no health without mental health - royal college of … print final.pdf6 no health without mental...

No HealtH witHout MeNtal HealtHtHe aleRt suMMaRy RepoRtJULY 2009

No HealtH witHout MeNtal HealtH

Copyright © Academy of Medical Royal Colleges 2009

Designed and Typeset byMillbank Media Ltd


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CONTENTS

NOTES AbOuT ThE REpORT………………...........……………………..................................................................…………...…... .3

ExECuTivE SuMMARy..........………………...........……………………..................................................................…………...…... .5

1. introduction………………………………………………………………….............................................………………….................. 9

2. Recommendations..........................................................................................................................................……………...... 11

3. Awareness...............................................................................................................................................................……….....12

4. Liaison psychiatry Services.................................................................…....................................................................…......20

5. Engaging patients and Carers.................................................................................................................................………...30

6. Re-organisation of Services, Commissioning and Quality Standards..............................................................................34

7. Training and Education..........................................................................................................................................................38

8. Summary.................................................................................................................................................................................41

ACKNOWLEDGEMENTS............................................................................................................................................................42

REFERENCES AND FuRThER READiNG.................................................................................................................................44

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• ThereportrefersprimarilytolegalframeworksandorganisationalstructuresinhealthcareservicesinEngland.However,thestatementoftheimportanceofrecognisingthelinkbetweenphysicalandmentalhealthandthecallforbetterservicesarelikelytoresonateacrossallcountriesoftheUnitedKingdom

• Whererelevant,guidanceprovidedbytheNationalInstituteofHealthandClinicalExcellence(NICE)andtheScottishIntercollegiateGuidelinesNetwork(SIGN)isreferredto.ForafullreportonthementalhealthcontentofNICEandSIGNguidelines,pleaseseewww.rcpsych.ac.uk/nohealth

NOTES AbOuT ThE REpORT

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Thereisaclearlinkbetweenmentalandphysicalhealthandanurgentneedtostrengthenboththeprovisionofmentalhealthcaretopeoplewithphysicalillness andthequalityofphysicalhealthcareprovidedtopeoplewithmentalhealth problemsingeneralhospitalsandprimarycare.Thisreportprovidesaframework withafocusonimprovementwithinthegeneralhospital,whichcanbebrought aboutatrelativelylittleadditionalcostbyfocusingonfivepriorityareas:

Awareness of the link between physical and mental health

Liaison Mental health Services

Engaging patients and Carers

Re-organisation, Quality & Commissioning

Training and Education

ExECuTivE SuMMARy

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Awareness

…of mental disorders in people with physical illness

Physicalillnesscanhaveprofoundsocialandemotionalconsequences.Asaresult,manypeoplewithphysicalillnesshavementalhealthproblems.Thisassociation istrueforchildrenandyoungpeopleandforolderpeople.Mentalhealthproblemscanimpederecoveryfromaphysicalillnessandincreasemortalityrates.Mentaldisordersoftengounrecognisedinpatientswithphysicalillness.Somepeoplehavephysicalsymptomswhichcannotbefullyexplained.Mentalhealthproblemsincreasethecostofphysicalhealthcare.

…of physical disorders in people with mental illness

Peoplewithmentalillnessaremorelikelytohavereducedlifeexpectancy,oftendue topoorphysicalhealth.Theincreasedmortalityisduetofactorsthatoftenoccurincombination.Theseinclude:socialdeprivation;lifestylefactors;adverseeffectsofmedicationandpooraccesstoservices.

…of physical disorders in people with learning disabilities

Thecausesoflearningdisabilitiescanpredisposethepersontocertainphysicalillnesses.Therearemanybarrierstomeetingthesephysicalhealthneeds.Theseinclude:difficultiesincommunication;diagnosticovershadowing;challengingbehaviour;attitudesamongprofessionalsandpoorlydevelopedlinksbetweenspecialistlearningdisabilityandgeneralhospitalservices.


