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Job planning in liaison psychiatry
Learn about the structure and activities specific to liaison psychiatry and read guidance regarding what would constitute an acceptable job plan.
Liaison psychiatrists specialise in the provision and development of integrated services and pathways which focus on improving the care of people of all ages with complex health problems.
They work closely with health and social care colleagues in a variety of settings, including the general hospital (e.g. emergency department, intensive care, inpatient wards and outpatient clinics) and more recently the community (e.g. primary care). The recent expansion of liaison mental health services outside of the general hospital setting supports improvements in integrated care pathways across the wider health and social care system.
Liaison mental health services (sometimes known as integrated psychological medicine services) are usually multidisciplinary comprising nurses and doctors, and variably clinical psychologists, allied health professionals and social workers.
Clinical expertise covers a wide range of areas including mental health problems in those with physical illness, psychological factors affecting physical health, persistent physical symptoms, substance misuse, organic brain disorders, dementia and delirium, eating disorders, self-harm, learning difficulties and autism, transplant surgery, the use of medication in physical ill health and psychological therapies in the context of physical illness.
An increasing number of liaison mental health services now serve people of any age. In some areas one team provides liaison expertise regardless of age, whilst in other areas there are separate teams for children, adults and older people. In these configurations there will be liaison consultants who are specialists in the mental health care of children, working age adults or older adults. In 2019 the College produced this position statement on the provision of liaison psychiatry services across the lifespan which gives helpful context.
A liaison psychiatrist has the following specific expertise:
- understanding the interface between physical illness and mental illness (e.g. comorbid mood disorders, persistent physical symptoms, organic mental states)
- diagnosis and formulation of management plans in complex situations, and advising medical teams on appropriate integrated care informed by guidance
- prescribing and giving advice on medication, including psychotropics
- providing expertise, and fulfilling a statutory role, in managing medico-legal issues in the general hospital, including application of mental health and mental capacity legislation
- providing evidenced based care of people with physical symptoms which are not wholly explained by the extent of pathology
- working at the interface between physical and mental health care in clinical populations with long-term conditions
- bridging the gap between primary and secondary care in the management of persistent physical symptoms and long-term conditions in the community
- supporting the care of people who present with acute psychiatric conditions or behavioural disturbances who are admitted to general medical beds, including whilst they wait for a specialist mental health bed or a social care placement. This may include people with delirium, dementia, eating disorders, autism and learning disabilities.
A key part of the liaison psychiatrist’s consultant role involves leadership and service development.
Leadership
- Leadership within clinical teams, including clinical supervision of colleagues. (Line management of non-medical staff would usually be provided by the team manager).
- Identifying good practice from national guidance and research and aligning the work plan and goals of the liaison mental health team according to these.
- Familiarity with the Psychiatric Liaison Accreditation Network (PLAN) quality assurance framework and providing leadership to support the achievement of these standards.
Service development
Working with clinical leaders, managers and commissioners from across the wider health and social care system [e.g. primary and secondary care, social care, third sector, mental and physical health trusts/boards] with a focus on improving pathways and integrating and improving care.
A liaison psychiatrist will play a key role in training non mental health staff to support people who have complex co-morbid mental and physical health difficulties. Having a presence in physical health settings and delivering both informal and formal education and training, including case discussion, will both help challenge stigma and improve the quality of care and associated outcomes. This support includes helping colleagues recognise and manage common mental health conditions and know when and how to refer on to appropriate pathways.
Most liaison mental health teams will have a variety of training placements which the consultant is expected to supervise. These include foundation, core, specialty residents, and advanced practitioner trainees. There should be 0.5 PAs in the job plan for each trainee supervised to support the formal 1 hour of supervision per week and additional ad hoc supervision and administrative tasks needed for training, including clinical and educational supervisor’s roles.
SAS psychiatrist job plans should follow the same principle as above. The College supports 8 DCC; 2 SPA for both speciality and specialist psychiatrists. The model job plan for SAS psychiatrists should reflect the 0.5 SPA difference, which should be added to patient facing DCC.
