Behind the scenes of the Liaison Faculty in Scotland

Dr Prakash Shankar shares insights from his four-year tenure as Chair of the Liaison Faculty in Scotland.

Well, the Olympics are over for another four years, and time to reminisce taking over the baton in October 2020 as the Chair of the Liaison Faculty in Scotland from my esteemed predecessor Dr Stephen Potts (Steve for most of us). I did not clearly fathom the responsibilities the role entailed as excitement tinged with apprehension hides the ‘strategic’ negotiations with various stakeholders prominently the Scottish Government.

However, with astute mentoring and support from colleagues, the challenges of the pandemic and the post-pandemic recovery was not insurmountable. I had not realised in my naiveté that these positions do not attract additional resources for busy jobbing clinicians. 

Strengthening the team

Faculties find it difficult to recruit office bearers, so I was lucky to be able to entice Dr Murray Smith to be the Vice-Chair (hitherto not tried in the Faculty) to share the journey. Fortunately, in the small world of the Liaison Faculty in Scotland, the Celtic bonhomie and camaraderie is phenomenal. It meant that we could be guided by experienced deckhands like Steve, Roger and others to navigate the choppy seas on era-defining changes.

Canvassing the voice of psychiatrists leading on the discussions on the Bill proposed to legalise assisted dying in Scotland remains a challenging area. Similarly, the legislative oversight group that monitors the implementation of recommendations from the Scott Review of Scottish Mental Health Act, Mental Health and Capacity Reform Program (MHCRP), Learning Disability, Autism, and Neurodiversity Bill (LDAN) will impact on the lives of liaison psychiatrists and it was reassuring to have liaison psychiatrists lead from the front.

The Liaison Psychiatry Service Survey

We discovered that the initial challenge was a lack of clarity around liaison psychiatry services in Scotland. We were envious of the regular surveys conducted by the Liaison Faculty in England (funded by NHS England and the Liaison Faculty of the Royal College of Psychiatrists). The stark inequalities and cost-effectiveness of well-resourced Liaison services attracted the attention of service commissioners that led to the rapid expansion of Liaison services across the border.

The bureaucratic hurdles of incorporating Scotland into the fold appeared insurmountable, so we decided to undertake one of our own. This unearthed the disproportionate distribution of resources and hopefully will draw similar attention of wider stakeholders locally. Following interminable discussions with our English colleagues, we hope that the next iteration of the Liaison Psychiatry survey is going to be a UK-wide endeavour.

We were able to successfully engage with the Scottish Government and multiple stakeholders to develop the new Self Harm Strategy that helped me understand policy evolution at scale. Dr Murray Smith represented the Faculty at the Oral Evidence Session Equalities, Human Rights and Civil Justice Committee that is undertaking a short inquiry on suicide prevention in Scotland.

They were keen to hear evidence on the Scottish Government and COSLA’s Scotland’s Suicide Prevention Strategy 2022-2032: Creating Hope Together in 2022 supported by the social movement ‘United to Prevent Suicide’. The prospect of doubling funding for suicide prevention work might help the development of third-sector resources to complement the work undertaken by various Liaison services.

Shaping the future 

We have also been proactive in engaging with the Scottish Government on the local challenges and the context for the new Scottish National Self-Harm Strategy drawing on from the new NICE guidelines. The Scottish Faculty is also liaising with College representatives in developing a position statement on the inappropriate use of criminal sanctions as a response to self-harm, suicidality, and contact with emergency services in the wake of the HMICS review and MWC Place of Safety report.

The Scottish Faculty is looking forward to working on the proposal for RCPsych to establish cross-College work programme at either Presidential Lead or Associate Registrar level to address contemporary institutional abuse depicted in the recent media reports.

We remain engaged in drafting the Mental Health and Wellbeing Workforce Action Plan reiterating a public health approach to reduce factors leading to mental disorders. In this context, the potential emergence of the National Care Service (NCS) will be an interesting development to keep our eye on (given the fiscal environment). The NCS Board proposes to oversee delivery across Scotland to improve transparency by reforming existing integration authorities, so we need to be mindful of the National Outcomes and its impact for Liaison Psychiatrists.

