RCPsych, RCN, NHS England and Unite’s Mental Health Nurses Association have worked to develop these guidelines which set out the key issues that liaison psychiatry staff teams should be conscious of at this time.
Acute hospitals have responded rapidly to the challenge of COVID-19 with radical operational changes. Corresponding system-wide changes have also taken place in mental health and social care provision which aims to care for all except the most acutely physically unwell outside of the acute hospital.
Liaison psychiatry services are integral to adapted acute care pathways and have a key role to play in contributing to system-wide planning in their local areas.
Liaison psychiatry services remain essential to the functioning of the acute hospital with a key role in facilitating safe and timely discharges. However, services need to be provided safely with teams minimising risk to patients, themselves and others with whom they have contact. Achieving this has involved significant alterations to the way services are provided planning ahead to maintain service continuity during the pandemic.
Areas will need to find solutions appropriate to their own circumstances while following the guidance below which addresses four key areas:
- Clinical service prioritisation
- Alternatives to acute hospital Emergency Departments for patients presenting with primary mental health problems
- Service continuity planning
- Maintaining staff and patient safety
- Mental wellbeing of staff.
This guidance should be applied across the age and range of patient presentations, but specific responses will vary according to clinical need.
This guidance should be read in conjunction with the broader guidance for psychiatry clinicians recently published by the Royal College of Psychiatrists.
The Faculty of Liaison Psychiatry has published Alternatives to emergency departments for mental health assessments during the COVID-19 pandemic (Aug 2020) which makes recommendations to inform the future of alternative care pathways and assessment units.
Clinical service prioritisation
- Prioritise activity which minimises patient exposure to infection risk and minimises delays of discharge. Government guidance has been issued on hospital discharge.
- Prioritise moving patients with mental health presentations away from high-risk areas such as the emergency department or medical assessment areas to alternative, dedicated space where possible.
- If not possible then prioritise minimising risk to those patients whilst their mental health is assessed and managed.
- Service to inpatient wards should be maintained in order to minimise delays to safe discharge
- Services may consider developing their own local prioritisation processes consistent with the principles within this guidance.
Alternatives to acute hospital Emergency Departments for patients presenting with primary mental health problems
At the outset of the pandemic, there was a desire to minimise the number of assessments of patients with mental health problems in the EDs to reduce the infection risk. Consequently, in several areas alternative care pathways were established, most commonly separate assessment facilities on mental health sites.1 The provision of what NHS England (NHSE) has referred to as ‘Mental Health Crisis / A&E Diversion Hubs’ has since been evaluated by the College and NHSE.1.2.
The alternative assessment facilities have varied in their location, the care environment, staffing, and access. Their context has also varied in how well pre-existing local crisis care pathways are established. Where emergency assessments are undertaken off-site, this will need to be planned with the wider mental health services including assessment teams, crisis and home treatment teams and others as relevant.
Potential advantages of the new assessment facilities have included:
- the provision of a more appropriate environment for assessment often described as being more calming than an ED;
- triage and assessment by staff with mental health expertise;
- provision of a ‘one-stop shop’ for multidisciplinary psychiatric care.
Potential drawbacks include:
- longer waiting times to assessment, especially when patients are transferred from an ED or where a unit serves a wide geographical area;
- units not being able to manage co-morbid physical health problems, including the consequences of self-harm;
- increased stigmatisation of patients with mental illness by ED staff, by encouraging a view that they should routinely be managed elsewhere;
- Use as proxy wards to relieve bed pressures;
- Not being cost-effective.
A key disadvantage has been that staff for the alternative assessment facilities have often been recruited from liaison psychiatry services, possibly under the misapprehension that there would be a significant decrease in workload for such services in the general hospitals. The experience of services has been that this has not been the case.
NHSE’s view is that such facilities are most likely to be viable in busy and urban areas, and where community crisis care pathways are less well developed. However, they do not replace liaison psychiatry services which are still required for the assessment of patients on the general hospital wards and in the EDs.
