It is best to make progress gradually

It is best to work closely, in the first instance, with those who are positively inclined towards psychiatry.

Much of the work will involve seeing patients referred from medical and surgical wards. This work should be shared between the consultant and psychiatric trainee, according to the complexity of the case.

It is important that the trainee is supervised regularly and knows that he/she has quick access to the consultant if a case proves more difficult than it appeared at first. If patients are seen quickly, within 24 hours, the service will be appreciated and this will facilitate more referrals to the service.

Although many services send a typed letter or summary, setting out the psychiatrist's opinion and treatment recommendations, it is more important that a summary of the findings and the opinion be written immediately in the medical notes so that the medical team knows what is being planned and whether further psychiatric input is going to take place.

It will be necessary to establish how referrals are to be received. This is done either by telephone to the secretary or junior doctor or, in less urgent cases, by internal mail. It is important that the case is discussed with the relevant doctor before the patient is seen and then again following the initial consultation on the ward. Adequate records should be kept to enable research and audit to be carried out.

It is important to develop an out-patient service so that patients can be referred from other clinics in the hospital. Liaison psychiatrists do not, in general, have a community catchment area. Their services should be offered to all patients who are attending the hospital they serve, regardless of the patient's geographical location.

Other specialists should be encouraged to refer patients they consider to have a major psychiatric component to their medical problems. These usually fall into two categories, firstly, patients with problems of somatisation and secondly, patients with psychiatric co-morbidity accompanying established physical illness.

Once the consultant has taken up the post he/she should write to appropriate clinical colleagues in the general hospital informing them of the availability of the new service. This can be followed by a series of meetings.

It may not be wise to offer the service for the whole hospital unless the liaison service is very well resourced. Instead, two to three specialties should be identified, in which there is known high psychiatric morbidity, and where the clinicians are keen to refer.

If possible, out-patient clinics should be conducted in medical departments. Patients often find this more acceptable than coming to a psychiatric clinic in which they may feel uncomfortable and out of place.

Once the service is established, it should be possible to arrange special out-patient clinics for particular groups of patients. This has been done successfully for patients with HIV/AIDS, malignant disease, neurological disease and for women with gynaecological or obstetric problems.

It is helpful if the clinics can be located in the departments which the patient is already attending. This will facilitate joint meetings with referring staff, including doctors, counsellors and social workers. Regular multi-disciplinary meetings foster good communication between all professionals involved in a patient's care.