Published: 01/04/2004, Volume II4, No. 5899 Page 30 31
Liaison psychiatry offers valuable support to general hospital patients but even the most developed service in England falls behind national recommendations. Carol Lewis reports
Tucked away up a narrow winding stairway at Leeds General Infirmary is the liaison psychiatry department. Small and obscure, patients and hospital staff are often unaware of its existence.
Liaison psychiatry is a relatively new discipline and does not, despite the best efforts of its advocates, have as high a profile as it could or should. It is concerned with the psychological and psychiatric care of general hospital patients - a person with diabetes and an eating disorder, the cancer sufferer with depression, or the hip fracture patient with dementia.
These patients might not tick enough boxes to be officially diagnosed with a psychiatric condition by a general psychiatrist, but they could still have problems that affect treatment of their medical condition.
Hospital patients with untreated psychological problems have been shown to take longer to recover and to have more complications than other patients.
Yet for most district general hospitals, liaison psychiatry means a specialist nurse in accident and emergency dealing with cases of deliberate self-harm and little else. In Leeds, the existence of a 'department' is something of a breakthrough.
Leeds' liaison psychiatry services cover two large hospital sites, Leeds General Infirmary and St James University Hospital, plus four smaller hospitals within the largest healthcare trust in the country. It also takes referrals from elsewhere in the country.
The service includes: A&E mental health and selfharm teams; an eight-bed inpatient ward for complex cases; group treatment programmes for both inpatients and outpatients, covering topics such as pain and anxiety management; an in-reach service which includes assessments of patients referred to outpatients; and specialist services for patients with chronic fatigue, HIV, cancer and diabetes.
The service is multidisciplinary, with four full-time equivalent consultant psychiatrists, a number of mental health and clinical nurse specialists, occupational therapists and physiotherapists, a liaison psychiatry social worker and a service manager.
It is the longest-running and most developed service in England, yet it is still far from perfect and doesn't meet the Royal College of Psychiatrists and Royal College of Physicians' recommendations for a standard liaison psychiatry service.
1Dr Peter Trigwell, associate medical director for liaison psychiatry in Leeds, explains that historically such services develop around the specialist interests of consultants. In Leeds they have tried to move beyond that to identify the patients' needs, but in today's political climate this often means linking their work to national targets and priorities.
For instance, the service received funding for a fulltime specialist in psychosexual medicine after it linked the service to waiting times - the outcome of which was a fall in waiting times from 26 to 13 weeks.
Linking service development to national service frameworks - usually a sure-fire way for managers to secure funding - is thwarted by the absence of any mention of liaison psychiatry in the mental health NSF.
However, the NSFs for older people and diabetes and the NHS cancer plan do emphasise the need for medical patients to have access to psychiatric and psychological services. And Dr Trigwell is hopeful that liaison psychiatry will be specifically mentioned in the forthcoming NSF on chronic medical conditions.
The NSF target to which liaison psychiatry most obviously relates is suicide reduction and in Leeds alone there are 3,000 incidents of self-harm a year.
Dr Sue Pemberton, clinical services manager for liaison psychiatry in Leeds, explains that another major driver of change is the team's relationship with medical colleagues. Good working relationships mean that the push for services can come from the medical and surgical teams themselves. Even if it is the liaison psychiatrist who identified the need, good relationships can make the difference between a service being funded or rejected.
Service development is hindered because the Leeds service is, as is usual for liaison psychiatry teams, employed by the mental health trust but providing services to the acute trust.
The Royal College of Physicians' and Royal College of Psychiatrists' report The Psychological Care of Medical Patients makes 11 recommendations. The first and most important is that liaison psychiatry services should be established in all general hospitals. These services should be multidisciplinary and include nurses, clinical psychologists, social workers and trainee psychiatrists, led by a consultant psychiatrist with special training in liaison psychiatry.
However, a survey last year by Dr Rachel Ruddy, Leeds Mental Health Teaching trust practice research network co-ordinator, showed that out of by 36 general hospital trusts in the North East, three had no liaison psychiatry service.
Of those that did provide services, 41 per cent were staffed solely by nurses, just 38 per cent had dedicated consultant psychiatrist time and none employed a clinical psychologist.
2A similar survey in the South West showed that the North East is not atypical. Of the 18 general hospital trusts surveyed in the South, just five had a dedicated liaison psychiatry service and a further six had a service for deliberate self-harm only.
