Liaison mental health services to acute hospitals - The Joint ...

Liaison mental health services to acute hospitals - The Joint ...
Guidance for commissioners of liaison mental health services to acute hospitals   1

Joint Commissioning Panel
for Mental Health

                                     Guidance for commissioners of

                  liaison mental health
            services to acute hospitals

                                             mental health
Liaison mental health services to acute hospitals - The Joint ...
Joint Commissioning Panel
for Mental Health

 Co-chaired by:

Liaison mental health services to acute hospitals - The Joint ...
2    Practical Mental Health Commissioning


    Executive                     Introduction          What are          Why is acute
    summary                                             acute liaison     liaison important
                                                        services?         to commissioners?

                                  04                    05                05
    What do we                     What would           Supporting        Resources
    know about the                 a good liaison       the delivery      and references
    current provision              service look like?   of the mental
    of acute liaison                                    health strategy

    07                             09                   12                14
Liaison mental health services to acute hospitals - The Joint ...
Guidance for commissioners of liaison mental health services to acute hospitals   3

Executive summary

• Physical and mental health are             • A liaison service should be an integral
  inextricably intertwined. Long-term          part of the services provided by acute
  conditions (LTCs), such as diabetes,         hospital trusts – trusts that have
  are associated with high rates of mental     incorporated a liaison service have
  illness. Some 70% of NHS spend goes          demonstrated much better cost-
  on the treatment of LTCs, a great deal       effectiveness.
  of which currently involves treatment
                                             • Commissioning of acute liaison
  in acute hospitals.
                                               services should be universally included
• Psychological stress is often expressed      in contracts for the provision of
  as physical symptoms, which are an           acute hospital services and concord
  example of medically unexplained             to standards set by professional and
  symptoms (MUS).                              regulatory authorities.
• The mental health needs of a patient       • Acute liaison services should have the
  in a physical health care setting often      resources and skills needed to support
  remain undiagnosed and therefore             all age groups.
  untreated. To optimise the physical
                                             • Liaison services may, over time, extend
  health care of patients, it is essential
                                               their remit to help primary mental health
  that their mental health and wellbeing
                                               care to manage people with LTCs and
  are addressed at the same time.
                                               MUS, in order to avoid unnecessary
• Liaison services should be provided          admissions to secondary care.
  throughout the acute hospital, including
  in A&E departments. Services should
  be provided to meet the needs of
  patients with a mental disorder
  secondary to their physical disorder,
  or a physical disorder alongside their
  mental disorder, and for patients
  (particularly those with MUS) where
  it is impossible to separate the two.
• Acute liaison services operate within
  existing (often ad hoc) local networks
  of other generic and disorder-specific
  clinical health psychology and
  multidisciplinary services. This should
  be mapped out by commissioners so
  that acute liaison becomes a primary
  partner in the effective management
  of the emotional and adjustment/
  behavioural needs of all patients
  presenting to acute services.
Liaison mental health services to acute hospitals - The Joint ...
4   Practical Mental Health Commissioning


The Joint Commissioning Panel                The JCP-MH has two primary aims:               How will this guide help you?
for Mental Health (JCP-MH)                   • to bring together service users, carers,     This guide has been written
( is a new                      clinicians, commissioners, managers and      by a group of acute liaison
collaboration co-chaired by                    others to work towards values-based
                                                                                            experts in consultation with
the Royal College of General                                                                patients and carers.
Practitioners and the Royal                  • to integrate scientific evidence, service
                                               user and carer experience and viewpoints,    The content is primarily evidence-based but
College of Psychiatrists,                                                                   ideas deemed to be best practice by expert
                                               and innovative service evaluations in
which brings together leading                  order to produce the best possible advice    consensus have also been included. By the
organisations and individuals                  on commissioning the design and delivery     end of this guide, readers should be more
with an interest in commissioning              of high quality mental health, learning      familiar with the concept of acute liaison
for mental health and learning                 disabilities, and public mental health       and better equipped to:
disabilities. These include:                   and wellbeing services.
                                                                                            • understand what a good quality,
                                             The JCP-MH:                                      modern, acute liaison service looks like
• Service users and carers                                                                  • understand why a good acute liaison
• Department of Health                       • has published Practical Mental Health
                                                                                              service delivers the objectives of the
• Association of Directors                     Commissioning,2 a briefing on the key
                                                                                              mental health strategy and the Quality,
  of Adult Social Services                     values and principles for effective mental
                                                                                              Innovation, Productivity and Prevention
• NHS Confederation                            health commissioning
                                                                                              (QIPP) challenge – not only in itself but
• Mind                                       • provides practical guidance and a              also by enabling changes in other parts of
• Rethink Mental Illness                       developing framework for mental health         the system.
• National Survivor User Network             • will support commissioners of public
                                                                                            This guide also addresses issues relating
• National Involvement Partnership             mental health to deliver the best
                                                                                            to the commissioning of acute liaison
• Royal College of Nursing                     possible outcomes for community
                                                                                            services. It describes:
• Afiya Trust                                  health and wellbeing
• British Psychological Society                                                             • the benefits of liaison services
                                             • has published a series of short guides
• Representatives of the English                                                            • the optimum liaison psychiatry team
                                               describing ‘what good looks like’ in
  Strategic Health Authorities                                                              • the mental health needs in acute care
                                               various mental health service settings.
• Mental Health Providers Forum                                                               settings that a liaison service addresses
• New Savoy Partnership                      Who is this guide for?                         • why a liaison service is important for
• Representation from                                                                         commissioners of acute hospital services.
  Specialised Commissioning                  This guide describes what
                                                                                            This guide draws on, and refers to,
• Healthcare Financial                       ‘good looks like’ for a modern                 previously published guidance including:
  Management Association.                    acute liaison service. It
                                                                                            • the Royal College of Psychiatrists
The JCP-MH is part of the implementation     should be of value to Clinical
                                                                                              College Centre for Quality Improvement
arm of the government mental health          Commissioning Groups (who                        PLAN standards3
strategy No Health without Mental Health.1   will be commissioning secondary                • the Royal College of Psychiatrists
                                             services, both specialist mental                 CCQI Mental Health Policy
                                             and acute).                                      Implementation Guide for Liaison
                                                                                              Psychiatry and Psychological Medicine
                                                                                              in the General Hospital4
                                                                                            • the Royal College of Psychiatrists
                                                                                              briefing No Health without Mental
                                                                                              Health: the Supporting Evidence5
                                                                                            • the NHS Confederation briefing
                                                                                              Healthy Mind, Healthy Body.6
Liaison mental health services to acute hospitals - The Joint ...
Guidance for commissioners of liaison mental health services to acute hospitals   5