Admissiontohospitalcanbeadistressingexperience.Morethanonequarterofgeneralhospitalpatientshaveamentaldisorder.Mentaldisordermanifestsasa rangeofcommonpresentationsinthegeneralhospitalincluding:self-harm;alcoholproblems;dementia;deliriumanddisturbedbehaviour.Liaisonservicesimprove thecareofpatientswithsuchproblems.


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Engaging patients and carers

Tobeactivelyinvolvedintheircare,patientsneedbetterinformation.Wellinformedpatientsexperiencelessanxietyandbetteroutcomes.Engagementincludesenquiringaboutmentaldistress.Patientscanbesupportedtoself-managelongtermdisease.Thereremainsastigmaaroundmentalillnessthatneedstobechallenged.Involvingpatientsinservicedevelopment,researchandauditcanimprovementalhealthcareintheacutesetting.Therearemanybarrierstoinvolvingpatientsinimprovingservicesbutthevalueofpatientexpertiseshouldnotbeunderestimated.

Re-organisation, Quality & Commissioning

Generalhospitalsneedflexibleandresponsiveliaisonpsychiatryservices.However,thereislittleincentivefortheNHStodevelopsuchservices.Therearedifferentmodelsofservice,butaliaisonpsychiatryteamrequiresadequatestaffingwitharangeofmulti-disciplinaryskills.Weneedqualitystandardsformentalhealthcare ingeneralhospitals,andthenationalPsychiatricLiaisonAccreditationNetworkwill helpsupporttheirimplementation.

Training and Education

Manyhealthcareprofessionalswouldwelcomebettermentalhealthtraining. Front-linestaffrecognisethisgapintheirknowledge.Doctorsneedbettertraining inthedetectionandtreatmentofmentalhealthproblemsinpatientswhoarephysicallyill.Competenciesneedtobecheckedandtraininginprimarycareneedstobeimproved.Trainingandnationalguidanceshouldensurethatmentalhealthissuesreceiveadequatefocus.

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In2008,theAcademyofMedicalRoyalCollegescommissionedtheRoyalCollegeofPsychiatriststowriteareportsummarisingthelinkbetweenphysicalandmentalhealth.Theaimwastodrawattentiontothementalhealthproblemsthatareassociatedwith,orarisefrom,physicalillnessandthephysicalhealthneedsofpeoplewithmentalillness.

TheRoyalCollegeofPsychiatrists’CentreforQualityImprovementworkedwiththeCollege’sFacultyofLiaisonPsychiatryandotherexpertstocollatetheevidenceandmakerecommendations.ThisispartoftheRoyalCollegeofPsychiatrists’FairDealcampaign:www.fairdeal4mentalhealth.co.uk.

FairDealisathreeyearcampaignfoundedontheviewsofpsychiatrists,serviceusersandcarers.OneofFairDeal'seightobjectivesisafundamentalshiftinunderstandingandpracticeamongallhealthprofessionalsabouttherelationshipbetweenmentalandphysicalhealth.

FairDealpromotesequalrightsandfairnessformentalhealthserviceusers,carers,andthoseworkingwiththem.Itchallengesustoaddressinequality,unfairnessanddiscriminationacrosseightkeyareas:

• Funding• AccesstoServices• In-patientServices• Recovery• DiscriminationandStigma• Engagementwithserviceusers/carers• Availabilityofpsychologicaltherapies• Linkingmentalandphysicalhealth.

Twodocumentshavebeenproduced;this‘ALERTsummaryreport’andamorein-depthreport‘NoHealthwithoutMentalHealth:theevidence’.Thelatterdescribesinmoredetailtheinterfacebetweenphysicalandmentalhealthinabroadrangeofpatientpopulationsanddifferentclinicalservices.Itunderpinsthefirst partoftheALERTreportwhichstatestheimportanceofawarenessofthelinkbetweenphysicalandmentalhealth.Toaccesstheevidencereport,pleasevisitwww.aomrc.ac.ukorwww.rcpsych.ac.uk/nohealth.

