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Department of Liaison Psychiatry, Adamson Centre for Mental Health, St Thomas’ Hospital, Lambeth Palace Road, London SE17EH, email: g.ranjith{at}iop.kcl.ac.uk
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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There are no national standards to evaluate the quality of delivery of inpatient liaison psychiatry services in general hospitals in the UK. In order to benchmark our service against best international practice, we adapted quality indicators from two peer-reviewed studies from Australia and Switzerland and monitored our performance standards over a period of 6 months.
RESULTS
There were 145 patients assessed over the study period. We set a priori target of 90% achievement on indicators in the areas of timeliness of response to all referrals, timeliness of response to referrals following self-harm and quality of supervision of junior medical staff attaining 93.8, 87.5 and 89.6% respectively.
CLINICAL IMPLICATIONS
We demonstrated that we provided a reasonably responsive consultation–liaison service with high levels of supervision of junior staff. National bodies should develop benchmarks in this area so that services can demonstrate the quality of their service and learn from others’ good practice.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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External benchmarking involves, but is not confined to, comparing standards in a service with other good services anywhere in the world. After a review of the literature we identified two recent studies that have explicitly set quality indicators and evaluated their services against these standards, one from Australia (Holmes et al, 2001) and the other from Switzerland (Archinard et al, 2005). The indicators were in the areas of timeliness of response, communication with referrers and follow-up agencies, and supervision of trainees. Holmes et al (2001) found that more than 70% of patients were seen within 48 h in specialist liaison psychiatry but services just failed to attain 90% targets for patients seen within 24 h in general liaison. Archinard et al (2005) reported that 93% of patients were seen within 36 h, 95.7% of emergencies were seen on the same day and 97.5% of patients were reported to supervising psychiatrists. The aim of our project was to adapt the quality indicators to a British setting, a priori set the targets for their attainment and to measure our achievement of these targets.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Development of benchmarks
We adapted timeliness of response and communication indicators from Holmes
et al (2001), and
supervision indicators from Archinard et al
(2005). Holmes et al
(2001) had two categories
dealing with timeliness of response to referrals from areas other than the
emergency department: general referrals being seen within 24 h and specialist
referrals being seen within 48 h, with targets of 90% for the former and 70%
for the latter. We adapted this into the following two standards:
The indicators dealing with communication related to communicating with the referrer both pre- and post-assessment and with the follow-up agency. We felt that since our style of work involved acceptance of telephone referral through a dedicated bleep, monitoring of the indicators relating to communicating with referrers was superfluous. Our indicator 3 was:
Archinard et al (2005) set 95% targets for discussion with a senior psychiatrist following assessment and joint assessment with a senior psychiatrist where indicated. We adapted this to our indicator 4:
Assessment of benchmarks
All evaluations were logged on a structured pro forma that recorded
socio-demographic information and clinical details, including diagnosis,
interventions and outcome. Our assessment tool contained questions designed to
assess the four indicators. We set a target of 90% for the attainment of these
standards. The study received approval from the Lambeth Clinical Governance
Committee of the South London and Maudsley NHS Trust.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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As the assessment sheet did not have enough information to meaningfully assess indicator 3, our analysis refers to the other three indicators. We chose to interpret missing information conservatively, classifying it as failure to comply with the standard. In the same spirit we classified referrals made on Friday and seen on Monday as having failed to comply with the standard. Overall, indicators 1, 2 and 4 were achieved in 93.8, 87.5 and 89.6% of cases respectively. Figure 1 shows the percentage of cases where the indicators were achieved in each month during the study.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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We have shown that it is possible to provide a responsive consultation–liaison service that maintains a high standard of supervision of junior medical staff. It is important to point out that our service, although better staffed than the average London general hospital liaison service (Kewley & Bolton, 2006), is by no means a ‘Rolls Royce’ service and largely conforms to the staffing recommendations of the Royal Colleges. The provision of liaison psychiatry services remains patchy in most parts of the UK, including in cities such as London (Ruddy & House, 2003; Kewley & Bolton, 2006), and recently some liaison services have been threatened with closure. This may be because liaison psychiatry is often equated with work in emergency departments and is seen as replaceable with crisis resolution services. In-patient liaison psychiatry requires the ability to respond quickly, to collect and integrate information from disparate sources in a short amount of time and implement a management plan in an environment not always conducive to psychosocial issues. Such a labour-intensive process is impossible to achieve without a dedicated service with input from experienced and senior specialists.
