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Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service
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General Hospital Psychiatry 33 (2011) 260 – 266
Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service Luke C. Solomons, M.R.C.Psych.a,⁎,1 , Ajoy Thachil, M.R.C.Psych.b , Caroline Burgess, B.Sc., Ph.D.c , Adrian Hopper, M.D., F.R.C.P.d , Vicky Glen-Day, R.M.N.a , Gopinath Ranjith, M.R.C.Psych.a , Andrew Hodgkiss, F.R.C.Psych.a a South London and Maudsley NHS Foundation Trust, London, UK Institute of Psychiatry, King's College London and Division of Mental Health Sciences, St. George's, University of London, UK c Kings College London, London, UK d Guys and St. Thomas' NHS Foundation Trust, London, UK Received 28 November 2010; accepted 15 February 2011
b
Abstract Aims: To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures. Methods: Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis. Results: Twenty-five referrers were interviewed. Four key themes were identified — benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management. Conclusions: Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services. © 2011 Elsevier Inc. All rights reserved. Keywords: General hospitals; Liaison psychiatry; Mental health; Outcome measures; Quality of health care
1. Introduction Mental illness is common in medical inpatients — prevalence rates are estimated to be around 40% with major clinical and economic implications [1]. In the UK, the Academy of Medical Royal Colleges (AOMRC) Report Managing urgent mental health needs in the acute trust and the joint report of the Royal Colleges of Physicians and Psychiatrists [2,3] call for the development of mental health services in general hospitals that meet the same standard of
⁎ Corresponding author. Tel.: +44 1635 292063; fax: +44 1635 292072. E-mail address: [email protected] (L.C. Solomons). 1 Current address: Berkshire Healthcare NHS Foundation Trust, Beechcroft, Hillcroft House, Rooke's Way, Thatcham RG18 3HR, UK. 0163-8343/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.02.003
urgent assessment, diagnosis and intervention as expected for physical health care. In spite of such exhortations by respected medical bodies, the provision of consultation–liaison psychiatry services, usually referred to as liaison psychiatry services, is variable in the UK [4,5]. This may be because there is little evidence of the specific views of frontline clinicians who utilize such liaison psychiatry services. There is some evidence demonstrating positive referrer perceptions in the UK from nurses in emergency settings and doctors surveyed by post [6–8]. Research data from the early 80s in the USA have demonstrated that doctors who refer to inpatient liaison services consider them crucial for positive outcomes [9,10]. Studies have examined the cost effectiveness of consultation–liaison services, but the authors argue that a focus on morbidity and mortality tends to overlook the global care
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extended to patients, their families and the medical staff in the context of consultation–liaison interventions [11,12]. Physical and mental health care is provided by different organizations called acute and mental health trusts, respectively, in England. Given this situation, the AOMRC report recommends that liaison psychiatry services be commissioned explicitly and asks if they should be commissioned by acute trusts, especially in the face of decreasing prioritization by mental health trusts [13]. There are difficulties in proving the utility of such services under the payment frameworks used by general hospitals. The absence of performance indicators against which activity and results can be benchmarked has hampered service development. Though some accident and emergency liaison (A&E) services were expanded to meet centrally mandated 4-h waiting time targets, there is concern that services for medical inpatients have been neglected [14,15]. This study is part of a broader project to develop evidence-based benchmarks for liaison psychiatry services. The aims of the study were: 1. To explore how a liaison psychiatry service to acute medical wards was perceived. 2. To identify good practice and areas for improvement. 3. To generate relevant performance indicators. 2. Methods 2.1. Setting The inpatient liaison psychiatry service we studied is broadly similar to services elsewhere in the UK and delivers multidisciplinary psychiatric care to working age adult patients within a 600-bedded acute care hospital in inner London. The team has one whole time equivalent (WTE) consultant psychiatrist, 0.6 WTE senior trainee doctor, 1.5 WTE junior trainee doctors, 1 WTE psychiatric liaison nurse (PLN) and 1 WTE alcohol nurse specialist attached to the team. The team sees approximately 350 new referrals a year and functions from 9 to 5, Monday to Friday. The acute admissions wards have a high turnover of patients (average duration of stay, 72 h). Majority of referrals to the inpatient liaison psychiatry service are from the senior clinicians on these acute wards — this study focussed on them. 2.2. Data collection The authors met to develop a shared understanding of the theoretical framework underpinning their work, i.e., ideas considered “common knowledge” within the medical and psychiatric services that were seldom systematically recorded and converted into usable data to inform good clinical practice. Views from the AOMRC report were identified to serve as an a priori skeletal framework [16]. An initial topic guide to inform interview probes was generated by a literature review and through a group consultation involving nurses, consultants and junior doctors from acute medicine and
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liaison psychiatry. Interview items addressed issues about expectations, satisfaction and areas for improvement. Having a neutral observer can reduce bias in qualitative research, but equally, an in-depth knowledge about the topic being investigated can be beneficial to the qualitative researcher [17]. L.S. and A.T., who conducted the interviews, informed all interviewees that they had left the team, having worked within the liaison team as psychiatry trainees 2 years prior to the commencement of the study. The likely impact of this on the interviewees' responses was considered early in the study. The interviewer's working knowledge of the hospital may have helped participants to speak more technically and raise local issues to help gain an insider or “emic” perspective. We also considered the possibility that the interviewees would have held back critical comments because of the background of the interviewers but felt that this potential problem was mitigated by the seniority of the interviewees relative to the interviewers. 2.3. Participants Two groups were sampled — senior nursing staff and medical consultants. All the consultants on the “acute take” rota and senior nurses on the four admissions wards were listed. The participants were then purposively selected by maximum variation sampling [18]. The sampling frame was designed to reflect a range of experience — from 3 months to 19 years. Data on referrers' perceptions were collected and analyzed between 2007 and 2009. Data collection was by face-to-face, individual, semistructured interviews. Participants were encouraged to clarify their answers and illustrate them with personal experiences. Interviews ranged from 30 min to 1 h. The interviews were conducted in cycles of five each. All interviews were recorded and transcribed verbatim. L.S., A.T., A.H. and G.R. met at regular intervals to review issues raised by participants that were fed iteratively into subsequent cycles of interviews until no new themes were found. 2.4. Analysis Following the criteria for qualitative research in health settings proposed by Green and Thorogood [19], the research was checked for transparency, validity, reliability, reflexivity and comparability. We used the framework method of qualitative analysis proposed by Ritchie and Spencer [20]. Analysis included familiarization with the content of the interview transcripts; developing a thematic framework; applying the framework to the data by coding sections of text according to each subtheme and summarizing themes and subthemes into charts for analysis and interpretation. Techniques used to ensure procedural clarity and systematic approaches to analysis included independent transcription, standardized coding and analysis of the data. Three transcripts were read and evaluated by an independent researcher (C.B.) to assess whether selected data were
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representative of the themes. The inclusion of direct quotes allows the reader to read the raw data and the author's interpretations contributing to rigor. Preliminary results were presented in four academic and professional forums, where feedback was obtained and used to confirm the validity of findings. Drafts of our results were presented to four of the participants for respondent validation. Ethical clearance for this research was obtained from the South London and Maudsley NHS Trust Research Governance Committee. Confidentiality and anonymity in the process of data collection and analysis and reporting of findings were ensured.
