Service development resources

Introduction

Many consultants in liaison psychiatry find the first few years of their appointment to be a struggle and feel ill-prepared to deal with the many administrative and managerial problems which have to be overcome, involving support services, office space, junior medical staffing and managerial responsibility.

These notes are written by liaison psychiatrists with a range of experience in establishing liaison services in different hospitals in the hope that they will help future consultants negotiate some of the difficult problems which will face them following their appointment.

Preliminary negotiations

It is important to learn as much as possible about the post before making an application and certainly before attending for interview if shortlisted.

Most liaison psychiatry consultant posts are new appointments; this implies that there is usually only a rudimentary service in place although this situation is likely to change in future. It is important to meet the Medical Director and Chief Executive of the employing Trust and to establish what their aspirations are for a liaison psychiatry service.

It should be clarified whether the post involves responsibility for emergencies in the Accident and Emergency department and provision of a service for patients admitted following deliberate self-harm.

With the expansion of posts for specialist psychiatric nurses in Accident and Emergency departments, some new consultant posts are being developed to provide supervision for these nurses who may also carry out deliberate self-harm assessments. In these cases, it is important to ensure that the post includes other aspects of liaison psychiatry, and sufficient time for this work.

If the liaison post is half-time or associated with sessions in general psychiatry, the liaison psychiatry sessions should be identified and protected.

The College will not approve job descriptions for a split post if there are fewer than five liaison sessions. The job description should clarify who will be covering the general psychiatry component of the post whilst the clinician is doing the liaison psychiatry sessions. The commitment to general psychiatry should be reduced in relation to the number of available sessions.

If the employer is a mental health trust it is also necessary to meet the key individuals of the acute general hospital trust in which the service will be located, including the Medical Director, Chief Executive and relevant academic clinicians.

Some liaison psychiatry posts have been developed specifically with the support of medical specialists, such as HIV, neurology or liver transplantation, and it is obviously important to discuss plans with these key individuals. The scope of the post should be established together with plans for accommodation, support staff and, if appropriate, in-patient beds.

If the job description does not reflect a post that is going to be workable then you will need to negotiate changes to the job description prior to interview. In many cases, the prospective candidate will be discussing the development of a new liaison service, and may well be involved in helping to write or formulate the job description.

If you are offered this role, you will be able to tailor the job according to your needs and ensure that resources will meet demands.

Managerial 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 SLA 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, The psychological care of medical patients by the College and the Royal College of Physicians in 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 and 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.

Junior medical staff

It is essential to have appropriate junior medical support. Indeed, no liaison psychiatry consultant should be expected to provide a service without junior medical staff. Training posts in liaison psychiatry are usually regarded as an enjoyable and useful learning experience.

If there is no post at SHO level prior to the consultant being appointed, arrangements must be made as soon as possible to establish such a post. This should be for six months, preferably whole time, and should form part of a rotational training programme. If a post needs to be established the consultant should lose no time in drawing up a job description for an SHO, together with a weekly time-table. The educational component of the post is crucial in determining its attractiveness.

 

The consultant must make it clear that he/she is going to supervise the trainee closely, provide support and allow one hour scheduled supervision each week. The post should be discussed with the local clinical tutor and regional postgraduate Dean.

Similar remarks apply to specialist registrars. Training at SpR level in liaison psychiatry currently forms part of a training in general adult psychiatry. In order to be endorsed on the specialist register as having higher training in liaison psychiatry, an SpR needs to spend twelve months in a whole-time post as part of general psychiatry training. This situation may change within the next few years if the duration of SpR training in psychiatry is extended to four years. Alternatively SpR's may opt to spend special interest sessions (up to two sessions weekly) in liaison psychiatry. The consultant may be approved as an SpR trainer after he/she has been in post for 12 months but can apply for consideration of such approval towards the end of the first year in post.

If an SpR is employed in a full-time liaison psychiatry post he/she should be expected to try to develop new services and to conduct a research project which hopefully would lead to a publication in the liaison psychiatry literature.

Non-medical professional staff

A liaison psychiatry service functions best if it is delivered by a multi-disciplinary team. There has been a recent increase in the number of liaison psychiatry nurses and every effort should be made to establish such posts where appropriate.

Suitably trained liaison nurses can provide an excellent service to an Accident and Emergency department where, among other responsibilities, they can assess patients following deliberate self-harm and make appropriate treatment plans for their aftercare. They also have a major role to play in the assessment and management of behaviourally-disturbed patients who are referred to an A&E department or who are self-referrals.