What are acute                                 Why is acute liaison important
liaison services?                              to commissioners?
An acute liaison service                       The problems acute liaison                           Mental and physical health
                                                                                                    are closely linked
is designed to provide                         addresses are common:
services for:                                  • mental disorder accounts for around                Mental illness increases risk
• people in acute settings (inpatient or         five per cent of A&E attendances, 25%              of physical illness and
  outpatient) who have, or are at risk           of primary care attendances, 30% of                complicates its management.
  of, mental disorder                            acute inpatient bed occupancy and 30%              Depression is associated with:
                                                 of acute readmissions7
• people presenting at A&E with urgent                                                              • reduced life expectancy of 10.6 years
  mental health care needs                     • self-harm accounts for between
                                                                                                      in men and 7.2 years in women12
                                                 150,000 and 170,000 A&E attendances
• people being treated in acute settings                                                            • increased risk of coronary heart disease13
                                                 per year in England8
  with co-morbid physical disorders such
                                               • MUS may account for up to 50% of                   • four-fold increased risk of myocardial
  as long-term conditions (LTCs) and
                                                 acute hospital outpatient activity9                  infarction (MI) and four-fold increased
  mental disorder
                                                                                                      risk of death within six months of
• people being treated in acute hospital       • 13–20% of all hospital admissions and
                                                                                                      myocardial infarction14
  settings for physical disorders caused         up to 30% of hospital admissions via
                                                 A&E at weekends are related to alcohol10           • two-fold increased risk of type 2
  by alcohol or substance misuse
• people whose physical health care is         • in England, alcohol-related hospital
                                                 admissions doubled in the 11 years up              • three-fold increased risk of non-
  causing mental health problems
                                                 to 2007, and alcohol-related deaths also             compliance with treatment
• people in acute settings with medically                                                             recommendations.16
                                                 doubled in the 15 years to 200611
  unexplained symptoms (MUS).
                                               • one quarter of all patients admitted to            Schizophrenia is associated with:
The service aims to increase the detection,      hospital with a physical illness also have
recognition and early treatment of                                                                  • reduced life expectancy of 20.5 years
                                                 a mental health condition that, in most              in men and 16.4 years in women17
impaired mental wellbeing and mental             cases, is not treated while the patient is
disorder to:                                                                                        • three-fold increased death rate from
                                                 in hospital6
                                                                                                      respiratory disease18
• reduce excess morbidity and mortality        • most patients who frequently re-attend
  associated with co-morbid mental and                                                              • two-fold increased risk of obesity, two
                                                 A&E departments do so because of an
  physical disorder                                                                                   to three-fold increased risk of smoking,
                                                 untreated mental health problem6
                                                                                                      two-fold increased risk of diabetes,
• reduce excess lengths of stay in acute       • two thirds of NHS beds are occupied                  two to three-fold increased risk of
  settings associated with co-morbid             by older people, up to 60% of whom                   hypertension, five-fold increased risk
  mental and physical disorder                   have or will develop a mental disorder               of dyslipidaemia and two to three-fold
• reduce risk of harm to the individual and      during their admission.6                             increased risk of metabolic syndrome.19
  others in the acute hospital by adequate
  risk assessment and management                                                                    Substance use disorder is associated
                                                                                                    with 13.6 year reduced life expectancy
• reduce overall costs of care by reducing
                                                                                                    for men and 14.8 years for women.12
  time spent in A&E departments and
  general hospital beds, and minimising                                                             Smoking is the main cause of preventable
  medical investigations and use of                                                                 death in the general population. People
  medical and surgical outpatient facilities                                                        with a mental disorder smoke much more
• ensure that care is delivered in the                                                              than people without a mental disorder:
  least restrictive and disruptive manner                                                           they consume 42% of all tobacco
  possible.                                                                                         consumed in England.20
Liaison mental health services to acute hospitals - The Joint ...
6   Practical Mental Health Commissioning