3. Results Fourteen senior nurses and eleven medical consultants were interviewed (two consultants declined, stating they were too busy). Four key themes (Table 1) were identified from the data, each of which contained multiple subthemes. 3.1. Liaison psychiatry makes an essential contribution to acute care 3.1.1. “Psychiatry is different from Medicine” Most consultants and nurses managed some common mental health problems like depression or delirium. However, they found management of severe mental illness challenging. Consultant 018, 6 years experience: “(mental illness) … that's a significant burden and I just don't have the skills to do that. Liaison psychiatry is more important than cardiology because (as a respiratory physician) I can muddle through cardiology, but I cannot muddle through psychiatry.…”
As a result of the split between acute and mental health services, referrers perceived psychiatric services as significantly different from other general hospital specialist services and difficult to access. The liaison psychiatry service was seen as a bridge. Consultant 022, 5 years experience: “… it seems to me that psychiatric services … are somewhat impenetrable unless you're a psychiatrist. There are many different units and there isn't a clear connection or cohesion between them.…”
Detaining mentally unwell against their will and the Mental Health Act 1983 assessments were felt to be outside the remit and expertise of medical services, and liaison psychiatry support in using it is indispensable. All consultants, however, were confident of using the legal Table 1 Key themes 1. 2. 3. 4.
Liaison psychiatry makes an essential contribution to acute care Where the service could improve Speed, nature and quality of response as indices of service performance Substance misuse services are important and need to be expanded
framework and making judgments on capacity and the Mental Capacity Act except in complex cases. Some nurses felt unsure about the detention of patients wanting to discharge themselves against medical advice, and wanted a clear “yes or no” answer from the liaison team about whether the patient was detainable (“sectionable” in British medical parlance). Nurse 002, 14 years experience: “You want a judgement … I find it unhelpful when a patient is assessed, not sectionable, but not allowed to leave the ward … it's not clear what to do if they are not on a section.”
3.1.2. “Liaison Psychiatry is a skill” Almost all referrers recognized the liaison psychiatry team as general hospital colleagues who were well versed in the running of the acute hospital. Referrers clearly delineated their skills as different from those possessed by generic mental health teams. Consultant 020, 5 years experience: “An acute hospital requires a particular liaison skill, and that means a working knowledge of what happens in acute hospitals.”
To the majority of referrers, the fact that the liaison team was on-site offered reassurance that they were readily accessible. Consultant 028, 6 years experience: “I think they have to be geographically close enough to be available should a patient need to be seen urgently … and also that they be seen as working within the trust, rather than a separate organization.”
3.1.3. “This is a complex patient group” Referrers recognized that mentally unwell inpatients were an especially complex group and caring for them was very demanding. They could be disruptive and increase tension on busy admission wards. Also, the busy ward environment exacerbated patient's distress. They acknowledged the input they received around patients with medically unexplained symptoms in particular, who were a significant drain on time and resources. Nurse 030, 7 years experience: “... having a patient with severe mental illness on a medical ward is very stressful (for staff) … you also feel sorry for patients — this isn't the right environment.”
3.1.4. “Valuable training resource” Referrers recognized that the liaison team possessed a set of skills that they lacked and could be invaluable in increasing their knowledge and management skills. Nurse 030, 7 years experience: “It would be good to have more education input, because we do frequently have patients that are very challenging … a bit more about risk assessments.…”
3.1.5. “Staff definitely benefit, and we think patients do too …” The consultants and nurses unanimously agreed that the liaison psychiatry service benefited patients, staff and service delivery on the acute medical wards. This perception was
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well developed and concordant across groups. Liaison interventions were felt to offer comprehensive plans of management rather than hasty discharge. The response of the team to referrals classed as “routine”, i.e., anxiety and depression, was felt to be comprehensive. However, pressures to decrease length of stay meant that, increasingly, such patients were being discharged without liaison psychiatry input and general practitioners were asked to follow up their mental health problems. Respondents linked this to the speed of response of the liaison team. Consultant 020, 5 years experience: “Liaison psychiatry underpins our ability to deliver medicine properly to a complex patient group.” Nurse 024, 14 years experience: “… (the liaison team) see patients and unlike some disciplines in medicine in hospitals at the moment, it does appear that the patient is in front of the agenda … there certainly isn't the desire to discharge, discharge, discharge if there are still issues outstanding.” Consultant 016, 11 years experience: “We get clear advice around routine mental health issues … the tension with us is that this is a high volume and bed utilisation service … but if the psychiatrist said keep the patient in for mental health reasons, and physical needs are stable, I would keep them in.”
3.2. Where the service could improve 3.2.1. Service delivery in psychiatric emergencies needs to improve Referrers across the sample felt that the service response was wanting in “psychiatric emergencies.” Consultant 018, 6 years experience: “... the problems I've always found are with the acutely disturbed patient on take, out of hours; I think that is where the problems are.…”
It emerged that most consultants had not had on-the-spot experience of emergencies with distressed or agitated patients for many years. This contrasted sharply with the nurses, many of whom recounted incidents from the previous weeks. They expected immediate telephone advice on medicating and detaining agitated patients and assessment within minutes. Nurse 032, 7 months experience: “... immediate advice over the telephone … regarding drugs and sedation and any sort of types of restraint … but we'd also want them to be quickly physically present on the ward.”
Four nurses were particularly frustrated about being asked for medical causes to be ruled out prior to psychiatric intervention. They saw themselves as trapped between the medical and psychiatric teams who visited the wards to review agitated patients without directly communicating with each other or reaching a consensus on management. Nurse 004, 6 years experience: “We get caught in a grey area — is it psychiatric or medical? … they (the patients) are new from A&E and bloods need to come back.”