3Since conducting the survey, Dr Ruddy has carried out a series of focus groups about service development with people from trusts. The main drivers were found to be national targets and good local relationships between medical and psychiatric services. The main barriers were a lack of understanding about the service and funding issues arising from services falling between mental health and acute trusts.
Dr Ruddy says: 'I think that you have to be a bit of a wheeler-dealer in liaison psychiatry, approaching different departments and saying, 'We could provide you with this service, do you have the money?'
'There is a huge need for liaison psychiatry services.
Something like 40 per cent of general hospital patients have a psychiatric morbidity.' She points to a study which found that 55 per cent of patients admitted for hip fracture had a cognitive impairment (dementia or delirium), 13 per cent a depressive illness and 2 per cent an alcohol misuse problem. The research showed that patients spent an average of 10 days longer in hospital if they had a cognitive impairment or depression.
4Royal College of Psychiatrists liaison psychiatry section chair Dr Geoffrey Lloyd says: 'The lack of any explicit reference in the mental health NSF to liaison psychiatry was a great omission. It reflects the fact that the NSF was written by people whose view of psychiatry is essentially that of community mental health services.
'We need to improve our profile, continue to make the case for expansion of services and persuade health service managers that adequate funding should be provided, ' he says. 'There needs to be national agreement on how liaison psychiatry is to be funded.
My own view is that because liaison psychiatrists treat patients within acute hospitals, that is where the funding should come from.'
In Scotland, there are no trusts.What is more, the small size of the country has meant that liaison psychiatrists have been able to join and co-ordinate lobbying. Scottish liaison psychiatrists have met with the chief medical officer and written to the health secretary. As a result, in the Scottish health policy document Our Nation's Health, liaison psychiatry is highlighted as an area for development.
In Glasgow, this has been translated into recruitment of an entire service team en masse - four liaison psychiatrists and full nursing team - a situation virtually unheard of in liaison psychiatry where growth is usually very slowly built around one or two professionals.
However, Edinburgh University reader in psychological medicine Dr Michael Sharpe says: 'The key to service development now is to mobilise patient pressure groups. A vast proportion of the hospital services budget is being used by people who do not have a medical disease. This is an ineffective use of resources and adds to the waiting lists. Liaison psychiatry will not necessarily save money but it would lead to more appropriate use of funds, ' he says.
But ultimately, Dr Sharpe would like to see all hospital staff trained to care for patients' psychological needs, with a small liaison psychiatry team on hand to act as consultants - giving advice, supervision and caring for the most complex cases. This is being put into practice with oncology nurses at Edinburgh's Western General Hospital. The nurses have been trained to deliver care for depression in cancer patients under the supervision of Dr Sharpe.He now wants to expand this approach to primary care to try to reduce the number of patients with medically unexplained problems being referred around the secondary care system.
'Liaison psychiatry is in a transitional phase as we work towards a more psychologically sophisticated health service, ' he says.
To contribute articles to HSJ's clinical management section, please e-mail ann. dix@emap. com
Benefit match: who needs liaison psychiatry?
General hospital patients who could benefit from liaison psychiatry include those who:
have a physical illness and co-existent psychiatric disorder;
have medically unexplained physical symptoms;
attend hospital after deliberate self-harm;
have a physical illness and associated psychological or emotional problems;
suffer from alcohol or drug misuse problems;
have behavioural problems such as repeated non-adherence to treatment.
1 Royal College of Physicians and Royal College of Psychiatrists.Psychological care of medical patients: A practical guide. (Council report CR108).2003 www. rcplondon. ac. uk
2 Ruddy R, House A. A standard liaison psychiatry service structure?A study of the liaison psychiatry services within six strategic health authorities.Psychiatr Bull; 27:457-450.2003 www. rcpsych. ac. uk
3 Howe A, Hendry J, Potokar J.A survey of liaison psychiatry services in the south-west.
Psychiatr Bull; 27:90-92.2003 www. rcpsych. ac. uk
4 Holmes J, House A.Psychiatric illness predicts poor outcome after surgery for hip fracture: a prospective cohort study.Psychol Med; 30 (4):921-929.2000 titles. cambridge. org/journals
Liaison psychiatry offers valuable support to general hospital patients, but remains an underdeveloped service.
Although there is no mention of liaison psychiatry in the mental health national service framework, other NSFs emphasise the need for medical patients to have access to such services.
Barriers to development are the lack of understanding of the service and funding issues arising from services falling between mental health and acute trusts.