
Okay. Maximum time in care was 1728 days.
We think that's probably an error, unfortunately,
but it is possible at the time that was possible since then and towards the end of the time that the cohort was was followed up.
There are now caps in the amount of time that patients are have care within military mental health services before discharge is considered.
That wasn't the case at the time. It was then heart stop, if you like, and it's still not too hard for us to hold the hospital now.
But there is more is greater scrutiny of people who need that level of care to continue that employment, which sounds really harsh,
but also both as an employer, but also in terms of the job that you want people to do and people needing long term mental health care.
That's not to say they don't need help. You know, they get better and then they need to.
Again, that's not what we're talking about. We're talking about long term mental health care, continuing need that support.
You have to question then whether their employment is why and whether they are best whether the individual is best served by continuing employment.
And so we did that another way and we did it as a survival function.
And basically what you see. So MFT is medically, fully deployable and instinctively this crap does look like vaguely what you think.
So basically if you're going to be medically fully deployable when you leave care, you're probably going to be in care for a short amount of time.
The graph here, which is your survival in treatment, as in the time you spent in treatment before you discharged, you going to leave?
You're going to need less care or at least a shorter length of treatment compared to those who have got a lot left,
who don't come out of treatment and just don't.
So discharged from here, I don't know how it works in the military,
but that you can be different for any number of reasons that you can just if you if you just never come back for like a therapeutic session,
you're discharged after like three phone call.
Like, you haven't come back. Yeah, you're discharged. Yeah.
I don't know. Is that the same in the military?
Like the discharge from care mean that therapeutic services were terminated because people had recurrently had like reduced symptoms and you are now.
Well. So the fact that some of them are discharged medically, non deployable tells you that, you know,
some people will still still have medical problems when they're discharged from care.
The military do not compel people into mental health treatment. They can't be ordered.
If it used to be, you could be ordered to attend your appointment,
but you couldn't be ordered to do anything other than say to the receptionist on here, okay, that used to be the case.
Once you done that, you reported to your place of duty and you know that you didn't.
But if you didn't do that, you could be disciplined for not turning up and going on here, that even that now is no longer the case.
You can't even be ordered to walk up to attend the appointment for mental health care.
Now you are only there because you won't care.
You have consented to care and you can withdraw that consent at any time.
And we do have patients who just go I believe justify it about this isn't relevant to me bubble on on off you
know staples house when there's like rubbish it's like nonsense or for people whose stigma levels are so high.
All right, like, you know what? I'm fine now. You know, they have their assessment.
You know, your wife's off my back. Yeah, because she's. Baby, come here.
I'm fine. Thank you very much. You know, and, you know, we cannot compel them into you know, we will not compel them into treatment.
But it doesn't get you a medically, fully deployable medical category,
because if we're concerned your mental health is impacting your ability to do your job,
we don't need your consent to restrict your duties,
to stop you potentially causing a harm to yourself, but also to the other people who depend on you.
We want to be that take it saying I'm fully deployable.
You've got a treadmill, you're it's not impossible, but you are unlikely to be given a clean bill of health by a non mental health professional.
If you haven't spoken to the mental health professional they referred you to, basically,
you know who's you know who they thought you probably needed the cat awful things and Carol
okay and I and and it's you know I certainly you know sometimes we just have some time.
It's very interesting because clinicians want to help patients.
You know, they like to know that there is someone who could benefit from their care who is choosing not to accept it.
And but sometimes that's the right thing to do because it's the wrong time for the patient, particularly when you've got conditions such as PTSD.
That avoidance is one of the cardinal symptoms of PTSD.
They will do anything to not have to go and confront the reason why they've got PTSD.
And it's part of the illness and so we have to recognise that,
but also as responsible employers and this working for an organisation as well and diversos ethically practising doctor as well.
You know, I have to do the best of my patient and sometimes the best of my patient isn't to agree that they can go back to the war zone.
You know, sometimes that isn't you know, that isn't the case.