Why is acute liaison important to commissioners? (continued)

Physical illness increases the risk of        Integrated mental                             Liaison services are important in facilitating
mental illness. Depression is more common     and physical health care                      collaborative care approaches to both
in those with a chronic physical illness.21                                                 mental and physical health conditions.
                                              The close links between
Risk of depression is doubled for people                                                    Closer working between primary and
with diabetes, hypertension, coronary         mental and physical health                    secondary care staff is particularly
artery disease and heart failure, and         highlight the importance of                   important in improving the confidence
tripled in those with stroke, end-stage       an integrated approach to                     of specialist mental health staff in
renal failure and chronic obstructive         treating physical and mental                  identifying, preventing and intervening
pulmonary disease.22                          illness. However, traditionally               early with physical health problems, and
                                                                                            vice versa (see the companion primary
Depression is more than seven times           mental and physical health
                                                                                            mental health care commissioning guide).
more common among people with two             care have been commissioned
or more chronic physical conditions.23        separately; it is rare that the               The quality and productivity
One in five people newly diagnosed with                                                     challenge (QIPP)
cancer or first hospitalised with a heart
                                              needs of patients with mental
attack will develop depression or anxiety     and physical health problems                  Commissioners are required
within one year.24                            are provided for through a                    to improve quality while
Children with physical illness are at
                                              single funding stream.                        at the same time increasing
increased risk of emotional or conduct        Mental health and physical health             productivity (QIPP). Liaison
disorder.25                                   are closely linked. Liaison services          services provide an excellent
                                              provide commissioners with a means to         opportunity to do this by:
                                              address this in the acute hospital setting.
                                                                                            • improving clinical outcomes
                                              Liaison services can significantly reduce
                                              incidence of mental illness associated        • reducing admissions to and lengths of
                                              with physical illness and vice versa,           stay in acute settings
                                              thereby reducing the burden on both           • ensuring patients with co-morbid long-
                                              primary and secondary care. The focus           term conditions receive better treatment
                                              of Improving Access to Psychological            while using fewer health care resources
                                              Therapies (IAPT) has been extended to         • treating and reducing costs for patients
                                              cover psychological interventions for           with MUS
                                              LTC co-morbidity and MUS.
                                                                                            • reducing psychological distress following
                                              Mental illness can frequently cause             self-harm, and reducing suicide.
                                              or aggravate physical disorder. These
                                              disorders are seen and treated in acute
                                              hospital settings. The commissioners of
                                              acute hospital services should therefore
                                              be responsible for commissioning acute
                                              liaison services to meet this need.
Liaison mental health services to acute hospitals - The Joint ...
Guidance for commissioners of liaison mental health services to acute hospitals   7

What do we know about the
current provision of acute liaison services?
There is currently no single,                   • participation in Mental Health Act                 • assessment, management and
uniform model for liaison services                and Mental Capacity Act assessments,                 signposting of patients with alcohol and
                                                  and performing risk assessments for                  substance misuse disorders.
across the country. Where such                    harm to self and others
services exist, they are often                                                                       The service could bring the
                                                • expert advice on capacity to consent               following benefits:
provided by the local mental                      for medical treatment in complex cases
health trust within the estate of                 involving both physical and mental                 • increased mental health care capacity
the acute hospital trust, which                   health problems                                      within the acute hospital through
may present logistical and                      • acting as a Responsible Clinician
operational challenges.                           under the Mental Health Act for people             • improved wellbeing of staff in acute
                                                  detained under the Act, and receiving                hospital settings, by relieving the anxiety
Liaison services are commonly                                                                          these staff sometimes feel when dealing
                                                  care in the acute hospital
commissioned by the commissioners of                                                                   with patients with complex needs –
mental health services (rather than the         • rapid response to requests for
                                                                                                       this may in turn help reduce levels
commissioners of acute hospital care).            assessment in the A&E department and
                                                                                                       of sickness absence
This is despite the fact that the acute trust     on acute hospital wards (assessment and
                                                  management of people who have self-                • improved patient self-management
should be providing them, and the quality
                                                  harmed forms a significant proportion                of their care
and productivity benefits that derive from
the service are realised within the acute         of this responsibility)                            • improved physical care of people
hospital setting.                               • development of care plans                            with mental disorder
                                                  post-assessment                                    • reduced stigma associated with
Most acute liaison services                     • arranging appropriate follow-up                      mental health care.
could provide the following:                      post-discharge
• advice, training and coaching on              • assessment of people with MUS
  the management of mental health               • management of people with MUS
  problems to other professionals in              who require a higher level of input
  the acute hospital                              than can be provided by lower
• biopsychosocial assessment,                     intensity services such as IAPT – in
  formulation and diagnosis for people            association with primary care, specialist
  identified by acute hospital staff              medical teams and other specialist
  as experiencing impaired mental                 multidisciplinary teams (eg. chronic
  wellbeing or whose physical symptoms            fatigue syndrome/ME services)
  are unexplained                               • contributing to the management
• brief interventions, advice and                 of people with long-term physical
  signposting to services in a range              conditions in collaboration with primary
  of agencies for patients in acute               care and specialist physical health
  hospital settings                               multidisciplinary teams (eg. diabetes
                                                  psychology and dietetics)
                                                • assistance with the management
                                                  of people with long-term physical
Liaison mental health services to acute hospitals - The Joint ...
8   Practical Mental Health Commissioning