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3.2.2. Communication A majority of referrers felt that communication needed to improve. There was a clear difference between groups — nurses felt the best way was for the assessor to speak directly to the nurse looking after the patient. This enabled them to voice their concerns and act as advocates for the patients and link between the psychiatric and medical teams. Nurse 024, 14 years experience: “the difficulty I have is that I am never sure when they've been and when they haven't been … we expect some sort of verbal feedback about the patients. Liaison people say things like ‘EMBRACE’ is going to pick them up, and I was like who on earth is that, what are you talking about and they were like, oh it's a mental health team.”
Conversely, consultants viewed themselves as holding clinical responsibility and attached more importance to overall management and discharge planning. They preferred succinct written notes, with clear clinical impressions, risk assessments and stepped management plans. Consultant 001, 18 years experience: “it's sometimes slightly unhelpful to have four pages of assessment (with no valid opinion) … standard for the hospital needs to be same day assessment … opinion that is valid, generally registrar or above.”
3.3. Speed, nature and quality of response as indices of service performance 3.3.1. Response times and length of stay The average inpatient length of stay is seen as a key indicator of acute hospital performance. Consultants referred to reduction in length of stay achieved in 2007 [21,22]. All consultants thought that it was vital for the liaison psychiatry service to not only respond quicker, but also facilitate discharges by providing a timely senior opinion and community follow-up plan for patients deemed “medically clear.” Five consultants felt that urgent referrals needed to be assessed within minutes and compared acceptable response times to those for a cardiac arrest crash call. All wanted routine referrals seen within 24 h. Consultant 02, 12 years experience: “I think the targets for us in acute medicine are shortening of length of stay but I think one of the really critical issues for liaison psychiatry is whether it shortens or lengthens the length of stay … quite honestly a lot of the time it looks like when the liaison psychiatrists are involved, the discharge is delayed because the person then hangs around for a psychiatry bed or hangs around whilst we wait for the consultant ward round.”
3.3.2. Issues related to Registered Mental Health Nurses “Specialling” refers to the deployment of Registered Mental Health Nurses (RMNs) on medical wards to provide specialist mental health nursing skills to care for the patients at high risk of self-harm and violence. The clinical decision to deploy such nurses is taken by the liaison team. Referrers were concerned, as they had no control over RMN deployment despite bearing the costs. Some consultants
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asked for patients with “specials” to be reviewed daily by a senior clinician who could withdraw them if the patient no longer posed immediate risks. The majority of nurses perceived the quality of service provided by RMN “specials” as unsatisfactory, especially in crisis situations. Nurse 029, 9 years experience: “One of the major problems we have is RMN cover … lot of difficulties sometimes to try and get that in place, to decide whether it is appropriate … I do tend to wonder how qualified they are in dealing with some of these patients … they just seem to sit there.…”
3.3.3. Transfers from medical to psychiatric beds The progressive decrease in the number of psychiatric inpatient beds [23] has meant that patients needing transfer to psychiatric wards are held up. All referrers expressed strong concerns about the delay in transfers and the implications in terms of patient safety as well as costs. Nurse 031, 7 years experience: “It does consume a lot of our time and again it uses a lot of temporary staffing … there are safety issues, especially if they are suicidal … and sometimes by the time we actually get a psychiatric bed, the patient has settled!”
3.3.4. Where the buck stops All referrers expressed anxieties about where final clinical responsibility lay in clinical situations involving patients with mental health problems. The majority believed that a specialist registrar or consultant from the liaison service should take responsibility for risk assessment and discharge decisions in complex cases. Consultant 018, 6 years experience: “I'm not sure about the role of the psychiatric liaison nurse (PLN); you see if a PLN comes along and says no they're not sectionable or whatever, I don't know how much sort of weight it has; is that a formal opinion … if they go and murder somebody, who takes the hit? Am I responsible for them all?”
Table 2 Suggested measures of performance Response times 1. Response time: from call to assessment by junior doctor/PLN 2. Response time: from call to review by senior psychiatrist and management plan 3. Response time: from time of initial assessment to definitive clinical decision 4. Productivity of team members: number of patients assessed/ reviewed per day Follow-ups and readmissions 5. Lengths of stay of patients needing liaison psychiatry input 6. Time taken to transfer from medical to psychiatric beds 7. Number of community psychiatric reviews following discharge from medical wards (in response to referrals to community psychiatric teams made by the liaison service) 8. Medical readmission rates for patients presenting with deliberate self harm 9. Monitoring incident forms on acute wards for aggression related to mental illness and substance misuse Quality 10. Clarity of documentation 11. Patient satisfaction questionnaires 12. Referrer satisfaction questionnaires Training 13. Number of training sessions conducted and wards covered 14. Participation in junior doctor induction program
They felt that these would help quantify outcomes and performance. They have been consolidated in Table 2. 4. Discussion Exploring and codifying the views of referrers, who are important stakeholders in liaison psychiatry services, make our study novel. It describes referrer experience in qualitative terms and seeks to define “referrer needs” as key determinants to define activity, structure services and measure performance. 4.1. Implications for policy and practice
3.4. Substance misuse services are important and need to be expanded Substance misuse was not included in our initial topic guide, but it was repeatedly raised as an issue with significant overlap with mental health. Alcohol misuse is a major problem in the inner-city boroughs served by the hospital, and referrers felt that the service was not sufficient to meet demand. Patients with these issues were perceived as complex, demanding and expensive in terms of needs, time and costs. Consultant 016, 11 years experience: “He (substance misuse nurse) is hugely helpful as a single point of contact. There needs to be more integrated services with the community … as the patients are chaotic … We desperately need more alcohol dependence services … (we) need more visibility for him and information on the intranet.”
3.5. Measures of performance Across all areas of input, referrers offered suggestions to measure the performance of the liaison psychiatry service.