A limitation of our study is that the data collection was in the course of routine clinical work, and hence some information is missing. This is particularly relevant to indicator 3, which was related to outcome, as opposed to the other quality indicators that dealt with process. Liaison psychiatrists need to prioritise outcome measurement and develop better and simple outcome measures, as outcome is of utmost importance to commissioners and policy makers. Although we measured the speed of response and the adequacy of supervision, we did not specifically evaluate the quality of the interventions either in terms of referrer or patient satisfaction, or the evidence-based nature of the interventions. It would have been impossible to measure satisfaction in our study and we are carrying out an independent qualitative study of referrer perceptions of our service. It is also relevant that a qualitative study of service users and hospital staff in east London found that speed of response and experience of the professional were considered important by both groups (Eales et al, 2006). As for the nature of the interventions, the evidence base for interventions in liaison psychiatry is rather weak and needs to be strengthened (Ruddy & House, 2005).
When trying to ‘prove’ its utility to commissioners, in-patient consultation–liaison psychiatry faces a unique problem, that is, the rapid turnover of patients on medical wards and the brief, intensive and often systemic nature of the interventions which makes it difficult to demonstrate symptomatic improvement or cost-effectiveness (Borus et al, 2000). The introduction of policies such as payment by results (Fairbairn, 2007) complicates the issue further for liaison psychiatry. On the positive side, there is an opportunity to establish psychiatric care as an integral part of the care package for medical inpatients; the risk is that general hospital managers might fear that the input of a high-quality liaison service would inflate the tariff for a treatment episode and primary care managers that the unmet psychosocial needs identified by the liaison service might prolong hospital stay. The acknowledgement of the importance of psychiatric care will only happen if national bodies such as the Faculty of Liaison Psychiatry lobby policy makers and quality assurance agencies such as the Healthcare Commission. Good data collected locally and benchmarked against national standards would go a long way in making this case. Such a benchmarking exercise will also help drive up the standard of care generally and allow learning from best practice, which is the essence of benchmarking (Bayney, 2005).
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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BAYNEY, R. (2005) Benchmarking in mental health: an
introduction for psychiatrists. Advances in Psychiatric
Treatment, 11, 305
-314.
BORUS, J. F., BARSKY, A. J., CARBONE, L. A., et al
(2000) Consultation-liaison cost offset: searching for the wrong
grail. Psychosomatics,
41, 285
-288.
DEPARTMENT OF HEALTH (1999) National Service Framework for Mental Health: Modern Standards and Service Models. Department of Health.
EALES, S., CALLAGHAN, P. & JOHNSON, R. (2006) Service users and other stakeholders’ evaluation of a liaison mental health service in an accident and emergency and a general hospital setting. Journal of Psychiatric and Mental Health Nursing, 13, 70-77.[CrossRef][Medline]
FAIRBAIRN, A. (2007) Payment by results in mental
health: the current state of play in England. Advances in
Psychiatric Treatment, 13, 3
-6.
HOLMES, A. C., JUDD, F. K., YEATMAN, R., et al (2001) A12-month follow up of the implementation of clinicalindicators in a consultation–liaison service. Australian and New Zealand Journal of Psychiatry, 35, 236 -239.[CrossRef][Medline]
KEWLEY, T. & BOLTON, J. (2006) A survey of liaison
psychiatry services in general hospitals and accident and emergency
departments: do we have the balance right? Psychiatric
Bulletin, 30, 260
-263.
ROYAL COLLEGE OF PHYSICIANS & ROYAL COLLEGE OF PSYCHIATRISTS (2003) The Psychological Care of Medical Patients: A Practical Guide (Council Report CR108). 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.
RUDDY, R. & HOUSE, A. (2005) Metareview of
high-quality systematic reviews of interventions in key areas of liaison
psychiatry. British Journal of Psychiatry,
187, 109
-120.
This article has been cited by other articles:
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  J. Bolton and N. Kaneza Benchmarking a liaison psychiatry service Psychiatr. Bull., December 1, 2007; 31(12): 467 - 467. [Full Text] [PDF]
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, indicator 1; 
,
indicator 2; 
, indicator 4.