What do we know about the current provision of acute liaison services? (continued)

Models of acute liaison service                 • chronic pain management teams and
vary greatly, from those that                     chronic fatigue teams, operating over a
                                                  wider area than a single acute hospital
provide a ‘core’ adult mental
                                                • cancer network of psychosocial support
health liaison service to those
                                                  professionals, organised to support
that cater for more complex                       sophisticated training arrangements for
needs (learning disability,                       medical and nursing oncology staff (and
dementia, children and young                      often including liaison psychiatrists)
people). However there is a                     • cardiac and pulmonary rehabilitation
considerable body of work that                    teams.
describes what liaison services                 Existing liaison services tend typically to
should do, how they should be                   be for adults with mental health needs,
organised and what standards                    and not for children and young people.
they should achieve.                            An important development would be
                                                for commissioners to commission liaison
Liaison psychiatry provision is often patchy,   services that are age-inclusive. The liaison
despite its core role in risk management        needs of children and young adults may
and in facilitating good physical health        differ in some respects from those of
care. The picture is further complicated by     adults and older people but the principles
the range of other services that provide        and benefits are applicable across all ages.
behavioural input to physical health            This all-age approach will present
care. Liaison services have a unique and        challenges to the way in which services
essential role in providing broad cover         are currently organised but is important
across health care settings, and in their       if the ambition of the English mental
capacity to handle the most severe and          health strategy is to be realised through
risky mental health problems. However,          the commissioning process.
commissioners will also need to consider
the range of other services that provide        Furthermore, the current patchy nature
evidence-based talking therapies and            of liaison services commissioning leads
rehabilitation for physical health problems,    to patchy provision. There should be
including MUS and LTCs. These include:          universal agreement to commission liaison
                                                services as part of the acute hospital care
• clinical health psychology embedded           commissioning process.
  in medical teams, such as oncology,
  diabetes, renal, rheumatology or
  respiratory teams and providing
  specialist talking therapies, assessment,
  consultation, training and research
Liaison mental health services to acute hospitals - The Joint ...
Guidance for commissioners of liaison mental health services to acute hospitals   9

What would a good liaison service look like?

Model of service delivery                       Key components of the service                        • broad capacity building across the health
                                                                                                       and social care system so that mental
A good liaison service functions A comprehensive liaison service                                       health is much more readily recognised
best as a discrete, specialised, will have the following features:                                     as a concomitant to physical health
fully integrated team comprising • ability to work closely with the acute                              (liaison clinicians should be able to assess
multi-professional health care     hospital through integrated governance,                             physical health as well as mental health,
staff, under single leadership     open (pre-referral) discussion with the                             manage mental health issues, recognise
                                                                                                       the remit of their capabilities, and refer
and management.                    hospital’s principal referring units, a
                                                  single point of referral and the capacity            to psychiatric services when appropriate)
A core service should be based on the             to serve the agreed hospital population            • provision of supervision, liaison and
following principles:                                                                                  direct clinical activity outside the acute
                                                • provision of comprehensive assessment
• staff members sole (or main)                    and formulation, including risk                      setting and into primary care when care
  responsibility is to the acute liaison team     assessment and joint assessment where                pathways for patients with MUS, LTCs
                                                  appropriate, using recognised formal                 or other issues require consistency of
• the team includes adequate skill mix
                                                  instruments to provide diagnosis and                 care in order to avoid deterioration or
• the team has strong links with specialist                                                            re-admission
                                                  formulation that leads to an agreed plan
  mental health services and good general
                                                  that is communicated in a timely manner            • all-age inclusive services, including
  knowledge of local resources
                                                • capacity to engage effectively with                  liaison services for children, older people
• there is clear and explicit responsibility                                                           and adults with dementia
                                                  the patient in a safe place that allows
  for all patients in the acute hospital
                                                  a positive therapeutic relationship to             • holistic and culturally responsive
                                                  be built                                             services.
• there is one set of integrated
                                                • provision of a range of interventions
  multi-professional healthcare notes
                                                  including signposting, support,
• consultant medical staff are fully
                                                  psychosocial interventions, therapeutic
                                                  interview, brief psychotherapeutic
                                                  interventions, and pharmacotherapy
                                                • effective liaison with other parts of
                                                  the health system, including general
                                                  practice, crisis and in-patient teams,
                                                  specialist mental health teams, social
                                                  services, emergency services and non-
                                                  statutory agencies
10   Practical Mental Health Commissioning