It is also helpful if the liaison nurses can see appropriate patients on general medical and surgical wards. They have particular skills in advising on the management of psychotic or suicidal patients and they can advise general medical nursing staff appropriately.

They should not be expected to provide individual nursing care to psychiatric patients on medical wards. If such a service is needed it is usually necessary to bring in a registered mental health nurse from a nursing agency.

Nurse therapists can also make an invaluable contribution to a liaison psychiatry service.

Senior nurses with either a cognitive behavioural training or a training in a relational (interpersonal) therapy can undertake treatment. Nurses on lower grades can be taught to implement simple behavioural programmes which may be especially helpful for the chronically ill who are under functioning. Similarly, an appropriately trained occupational therapist who can offer behavioural interventions in addition to occupational therapy assessments will be invaluable.

A clinical psychologist specialising in health psychology, is also an important member of the liaison service. This individual may take direct referrals from physicians and surgeons but in most cases it is likely that referrals will be made by the consultant psychiatrist and psychiatric trainees. Health psychology is an expanding discipline. It is important that money is earmarked for the establishment of such a post.

The role of a social worker is less clearly defined. If the liaison service is responsible for assessing patients referred urgently to an Accident and Emergency department from the community (e.g. general practitioners or the police) it is important that there is an approved social worker attached to the service, located predominantly in the Accident and Emergency department.

This individual will be invaluable in assessing patients if admission to hospital under Mental Health Act, 1983, is thought to be necessary.

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.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 they 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.

Teaching

Liaison psychiatry offers excellent opportunities for undergraduate teaching, both within a psychiatric programme and for students attached to a medical firm. It is also helpful if the liaison team can present cases at medical grand rounds or other departmental meetings, such as neurology, diabetes or AIDS.

Opportunities should be sought to give lectures to groups of other medical specialists at postgraduate meetings. These functions have an excellent public relations role.

Research

Research opportunities should be developed. They are important in themselves, to further the understanding of psychological factors in medical practice. They also facilitate links with other departments. It is helpful if research proposals are drawn up jointly with non-psychiatry specialists.

There are opportunities for applying for research funds and appointing research workers from a psychiatric background. If the post is an NHS consultant post it is an advantage if it carries an honorary academic appointment with the local university department of psychiatry.

Links with colleagues

A liaison psychiatry post can be isolated initially, before clinical contacts are established. The person appointed needs to maintain professional contacts with both medical and psychiatry colleagues; this can be difficult if the liaison psychiatrist is situated in a general hospital while the main community psychiatry service is located elsewhere. The liaison psychiatrist may thus come to be seen as occupying a no-man's land between medicine and psychiatry, but being a member of neither.

Our faculty already has a trainees and new consultants group and is establishing a panel of mentors - any one of whom may be approached in confidence by a newly appointed consultant to obtain advice and support about service development.

It is important to maintain your identity as a psychiatrist and to attend committee meetings, postgraduate teaching sessions, case conferences and audit meetings with your colleagues, and to take part in CPD.

Annual appraisals will need to be carried out. These should provide a useful opportunity to review progress and to highlight any deficiencies in the facilities and staff associated with the service. Our Faculty recommends that liaison psychiatrists should be appraised by specialists in the field and not by a general adult psychiatrist.

Many district hospitals have no existing liaison service and a new post and team may have to be developed from scratch.

Trainees who are interested in liaison psychiatry may find themselves having to take a major role in the development of the post.

In these circumstances it is helpful to have a good grasp of background information. This would include:

Another useful initiative is to arrange to be invited to a forum within the general hospital to make the case for liaison psychiatry: e.g. the Trust Management Board. Your presentation should be tailored around how it will meet the requirements of the NHS Plan, NSFs etc, and improve the quality of care for patients, and has the potential to reduce costs and waiting times.

It is also helpful to consider putting in a bid to the health authority or primary care group for the development of a liaison service. If you have general support, even it if not successful, the trust may fund your service from within existing resources.

Visit other liaison services and speak to other liaison consultants to ask how they managed to set up their services. Do not be afraid to ask for advice or support. Consultants in established liaison psychiatry posts have often experienced problems identical to those which you may be facing. There is a growing pool of knowledge and experience which we are all keen to share.

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