1. iNTRODuCTiON

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Awareness

• Allnationalguidelinesaboutmedicalconditions–includingthoseissuedbyNICEandSIGN–shouldincludespecificadviceaboutthedetectionandtreatmentofmentalhealthproblemsassociatedwithmedicalconditions

• ScreeningfordepressioninspecificlongtermconditionsinprimarycareshouldbecontinuedandextendedundertheQualityandOutcomesFramework(QOF)

• Screeningfordepressionandothercommonmentalhealthproblemsshould beroutinelyintroducedintheacutehospitalsetting

• Peoplewithlearningdisabilitiesandpeoplewithseverementalillnessshouldreceiverelevantannualphysicalhealthchecks.


• Eachgeneralhospitalshouldhaveanadequatelyfundedliaisonmentalhealthservicetoprovidementalhealthcarethroughouttheentirehospitaltoallwhoneedit,includingthosewithlearningdisabilities

• Liaisonservicesshouldincludespecifiedandappropriateprovisionforolderpeople,aswellaschildrenandyoungpeople

• Patientsingeneralhospitalswithmentalhealthproblemsshouldhavethesamelevelofaccesstoaconsultantpsychiatristastheywouldfromaconsultantspecialisinginphysicalhealthproblems.

Engagement with users and carers

• Informationandeducationshouldbedevelopedandprovidedinappropriatewaysforserviceusers,carersandthepublictodevelopcommunityawarenessofthepsychologicalaspectsofphysicalconditions

• Serviceusersandcarersshouldbeinvolvedindesigningandimprovingmentalhealthservicestogeneralhospitalsandprimarycaresettings,throughaudit,researchandtraining.Fullsupportshouldbeprovided.

Re-organisation, commissioning and quality • Liaisonmentalhealthservicesshouldbecommissionedandreviewedagainst

agreedspecificservicestandards,toensuretheyprovideeffective,evidencebasedinterventionstotreatmentalhealthproblemsinthegeneralhospital

• Allcarepathwaysfordeliveringphysicalhealthcareshouldhaveamentalhealthcomponent.Thereshouldbeacounterpartpathwayforcommissioningpracticetoensuretheservicesareinplacetodeliverthis.

Training

• Allhealthpractitionersshouldhavetraininginmentalhealth• Thecurriculaandassessmentofalldoctorsintrainingandthecontinuing

professionaldevelopmentofqualifieddoctorsshouldreflecttherelationshipbetweenmentalandphysicalhealth,bothingeneralandinspecificconditions

• Nationalguidanceshouldensurethatmentalhealthissuesreceive adequatefocus.

2. RECOMMENDATiONS

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3.1 Awareness of psychological disorders in people with physical illness

physical illness can have profound social and emotional consequences

Peoplewhohaveseverephysicalillnessoftenlosetheabilitytoperformarange ofactivitieswhichpreviouslymaintainedtheir‘senseofthemselves’ashumanbeings,whetherasaparent,providerorworker.1,2Thisisparticularlytrueforthosewithalongtermcondition.Oneexampleofthisisdiabetes.Althoughpeoplein theearlystagesoftreatedtype1diabetesmayfeelphysicallywell,theyhavetochangetheirnormallifestyle.Thismightincludelimitingtheirdietandhavingtocomplywithademandingtreatmentregime.Somefinditdifficulttoaccepttheserestrictions.Later,ascomplicationsdevelop,peoplewithdiabetesmayexperiencearangeofgradualorsuddendeteriorationsinhealth,includingimpairedvision, poorrenalfunction,andcardiovascularvasculardisease.Thelossofphysicalfunctioncanresultinunemployment,financialhardship,stresswithinthefamily,lossofsexualfunction,lossofsocialactivities,andthreattolife.Physicalillnessthereforecanhaveamajoradverseeffectonaperson’squalityoflife.3,4

Many people with physical illness have mental health problems

Patientswithanyformoflongtermphysicalillnesshaveanincreasedriskofdepression,5,6andthemorethreateningapatientperceivestheirphysicalillness tobe,themorelikelytheyaretobecomedepressed.7Thebiologicalfactorsassociatedwithsomephysicalillnessalsoincreasetheriskofdepression. Thesefactorsincludehormonal,nutritional,electrolyteorendocrine abnormalities,theeffectsofmedicationandthephysicalconsequencesof systemicand/orintracerebraldisease.