We have alluded to the variable provision of liaison psychiatry services in the UK, though this is not a uniquely British problem [4,5,24]. Models of funding have evolved differently from region to region for historical reasons, with little Department of Health guidance. An impediment to service development has been relatively weak clinical outcome and cost–benefit evidence. While there is sound evidence from randomized controlled trials for several psychological therapies in liaison work [25], there is less to support day-to-day psychiatric interventions on medical wards. Devising clinical outcomes that capture the heterogeneity of clinical practice in liaison psychiatry has proven difficult. The Health of the Nation Outcome Scales [26] is the most commonly used outcome measure in British psychiatric services, but is not suitable for detecting change in the short timescales of liaison work on medical wards [27]. Liaison contacts with patients are often brief (about 1–2 days), with some interventions being aimed at the referrer or referring institution rather than directly at the patient
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(e.g., managing risk, facilitating transfer to mental health services). Referrer views can thus be considered important performance indicators. The performance indicators for evaluating outcomes that we elicited are important and meaningful to acute medical services and could be used by health care commissioners. These have the potential as markers of activity and outcomes against which payment by results could be benchmarked. Since these referrer-generated measures were perceived as being important in quantifying outcomes against expectations, they have a measure of validity that merits testing in larger, multicenter studies using both qualitative and quantitative methods. The outcomes could potentially generate evidence-based activities, which can then be recompensed by appropriate tariffs. Requests from medical consultants for clear management plans devised by consultant liaison psychiatrists are in keeping with the recommendations of the AOMRC Report of an ideal service [2]. This and other arguments strongly support provision of a consultant-led, hospital-based service rather than an in-reach service provided by a community-based team. Respondents strongly linked substance misuse with mental health and repeatedly raised the need for expanded roles for substance misuse workers within liaison psychiatry. Referrers were unanimous in recognizing the liaison psychiatry team as general hospital colleagues who were an integral part of the acute service they provided. We hope clinical managers and commissioners will take note and move towards integrating liaison psychiatry into acute medical directorates and commission these services directly. 4.2. Differing perceptions between nurses and consultant physicians As nursing and medical staff play different roles in patient care and have differing interactions with the liaison team, we expected their perspectives to vary. But these were more divergent than expected. Understanding differing demands could help tailor a more responsive service for both groups of referrers [3]. This was based on four core interrelated themes: the degree of direct patient contact and involvement in on-thespot management, direct contact with the liaison service, the nature and degree of overall clinical responsibility and the nature of their relationships with patients. Table 3 summarizes the defining features of referrers belonging to the two professional groups. 4.3. Limitations and strengths We intentionally interviewed senior clinicians, which means our findings do not reflect the views of trainee medical staff “on the shop floor.” Our inability to elicit contrasting views on the value of liaison psychiatry may reflect the views of clinicians with interests in maintaining the status quo. As mentioned earlier, despite efforts to stress
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Table 3 Defining features of referrers belonging to the two professional groups Senior nurses
Medical consultants
1. “On the frontline”: with patients for long periods; act as patient advocates but also exposed to abuse, violence and psychiatric emergencies 2. Demand liaison psychiatry input “here and now”: advice on sedation; help to detain patients leaving wards 3. Prefer an on-the-spot verbal handover and advice once patient is assessed 4. Generally do not make direct referrals; have to get a junior doctor from the medical team to make referral 5. Responsible for managing evolving patient presentations on-the-spot 6. Engage directly with nurse members of the liaison team, which they find easier
1. Review patients for brief periods; have little direct exposure to psychiatric emergencies
2. Demand at least Specialist Registrar level diagnoses and plans for overall management and discharge planning 3. Prefer succinct written clinical impressions, risk assessments and plans 4. Instruct junior doctors to make referrals
5. Have overall clinical responsibility 6. Wary of clinical opinions/risk assessments by nurse members of the liaison team
to all interviewees that the interviewers were neutral observers, the fact that the interviewers had been associated with the team in the past could have influenced responses and introduced a response bias. Another potential limitation is the lack of generalization as this was a study of clinicians in a single London teaching hospital. In spite of this, we believe that the themes identified are generic enough to be applicable to most general hospitals with an established liaison psychiatry service. Although our findings will be considered common knowledge by clinicians, it is important to have the evidence recorded for wider policy decisionmaking and as a foundation for future research. Some referrer demands would be difficult to implement within current resources. Immediate “crash call” responses to psychiatric emergencies 24 h a day, consultant management plans within 24 h and more training for medical and nursing staff support the Report's recommendations, but would require increased resources. For such demands to be met, both acute medical and liaison psychiatry services need to move towards an integrated model, where both are subject to the same quality standards in terms of access to care and speed and nature of response. This would be helped if acute trusts were commissioned to provide liaison psychiatry services. Some suggested outcome measures, such as shorter transfer times from medical to psychiatric beds, lie beyond the control of liaison services and reflect the overall reduction in psychiatric bed numbers nationally.
5. Conclusions In summary, the views of staff working on acute medical wards support policymakers' recommendations concerning
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liaison psychiatry service provision. Establishing a national funding mechanism, possibly by payment by results, for such services and working towards integrated services will greatly improve patient care. Regulatory bodies such as the Care Quality Commission could also assist in even development of liaison services by making the provision of an accredited and integrated liaison service a criterion by which all acute hospital trusts are measured. The Royal College of Psychiatrists Research Unit, through the Psychiatric Liaison Accreditation Network, has laid down benchmarks for accreditation — a step in this direction [28]. Acknowledgments We are grateful to Michelle Fitzpatrick from the Liaison Psychiatry Service and to Julia Munford and Karen Brown for help with editing. References [1] Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, MunkJorgensen P. Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. J Psychosom Res 2001;50:199–204. [2] Academy of Medical Royal Colleges. Managing urgent mental health needs in the acute trust: a guide by practitioners, for managers and commissioners in England and Wales. London: Academy of Medical Royal Colleges; 2008. [3] Royal College of Physicians and Royal College of Psychiatrists. The psychological care of medical patients: a practical guide. 2nd edition (Council Report CR108). London: Royal College of Physicians & Royal College of Psychiatrists; 2003. [4] Ruddy R, House A. A standard liaison psychiatry service structure? A study of the liaison psychiatry services within six strategic health authorities. Psychiatr Bull R Coll Psychiatr 2003;27:457–60. [5] Sakhuja D, Bisson JI. Liaison psychiatry services in Wales. Psychiatr Bull R Coll Psychiatr 2008;32:134–6. [6] Eales S, Callaghan P, Johnson B. Service users and other stakeholders' evaluation of a liaison mental health service in an accident and emergency department and a general hospital setting. J Psychiatr Ment Health Nurs 2006;13(1):70–7. [7] Mayou R, Smith EBO. Hospital doctors' management of psychological problems. Br J Psychiatry 1986;148:194–7. [8] Morgan JF, Killoughery M. Hospital doctors’ management of psychological problems: Mayou and Smith revisited. Br J Psychiatry 2003;182:153–7. [9] Cohen-Cole SA, Friedman CP. Attitudes of non-psychiatric physicians towards psychiatric consultation. Hosp Community Psychiatry 1982;33(12):1002–5.
