Why do we need Learning Disability psychiatrists in Learning Disability liaison teams?
24 January, 2024
Professor Cath Bright reflects on the importance of having Learning Disability (LD) psychiatrists as a part of the LD liaison teams.
When I retired from my full-time NHS community consultant post I was keen to embrace a new challenge. I had always taken the view that LD consultants had a strong role in health advocacy for the people they work with. Aneurin Bevan University Health Board (ABUHB) has invested in both Primary and Secondary Care Liaison Nurses and I was asked to join the Acute LD Liaison team 2 days per week.
This team work in all of the acute and stepdown hospitals in ABUHB approx. 774 beds in 9 wards. When I started in the team we relied on internal referrals to the team, but now we access a daily electronic record of current inpatients (those with an LD Flag on our system) who we visit even if a referral has not been made by ward staff. Occasionally we receive referrals for people with LD, who have not been previously known to services.
The team comprises of 1 fulltime, 2 60% WTE and 1 40% WTE Band 6 nurses, plus myself. Their remit is to develop and deliver training including LD Champions Training, to monitor the implementation of the LD nursing care bundle and to offer support and advice to wards regarding people with LD and reasonable adjustments. The team also support reasonable adjustments for outpatient appointments and investigations.
So, what is the role of a Consultant Psychiatrist in this service? Initially, it was thought that most of the work would center around the mental health issues of patients with LD in acute hospitals much like the standard hospital liaison role in general psychiatry. However, after a period of nearly 2 years in this role it is apparent that the role of the LD psychiatrist in an Acute Liaison Team is much broader than this. I do see people where there is an identified or suspected mental health issue or where there is challenging behaviour (Neurology often review inpatients with epilepsy and so this is not a significant part of my role).
LD doctors can provide an invaluable resource to our nursing colleagues in relation to treatment rationale, drug regimes, interpreting test results and options for surgical interventions. We have a medical-based view of palliative care and we have a broad understanding of pathology and prognostic indicators. These skills bring a balanced view to the work of the team and provide support and advice to the team when issues of support and care for a patient with LD is being discussed. We are also in a better position to identify and flag up poor medical care (in a similar way the Liaison nurses can identify poor standards in nursing care)
As LD Consultants we have a detailed knowledge of MHA and MCA and are also skilled at assessment of capacity. We understand the need and mechanism for best interest decisions if someone lacks capacity and we often have good knowledge of policy such as DNACPR. This represents an important role in the Acute Liaison team, especially if there is conflict between acute care professionals and family or uncertainty about the provisions of MCA (sadly this is not uncommon).
As an LD consultant, I also have a role in the team in “unsticking situations”. One of the major frustrations for our nurses is that although they can influence nursing practice on wards to some extent, their requests to doctors can sometimes be overlooked or even ignored. My role can sometimes simply be sending an email to a consultant colleague outlining the concerns of the liaison team, or requesting a best interests meeting. My direct contact to the Consultant is often successful more quickly than the nursing team attempting to escalate concerns via the nursing and medical hierarchy on the ward.
I have a role in supporting teaching and education and expanding the groups that we train as LD Champions. I have supported the updating of the training packages, I am exploring with colleagues how we get training to colleagues early in their clinical training and I have trained cohorts of individuals as LD champions and supported induction for groups of doctors.
Perhaps unique to me is the fact that I have worked for many years as a community LD Psychiatrist in ABUHB and so inevitably I have some previous knowledge of a proportion of our inpatients and their families and carers. It has been a real privilege to see patients I have known for years come into our acute hospitals, receive good care and go home again but it is equally a privilege and a sadness to see those I have worked with in the past come into the hospital and die.
A good death can and often does happen for people with LD, but my role and that of the team I work with, is to highlight and pursue instances of poor care which has led to morbidity or mortality. We raise concerns through all the appropriate mechanisms in our organisation and provide support and training for clinicians involved in these incidents.
As people with LD lead longer lives than in the past, the diseases of old age and acute illness become more of an issue for them and extended periods of hospitalisation appear to be becoming more common, there is therefore likely that LD doctors will be a useful adjunct to LD Liaison teams.