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Title:Model Service Specifications for Liaison Psychiatry Services - Guidance for

Edition:1st edition

Date:February 2014

URL:

Commissioner:Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions South West

Editors:Dr Peter Aitken, Dr Sarah Robens, Tobit Emmens
Devon Partnership NHS Trust, Dryden Road, Wonford House, Exeter, EX2 5AF

Preface

This service specification describes four models of hospital based liaison psychiatry service, which have evidence for cost and quality effectives impacting on emergency and unplanned care. Each model builds on the level previous one.

This document uses the current (January 2013) Department of Health Service Specification Template.

This service specification is part of a suite of four related documents, each with increasing levels of detail:

• Liaison Psychiatry Services - Guidance - sets out the key consideration to be made when commissioning liaison psychiatry services.

• An Evidence Base for Liaison Psychiatry - Guidance - sets out the evidence gathered from lay people, professionals, commissioners and the literature about what is needed from liaison psychiatry services.

• Developing Models for Liaison Psychiatry Services - Guidance - provides the technical information needed for commissioning liaison psychiatry services.

• Model Service Specifications for Liaison Psychiatry Services - sets out exemplar service specifications for four models of liaison psychiatry.

The guidance was commissioned by the Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions South West.

With thanks and appreciation

We would like to recognise and appreciate the contribution of the following people for their work in putting together this guidance:

  • people with an experience of our services, commissioners and commissioning supporters
  • the Faculty of Liaison Psychiatry at the Royal College of Psychiatrists
  • the Academy of Emergency Medicine
  • the National Clinical Director for Mental Health
  • the Centre for Mental Health
  • the Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions South West
  • the research and development team at Devon Partnership NHS Trust, and
  • Dr William Lee, Reader in Psychiatric Epidemiology, Plymouth Peninsula Schools of Medicine and Dentistry.

Dr Peter Aitken's time was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula (PenCLAHRC).

The views and opinions expressed in this paper are those of the authors and not necessarily those of NHS England, the NIHR or the Department of Health.

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Summary of liaison psychiatry service models

The four models of hospital based liaison psychiatry service described in this specification are:

• Core Liaison Psychiatry Services

• Core 24 Liaison Psychiatry Services

• Enhanced 24 Liaison Psychiatry Services (Enhanced with adjustments to fill local gaps in service and some outpatient services)

• Comprehensive Liaison Psychiatry Services (Enhanced with inpatient and outpatient services to specialties at regional and supra regional level)

Table 1: High level summary of differences between models

Core / Core 24 / Enhanced 24 / Comprehensive
Example Number of Beds / c 500 / c 500 / c 500 / c 2000
Consultants / 2 / 2 / 4 / 5
Other Medical / 0.6 / 2 / 2 / 2
Nurses / 2 Band 7
6 Band 6 / 6 Band 7
7 Band 6 / 3 Band 7
7 Band 6 / 2 Band 8b
17 Band 6
10 Band 5
Other Therapists / 0 / 4 / 2 / 16
Team Manager Band 7 / 1 / 1 / 1 / 3
Clinical Service manager Band 8 / 0.2 / 0.2 - 0.4 / 0.2 - 0.4 / 1
Admin Band 2, 3 and 4 / 2.6 / 2 / 2 / 12
Business support (band 5) / 0 / 1 / 1 / 1
Total Whole Time Equivalent / 14.4 / 25.2 - 25.4 / 22.2 – 24.4 / 69
Hours of Service / 9-5 / 24/7 / 24/7 / 24/7
Age / 16+ / 16+ / 16+ / 16+
Older Person / Yes / Yes / Yes / Yes
Drug and Alcohol / No / Yes / Yes / Yes
Out Patient / No / No / Yes / Yes
Specialities / No / No / No / Yes
Approx Costs / £0.7M / £1.1M / £1.4M / £4.5M

Detailed descriptions on these models and their differences in terms of staff size and skill mix can be found in document 3, ‘Developing Models for Liaison Psychiatry Services - Guidance’. An example of further defining the optimal service for your local context can be found in appendix 3 of document 2, ‘An Evidence Base for Liaison Psychiatry Services - Guidance’.