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Quality of psychiatric care in the general hospital: referrer perceptions of an inpatient liaison psychiatry service Luke C. Solomons, M.R.C.Psych.a,⁎,1 , Ajoy Thachil, M.R.C.Psych.b , Caroline Burgess, B.Sc., Ph.D.c , Adrian Hopper, M.D., F.R.C.P.d , Vicky Glen-Day, R.M.N.a , Gopinath Ranjith, M.R.C.Psych.a , Andrew Hodgkiss, F.R.C.Psych.a a South London and Maudsley NHS Foundation Trust, London, UK Institute of Psychiatry, King's College London and Division of Mental Health Sciences, St. George's, University of London, UK c Kings College London, London, UK d Guys and St. Thomas' NHS Foundation Trust, London, UK Received 28 November 2010; accepted 15 February 2011
b
Abstract Aims: To explore the experience of senior staff on acute medical wards using an established inpatient liaison psychiatry service and obtain their views on clinically relevant performance measures. Methods: Semistructured face-to-face interviews with consultants and senior nurses were taped, transcribed and analyzed manually using the framework method of analysis. Results: Twenty-five referrers were interviewed. Four key themes were identified — benefits of the liaison service, potential areas of improvement, indices of service performance such as speed and quality of response and expanded substance misuse service. Respondents felt the liaison service benefited patients, staff and service delivery in the general hospital. Medical consultants wanted stepped management plans devised by consultant liaison psychiatrists. Senior nurses, who perceived themselves as frontline crisis managers, valued on-the-spot input on patient management. Conclusions: Consultants and senior nurses differed in their expectations of liaison psychiatry. Referrers valued speed of response and regarded time from referral to definitive management plan as a key performance indicator for benchmarking services. © 2011 Elsevier Inc. All rights reserved. Keywords: General hospitals; Liaison psychiatry; Mental health; Outcome measures; Quality of health care
1. Introduction Mental illness is common in medical inpatients — prevalence rates are estimated to be around 40% with major clinical and economic implications [1]. In the UK, the Academy of Medical Royal Colleges (AOMRC) Report Managing urgent mental health needs in the acute trust and the joint report of the Royal Colleges of Physicians and Psychiatrists [2,3] call for the development of mental health services in general hospitals that meet the same standard of
⁎ Corresponding author. Tel.: +44 1635 292063; fax: +44 1635 292072. E-mail address: [email protected] (L.C. Solomons). 1 Current address: Berkshire Healthcare NHS Foundation Trust, Beechcroft, Hillcroft House, Rooke's Way, Thatcham RG18 3HR, UK. 0163-8343/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2011.02.003
urgent assessment, diagnosis and intervention as expected for physical health care. In spite of such exhortations by respected medical bodies, the provision of consultation–liaison psychiatry services, usually referred to as liaison psychiatry services, is variable in the UK [4,5]. This may be because there is little evidence of the specific views of frontline clinicians who utilize such liaison psychiatry services. There is some evidence demonstrating positive referrer perceptions in the UK from nurses in emergency settings and doctors surveyed by post [6–8]. Research data from the early 80s in the USA have demonstrated that doctors who refer to inpatient liaison services consider them crucial for positive outcomes [9,10]. Studies have examined the cost effectiveness of consultation–liaison services, but the authors argue that a focus on morbidity and mortality tends to overlook the global care
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extended to patients, their families and the medical staff in the context of consultation–liaison interventions [11,12]. Physical and mental health care is provided by different organizations called acute and mental health trusts, respectively, in England. Given this situation, the AOMRC report recommends that liaison psychiatry services be commissioned explicitly and asks if they should be commissioned by acute trusts, especially in the face of decreasing prioritization by mental health trusts [13]. There are difficulties in proving the utility of such services under the payment frameworks used by general hospitals. The absence of performance indicators against which activity and results can be benchmarked has hampered service development. Though some accident and emergency liaison (A&E) services were expanded to meet centrally mandated 4-h waiting time targets, there is concern that services for medical inpatients have been neglected [14,15]. This study is part of a broader project to develop evidence-based benchmarks for liaison psychiatry services. The aims of the study were: 1. To explore how a liaison psychiatry service to acute medical wards was perceived. 2. To identify good practice and areas for improvement. 3. To generate relevant performance indicators. 2. Methods 2.1. Setting The inpatient liaison psychiatry service we studied is broadly similar to services elsewhere in the UK and delivers multidisciplinary psychiatric care to working age adult patients within a 600-bedded acute care hospital in inner London. The team has one whole time equivalent (WTE) consultant psychiatrist, 0.6 WTE senior trainee doctor, 1.5 WTE junior trainee doctors, 1 WTE psychiatric liaison nurse (PLN) and 1 WTE alcohol nurse specialist attached to the team. The team sees approximately 350 new referrals a year and functions from 9 to 5, Monday to Friday. The acute admissions wards have a high turnover of patients (average duration of stay, 72 h). Majority of referrals to the inpatient liaison psychiatry service are from the senior clinicians on these acute wards — this study focussed on them. 2.2. Data collection The authors met to develop a shared understanding of the theoretical framework underpinning their work, i.e., ideas considered “common knowledge” within the medical and psychiatric services that were seldom systematically recorded and converted into usable data to inform good clinical practice. Views from the AOMRC report were identified to serve as an a priori skeletal framework [16]. An initial topic guide to inform interview probes was generated by a literature review and through a group consultation involving nurses, consultants and junior doctors from acute medicine and
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liaison psychiatry. Interview items addressed issues about expectations, satisfaction and areas for improvement. Having a neutral observer can reduce bias in qualitative research, but equally, an in-depth knowledge about the topic being investigated can be beneficial to the qualitative researcher [17]. L.S. and A.T., who conducted the interviews, informed all interviewees that they had left the team, having worked within the liaison team as psychiatry trainees 2 years prior to the commencement of the study. The likely impact of this on the interviewees' responses was considered early in the study. The interviewer's working knowledge of the hospital may have helped participants to speak more technically and raise local issues to help gain an insider or “emic” perspective. We also considered the possibility that the interviewees would have held back critical comments because of the background of the interviewers but felt that this potential problem was mitigated by the seniority of the interviewees relative to the interviewers. 2.3. Participants Two groups were sampled — senior nursing staff and medical consultants. All the consultants on the “acute take” rota and senior nurses on the four admissions wards were listed. The participants were then purposively selected by maximum variation sampling [18]. The sampling frame was designed to reflect a range of experience — from 3 months to 19 years. Data on referrers' perceptions were collected and analyzed between 2007 and 2009. Data collection was by face-to-face, individual, semistructured interviews. Participants were encouraged to clarify their answers and illustrate them with personal experiences. Interviews ranged from 30 min to 1 h. The interviews were conducted in cycles of five each. All interviews were recorded and transcribed verbatim. L.S., A.T., A.H. and G.R. met at regular intervals to review issues raised by participants that were fed iteratively into subsequent cycles of interviews until no new themes were found. 2.4. Analysis Following the criteria for qualitative research in health settings proposed by Green and Thorogood [19], the research was checked for transparency, validity, reliability, reflexivity and comparability. We used the framework method of qualitative analysis proposed by Ritchie and Spencer [20]. Analysis included familiarization with the content of the interview transcripts; developing a thematic framework; applying the framework to the data by coding sections of text according to each subtheme and summarizing themes and subthemes into charts for analysis and interpretation. Techniques used to ensure procedural clarity and systematic approaches to analysis included independent transcription, standardized coding and analysis of the data. Three transcripts were read and evaluated by an independent researcher (C.B.) to assess whether selected data were
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representative of the themes. The inclusion of direct quotes allows the reader to read the raw data and the author's interpretations contributing to rigor. Preliminary results were presented in four academic and professional forums, where feedback was obtained and used to confirm the validity of findings. Drafts of our results were presented to four of the participants for respondent validation. Ethical clearance for this research was obtained from the South London and Maudsley NHS Trust Research Governance Committee. Confidentiality and anonymity in the process of data collection and analysis and reporting of findings were ensured.