And and then that's where the skill of my job comes in terms of reconciling patients expectations,
organisational expectations and the care, you know, and delivering care.
Because my duties of a doctor trump my military duties, basically, I report to the GMC first within the Navy.
And that is that's very clear that the Navy recommends. Um, so, um, so yes, that's just another way of looking at it.
Essentially. That was, it was a way to try and make that graph look a bit clearer, which I'm not sure it does, but that was it.
That was the effort. But what's also interesting, I think, is these two are pretty entwined, that it's very different.
You'd be very hard pressed to sort of look at two.
You know, the plateau doesn't look much isn't that much different than.
So any questions on the results?
Okay. Good. Not sure. I'll go. More states. Well, think about it.
So what came next? So for the research on this.
So having having done the research, it was it was presented internally within the military.
It was actually incorporated into non patient information materials about by seeking care but also around and destigmatizing mental health,
including the Navy and commanding officers guide for mental health.
So immediately, as soon as it was done, it hit the ground running.
It did what it was supposed to do, which is very gratifying, and particularly when you've been through such a convoluted research process.
To have it stock would have been quite painful.
To be brutally honest with you. This was done with patients in mind and have felt it wasn't there.
And I have to say that the Knowledge Interaction module was very,
very helpful in terms of being able to look at the engagement and to look at how
that research to be disseminated for the purpose that it was intended intended to.
And I still got an email from one of my one nursing colleagues who basically emailed me to say,
I just had a patient who saw the publication and is here because it changed their lives.
Which that's it. That's it. You're done then. You know, all those years of blood, sweat and tears then become, you know,
really do become become worth it, I think, you know, and it was it was a slog.
It was a slog.
I think the particular I think the particular low point was being given a direct order that I would not be finishing my masters on time.
I'd had a patient suicides. And I was like, I've got a dissertation in the queue.
And she was like, No, you need, you needs, you know, you've got other things to do.
You've got other things that you need to concentrate on. Give it, give it what we thought under the terms before.
So I've been processing and although we got an interim, they took it to make them go back anyway.
So it's kind of like I'd had a baby in that time.
Anyway, my, my attention had been gone even further away from my research.
But yeah, it certainly but for me, I, you know, I had no concept whatsoever when I was in the, you know, this, you know,
this module now and all those years ago, what I would be able to produce the difference that that in itself could potentially make for patients.
But also then sort of what came what came next for me. So I qualified as a consultant psychiatrist.
In February 20, 2017, I passed my Armed Forces consults written report in March, which I probably wouldn't have done without the researched it,
and I probably wouldn't have passed the board without the officers, you know,
that I could show that I'd produced and then had my son the following month.
Tick, tick, tick. So and then after after some maternity leave came back as a case of came back from maternity leave and into a military job.
And within six months, I was consultant adviser in psychiatry for the war.
So which was a bit of a shocker to everyone, including me.
I from that point. Okay.
We we've completely, completely changed, but we very much put deployed and mental health treatment on the front foot because we couldn't use,
you know, numbers like this to say to people, look, what you've you've got to you've got to think about what you think, what you think.
And you may or may not have seen the documentary on HMS Queen Elizabeth.
So I had a mental health team on board on this have been fortunate they took his life during that was not under the care but
that was mental health and team embedded embedded within that and within that deployment and and and able to look after that.
And the personnel out there. And that is something that, again, you know,
the skills that I learned the and I see both in the study design and the the teaching
evidence base health care until I did as well and the knowledge into action and augment
that we could then really as a navy mental health service set things up using very much
on the front foot so that we were getting mental health care where it was needed.
But we could do it from an evidence base which showed where,
where I was coming from and which has also then enabled me to come back here to Oxford again,
which never, ever thought I would never, ever thought I would do.
And I'm looking at two point to point mental health support and research in the maritime space.
I'm trying to get people actually here to clinical research on here to look at policy and strategy.
So this has enabled me to then build on that and to to hopefully go on certainly with my my psychiatric career.
As well. So it's been you know, as I say, looking back, I cannot believe where I am now from where I started.