What would a good liaison service look like? (continued)

Standards                                      Table 1: Examples of levels and skill mix for a team serving a general
                                               hospital with 650 beds and 750 new self-harm patients per year.
Commissioners will need to                     (Mental Health Policy Implementation Guide, 2008)
commission liaison services
that can demonstrate that they
                                                 role            grade          time            comment
meet the recognised standards
for the service.                                 Medical         Consultant     Whole time      Consultant involvement is essential,
                                                                                                including managing risk, providing
These are set out in the Royal College                                                          supervision and training, and offering
of Psychiatrists College Centre for                                                             expertise on psychopharmacological
Quality Improvement (CCQI) Plan                                                                 treatment, complex patients, capacity
standards,3 against which liaison services                                                      and the Mental Health Act.
may be accredited. These are not
                                                 Nursing         Band 8         Whole time      One of the nursing roles should be as
currently mandatory. It is suggested
                                                                                                team leader.
that the PLAN accreditation process
becomes a commissioning requirement,             Nursing         Band 7         3x              The nurses operate as autonomous
with the joining fee included in the                                            whole time      practitioners, undertaking assessments,
commissioning process.                                                                          and brief treatment interventions, and
                                                                                                liaising with mental health teams in
The optimum liaison team                                                                        primary care. Those working with older
                                                                                                adults will become involved in detailed
To provide the breadth                                                                          discharge planning.
of services set out above,                       Clinical        Band 8         1               May be provided from health
a range of staff operating                       Psychology                                     psychology team, but should be
within a multidisciplinary                                                                      an integral part of a liaison team
team is essential.                                                                              to provide supervision, training
                                                                                                and delivery of brief psychological
Table 1 sets out the absolute minimum                                                           treatments.
staff requirements to provide an adult
                                                 Team PA         Band 4         1.5 x           Core to referral management,
care liaison service working office-
                                                                                whole time      information gathering and
hours within an acute hospital with 650
beds, as described in the Royal College
of Psychiatrists Mental Health Policy
Implementation Guide.4
                                               • adults with complex needs                      The model of acute liaison services
additional staffing requirements                                                                outlined in this guide will require a number
                                               • older-age adults –all senior staff will need
                                               experience in older people’s mental health,      of additional therapists with experience
If liaison professionals are to                and all teams should have the necessary          of working with people with MUS. These
provide teaching, training and                 requirements to allow training of juniors        therapists may come from a variety of
support to colleagues within                   and students for all professional groups         backgrounds, including social work,
                                                                                                occupational therapy and physiotherapy
their team and throughout the                  • CAMHS – child and adolescent mental
general hospital, the staffing                 health services to general hospitals should      For examples of guidance on appropriate
ratios above would need to be                  be provided by specialist multidisciplinary      staffing levels for older-age adults and
                                               CAMHS liaison teams, but current                 other population groups please see
increased to allow for this.
                                               provision is patchy and further investment       references26-31,as well as the existing
Similarly, a greater number of staff will be   is required.                                     JCP-MH series of guides on commissioning
needed to provide a comprehensive office                                                        (
hours liaison service for:
Guidance for commissioners of liaison mental health services to acute hospitals   11