How to use this template service specification

The italicised (coloured or black) text represents the four different service models. This text can be modified or deleted in line with the guidance to create a service specification suitable for local needs. To help determine which level of service is most appropriate to your local need please read document 3, ‘Developing Models for Liaison Psychiatry Services - Guidance’.

We recommend that you consider the whole care pathway being designed and how it will be completed with the addition of a liaison psychiatry service.

To help decision with regard to choice of model of service the commissioner is recommended to identify:

• Urban or rural setting.

• Emergency and unplanned care pathways in your local context.

• The presence and pattern of existing rudimentary services for mental health presentations serving Emergency Departments (ED) and the acute care hospital in and out of working hours.

• Number of beds in the hospital.

• That ED is present but limited or no out of hours demand.

• That ED is present with out of hours demand and adequate outflow care pathways.

• That ED is present with out of hours demand but gaps in supporting pathways.

• Regional or supra regional services present or academic teaching hospital.

It is also important to consider the detail of surrounding service pathways specifically:

• Local pattern, volume and timing of demand on ED and acute care hospital.

• Out of hours services other than mental health creating demand.

• Any need to serve community or virtual hospital wards that will take staff away from the ED site.

Considering these points in conjunction with reading document 3, ‘Developing Models for Liaison Psychiatry Services - Guidance’ should help commissioners select the optimum model for their local context.

Example for scaling models to meet local need

A rural or provincial 750-bed hospital with a 24 hour Emergency Department might not have sufficient volume of work to warrant a Core24 Liaison Psychiatry Service and therefore the number of nurses could be reduced from 13 towards Core depending on identified demand.

A hospital with less than 500 beds will still require a team that meets the Core Liaison Psychiatry Service Staff Specification to provide sufficient working hours coverage. This level of staffing will enable sufficient headroom to support other areas, for example, community hospitals and virtual wards.

An urban hospital with 500 beds and a 24-hour Emergency Department is likely to benefit from 24 hour, seven day services due to the volume of walk in referrals.

A hospital with more than 1000 beds is likely to need a comprehensive service due to the volume of referrals especially if it provides regional or supra-regional services.

There is limited scope to reduce the overall number of staff below the level described in the models. Fewer staff in either the Core or Core24 model will be unable to provide adequate cover when taking into account annual leave, training, sickness, or unplanned leave.

Diagram 1 on page 6 is a guide to identifying the best model to start from when designing the most appropriate service for your local context.

Diagram 1: Scaling models to meet local need

Broadly speaking the minimum and maximum commissioning envelope should be

Number of Beds / Model / Minimum
Per 500 beds / Maximum
Per 500 beds
<500 / Core / £0.6M / £0.7M
>500 / Core24 / £0.7M / £1.4M
>1000 / Enhanced24 / Comprehensive / £1.1M / £1.4M*

*Depending on level of enhancements required for regional and supra-regional services.

Therefore, a large urban 1000 bed hospital would require a commissioning envelope between £2.2M and £2.8M and would provide an Enhanced24 or Comprehensive Service.

Scaling the base model to meet local context

We recommend that commissioners consider the whole care pathway being designed and how it will be complemented with the addition of a liaison psychiatry service. The base model will be scaled according to hospital bed numbers served, adequacy of surrounding care pathways, 24 hour demand, presence of regional or supra-regional services and urban or rural location.

We recommend that the project group work through P26 and P27 of document 3 ‘Developing Models for Liaison Psychiatry Services – Guidance’ and appendix 3 from document 2 ‘An Evidence Base for Liaison Psychiatry - Guidance’.

Notes on local modifications

A hospital with less than 500 beds will still require a team that meets the Core Liaison Psychiatry Service Staff Specification to provide sufficient working hours coverage. In this situation the Core model can support other areas, for example, community hospitals and virtual wards.

A rural or provincial 750 bed hospital with a 24hour Emergency Department may still not have sufficient night time activity to warrant a Core 24 Liaison Psychiatry but instead scales up the size of the Core model to meet office or extended office hours.

