NEUROCARE
Specialist Neuropsychiatric Liaison Service

brain . mind . body integrative health

"Healthy mind, healthy body "

Extracts from: "The NHS UK Confederation Briefing ISSUE 179"

How Liaison Neuropsychiatry Services can transform quality and productivity in acute settings

This Briefing looks at opportunities to improve quality and efficiency in acute services by focusing on the needs of the significant number of (physically ill) Patients who also have mental health problems complicating their care and discharge.

It sets out some good practice examples together with academic evidence to build a business case for Liaison Neuropsychiatry Services.

Mental health needs in acute settings

Patients with a physical illness are three to four times more likely to develop a mental illness than a member of the average population.

Patients admitted to an Acute setting(such as a general hospital) have a 28% chance of also having a diagnosable psychiatric disorder. A further 41% have sub-clinical symptoms of anxiety or depression.

The rates of psychiatric illness for older adults in general hospital beds are as follows:

up to 40% have dementia, 53% have depression and 60% have delirium.

During an economic downturn these figures are likely to increase.

Most of these mental illnesses are treated very quickly and effectively if the symptoms are identified early.

However, the current composition of some acute and mental health services means that the physical and mental conditions of Patients are treated separately.

This means that many general hospital inpatients with co-morbid physical and mental illness have little access to appropriate mental health services, either while in hospital or following discharge.

There has also been a lack of specific policies to incentivise the creation of an integrated service. Commissioning for mental and physical health are often separate processes and it is rare for the special needs of Patients with both physical and mental health problems to be considered in either funding stream.

A solution: Liaison Neuropsychiatry

Providers need a solution to the unequal treatment of Patients with both mental and physical healthcare needs in acute settings. Evidence suggests that Liaison Neuropsychiatry could be the answer.

Liaison Neuropsychiatry brings together the diagnosis, treatment and management of Patients with co-morbid physical and mental disorders.

Most services are based in acute hospitals or stay somewhere in between the primary and secondary care border. Services in England are patchy, although there has been a gradual expansion over the last ten to 15 years, which has been driven by local Clinicians.

Benefits for acute hospital trusts

There is good evidence, from a variety of different sources, to suggest that Liaison Neuropsychiatry services can improve care in general hospitals and can contribute to improving on other important health targets. These include improvements in both quantitative and qualitative outcomes.

In summary, Liaison Neuropsychiatry services can:

Above all, Liaison Neuropsychiatry teams can significantly improve the quality of care received by Patients.

The quality outcomes of Liaison Neuropsychiatry services include:

Benefits of Liaison Neuropsychiatry

It is difficult to calculate the exact benefits of Liaison Neuropsychiatry since the services vary across the country and the concept has been developed quite recently.

Some of the already proven benefits are detailed below.

1. Improved care and cost savings

The most striking benefit is the improved care for the Patient. Although it will need an initial investment, in the medium to long term Liaison Neuropsychiatry can bring savings for the trust.

2. The needs of older adults

The inequality of access to full healthcare is most noticeable within the older population. Two-thirds of NHS beds are occupied by older people and up to 60% have or will develop a mental disorder during their admission, with delirium and dementia being the most common.

Mental disorder in older people is an independent predictor of poor outcome, including increased mortality, greater length of stay, loss of independent function and higher rates of institutionalisation.

These outcomes are exacerbated by the inadequate funding of mental health services for older people and the fact that general hospital staff often lack specialist knowledge and support.

For example, acute staff may not recognise delirium in 50% of cases.

This is important as a UK study has shown that where dementia, delirium or depression are present after hip fracture, length of hospital stay is increased by an average of 11 days.

Improving and aligning mental and physical health is a key concern to older patients. Evidence shows that most complaints are made by older patients and that Liaison Neuropsychiatry could improve the level of satisfaction by providing a more complete service.

3. Dementia

Failure to detect and manage dementia at early stages leads to longer length of stay. Liaison Neuropsychiatry reduces length of stay while it also improves patient outcome.

4. Re-attendance

The untreated mental health problems of Patients make them more likely to re-attend AE departments. Early assessment and treatment of all the needs of the Patient can decrease the rate of re-attendances considerably.

5. Psychological reaction to physical illness

Many Patients are admitted to hospital following traumatic events – for example, road traffic accidents – or develop major depression or anxiety as a consequence of their physical disorder. Evidence suggests that Liaison Neuropsychiatry can treat depression and this leads to reduced healthcare costs.

There is a strong cost-effective argument for treatment of depression in cancer patients.

6. Decreased rates of self-harm

Self-harm is one of the most common reasons for admission to a general medical bed. The Patients who are admitted are those who have made the most serious attempts to kill themselves.

There is robust evidence that Liaison services can effectively assess and treat self-harm.

7. Medically unexplained symptoms

Of all new referrals to general hospital outpatient departments 30% have no demonstrable organic illness to account for their symptoms.

These Patients are high users of healthcare resources. Studies demonstrate that Liaison Neuropsychiatry interventions can improve Patient outcomes and reduce costs.

8. Alcohol abuse

Of all male medical inpatients, 20% have significant alcohol problems. There is poor management of alcohol withdrawal states resulting in unnecessary increased length of stay.

Robust evidence shows that brief Liaison interventions can be effective in the reduction of alcohol use by Patients identified as having alcohol problems in the general medical setting.

9. Severe mental illness

A small proportion of medical inpatients have severe mental illness (for example, schizophrenia).

Hospital staff are normally specialised in physical healthcare. They may be anxious when a patient presents several mental illnesses.

Liaison services can respond rapidly and provide a continuity of service between community and hospital while the Patient’s physical needs are being attended to in the general hospital setting. They can also provide the necessary training to general acute staff.

10. Capacity

The introduction of the Mental Capacity Act 2005 has highlighted the need for rapid assessments of capacity to consent to medical treatment in the general hospital setting.

For Patients with complex physical and mental health problems, an experienced Liaison Neuropsychiatrist is a key professional with appropriate training to make an informed judgement.

11. Training

Professionals in acute services currently lack a wide knowledge about the mental health needs of Patients. A Liaison mental health team ensures that:

Setting up a Liaison team

There are different models of service, but Liaison services work most effectively when they are embedded into general hospital work.

In this model, mental health staff work closely with general staff to improve rapid detection and treatment of Patients with mental health problems.

Most services include training and educational components to improve the overall quality of service provision and ensure appropriate guidelines (for example, NICE guidelines) are being followed and clear pathways of care are developed for Patients with particular mental health problems.

Liaison services should ‘map’ onto the specific needs of an acute hospital. As acute hospitals vary in size and service delivery, the size and composition of each Liaison service will also vary.

Staffing

A Liaison Neurosychiatry team needs to be multi-disciplinary, requiring a range of skills. The Neuropsychiatric input should be from a consultant level doctor who will provide leadership and manage and supervise risk.

Easing the way for Liaison Neuropsychiatry

As identified above, Liaison Neuropsychiatry can be a cost effective service for both providers and commissioners.

There are key components that make up a Liaison team, but there is no single model for all settings. Therefore hospitals are increasingly designing a version of the team that suits their specific needs.

The NHS Confederation agrees that team structures should be designed according to local needs and the system should allow a certain flexibility.

The structural barriers to developing these services need to be addressed and new approaches explored to enable Liaison Neuropsychiatry services to be provided more consistently.