3. Results Fourteen senior nurses and eleven medical consultants were interviewed (two consultants declined, stating they were too busy). Four key themes (Table 1) were identified from the data, each of which contained multiple subthemes. 3.1. Liaison psychiatry makes an essential contribution to acute care 3.1.1. “Psychiatry is different from Medicine” Most consultants and nurses managed some common mental health problems like depression or delirium. However, they found management of severe mental illness challenging. Consultant 018, 6 years experience: “(mental illness) … that's a significant burden and I just don't have the skills to do that. Liaison psychiatry is more important than cardiology because (as a respiratory physician) I can muddle through cardiology, but I cannot muddle through psychiatry.…”
As a result of the split between acute and mental health services, referrers perceived psychiatric services as significantly different from other general hospital specialist services and difficult to access. The liaison psychiatry service was seen as a bridge. Consultant 022, 5 years experience: “… it seems to me that psychiatric services … are somewhat impenetrable unless you're a psychiatrist. There are many different units and there isn't a clear connection or cohesion between them.…”
Detaining mentally unwell against their will and the Mental Health Act 1983 assessments were felt to be outside the remit and expertise of medical services, and liaison psychiatry support in using it is indispensable. All consultants, however, were confident of using the legal Table 1 Key themes 1. 2. 3. 4.
Liaison psychiatry makes an essential contribution to acute care Where the service could improve Speed, nature and quality of response as indices of service performance Substance misuse services are important and need to be expanded
framework and making judgments on capacity and the Mental Capacity Act except in complex cases. Some nurses felt unsure about the detention of patients wanting to discharge themselves against medical advice, and wanted a clear “yes or no” answer from the liaison team about whether the patient was detainable (“sectionable” in British medical parlance). Nurse 002, 14 years experience: “You want a judgement … I find it unhelpful when a patient is assessed, not sectionable, but not allowed to leave the ward … it's not clear what to do if they are not on a section.”
3.1.2. “Liaison Psychiatry is a skill” Almost all referrers recognized the liaison psychiatry team as general hospital colleagues who were well versed in the running of the acute hospital. Referrers clearly delineated their skills as different from those possessed by generic mental health teams. Consultant 020, 5 years experience: “An acute hospital requires a particular liaison skill, and that means a working knowledge of what happens in acute hospitals.”
To the majority of referrers, the fact that the liaison team was on-site offered reassurance that they were readily accessible. Consultant 028, 6 years experience: “I think they have to be geographically close enough to be available should a patient need to be seen urgently … and also that they be seen as working within the trust, rather than a separate organization.”
3.1.3. “This is a complex patient group” Referrers recognized that mentally unwell inpatients were an especially complex group and caring for them was very demanding. They could be disruptive and increase tension on busy admission wards. Also, the busy ward environment exacerbated patient's distress. They acknowledged the input they received around patients with medically unexplained symptoms in particular, who were a significant drain on time and resources. Nurse 030, 7 years experience: “... having a patient with severe mental illness on a medical ward is very stressful (for staff) … you also feel sorry for patients — this isn't the right environment.”
3.1.4. “Valuable training resource” Referrers recognized that the liaison team possessed a set of skills that they lacked and could be invaluable in increasing their knowledge and management skills. Nurse 030, 7 years experience: “It would be good to have more education input, because we do frequently have patients that are very challenging … a bit more about risk assessments.…”
3.1.5. “Staff definitely benefit, and we think patients do too …” The consultants and nurses unanimously agreed that the liaison psychiatry service benefited patients, staff and service delivery on the acute medical wards. This perception was
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well developed and concordant across groups. Liaison interventions were felt to offer comprehensive plans of management rather than hasty discharge. The response of the team to referrals classed as “routine”, i.e., anxiety and depression, was felt to be comprehensive. However, pressures to decrease length of stay meant that, increasingly, such patients were being discharged without liaison psychiatry input and general practitioners were asked to follow up their mental health problems. Respondents linked this to the speed of response of the liaison team. Consultant 020, 5 years experience: “Liaison psychiatry underpins our ability to deliver medicine properly to a complex patient group.” Nurse 024, 14 years experience: “… (the liaison team) see patients and unlike some disciplines in medicine in hospitals at the moment, it does appear that the patient is in front of the agenda … there certainly isn't the desire to discharge, discharge, discharge if there are still issues outstanding.” Consultant 016, 11 years experience: “We get clear advice around routine mental health issues … the tension with us is that this is a high volume and bed utilisation service … but if the psychiatrist said keep the patient in for mental health reasons, and physical needs are stable, I would keep them in.”
3.2. Where the service could improve 3.2.1. Service delivery in psychiatric emergencies needs to improve Referrers across the sample felt that the service response was wanting in “psychiatric emergencies.” Consultant 018, 6 years experience: “... the problems I've always found are with the acutely disturbed patient on take, out of hours; I think that is where the problems are.…”
It emerged that most consultants had not had on-the-spot experience of emergencies with distressed or agitated patients for many years. This contrasted sharply with the nurses, many of whom recounted incidents from the previous weeks. They expected immediate telephone advice on medicating and detaining agitated patients and assessment within minutes. Nurse 032, 7 months experience: “... immediate advice over the telephone … regarding drugs and sedation and any sort of types of restraint … but we'd also want them to be quickly physically present on the ward.”
Four nurses were particularly frustrated about being asked for medical causes to be ruled out prior to psychiatric intervention. They saw themselves as trapped between the medical and psychiatric teams who visited the wards to review agitated patients without directly communicating with each other or reaching a consensus on management. Nurse 004, 6 years experience: “We get caught in a grey area — is it psychiatric or medical? … they (the patients) are new from A&E and bloods need to come back.”