Outcomes                                  RAID is a new model for acute liaison                Quality indicators have confirmed good
                                          services developed by Birmingham and                 patient feedback on improved holistic care
The quality outcomes of                   Solihull Mental Health Foundation Trust              in acute care settings. Staff feedback has
liaison services include:                 and the University of Staffordshire. It              confirmed that the team is popular and has
• improved service user experience        has been piloted at Birmingham’s City                built capacity and confidence in managing
  and care outcomes                       Hospital, an inner city general hospital             patients with mental health issues,
                                          with some 600 beds.31                                reduced violence and improved morale (as
• improved access to mental health care
                                                                                               evidenced in the annual staff survey).
  for a population with high morbidity    The service offers consultation and liaison
• reduced emergency department waiting    to A&E, the medical assessment unit and              In terms of hospital efficiency, waiting
  times for people with mental illness    the medical, maternity and surgical wards,           times for mental health patients in A&E
                                          with response targets of one hour for A&E            have been reduced by 70%, which is
• reduced admissions, re-admissions
                                          and 24 hours for inpatients.                         reflected in an overall improvement in
  and lengths of stay
                                                                                               A&E waiting times.
• reduced use of acute beds by patients   RAID builds on existing liaison services,
  with dementia                           adding health and social care capacity to            The service is to expand across the
                                          the liaison team, plus specialist skills in          Birmingham acute care health economy
• reduced risk of adverse events
                                          older adults and addictions – as such, it is         to cover five acute hospitals with 3,600
• enhanced knowledge and skills of        a complete, all-age mental health service            beds in total. Throughout this expansion
  acute hospital clinicians               within an acute trust.                               it will be subject to ongoing evaluation.
• improved compliance of acute trusts
                                          RAID is viable at a cost of circa £1 million
  with legal requirements under the
                                          for a hospital of circa 600 beds.
  Mental Health Act (2007) and Mental
  Capacity Act (2005)                     Economic evaluation of RAID, undertaken
• improved compliance with NHS            by the London School of Economics, has
  Litigation Authority Risk Management    demonstrated that it can achieve the
  Standards and the Clinical Negligence   following outcomes, over and above
  Scheme for Trusts (CNST).               traditional liaison services:
                                          • reduce admissions, leading to a
RAID: an example of
                                            reduction in daily bed requirement
service innovation
                                            of 44 beds per day, saving the NHS
The Rapid Assessment Interface              £3.55 million per annum through
and Discharge (RAID) service is             decommissioning acute beds
an age-inclusive, drugs/alcohol           • reduce discharges to institutional care
inclusive, consultant-led service           for elderly people by 50%, saving local
                                            authorities £3 million per annum in
that is fully integrated into the           contributions to residential care
structure and function of an
                                          • produce a consequent cost-to-return
acute hospital in Birmingham. It            ratio of £1 to £4.
has shown dramatic reductions
in bed use,particularly use of
acute/elderly ward beds by
patients with dementia.
12   Practical Mental Health Commissioning

Supporting the delivery of the mental health strategy

The JCP-MH believes that                        Shared objective 4:
commissioning that leads to                     More people will have a positive
good acute liaison services,                    experience of care and support.
as described in this guide,                     By addressing both physical and mental
will support the delivery of                    health needs together, acute liaison
the mental health strategy1                     services can improve the likelihood of
in a number of ways.                            patients experiencing more holistic and
                                                positive care in acute hospital settings.
Shared objective 1:
More people will have                           Shared objective 5:
good mental health.                             Fewer people will suffer
                                                avoidable harm.
Commissioning acute liaison services will
increase the number of people receiving         One of the key components of a
appropriate care and support and reduce         good liaison service is to assess the
the number developing mental illness. This      risk of self-harm and harm to others.
is because they provide early identification,   Commissioners should look to a liaison
diagnosis, and either treatment or referral,    service to both provide short-term
for people with mental health needs             interventions and appropriate onward
admitted to acute hospital.                     referral and signposting. Reducing
                                                outpatient attendance, hospital admissions
Shared objective 2:                             and readmissions protects patients from
                                                avoidable harm.
More people with mental
health problems will recover.                   Shared objective 6:
A patient’s road to recovery is often           Fewer people will experience
made more difficult by the co-morbidity         stigma and discrimination.
of physical and mental health needs.
By commissioning a liaison service that         By commissioning services that recognise
addresses both physical and mental              mental and physical health as inseparable
health needs together, the prospects            and inter-related, commissioners will be
of recovery are enhanced.                       actively addressing the stigma that derives
                                                from the artificial separation of physical
Shared objective 3:                             and mental health and increasing public
                                                and professional understanding of their
More people with mental
                                                frequent coexistence.
health problems will have
good physical health.
Ensuring that a person’s mental health
needs are also addressed when they are
in an acute hospital for treatment for their
physical health needs removes one of
the potential barriers to provision of
good physical health care. Liaison
services can reduce the risk of self-harm
and suicide while also addressing the
long-term conditions and medically
unexplained symptoms with which
many patients present.
Guidance for commissioners of liaison mental health services to acute hospitals   13