This will have impact in areas such as ME/CFS by revision of Scottish Guidelines, the implementation of the MEED guidelines in acute hospitals and pathways being proposed by Grampian colleagues for patients with eating and personality disorders. One of the themes close to my heart is how do we capture the quality of the service we provide in terms of standards and outcomes. So, when the opportunity arose, we were able to respond to the Scottish Government’s Review of National Outcomes. We made concerted efforts to align the Scottish attempts by ‘tartanising’ the more widely accepted 'RCPsych new Psychiatric Liaison Accreditation Network (PLAN- 7th Edition)'.

Addressing capacity, demand, and service quality; and getting our voice heard

Scottish Faculties struggle to get a proportional hearing at the National congregations, and I had endeavoured to have closer working relationship with the larger RCPsych Liaison Faculty. We were able to have Chair/Vice Chair meetings as a prelude to the national meeting so that the agenda fairly represented the heterogeneity of devolved issues. We were thus able to provide meaningful contribution to the development of National Liaison Strategy for workforce development and supporting members in influencing NHS clinical and operational delivery.

We were able to get our voices heard at the national level for crafting a meaningful RCPsych response to RCEM position statement on managing acute behavioural disturbance. We were able to push back on the proposed introduction of unevaluated models to relieve the pressure on services to plug the gaps as this will cause diversion of existing staffing and resources from liaison psychiatry.

It was important that any prospective changes were underpinned by evidence and data driven. So, it was surprising to learn that in Scotland neither MWC nor PHS collect this data to help us understand demand.  On the other hand, understanding capacity became easier by reflecting the diversity of service provisioning in the heterogenous conglomerate of ‘devolved nations’ by being closely aligned with the development of the next iteration of CR207- ‘Safe patients and high-quality services: Job descriptions for consultant Liaison psychiatrists.

We remain engaged in continuing to work with the National lead to develop framework for integrated psychological medicine specially to manage long term conditions and the rather niche area of the special interest group on Factitious/perplexing presentations.

Reflections on leadership

Away from the policy discussions, one of the most exciting and challenging endeavour undertaken by the Faculty Chair is to deliver the Scottish Liaison Faculty Annual Conferences. It was our privilege to deliver four sold out conferences during my tenure that was well received widely. Another privilege for the Chair was to be invited to annual stakeholder meeting for research projects such as CoMorMent (The EU-H2020 funded project coordinated by University of Edinburgh and Oslo) in Tallin Estonia. It investigated how and why mental ill health interacts with cardiovascular disease by using a 'big data' approach, to find new methods to reduce the risk of developing multiple diseases at the same time).

One of my aspirations was to widen the diversity within the Faculty and we were able to get an Equality Inclusion Trainee Rep, patient representative and incorporate Scottish voice into the Curricula Revision Project and Liaison Credentialing for the GMC.

So, looking back, it was a hectic and eventful four years that taught me so much about ‘soft leadership’ skills. Guidelines, changes to legislation and risk assessments are well-meaning aspirations but miss the complexity of the health care environment. As Faculty chairs it is our responsibility to hold the politicians to be honest with the public about how scarce services are being rationed and to be not gaslit by vacuous talk of “efficiency savings”.

This undermines the relentless pressure on liaison psychiatrists often at the coalface of unscheduled services with ‘resilience shaming’. The incentives aligned towards rapid discharge makes repeat presentations inevitable due to yawning gaps in community care with limited continuity of care.

Practising careful, thoughtful liaison psychiatry requires time and compassion limited by the peripatetic nature of our work to see our interventions bear fruit as feedback. Legislating our way out of what is fundamentally a problem of resources and a deeply rooted distorted culture of asking us to predict the unpredictable is unsustainable!

So, it is with a heavy heart I relinquish my role ably supported by the ever-cheerful RCPsych office team. For my successor, perhaps the sage words of one of my role models - Arthur Ashe 'Start where you are, use what you have, do what you can’ - no pressure at all...

Dr Prakash Shankar, Chair, Liaison Faculty in Scotland