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3.2.2. Communication A majority of referrers felt that communication needed to improve. There was a clear difference between groups — nurses felt the best way was for the assessor to speak directly to the nurse looking after the patient. This enabled them to voice their concerns and act as advocates for the patients and link between the psychiatric and medical teams. Nurse 024, 14 years experience: “the difficulty I have is that I am never sure when they've been and when they haven't been … we expect some sort of verbal feedback about the patients. Liaison people say things like ‘EMBRACE’ is going to pick them up, and I was like who on earth is that, what are you talking about and they were like, oh it's a mental health team.”
Conversely, consultants viewed themselves as holding clinical responsibility and attached more importance to overall management and discharge planning. They preferred succinct written notes, with clear clinical impressions, risk assessments and stepped management plans. Consultant 001, 18 years experience: “it's sometimes slightly unhelpful to have four pages of assessment (with no valid opinion) … standard for the hospital needs to be same day assessment … opinion that is valid, generally registrar or above.”
3.3. Speed, nature and quality of response as indices of service performance 3.3.1. Response times and length of stay The average inpatient length of stay is seen as a key indicator of acute hospital performance. Consultants referred to reduction in length of stay achieved in 2007 [21,22]. All consultants thought that it was vital for the liaison psychiatry service to not only respond quicker, but also facilitate discharges by providing a timely senior opinion and community follow-up plan for patients deemed “medically clear.” Five consultants felt that urgent referrals needed to be assessed within minutes and compared acceptable response times to those for a cardiac arrest crash call. All wanted routine referrals seen within 24 h. Consultant 02, 12 years experience: “I think the targets for us in acute medicine are shortening of length of stay but I think one of the really critical issues for liaison psychiatry is whether it shortens or lengthens the length of stay … quite honestly a lot of the time it looks like when the liaison psychiatrists are involved, the discharge is delayed because the person then hangs around for a psychiatry bed or hangs around whilst we wait for the consultant ward round.”
3.3.2. Issues related to Registered Mental Health Nurses “Specialling” refers to the deployment of Registered Mental Health Nurses (RMNs) on medical wards to provide specialist mental health nursing skills to care for the patients at high risk of self-harm and violence. The clinical decision to deploy such nurses is taken by the liaison team. Referrers were concerned, as they had no control over RMN deployment despite bearing the costs. Some consultants
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asked for patients with “specials” to be reviewed daily by a senior clinician who could withdraw them if the patient no longer posed immediate risks. The majority of nurses perceived the quality of service provided by RMN “specials” as unsatisfactory, especially in crisis situations. Nurse 029, 9 years experience: “One of the major problems we have is RMN cover … lot of difficulties sometimes to try and get that in place, to decide whether it is appropriate … I do tend to wonder how qualified they are in dealing with some of these patients … they just seem to sit there.…”
3.3.3. Transfers from medical to psychiatric beds The progressive decrease in the number of psychiatric inpatient beds [23] has meant that patients needing transfer to psychiatric wards are held up. All referrers expressed strong concerns about the delay in transfers and the implications in terms of patient safety as well as costs. Nurse 031, 7 years experience: “It does consume a lot of our time and again it uses a lot of temporary staffing … there are safety issues, especially if they are suicidal … and sometimes by the time we actually get a psychiatric bed, the patient has settled!”
3.3.4. Where the buck stops All referrers expressed anxieties about where final clinical responsibility lay in clinical situations involving patients with mental health problems. The majority believed that a specialist registrar or consultant from the liaison service should take responsibility for risk assessment and discharge decisions in complex cases. Consultant 018, 6 years experience: “I'm not sure about the role of the psychiatric liaison nurse (PLN); you see if a PLN comes along and says no they're not sectionable or whatever, I don't know how much sort of weight it has; is that a formal opinion … if they go and murder somebody, who takes the hit? Am I responsible for them all?”
Table 2 Suggested measures of performance Response times 1. Response time: from call to assessment by junior doctor/PLN 2. Response time: from call to review by senior psychiatrist and management plan 3. Response time: from time of initial assessment to definitive clinical decision 4. Productivity of team members: number of patients assessed/ reviewed per day Follow-ups and readmissions 5. Lengths of stay of patients needing liaison psychiatry input 6. Time taken to transfer from medical to psychiatric beds 7. Number of community psychiatric reviews following discharge from medical wards (in response to referrals to community psychiatric teams made by the liaison service) 8. Medical readmission rates for patients presenting with deliberate self harm 9. Monitoring incident forms on acute wards for aggression related to mental illness and substance misuse Quality 10. Clarity of documentation 11. Patient satisfaction questionnaires 12. Referrer satisfaction questionnaires Training 13. Number of training sessions conducted and wards covered 14. Participation in junior doctor induction program
They felt that these would help quantify outcomes and performance. They have been consolidated in Table 2. 4. Discussion Exploring and codifying the views of referrers, who are important stakeholders in liaison psychiatry services, make our study novel. It describes referrer experience in qualitative terms and seeks to define “referrer needs” as key determinants to define activity, structure services and measure performance. 4.1. Implications for policy and practice
3.4. Substance misuse services are important and need to be expanded Substance misuse was not included in our initial topic guide, but it was repeatedly raised as an issue with significant overlap with mental health. Alcohol misuse is a major problem in the inner-city boroughs served by the hospital, and referrers felt that the service was not sufficient to meet demand. Patients with these issues were perceived as complex, demanding and expensive in terms of needs, time and costs. Consultant 016, 11 years experience: “He (substance misuse nurse) is hugely helpful as a single point of contact. There needs to be more integrated services with the community … as the patients are chaotic … We desperately need more alcohol dependence services … (we) need more visibility for him and information on the intranet.”
3.5. Measures of performance Across all areas of input, referrers offered suggestions to measure the performance of the liaison psychiatry service.
