As physical healthcare shifts from the hospital to the community, so liaison psychiatry should too. Lawrence Moulin and Michael Parsonage look at a service doing just that
Questions have been raised as to why liaison psychiatry is delayed until patients with comorbid physical and mental health conditions are admitted to hospital.
‘There are exciting innovations and developing models of community liaison services across England’
In HSJ last October we reviewed recent developments in liaison psychiatry in acute hospitals, including evidence on the health benefits for these patients and the scope for cost savings in the NHS.
Some people ask why we wait until these patients are in hospital before intervening. Supported by the focus in the revised mandate to increase support for people with multiple long term physical and mental health conditions, there are exciting innovations and developing models of community liaison services across England.
Modelling community liaison
The current concentration of liaison psychiatry services in acute hospitals is justified by the high prevalence of mental health problems in this setting and the very high costs of hospital care. Liaison psychiatry is the provision of psychiatric care to patients attending general hospitals. But the sub-specialty needs to reflect and reinforce wider trends in healthcare, particularly the growing impact of chronic, rather than acute, physical illness and an associated shift in the balance of care from hospital to the community.
The developing models of community liaison build on the integration of mental and physical health treatment, rather than simply providing mental health interventions on top of existing treatment programmes for the physical condition.
Major roles of liaison psychiatry in integrated community care include:
- Diagnosis and formulation, particularly for patients presenting with complex psychiatric morbidity.
- Case management of complex cases including the provision of high intensity psychological interventions.
- Supervision and support for other professionals including GPs and Improving Access to Psychological Therapies professionals.
- Training of all staff working in integrated care services.
- Development of educational materials for supported self-care by patients.
- A focus on the needs of people with long term conditions and of those with medically unexplained symptoms.
Impact on physical health
People with long term physical health conditions account for around 70 per cent of all expenditure in the NHS and are two to three times more likely to experience mental health problems such as depression, anxiety or dementia than the general population. In total, there are 4.6 million people in England with comorbid physical and mental health problems.
Mental health comorbidities also lead to much poorer physical health outcomes. For example, mortality rates for individuals with comorbid asthma and depression are twice as high as patients with just asthma; people with chronic heart failure are eight times more likely to die within 30 months if they also have depression; and the quality of life for those with comorbid mental and physical health problems is considerably worse than it is among people with two or more physical health problems.
Mental health comorbidities also result in substantially increased costs of physical health care, an estimated £10.5bn a year in aggregate. This is equivalent to nearly 10 per cent of the total NHS budget.
The health service spends on average an extra £2,300 a year on each patient with comorbid mental and physical health problems compared to one with just a physical condition, equal to an increase of about 60 per cent per case.
There are also costs to the wider economy, with one study finding that people with diabetes and depression are seven times more likely to take time off work than those with just diabetes.
Diabetes case study
The 3 Dimensions for Diabetes (3DFD) pilot programme, based in the inner London boroughs of Lambeth and Southwark, combines medical, psychological and social care (the three dimensions) to improve diabetes control and reduce complications in a diverse and growing diabetes population. It is fully integrated into local hospital and community based diabetes services and consists of a consultant liaison psychiatrist and two social support workers from Thames Reach, a local third sector social welfare organisation.
Many people with poor diabetes control have mental health problems, such as depression, or social problems, such as debt or housing insecurity, which interfere with their ability to self manage their physical health condition.
Often these patients either present frequently to accident and emergency with serious diabetes related problems, which may require inpatient treatment, or do not engage with services at all.
‘Many people with poor diabetes control have mental health or social problems’
To meet the multiple complex needs of such patients, 3DFD provides a “wraparound” service based on intensive case management, which combines physical health interventions such as medication support, biomedical monitoring and diabetes education; mental health interventions such as medication and brief psychological treatment; and social interventions such as debt management and occupational rehabilitation.
The service’s caseload is currently around 300 patients a year, with about 60 per cent of them from ethnic minority groups.
Results from an ongoing evaluation show significant improvements in outcomes across all three dimensions of care. In particular, the service has produced improvements in glycated haemoglobin and other biomedical variables that compare favourably with those from new antidiabetic medications and with the outcomes of local non-integrated services.
In turn these improvements in diabetes control have led to significant reductions in health service use, including a 45 per cent drop in accident and emergency attendances and 43 per cent of inpatient admissions.
In the area of mental health, the service has not only recorded improvements in measures of depression, anxiety and diabetes related distress, but has also brought to light a substantial number of previously undiagnosed psychiatric comorbidities within the 3DFD population.
Treating unexplained symptoms
Medically unexplained symptoms are a common and costly problem in all healthcare settings, accounting for at least 20 per cent of all new consultations with GPs and more than half of first outpatient attendances in specialties such as gastroenterology, neurology and gynaecology. A significant proportion of patients with unexplained symptoms become frequent users of primary and secondary care services.
The overall cost of medically unexplained symptoms to the NHS is estimated at around £3bn a year.
The Primary Care Psychotherapy Consultation Service (PCPCS) is an innovative outreach service provided by Tavistock and Portman Foundation Trust, which supports GPs across the London boroughs Hackney and City in the management of patients with unexplained symptoms and related complex needs that result in frequent health service use.
Many of these patients are often missed in existing service provision and are difficult to manage in primary care because of the complexity of their health conditions.
Support patients and staff
The service has two main functions. First, it supports GPs and practice staff in their management and treatment of patients through case discussions; joint consultations with GP and patient; and bespoke training. Second, it provides a direct clinical service for referred patients through assessments and a range of psychological interventions in a more focused and efficient manner (up to 16 sessions).
‘Patients with medically unexplained symptoms are often missed in existing service provision and are difficult to manage in primary care’
Every year the service receives around 600 referrals, treats more than 300 of those and costs just under £600,000. A typical course of treatment lasts 12-13 sessions at a cost of £1,350 per patient.
The results of a recent evaluation of the service by the Centre for Mental Health, in collaboration with PCPCS, will be published in March.
The service has had a positive impact on health outcomes and has led to some reduction in health service use in both primary and secondary care over a 12 month follow-up period. About three quarters of all patients treated by the service showed improvements in their mental health and well being, and over half showing signs of recovery.
There is also evidence of high levels of GP satisfaction with the service in terms of its responsiveness to local needs and operational requirements in primary care; the degree to which it complements rather than duplicates other services; its focus on difficult to engage patients and its impact on health outcomes; and service use including GP workload.
It is increasingly clear that there are robust service models for community psychiatric liaison services that can support people with mental and physical health problems, or with medically unexplained symptoms.
These models of care improve patients’ quality of life and reduce costs incurred by the NHS. The challenge now is the coherent and effective implementation of this work on a national scale.
Lawrence Moulin is former West Midlands Strategic Health Authority lead for mental health and learning Disabilities, and Michael Parsonage is senior policy adviser at the Centre for Mental Health and a visiting senior fellow at the Personal Social Services Research Unit