Liaison Expert Reference Group Members

• Paul Gill (ERG Chair)                  • Rebecca Harrington                              Development process
  Consultant Psychiatrist                  Assistant Director                              This guide has been written by a group
  Sheffield Liaison Psychiatry Service     (Strategic Planning and Joint                   of liaison care experts, in consultation
  Sheffield Health and Social Care         Commissioning)                                  with patients and carers. Each member
  NHS Foundation Trust                     London Borough of Camden                        of the Joint Commissioning Panel for
                                           & Camden PCT                                    Mental Health received drafts of the guide
• Jonathan Campion                                                                         for review and revision, and advice was
  Consultant Psychiatrist                • Lance McCracken                                 sought from external partner organisations
  South London and Maudsley                Consultant Clinical Psychologist                and individual experts. Final revisions
  NHS Foundation Trust                     Bath Centre for Pain Services                   to the guide were made by the Chair
                                           Royal National Hospital for                     of the Expert Reference Group in
• Mike Clarke                              Rheumatic Diseases                              collaboration with the JCP’s Editorial Board
  London School of Economics                                                               (comprised of the two co-chairs of the
  and Political Science                  • Stella Morris                                   JCP-MH, one user representative, one
                                           Consultant Psychiatrist                         carer representative, and technical and
• Chris Fitch                              Humber NHS Foundation Trust                     project management support staff).
  Research and Policy Fellow
  Royal College of Psychiatrists         • Kieron Murphy
                                           Director of Delivery
• Jeremy Gauntlett-Gilbert                 Joint Commissioning Panel
  Senior Clinical Psychologist             for Mental Health
  Bath Centre for Pain Services
  Royal National Hospital for            • Chris Naylor
  Rheumatic Diseases                       Fellow (Health Policy)
                                           King’s Fund

                                         • Annemarie Smith
                                           Carer Representative
14   Practical Mental Health Commissioning

Resources                                                                                 References

The Joint Commissioning Panel                  Healthy Mind, Healthy Body                 1 HM Government (2011).
for Mental Health (JCP-MH)                     NHS Confederation (2009)                   No health without mental health:                                                                            a cross-government mental health
                                                                                          outcomes strategy for people of all ages.
This website describes the function            Documents/Briefing_179_
                                                                                          London: Department of Health.
and intended outputs of the JCP-MH             Healthy_mind_healthy_body_MHN.pdf
                                               This briefing explains how liaison         2 Bennett, A., Appleton, S., Jackson, C.
Quality standards for liaison                  psychiatry services can transform          (eds) (2011). Practical mental health
psychiatry services (2nd ed).                  quality and productivity in acute          commissioning. London: JCP-MH.
Royal College of Psychiatrists                 settings. It sets out some good practice
College Centre for Quality Improvement         examples together with academic            -%20Vol%20One%20(web%20
Psychiatric Liaison Accreditation              evidence to build a business case for      11_04_05).pdf
Network (PLAN) (2010)                          liaison psychiatry services.               3 Palmer, L., Dupin, M., McGeorge,                                                                    M., Soni, M. (eds) (2010). Quality
PLANStandards%202nd%20Edition                  Managing Urgent Mental                     standards for liaison psychiatry services
%20Final.pdf                                   Health Needs in the Acute Trust            (2nd ed). London: Royal College of
This report sets out standards for             Academy of Medical Royal                   Psychiatrists College Centre for Quality
acute liaison services.                        Colleges (2008)                            Improvement.
Mental Health Policy Implementation            ManagingurgentMHneed.pdf                   Final.pdf
Guide: Liaison Psychiatry and                  This report outlines the case for          4 Aitken, P. (2007). Mental health policy
Psychological Medicine in the                  investing in liaison mental health         implementation guide: liaison psychiatry
General Hospital                               services and sets out a set of             and psychological medicine in the
Royal College of Psychiatrists (2008)          recommendations and standards              general hospital. London: Royal College                 that should underpin these services.       of Psychiatrists.
This report focuses on the key components                                                 PIG2.pdf
                                               Department of Health
that should be in place in a liaison team if                                              5 Royal College of Psychiatrists (2007).
                                               mental health website
the service is to operate effectively.                                                    No health without mental health: the
                                                    supporting evidence. London: Academy
No Health without Mental Health:               Mentalhealth/MentalHealthStrategy/         of Medical Royal Colleges/Royal College
the ALERT summary report.                      index.htm                                  of Psychiatrists.
Academy of Medical Royal Colleges
                                               National Institute for Health              6 NHS Confederation (2009).
                                               and Clinical Excellence (NICE)             Healthy mind, healthy body: how liaison                                                            psychiatry services can transform quality
print%20final.pdf                                                                         and productivity in acute settings. London:
This report, produced by the PLAN                                                         NHS Confederation.
team with the Royal College of                                                            Publications/Documents/Briefing_179_
Psychiatrists Liaison Faculty highlights                                                  Healthy_mind_healthy_body_MHN.pdf
the importance of liaison services and
                                                                                          7 Royal College of Psychiatrists and British
argues that every hospital should have
                                                                                          Association for Accident and Emeregency
access to these services.
                                                                                          Medicine, 2004, Psychiatric services to
                                                                                          accident and emergency departments
                                                                                          (CR118) London, Royal College of
                                                                                          8 Yeo, H.M. (1993). The cost of
                                                                                          treatment of deliberate self-harm.
                                                                                          Archives of Emergency Medicine,
                                                                                          10(1), pp. 8–14.
Guidance for commissioners of liaison mental health services to acute hospitals   15

