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| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
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Department of Liaison Psychiatry, St Helier Hospital, Wrythe Lane, Carshalton, Surrey SM5 1AA, e-mail: jim.Bolton{at}swlstg-tr.nhs.uk
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionConclusionsReferences |
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By use of a telephone survey, we aimed to investigate liaison psychiatry services of all 29 general hospitals in Greater London. We specifically enquired about services to accident and emergency (A&E) departments.
RESULTS
We identified wide variations in staffing, working hours and patient groups seen. Fourteen services (48%) worked over 24 h and 4 (14%) had specific A&E teams. Twelve services (41%) had established or planned working links with community crisis services.
CLINICAL IMPLICATIONS
Generally staff numbers fell below national recommendations and there were frequent gaps in service provision. The recent focus on emergency care has lead to an increase in A&E services, but there is a risk that liaison psychiatry services for other general hospital patients are being neglected.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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Recent English health service initiatives have led to an increased focus on emergency mental healthcare, which potentially influences liaison psychiatry provision to accident and emergency (A&E) departments. The Department of Health (2001) has recently set standards to reduce patients’ attendance times in A&E departments. In addition, the National Service Framework for Mental Health (Department of Health, 1999) has required specific services to be established for patients in crisis, many of who will attend A&E departments. However, there is no optimum model of psychiatric service delivery to A&E. Also, there is a risk that A&E mental health services develop at the expense of other hospital departments.
As a city, London is unique in the UK in terms of its size, ethnic diversity and organisation of health services. As part of the establishment of a network of liaison psychiatry services in Greater London, we surveyed the current service provision to all the district general hospitals. We aimed to investigate the staffing and service provision of each service and to enquire about service developments, particularly with regard to A&E departments.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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During the second quarter of 2004, a telephone survey was carried out using a predetermined list of questions. In each case, we tried to speak to a well-established member of the liaison psychiatry team. We enquired about the number of clinical team members and their professions. Specialist registrars (SpRs) in psychiatry were not included in these figures, as such posts are supernumerary and may not continue beyond the current trainee’s attachment. We established details of service delivery. Hours of work were categorised into services operating within core ‘working hours’ (09.00 to 17.00 h, Monday to Friday), those delivering an extended-hours service and those running 24 h per day. The survey enquired about specific patient groups seen and whether teams were funded and managed by a mental health or an acute trust. We also enquired whether the hospital had a mental health in-patient unit on site. Efforts were made to establish whether there were trends in service development by asking about recent service changes and teams’ priorities for future development.
Data were analysed using the Statistical Package for the Social Sciences version 11.5 for Windows. Staffing levels were compared with the joint Royal College recommendations (Royal Colleges of Physicians & Psychiatrists, 2003).
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Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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Bed numbers
The mean number of in-patient beds for the hospitals surveyed was 635
(range 257–1267, s.d.=228).
Working hours
Of the ten services working extended hours, seven included weekends and
three operated on weekdays only.
Staffing
Overall, the size of teams varied between 1 and 25 whole-time equivalent
staff (mean=8.2, s.d.=5.9). Nine teams (31%) consisted of nursing staff only.
Ten services (34%) had no dedicated consultant psychiatry sessions, although
these teams usually mentioned that they could contact a psychiatrist for
advice.
Patient groups
All teams provided a service to their A&E department and assessed
patients following episodes of self-harm. Five services (17%) operated in
A&E departments only. Patient groups seen are listed in
Table 1.
Services for older adults
Nineteen services (66%) accepted referrals of older adults, although 3 of
these teams worked only in the A&E department. Several teams mentioned
that community psychiatry services for older adults visited the hospital to
see patients. Four on-site liaison psychiatry services specifically for older
adults were identified, for which limited data were collected. Each had a
half-time consultant with one to two additional nursing or junior medical
staff.
Funding and management
Twenty-five services (86%) were managed by the mental health trust, 3 (10%)
by the acute trust and 1 (3%) was jointly managed. Fifteen services (52%) were
funded by the mental health trust, 10 (35%) were jointly funded and 4 (14%)
were funded by the acute trust.
On-site psychiatric unit
Eighteen district general hospitals (62%) also had a psychiatric unit on
site. There was a significant association between the presence of an on-site
unit and the liaison psychiatry team delivering a 24-h service
(
2=6.43, P=0.01).