An urban hospital with 500 beds and a busy 24-hour Emergency Department is likely to benefit from Core 24 service due to the volume of walk in referrals.

An urban hospital of any size hosting regional and supra-regional services may need an enhanced or comprehensive model.

Reducing staffing below the levels described in the models means that they will be unable to provide adequate service cover when taking into account annual leave, training, sickness, or unplanned leave. This reduces the models to ‘rudimentary’ for which there is no evidence of effectiveness.

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Service Specification Template

Department of Health, updated January 2013

Service Specification No:
Service:
Commissioner Lead:
Provider Lead:
Period:
Date of Review:
  1. Population Needs (Mandatory)

1.1. National/local context and evidence base

Liaison psychiatry, also known as Psychological Medicine, is the medical specialty concerned with the care of people presenting with both mental and physical health symptoms regardless of presumed cause. The specialty employs the bio-psychosocial model being concerned with the inter-relationship between the physiology, psychology and sociology of human ill health.

Liaison psychiatry services are designed to operate away from traditional mental health settings, in the main in acute care hospital emergency departments and wards, and medical and surgical outpatients.

Liaison psychiatry teams are multidisciplinary, clinically led by a consultant liaison psychiatrist who will have higher specialty training in general adult psychiatry with sub specialty endorsement in liaison psychiatry. Many liaison psychiatrists will also have higher specialty training in general medicine or general practice.

Liaison psychiatrists as well as being in a position to diagnose and prescribe can also formulate and deliver brief psychotherapeutic interventions most commonly cognitive behavioural therapy or psychodynamic interpersonal therapy.

The multidisciplinary liaison psychiatry team will typically include specialist mental health nurses, clinical psychologists, occupational therapist and social workers.

Liaison psychiatry services hold expert knowledge on the safe operation of the mental health act in general health settings and provide expertise to capacity assessments.

25% of all patients admitted to hospital with a physical illness also have a mental health condition, and in most cases this is not treated whilst the patient is in hospital.

25 – 33% of patients with a long-term physical health problem also have a concurrent mental illness which increases the risk of physical health complications and increases the costs of treating the physical illness.

Mental disorders account for 5% of all Emergency Department attendances. These presentations are often resource heavy and labour intensive.

Chronic repeat attenders at Emergency Departments accounts for 8% of all Emergency Department attendances. The most common reason for frequent attendance is an untreated mental health problem.

Self-harm accounts for 150,000 – 170,000 Emergency Department attendances per year in England.

95% of acute hospital admissions for people with dementia occur in an emergency, with over 60% of these coming through Emergency Department. Emergency admissions for people with dementia account for nearly 10% of all hospital admissions. 25% of all emergency presentations in people with dementia are preventable.

Liaison Psychiatry services should respond to need as it presents in the Emergency Department / ward and not restrict on the basis of age, presenting symptoms or underlying condition or health state.

Descriptive evidence shows a list of benefits including decreased length of stay, reduction in psychological distress, improved service user experience, improved dementia care and enhanced knowledge and skill of general hospital clinicians.

“The status of liaison psychiatry should change. It needs to be recognised as an essential ingredient of modern health care and not an optional extra which is merely nice to have.” (Parsonage, Fossey and Tutty 2012: 6)

A more detailed summary of the literature, essential reading, references and lay, commissioner and professional views can be found in the documents 2 and ‘3: An Evidence Base for Liaison Psychiatry Services – Guidance’ and ‘Developing Models for Liaison Psychiatry Services. Guidance’.

  1. Outcomes

2.1. NHS Outcomes Framework domains and Indicators

Domain 1 / Preventing People from dying prematurely
  • Reducing premature death in people with serious mental illness

Domain 2 / Enhancing quality of life for people with long-term conditions
  • Ensuring that people feel supported to manage their condition
  • Enhancing quality of life for people with mental illness

Domain 3 / Helping people to recover from episodes of ill health or following injury
  • Improving outcomes from planned treatments
  • Improving outcomes from injuries and trauma

Domain 4 / Ensuring people have a positive experience of care
  • Friends and Family Test
  • Improving peoples experience of out-patient care
  • Improving access to primary care services
  • Improving experiences of healthcare for people with mental illness

