Mangerial arrangements

Most liaison psychiatry posts are now managed and administered by a mental health trust.

The consultant is therefore likely to be employed by the mental health trust although many people believe this is not an optimum arrangement.

There is usually a Service Level Agreement (SLA) between the mental health trust and the acute general hospital trust for the provision of a liaison psychiatry service. In a few hospitals the liaison psychiatry service forms part of the acute general hospital trust and is managed by that organisation.

The funding arrangements should be clarified. If the liaison psychiatry service forms part of a Service Level Agreement it should be established what budget the acute trust makes for the service and what level of provision is agreed. Ideally the budget for the liaison psychiatry service should be identified and the consultant should have considerable influence in determining how this is deployed.

The joint report on "The psychological care of medical patients" (RCP and RCPsych, 1995) recommended that funding for a liaison psychiatry service should come from a medical and surgical budget but should be managed within a mental health service. There should be one manager who has direct responsibility for the service, who works with the liaison psychiatry consultant and who reports to the relevant Chief Executive.

After you have started your post it is helpful to arrange business meetings every four to six weeks with managers from both the acute (general medical) and community trust (psychiatry). These meetings can be extremely helpful in terms of resolving issues between the general hospital and psychiatry. They can also be helpful in terms of future expansion of the service.

Facilities

Accommodation is a vital component of the service and should be located in a convenient position within the main general hospital where the service is provided.

A consultant's office is essential. This should be identified and shown to the consultant before taking up the appointment. It is also essential that there is secretarial and administrative support with appropriate office accommodation and space for filing and record keeping. One secretary should be identified to provide secretarial support to the consultant.

It should be explicitly stated in the job description which consultant has clinical responsibilities if a patient needs to be admitted to a psychiatric ward. Likewise, if a patient is admitted to a medical ward, the medical responsibility for that patient should be clearly stated.

If the post holder is to retain medical responsibility for patients admitted to psychiatric services, the location of the beds should be identified and the number specified although it is likely that the full bed complement will not always be taken up.

An acute adult psychiatry admission ward is often not ideal for the management of patients with combined medical and psychiatric problems but very few services have access to a special ward devoted to this type of patient.

In many cases it is preferable to manage patients with physical and psychiatric co-morbidity on a medical ward, ideally a side room, with special psychiatric nursing (RMN status) provided for as long as is required.

In these circumstances the funding for the RMN should be clarified. It is usual practice for this to come from the budget of the medical division from which the patient has been referred.

If the liaison psychiatrist has no access to in-patient beds there must be an agreement with psychiatric colleagues to admit patients who require in-patient care to the relevant catchment area psychiatric ward.

The medical responsibility of patients in the Accident & Emergency Department should be clearly established and stated in the job description. The position of patients seen by psychiatric nurses, but not by psychiatric junior staff, should be explicitly stated.