We have alluded to the variable provision of liaison psychiatry services in the UK, though this is not a uniquely British problem [4,5,24]. Models of funding have evolved differently from region to region for historical reasons, with little Department of Health guidance. An impediment to service development has been relatively weak clinical outcome and cost–benefit evidence. While there is sound evidence from randomized controlled trials for several psychological therapies in liaison work [25], there is less to support day-to-day psychiatric interventions on medical wards. Devising clinical outcomes that capture the heterogeneity of clinical practice in liaison psychiatry has proven difficult. The Health of the Nation Outcome Scales [26] is the most commonly used outcome measure in British psychiatric services, but is not suitable for detecting change in the short timescales of liaison work on medical wards [27]. Liaison contacts with patients are often brief (about 1–2 days), with some interventions being aimed at the referrer or referring institution rather than directly at the patient
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(e.g., managing risk, facilitating transfer to mental health services). Referrer views can thus be considered important performance indicators. The performance indicators for evaluating outcomes that we elicited are important and meaningful to acute medical services and could be used by health care commissioners. These have the potential as markers of activity and outcomes against which payment by results could be benchmarked. Since these referrer-generated measures were perceived as being important in quantifying outcomes against expectations, they have a measure of validity that merits testing in larger, multicenter studies using both qualitative and quantitative methods. The outcomes could potentially generate evidence-based activities, which can then be recompensed by appropriate tariffs. Requests from medical consultants for clear management plans devised by consultant liaison psychiatrists are in keeping with the recommendations of the AOMRC Report of an ideal service [2]. This and other arguments strongly support provision of a consultant-led, hospital-based service rather than an in-reach service provided by a community-based team. Respondents strongly linked substance misuse with mental health and repeatedly raised the need for expanded roles for substance misuse workers within liaison psychiatry. Referrers were unanimous in recognizing the liaison psychiatry team as general hospital colleagues who were an integral part of the acute service they provided. We hope clinical managers and commissioners will take note and move towards integrating liaison psychiatry into acute medical directorates and commission these services directly. 4.2. Differing perceptions between nurses and consultant physicians As nursing and medical staff play different roles in patient care and have differing interactions with the liaison team, we expected their perspectives to vary. But these were more divergent than expected. Understanding differing demands could help tailor a more responsive service for both groups of referrers [3]. This was based on four core interrelated themes: the degree of direct patient contact and involvement in on-thespot management, direct contact with the liaison service, the nature and degree of overall clinical responsibility and the nature of their relationships with patients. Table 3 summarizes the defining features of referrers belonging to the two professional groups. 4.3. Limitations and strengths We intentionally interviewed senior clinicians, which means our findings do not reflect the views of trainee medical staff “on the shop floor.” Our inability to elicit contrasting views on the value of liaison psychiatry may reflect the views of clinicians with interests in maintaining the status quo. As mentioned earlier, despite efforts to stress
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Table 3 Defining features of referrers belonging to the two professional groups Senior nurses
Medical consultants
1. “On the frontline”: with patients for long periods; act as patient advocates but also exposed to abuse, violence and psychiatric emergencies 2. Demand liaison psychiatry input “here and now”: advice on sedation; help to detain patients leaving wards 3. Prefer an on-the-spot verbal handover and advice once patient is assessed 4. Generally do not make direct referrals; have to get a junior doctor from the medical team to make referral 5. Responsible for managing evolving patient presentations on-the-spot 6. Engage directly with nurse members of the liaison team, which they find easier
1. Review patients for brief periods; have little direct exposure to psychiatric emergencies
2. Demand at least Specialist Registrar level diagnoses and plans for overall management and discharge planning 3. Prefer succinct written clinical impressions, risk assessments and plans 4. Instruct junior doctors to make referrals
5. Have overall clinical responsibility 6. Wary of clinical opinions/risk assessments by nurse members of the liaison team
to all interviewees that the interviewers were neutral observers, the fact that the interviewers had been associated with the team in the past could have influenced responses and introduced a response bias. Another potential limitation is the lack of generalization as this was a study of clinicians in a single London teaching hospital. In spite of this, we believe that the themes identified are generic enough to be applicable to most general hospitals with an established liaison psychiatry service. Although our findings will be considered common knowledge by clinicians, it is important to have the evidence recorded for wider policy decisionmaking and as a foundation for future research. Some referrer demands would be difficult to implement within current resources. Immediate “crash call” responses to psychiatric emergencies 24 h a day, consultant management plans within 24 h and more training for medical and nursing staff support the Report's recommendations, but would require increased resources. For such demands to be met, both acute medical and liaison psychiatry services need to move towards an integrated model, where both are subject to the same quality standards in terms of access to care and speed and nature of response. This would be helped if acute trusts were commissioned to provide liaison psychiatry services. Some suggested outcome measures, such as shorter transfer times from medical to psychiatric beds, lie beyond the control of liaison services and reflect the overall reduction in psychiatric bed numbers nationally.
5. Conclusions In summary, the views of staff working on acute medical wards support policymakers' recommendations concerning
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liaison psychiatry service provision. Establishing a national funding mechanism, possibly by payment by results, for such services and working towards integrated services will greatly improve patient care. Regulatory bodies such as the Care Quality Commission could also assist in even development of liaison services by making the provision of an accredited and integrated liaison service a criterion by which all acute hospital trusts are measured. The Royal College of Psychiatrists Research Unit, through the Psychiatric Liaison Accreditation Network, has laid down benchmarks for accreditation — a step in this direction [28]. Acknowledgments We are grateful to Michelle Fitzpatrick from the Liaison Psychiatry Service and to Julia Munford and Karen Brown for help with editing. References [1] Hansen MS, Fink P, Frydenberg M, Oxhoj M, Sondergaard L, MunkJorgensen P. Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. J Psychosom Res 2001;50:199–204. [2] Academy of Medical Royal Colleges. Managing urgent mental health needs in the acute trust: a guide by practitioners, for managers and commissioners in England and Wales. London: Academy of Medical Royal Colleges; 2008. [3] Royal College of Physicians and Royal College of Psychiatrists. The psychological care of medical patients: a practical guide. 2nd edition (Council Report CR108). London: Royal College of Physicians & Royal College of Psychiatrists; 2003. [4] Ruddy R, House A. A standard liaison psychiatry service structure? A study of the liaison psychiatry services within six strategic health authorities. Psychiatr Bull R Coll Psychiatr 2003;27:457–60. [5] Sakhuja D, Bisson JI. Liaison psychiatry services in Wales. Psychiatr Bull R Coll Psychiatr 2008;32:134–6. [6] Eales S, Callaghan P, Johnson B. Service users and other stakeholders' evaluation of a liaison mental health service in an accident and emergency department and a general hospital setting. J Psychiatr Ment Health Nurs 2006;13(1):70–7. [7] Mayou R, Smith EBO. Hospital doctors' management of psychological problems. Br J Psychiatry 1986;148:194–7. [8] Morgan JF, Killoughery M. Hospital doctors’ management of psychological problems: Mayou and Smith revisited. Br J Psychiatry 2003;182:153–7. [9] Cohen-Cole SA, Friedman CP. Attitudes of non-psychiatric physicians towards psychiatric consultation. Hosp Community Psychiatry 1982;33(12):1002–5.
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