Michael Yousif explains the unprecedented steps Oxford University Hospitals took to address the challenge of integrating mental health and physical healthcare
In older patients especially, the presence of conditions such as depression, delirium and dementia can lead to increased care needs
Psychological medicine (traditionally known as liaison psychiatry) specialises in providing mental health care in acute hospitals. These services are seen by many as a key driver towards more integrated health services.
And they are consequently undergoing a boom across the health service. The NHS Confederation, royal colleges and the Centre for Mental Health have all set out the clinical and economic necessity to address patients’ mental health needs alongside their usual medical care.
‘There must be an organised and strategic integration within the hospital’s systems and practices in order to deliver genuinely holistic care’
There is substantial evidence showing the adverse effects of comorbid mental illness on the outcomes of people admitted into hospital. In older patients especially, the presence of conditions such as depression, delirium and dementia can lead to increased care needs, mortality, and longer and more frequent hospital admissions.
Conversely, there is less evidence to tell us the best way of addressing this need in hospitals.
Ad hoc services
Services in the UK have consequently mostly developed in an ad hoc manner, depending on local priority and funding opportunities. This has led to a wide variation in the make-up and function of services around the UK.
Psychological medicine services have been traditionally provided as outreach (hence the term “liaison” psychiatry) services from mental health trusts. This arrangement seems entirely logical given the expertise available. It does, however, have disadvantages. It can actually perpetuate the split between mental and physical healthcare; although linked, they remain organisationally separate.
Furthermore, each trust has its own policies, procedures and records system, which creates logistical and practical obstacles for any externally provided service to fully integrate into the hospital.
‘The emphasis on clinical leadership enables support and supervision of hospital staff in delivering mental health care’
A fundamental aim of psychological medicine is to closely integrate physical and mental healthcare. This cannot be achieved merely by being present in the hospital; rather, there must be an organised and strategic integration within the hospital’s systems and practices in order to deliver genuinely holistic care.
Like any clinical intervention, psychological medicine services themselves can cause “side-effects” in the acute hospital. If available in the hospital there is an inevitable risk that patients’ mental health needs are immediately franchised out to this service. Somewhat perversely, the psychological medicine service could thereby worsen patient care by deskilling hospital staff in mental healthcare and reinforce potentially stigmatising misunderstandings of mental illness.
This “side-effect” can be prevented if the psychological medicine service, alongside direct patient care, actively develops mental healthcare skills in hospital staff and leads a culture of holistic care.
An integrated approach
Oxford University Hospitals Trust has attempted one radical solution to the challenge of integrating mental and physical care. This acute trust has set up and funded its own psychological medicine service. It is one of the first acute trusts in England to do this.
Prior to 2013, Oxford University Hospitals, like many acute trusts in England, had a limited liaison psychiatry service focused on deliberate self-harm. Partly in response to the requests of its own physicians the trust took the unprecedented step of establishing a psychological medicine service, employing its own psychiatrists, for inpatient services.
A key benefit is greater scope to align the objectives and processes of the psychological medicine service with those of the acute trust.
‘The nature of mental disorders means that for any mental health service clinical outcomes are notoriously difficult to measure’
This arrangement also affords more opportunity to be incorporated into the training programs for clinical staff. With 1,800 beds, teaching and training is an essential strategy in delivering integrated care across the whole trust.
The trust took another unprecedented step by establishing a consultant psychiatrist delivered service. This symbolises a parity of esteem of psychological medicine alongside other medical and surgical specialities.
The emphasis on clinical leadership enables support and supervision of hospital staff in delivering mental health care. This extends the range of patients who can be managed by the service while simultaneously developing staff skills in mental healthcare.
This occurs alongside the provision of a higher volume of direct, rapid, senior psychiatric opinions. The service has been in place for less than a year. So far it has been successful as judged by physician feedback and additional investment for service expansion.
Challenges and future developments
While offering a great deal of promise, this fully joined up approach to providing mental healthcare to an acute hospital is not a panacea to all the challenges of integrating mental health into “usual” medical care.
The issue of defining and measuring outcomes remains a challenge, and is a national conversation taking place within the speciality.
‘The challenge of integrating mental and physical health care reflects the one being faced in a range of settings and specialties’
The nature of mental disorders means that for any mental health service clinical outcomes are notoriously difficult to measure; what should be measured, when and how differs between clinicians, patients and commissioners.
The challenge is further complicated in acute hospitals, where the brevity of most admissions precludes achieving clinical change in enduring mental health conditions. Services, usually community based, downstream to psychological medicine services provide most of a patient’s mental health care.
The role of psychological medicine is often therefore necessarily restricted to identification of need and signposting to appropriate services. It is far from obvious how to measure a service’s effectiveness at identifying need and facilitating the patient journey.
Fill in the gaps
In breaking old boundaries this new model creates new ones. In traditional liaison psychiatry, transfers of care to mainstream mental health services occur within the same organisation.
In the new model, formal protocols and policies are needed to ensure effective transfer of care across the organisational boundaries between acute and mental health trusts.
At the non-clinical level, governance of mental health processes (such as mental health legislation) and mental health staff performance (including continuing professional development) is new territory for acute hospital trusts that do not have experience providing this type of oversight.
The challenge of integrating mental and physical health care in many ways reflects the one being faced in a range of settings and specialties.
Integrating care between multiple providers under any qualified provider will necessitate innovations and partnerships to ensure care feels joined up to service users and which minimises risks of miscommunication and service gaps.
Dr Michael Yousif is consultant psychiatrist at the psychological medicine service, Oxford University Hospitals Trust. The psychological medicine service was developed by the trust’s management with advice from Professor Michael Sharpe of Oxford University.