If an off-site mental health emergency department is being established, it will require planning for:
- Location and facilities, including consideration of what degree of physical comorbidity, can be managed
- Consideration of how a service can be delivered to both an offsite service and the general hospital, where there are still likely to be cases that require liaison psychiatry assessment and management
- Hours of work - 24/7 likely to be most effective where possible
- Staffing models – one model would be to have dedicated onsite mental health staffing, as for a ward, with more experienced staff from other services (e.g. CHHTs, Liaison Psychiatry, community assessment teams) undertaking assessments and possibly working across sites
- The degree of physical comorbidity and interventions that can be managed and what equipment would need to be available to support this
- Access to IT and administrative support
- Access to medication
- Access to pathology services
- Escalation protocol for patients with comorbid physical illness, including access to medical advice and when to transfer patients to an acute hospital
- Transport of patients between the facility and acute and mental health sites (if not co-located)
- Access to assessments under mental health legislation
- Access to senior psychiatry advice
In England, NHSE has not endorsed the provision of alternative assessment facilities. They recognise that in some areas they may be a temporary measure during the pandemic, depending on the local context. Where they are established, staff should be mindful of the potential drawbacks. NHSE has emphasised that the aims of the NHS Long Term Plan, including the provision of 24/7 core-24 liaison psychiatry services, remain a priority.
- Parmar N, Bolton J (2020) Alternatives to emergency departments for mental health assessments during the COVID-19 pandemic. The Faculty of Liaison Psychiatry, Royal College of Psychiatrists.
- NHS England & NHS Improvement (2020) Mental Health Crisis / A&E Diversion Hubs. NHS England national findings and position October 2020.
Service continuity planning
Liaison psychiatry services vary in size, configuration, working hours, skill mix, and numerous other parameters, so no single document can provide all of the detail needed for every service. This section, therefore, sets out key overarching principles that services should follow:
- Protect and preserve senior liaison psychiatry expertise to the acute hospital in order to deliver the most effective support to hospital services
- Every service should design a continuity action plan which sets out how key activities will be safely maintained with reduced staffing numbers whilst preserving quality and skill mix
- Continuity action plans will vary depending on local contexts and may require collaboration between two or more acute hospital liaison services and across healthcare providers
Maintaining patient and staff safety
This section sets out principles to optimise ongoing staff capacity and reduce exposure to vulnerable patients and others
- A decision to undertake face to face assessment should be made on clinical need. Minimising face-to-face contact is especially important when patients are in a higher risk category for COVID-19 infection e.g. older patients, those with compromised immunity or significant physical comorbidity.
- Where face to face assessment is clinically indicated, liaison psychiatry staff should be supported by their organisation(s) to practice safely. They should be given the same access to relevant PPE as other services in the acute hospital and be supported to follow national and local guidance on safe working practices
- Whilst at work maintain social distancing. This will involve changes to working practice likely to include:
- Minimising face to face meetings
- Reviewing administration processes
- Reviewing the use of office facilities and enabling remote working
- Exploring the viability of telephone and video assessments
Mental wellbeing of staff
It is essential that it is recognised that liaison psychiatry staff and their colleagues in the general hospital have and will be under significant pressure and stress related to issues at both work and home, and require support.
- Within the limits of social distancing measures, liaison psychiatry team members should be encouraged to check how their colleagues are doing and to support each other. Specific team meetings, which may be held virtually, can be used to encourage reflection and provide mutual support.
- Senior staff should ensure that other team members are aware of where they can access support services.
- Senior staff should also be mindful that they are facing similar stresses to their staff and potentially additional pressures due to their roles and responsibilities. Such staff should role model self-care strategies to mitigate stress.
Liaison psychiatry services may be asked to contribute to the psychological support of hospital colleagues. However, services should be mindful of the stress that their own staff are experiencing and their own team resilience when considering what support they are able to provide for other colleagues.
- Essential patient care should take priority over the provision of hospital staff support.
- Where liaison psychiatry teams have the staffing and emotional resilience, they should consider using their expertise to either advise on or contribute to the provision of psychological support for other hospital staff, while remaining mindful of the need to also support staff within liaison psychiatry.
- Within a hospital, where possible seek to develop a coordinated approach to staff support using liaison psychiatry, staff counselling services, clinical health psychology, and the hospital chaplaincy
Information about supporting patients and staff manage the psychological impacts of COVID is also available.