9 Reid, S., Wessely, S., Crayford, T.,        17 Brown, S. (1997). Excess mortality of             24 Burgess, C., Cornelius, V., Love, S.,
Hotopf, M. (2001). Medically unexplained      schizophrenia: a meta-analysis. British              Graham, J., Richards, M., Ramirez, A.
symptoms in frequent attendees of             Journal of Psychiatry 171, pp. 502–8.                (2005). Depression and anxiety in
secondary health care: retrospective                                                               women with early breast cancer: five
                                              18 Saha, S., Chant, D., McGrath, J.
cohort study. British Medical Journal                                                              year observational cohort study. British
                                              (2007). A systematic review of mortality in
322(7289), p. 767.                                                                                 Medical Journal 330: 702 doi: 10.1136/
                                              schizophrenia; is the differential mortality
10 Fernandes, A. (2011). Guidance             gap worsening over time? Archives of
for commissioning integrated urgent           General Psychiatry 64(10), pp. 1123–31.              25 Parry-Langdon, N. (ed) (2008).
and emergency care. A whole system                                                                 Three years on: survey of the development
                                              19 De Hert, M., Dekker, J.M., Wood, D.,
approach. Centre for Commissioning,                                                                and emotional well-being of children
                                              Kahl, K.G., Holt, H., Möller, K. (2009).
Royal College of General Practitioners.                                                            and young people. Cardiff: ONS.
                                              Cardiovascular disease and diabetes in
11 National Audit Office (2008).              people with severe mental illness: position          26 Royal College of Psychiatrists. (2005).
Department of Health Reducing Alcohol         statement from the European Psychiatric              Who Cares Wins. London: Royal College
Harm: health services in England and          Association (EPA), supported by the                  of Psychiatrists.
alcohol misuse. Report by the Comptroller     European Association for the Study of
                                                                                                   27 Royal College of Psychiatrists. (2006).
and Auditor General.                          Diabetes (EASD) and the European Society
                                                                                                   Raising the Standard - specialist services
                                              of Cardiology (ESC) European Journal of
12 Chang, C-K., Hayes, R,D., Perera, G.,                                                           for older people with mental illness.
                                              Psychiatry. European Psychiatry 24(6),
Broadbent, M.T.M., Fernandes, A.C. et al                                                           London: Royal College of Psychiatrists.
                                              pp. 412–24.
(2011). Life expectancy at birth for people
                                                                                                   28 British Psychological Society. (2008).
with serious mental illness and other         20 McManus, S., Meltzer, H., Campion,
                                                                                                   Briefing Paper No. 27 - Clinical Health
major disorders from a secondary mental       J. (2010). Cigarette smoking and mental
                                                                                                   Psychologists in the NHS. London: British
health care case register in London. PLoS     health in England. Data from the Adult
                                                                                                   Psychological Society.
ONE 6(5): e19590. doi:10.1371/journal.        Psychiatric Morbidity Survey. London:
pone.0019590                                  National Centre for Social Research.                 29 British Psychological Society. (2006).
                                                        Briefing Paper No. 5 - Commissioning
13 Hemingway, H., Marmot, M. (1999).
                                              smoking--mental-health                               Clinical Psychology Services for older
Psychosocial factors in the aetiology
                                                                                                   people, their families and other carers.
and prognosis of coronary heart disease:      21 NICE (2009). Depression with a chronic
                                                                                                   London: British Psychological Society.
systematic review of prospective cohort       physical health problem: the treatment
studies. British Medical Journal 318, pp.     and management of depression in adults               30 British Psychological Society. (2010).
1460–67.                                      with chronic physical health problems                Commissioning Clinical
                                              (partial update of CG23). Clinical guidance          Neuropsychology Services.
14 Lesperance, F., Frasure-Smith, N.,
                                              91. London: NICE.                                    London: British Psychological Society.
Juneau, M., Theroux, P. Depression and
1-year prognosis in unstable angina. Arch     22 Egede, L. (2007). Major depression in             31 NHS Confederation (2011).
Intern Med. 2000, 160(9), pp. 1354–60.        individuals with chronic medical disorders:          With money in mind.
                                              prevalence, correlates and association with          The benefits of liaison psychiatry.
15 Fenton, W.S., Stover, E.S. (2006).
                                              health resource utilization, lost productivity       London: NHS Confederation.
Mood disorders: cardiovascular and
                                              and functional disability. General Hospital
diabetes comorbidity. Current Opinion
                                              Psychiatry 29(5), pp. 409–16.
in Psychiatry 19(4), pp. 421–27.
                                              23 Moussavie, S., Chamnatti, S., Verdes,
16 Di Matteo, D., Martin, L., Williams, S.,
                                              P., Tandon, A., Patel, V., Ustun, B. (2007).
Haskard, K. (2005).The challenge of patient
                                              Depression, chronic diseases, and
adherence. Therapeutics and Clinical Risk
                                              decrements in health: results from the
Management 1(3): pp. 189–99.
                                              World Health surveys. The Lancet 370,
                                              pp. 851–58.
Guidance for commissioners of liaison mental health services to acute hospitals   17

A large print version of this document is available from

Published February 2013

Produced by Raffertys
You can also read