Domain 5 / Treating and caring for people in safe environment and protecting them from avoidable harm
  • Patient Safety Incidents Reported
  • Reducing the incidence of avoidable harm

2.2. Locally defined outcomes

Example LIAISON PSYCHIATRY SERVICE PERFORMANCE INDICATORS

Performance indicator / Indicator details / Weekly target / Monitoring
Acute hospital activity targets
Minimum reduction in mental health related A&E waiting times breaches / Weekly activity reporting
Month 1 weekly target / 3
Month 2 weekly target / 5
Month 3 weekly target / 6
30 % Reduction in emergency re-admission rates for patients accepted by the team / 30% of all patients seen by the team / Audit of patients under the care of the team
Attendances at Emergency Departments for self-harm per 100,000 population
Percentage of attendances at Emergency Departments for self-harm that received a psychosocial assessment.
Quality measures
Total number of assessments undertaken by the team / 100% / Weekly activity reporting
Total number of patients accepted under the care of the team / 100% / Weekly activity reporting
Prevention of discharge to institutional care e.g. residential placements / Age, sex, source of referral, / 97% of all patients seen by the team / Monthly activity reporting
Audit of discharge location and length of stay of patients under the care of the team
ICD-10 coding of mental health conditions completed for all patients seen by the team / 80% / Monthly activity reporting
Provision of rapid access to psychiatric assessment / 1 hour response time ED referral / 80% / Weekly activity monitoring
24 hour response time ward referral / 80% / Weekly activity monitoring
All patients 65+ with a diagnosis of dementia, under the care of the team to have a review of antipsychotic medication / 90% / Monthly activity reporting
Improved referrer, patient and carer satisfaction / Baseline survey of satisfaction of patients, carers and referrers
  1. Scope (Mandatory)

3.1. Aims and objectives of service

  • To provide Emergency Departments and Acute Care Hospital Inpatient units with 24hour rapid access to specialist mental health assessment within 1hour and 24hours respectively aimed at avoiding unnecessary admission.
  • To provide effective mental health interventions in Emergency Departments and Acute Care Hospital Inpatient Wards to optimise the time the patient spends in these environments aimed at reducing length of stay.
  • To provide connection with community services for mental health, addictions, housing, care support and primary care to accelerate the onward care of people into a community setting.
  • To train and supervise general hospital staff in the recognition and management of common mental health presentations including depression and anxiety, self-harm, alcohol and addictions, personality and eating disorders, psychosis, delirium and dementia.
  • To provide advice and action in support of hospital staff in respect of the safe operation of the mental health act and complex capacity assessments.
  • To provide to regional and supra-regional specialist units where they are present.
  • To help hospital services meet NICE guidance criteria for managing mental health and psychological conditions and those co-morbid with long-term conditions.

3.2. Service description/care pathway

  • Services should be all-age (including those under 16 and those over 65).
  • Services should be delivered 7 days a week, and beyond office hours, but this will depend on local context, in support of emergency and unplanned care pathways.
  • If there is no 24hour liaison psychiatry service then there should an alternative service to provide support to ED and avoid mental health admissions out of hours.
  • For hospitals without an emergency department the liaison psychiatry team can operate to support community hospitals and virtual hospital wards in the community.
  • The Liaison Psychiatry team will be in or very close by to the acute care hospital it serves.
  • The Liaison psychiatry service will be supported by business and administrative support enabling effective communication and information exchange with surrounding agencies.
  • The Liaison Psychiatry service will have a single point of access for referrals.
  • As well as the Core set of consultants (Including expertise in self-harm, older people and addictions) and nurses, liaison psychiatry teams should be multidisciplinary, depending on the model being implemented, include social workers, occupational therapists, STR workers, drug and alcohol workers and learning disability nurses. These decisions will be informed by pre-commissioning needs assessment.
  • The liaison psychiatry service should have access to professional expertise in psychological therapies.
  • Liaison psychiatry services should have strong links with Health Psychology.

Evidence-based model of liaison psychiatry service for local context