In light of the incident of a patient with schizophrenia killing two fellow patients, Michael Sharpe asks for greater integration between mental and physical healthcare
We have recently heard in HSJ about a tragic incident which took place at St James’s University Hospital in Leeds in 2015. It has been reported that a patient with a previous diagnosis of paranoid schizophrenia beat two fellow patients to death, that medical staff had stopped his antipsychotic medication and that ward staff had had little training in mental healthcare.
This is a truly shocking and tragic occurrence for all concerned. However, it represents only the tip of a much larger iceberg of unmet psychiatric need amongst general hospital patients. And, whilst violence associated with psychosis is thankfully rare, inadequately managed distress, depression, delirium and dementia are not.
The very division of illnesses into mental and physical categories is scientifically questionable
The reality is that our healthcare system is predicated on a false assumption. That is, the belief that there are two populations of patients: the mentally ill and the physically ill.
As any general hospital clinician knows, in reality the overlap is huge and indeed as neuroscientists will tell you the very division of illnesses into mental and physical categories is scientifically questionable.
However, we are so invested in this assumption of separate populations of the mentally and the physically ill, that we have created separate organisations (trusts) for each. This was surely a mistake.
A partial solution to the consequences of that false assumption is for the work of acute trusts to be assisted by linking (liaison) psychiatric teams that outreach from mental health trusts into the acute trust wards and clinics. They do an important job and NHS England’s recent investment in them is to be welcomed. But we have to ask are they really a solution or are they merely a sticking plaster?
What we need to accept is that so called “mental healthcare” is bread and butter work for acute trusts; as many as half of the people who depend on their services require it in some form
For any organisation, outsourcing services may make sense for especially complex and rare problems. But it makes no sense at all to outsource its bread and butter work. And what we need to accept is that so called “mental healthcare” is bread and butter work for acute trusts; as many as half of the people who depend on their services require it in some form.
The only sensible solution for any organisation faced with such a challenge is to develop and deliver its own robust “in house” capability that can address the problem in a way that is fully integrated with its other activities and at the scale it requires.
The ultimate solution may appear to require a complete reconfiguration of health services, a potentially desirable but daunting task. However, more practical and immediate solutions are available.
We can build on liaison psychiatry services to fully integrate mental health staff and expertise into the acute trust. A working example can be seen in Oxford University Hospitals Foundation Trust. This large acute trust directly employs psychiatrists and psychologists within its medical services.
These staff are not visitors from a separate trust, they are fully part of the acute trust and members of the medical teams. Rather than a separation of medical and psychiatric services the trust has, thereby, developed “super competent” medical teams that are both effective and efficient in addressing the full breadth of their patients’ needs – both physical and mental. That is, these teams are capable of delivering truly patient centred care.
We can build on liaison psychiatry services to fully integrate mental health staff and expertise into the acute trust
This solution to the mistaken separation of physical and mental care may not be perfect, but it works. Patient care is improved, staff stress is reduced and the stigma associated with mental illness is diminished. Most importantly the organisational culture moves from seeing its mission as treating only the “physical” part of the patient’s problem, to treating the patient entirely.
We will have to await the published report to learn more about what actually happened in Leeds. However, whatever the precise findings, the challenge now facing all acute trusts is not only how to prevent recurrences of this awful tragedy, but also to adequately address the much larger and hidden part of the iceberg of mental health need in their patients.
This means that that we need to move from liaison (and Leeds has a very good liaison psychiatry service) toward fuller integration of mental and physical healthcare. Such integration will not only provide more much needed psychiatry expertise on medical teams but will also be a key part of upskilling the doctors and nurses who work in acute trusts to be both competent and confident in addressing both the physical and the mental care of their patients.