Service developments
Those teams providing extended and 24-h services generally reported that
they had increased their hours of service during the previous 2 years. Three
teams (10%) reported that they also delivered the local mental health crisis
or home treatment service. A further 9 services (31%) reported plans to
establish closer links between liaison psychiatry and community crisis
services.
The most frequently cited priority for service development was for more staff, mentioned by 24 services (83%). However, only 8 teams (28%) had plans to expand. The second most common priority was for more accommodation, which was mentioned by 10 services (35%).
College recommendations
The joint recommendations of the Royal Colleges of Physicians &
Psychiatrists (2003) for a
liaison psychiatry service are based on a 09.00 to 17.00 h service in an
average-sized district general hospital. Such a service should include one
full-time consultant, a senior house officer, 5 nursing staff and 1–2
psychologists.
It is difficult to compare the recommendations with services delivering extended-hours and crisis services. However, only 13 teams (45%) had a full-time equivalent consultant and 17 (59%) had a full-time junior doctor. Only 14 services (48%) had 5 or more full-time equivalent nursing staff; 13 of these delivered a 24-h service and 1 an extended-hours service. Only 1 team had more than 1 full-time equivalent psychologist. Overall, only 1 extended-hours service had all of the recommended components.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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Many teams reported that changes in service provision to A&E departments had occurred as a result of recent government targets. A minority of teams also delivered community crisis and home treatment services, work that falls outside the generally accepted remit of a liaison psychiatry service and complicates the interpretation of the survey data.
The recent government targets for emergency mental health provision can be considered an opportunity to bring mental health resources into the district general hospitals. However, there is also a danger that the development of A&E services will be at the expense of services for other general hospital patients.
There is no recommended model for psychiatry service provision to A&E departments. Further qualitative research might help to establish recommendations for A&E services and how emergency mental health services in general should be delivered.
The London population has a number of characteristics that, although not unique among urban areas in the UK, contribute to relatively high levels of mental illness and an associated need for services (Mayor of London, 2003). These include large refugee and minority ethnic populations, high levels of homelessness and single occupancy households, and the fact that London contains many of the most deprived areas in the UK.
Compared with data from previous regional surveys in the UK (Howe et al, 2003; Ruddy & House, 2003), a higher proportion of London district general hospitals had some form of liaison psychiatry service and a higher proportion of services had dedicated consultant psychiatry sessions. However, the combined picture is one of unmet need and a lack of rational planning of services.
Limitations
This study is likely to underestimate the provision of mental health
services for general hospital patients, as a number of possible psychiatric
and psychological services were not surveyed. Community psychiatric services
for children, older adults and substance misuse may provide a consultation
service to their local hospital. In addition, individual hospital departments
may also employ therapists and psychologists to work with individual patient
groups.
An underestimate of services may also have been a result of the omission of SpRs from the survey. Although SpRs are supernumerary and posts are not necessarily filled every year, where present SpRs make a significant contribution to service provision.
We compared each service with the recommendations for an average district general hospital. However, the needs for psychological services of individual hospitals will vary depending on bed numbers, the workload of the A&E department and the epidemiology of the local population. The Colleges’ recommendations also point out that larger teaching hospitals with tertiary referral centres will require a larger liaison psychiatry team, including at least two full-time consultant psychiatrists.
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Conclusions |
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsReferences |
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DEPARTMENT OF HEALTH (2001) Reforming Emergency Care: First Steps of a New Approach. London: Department of Health.
HOWE, A., HENDRY, J. & POTOKAR, J. (2003) A survey
of liaison psychiatry services in the south-west of England.
Psychiatric Bulletin,
27, 90
–92.
MAYOR OF LONDON (2003) Availability of Mental Health Services in London. Highlights of a Report to the Mayor of London. London: Greater London Authority. http://www.london.gov.uk/mayor/health/mentalhealth_availability/mentalhealth_highlights.pdf
ROYAL COLLEGE OF PHYSICIANS & ROYAL COLLEGE OF PSYCHIATRISTS (2003) The Psychological Care of Medical Patients: A Practical Guide (Council Report CR108). London: Royal College of Physicians & Royal College of Psychiatrists.
RUDDY, R. & HOUSE, A. (2003) A standard liaison
psychiatry service structure? A study of the liaison psychiatry services
within six strategic health authorities. Psychiatric
Bulletin, 27, 457
–460.
SWIFT, G. & GUTHRIE, E. (2003) Liaison psychiatry
continues to expand: developing services in the British Isles.
Psychiatric Bulletin,
27, 339
–341.
This article has been cited by other articles:
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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