If the SAS doctor does not have formal or informal educational responsibilities in relation to resident doctors, medical students and other health professionals, the specific time allocated for this in the consultant model job plan should be added to DCC activities for either patient reviews or for liaison with families/carers/other professionals in relation to patient care as appropriate to the service and their role in the team.
Below is a model job plan for a FT consultant in a hospital-based liaison mental health service. The job plan will vary with the nature and role of the team and may vary from service to service:
FT liaison hospital-based
| Description | Professional activities |
|---|---|
| Direct clinical care, including: | 7.5 |
| Face-to-face contact with patients in clinic or wards | 3-4 |
| Multidisciplinary team meeting and support for team members outside the meeting | 1 |
| Emergency work and clinical administration | 1-2 |
| Mental health legislation work/complex patient reviews or liaison with other specialties | 1.5 |
| Supporting professional activities (SPAs) including CPD, QI activity, supervision, appraisal and job planning | 2.5 |
FT liaison community-based
| Description | Professional activities |
|---|---|
| Direct clinical care, including: | 7.5 |
| Face-to-face contact with patients in clinic or wards | 3 |
| Multidisciplinary team meeting and support for team members outside the meeting | 1.5 |
| Consultation and liaison with and supervision and training for health/ social care staff outside the team | 1.5 |
| Mental health legislation work/complex patient reviews or liaison with other specialties | 1.5 |
| Supporting professional activities (SPAs) including CPD, QI activity, supervision, appraisal and job planning | 2.5 |
Factors that should be taken into consideration in a job description include the following:
There is great variation in liaison mental health services across the four nations, reflecting local demographics, needs and priorities, available resources and historic development of services.
A liaison mental health service may include some or all of the following components:
- Emergency department liaison psychiatry
- Self-harm service
- Liaison mental health service for general hospital in-patients
- Substance misuse liaison teams
- Out-patient clinics
- Additional specialised services (e.g. chronic fatigue syndrome, persistent physical symptoms, psycho-oncology, transplant surgery, persistent pain, post covid syndrome, gender dysphoria)
- Primary care and community-based clinics
- Home visits
- ·Multidisciplinary meetings with health and social care staff
- Teaching, training and supervision
- Leadership of service developments and pathways of integrated care
There is a wide variation in the composition and size of the teams. The nature and volume of work may differ according to the local referral criteria (e.g. age range, referral sources, catchment area), hours of operation, other resources available (e.g. separate alcohol and substance misuse liaison services) and focus of the service (general hospital or community). Some liaison psychiatry teams provide services for peoples of all ages (often with specialist sub-teams in larger hospitals). If the consultant works in more than one site, then travel time should be taken into consideration in their job plan.
The expected workload and distribution of work-related activities of a consultant liaison psychiatrist therefore depends on the nature of the post, including whether it is an acute health or community-based post, the nature and size of the hospital, the proportion of consultation vs direct clinical care, and the amount of involvement in service development, education and training roles. For hospital-based services in England guidance from the National Institute for Clinical Excellence in 2016 proposed a model of care called ‘Core 24’ which operates over 24 hours, 7 days a week. This stipulates 2 whole time equivalent liaison consultants for a hypothetical 500 bedded hospital. There is no similar guidance for community based posts currently.
The distribution of activities below is for guidance only and should be adapted according to local needs in terms of the leadership role, the model of service and staffing of the team. For example, a liaison service in a large hospital may need increased professional activity time in the job plan of the consultant to support leadership, service development and governance arrangements. Similar will apply to a liaison service working within integrated pathways of care across the community, primary and secondary care at the interface of physical and mental health. To fulfil all the below roles in one team more than 1 consultant is likely to be needed. For both efficiency and context feedback from the PLAN process, Friends and Family Test and 360-degree review can be used to support the appraisal process .
The hospital model would work if staffing numbers are appropriate. Where staffing numbers do not match PLAN suggestions, I would suggest more time for consultation work with other team members. In this instance I would suggest for hospital based liaison mental health services, face to face is limited to 3, sessions, emergency work 1 session, MH work 1.5, admin 1 session with 1.5 PAs for MDT meeting / support for team members.