As the NHS tries to move towards parity between physical and mental health, it faces major challenges in developing liaison services and to understand the costs and savings it creates in the wider care system. Lawrence Moulin reports
There is an increasing focus both on the physical health of people with mental health problems and the mental wellbeing of people with physical health issues. The Department of Health’s aim of “parity of esteem” between physical and mental health is clear in its mandate to NHS England and it seems likely to be strengthened by the refreshed mandate.
‘The prevalence of mental and physical health comorbidities is particularly high among patients in acute hospitals’
Not only is this philosophically and ethically the right direction, but financially there is evidence of high costs if we fail to treat the mental wellbeing of people with physical illnesses, as well as developing evidence about models of psychiatric liaison that meet the needs of these people.
Evidence of need and cost
People with long term physical health conditions, who account for around 70 per cent of all expenditure in the NHS, are two to three times more likely than the general population to experience mental health problems such as depression, anxiety or dementia.
The prevalence of mental and physical health comorbidities is particularly high among patients in acute hospitals, resulting from several factors that often interact with each other:
- pre-existing mental illness contributing to the development of physical illness;
- psychological reactions to physical illness;
- organic effects of physical illness on mental function, such as delirium;
- the effects of medically prescribed drugs on mental functions and behaviour;
- medically unexplained physical symptoms that mask underlying mental illness; and
- alcohol and drug misuse.
An analysis of likely costs to the NHS shows that comorbid mental health problems are associated with increases of 45-75 per cent in the costs of physical healthcare for long term conditions.
Further analysis suggests the overall cost for the NHS as a whole of comorbidities is in the range of £8bn-£13bn, of which around 40 per cent falls on the acute and general inpatient sector − a likely cost to the acute sector of about £4.2bn a year.
Service models to meet needs
Historically there have been ad hoc and usually unevaluated local models of psychiatric liaison services developed to meet these needs.
‘The national picture, with respect to the size, remit and focus of current liaison services across England, varies greatly’
One provider that has developed a robust and evaluated model is Birmingham and Solihull Mental Health Trust, through its rapid assessment, interface and discharge (RAID) programme, initially based in City Hospital Birmingham.
The evaluation of this work has been added to other evidence of the quality and cost benefits of effective liaison work in acute hospitals. This has come from other pioneering areas such as Exeter, Hull, Leeds and services developed specifically for older people such as the triage and rapid elderly assessment team (TREAT) in London. Models for delivering evidence based service response is becoming increasingly clear.
Using the RAID psychiatric liaison service model as an example:
- The service offers a comprehensive range of mental health specialties within one multidisciplinary team, so all patients over 16 can be assessed, treated, signposted or referred appropriately, regardless of age, address, presenting complaint, time of presentation or severity.
- The service operates 24/7; it emphasises rapid response, with a target time of one hour within which to assess referred patients who present to the accident and emergency department, and 24 hours for seeing referred patients on the wards.
- The RAID model aims to meet the mental health needs of all adult patients in the hospital, including those who self-harm, have substance misuse issues or have mental health difficulties commonly associated with old age, including dementia.
- The service provides formal teaching and informal training on mental health difficulties to acute staff throughout the hospital.
- The service puts an emphasis on diversion and discharge from A&E and on the facilitation of early but effective discharge from general admission wards.
Evidence from RAID
Over 80 per cent of patients who received services from RAID said they were satisfied or very satisfied, with a similar satisfaction level reported by other staff working in the acute hospital. The rating for training provided for acute staff was even better, with over 90 per cent of staff finding it very relevant and believing it would improve their practice.
‘Some of the liaison services are asking why they wait until vulnerable people with multiple problems are in the acute hospital before they can intervene’
The evidence shows admissions from the emergency department into hospital beds were reduced, the length of stay for people who received a service was reduced, and more older people were able to return to their homes.
An analysis by the Centre for Mental Health and the London School of Economics indicated a cost-to-benefit ratio of more than £4 for every £1 invested, and further analyses have shown £2.50 saved for every £1 invested.
Based on the evidence of improved quality and cost effectiveness, a rollout programme was initiated in the West Midlands. This consisted of the following key elements:
- Workshops for acute and mental health organisations across the region, in addition to a national conference run by Birmingham and Solihull Mental Health Trust. This allowed the rapid sharing of expertise and evidence.
- Support to analyse current demand in A&E; analyse current service costs; and ensure IT specifications for data needed to monitor the impact of a liaison service.
- Sharing model service and job specifications.
- Development and sharing an evaluation methodology and data format to support local services to analyse the effectiveness of new services as they are implemented.
- Facilitation and brokerage.
Acute providers in every primary care trust cluster across the West Midlands moved forward with local developments inspired by RAID and their own local work.
The national picture, with respect to the size, remit and focus of current liaison services across England, varies greatly.
For example, maximum cost savings may be realised by working with older people by reducing length of hospital stay. However, maximum health benefits throughout a person’s life might be realised by intervention with young people in A&E who have self-harmed.
There needs to be a strategic view of the desired high level outcomes and shape of liaison services to achieve these.
Moving into the community
Some of the liaison services are asking why they wait until vulnerable people with multiple problems are in the acute hospital before they can intervene. Trials of community liaison services are beginning, and interestingly, the developing models seem similar to some of the structures described in the proposals from the Future Hospital Commission.
There is a major challenge in developing liaison services to understand and navigate the costs and savings it creates for different parts of the NHS and the wider care system, and then structure these to incentivise the implementation of these services.
Early work on the RAID development showed that a significant part of the impact was through training and supporting acute staff in their work. This is essential and potentially a pre-eminent part of the role of such a service.
Lawrence Moulin is director of Lawrence Moulin Consulting and former lead for mental health and learning disabilities at the West Midlands Strategic Health Authority