The association is also present for children and young people

Aswellashavingahigherincidenceofmentalhealthproblemsthanthegeneralpopulation,childrenandyoungpeoplewithphysicalillnessaremorelikelyto havelearninganddevelopmentandautisticspectrumdisorders.8 Disabled childrenaremoreatriskofexperiencingabuseandthisabusecanleavealegacy ofmentalillhealth.9,10

…and for older people

Thenumberofolderpeoplewithmentalhealthproblemswillincreasebyathirdoverthenext15yearsto4.3million,whichisoneinevery15olderperson.11Inthegeneralhospitalsettingtheprevalenceofmentalhealthproblemsinolderpeople isveryhigh:sixtypercentofpeopleovertheageof65whoareadmittedtoageneralhospitalhaveorwilldevelopamentaldisorderduringtheiradmission, themostcommonbeingthe‘threeDs’—dementia,deliriumanddepression.10 Particularattentionshouldbepaidtoolderpeoplewithaphysicalillnessbecausepoorphysicalhealthincreasestheriskofsuicide.12TheCareServicesImprovementPartnershiphasdevelopedatoolkitprimarilyaimedathealthcarestaffcaringforolderpeoplewithmentalhealthneedsinacutehospitals (www.olderpeoplesmentalhealth.csip.org.uk/lets-respect.html).

3. AWARENESS


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Mental ill health impedes recovery from physical illness

Mentalhealthproblemscanaffectrecoveryfromeverykindofphysicalillness. Inextremecases,anindividualwithseveredepressionmaysimplygiveupontreatmentbecausetheybelievetheyareaburdenontheirfamilyorthehealthcaresystemandwouldbebetteroffdead.Evenrelativelymildmentalhealthproblems inpatientswithphysicalillnesscanhaveamajoreffectontheirphysicalcondition. Forexample,amildeatingdisorderinapatientwithdiabeteswillhavepotentiallyseriouslongtermconsequences,ofadisproportionatenaturetotheseverityoftheeatingdisorderitself.

Factorswhichpredisposeapersontomentalillness(childhoodadversity,maladaptivebehavioursandmaladaptivepatternsofattachment)increasethelikelihoodofpoorerself-careandincreaseduseofhealthservices.13Mentalhealthproblemscanalsoaffectaperson’sconfidenceinparticipatingincomplexcare orrehabilitationprogrammes.Poormentalhealthalsoaffectsaperson’sability torespondtopaincontrol.14

Forolderpeople,thepresenceofmentalillnessisanindependentpredictorof poorphysicalhealthoutcomes,suchasincreasedmortality,greaterlength ofstay,lossofindependentfunctionandhigherratesofinstitutionalisation.15

Mental disorders often go unrecognised in patients with physical illness

Overhalfofallcasesofdepressioninthegeneralhospitalsettinggounrecognisedbyphysiciansandnursingstaff20andtherearesimilarproblemswithdetectioninprimarycare.21,22,23Thismaybebecausehealthcareprofessionalsdonotthinktoenquireaboutpsychologicalsymptoms,orbecausetheyfeeluncomfortabledoingso.Evenifthesesymptomsarediscussed,practitionersmight,quitereasonably,regarddepressionandanxietyasanunderstandablereactiontobeingphysicallyunwell.Assuch,thepatient’ssymptomsarenormalised24andpractitionersmaynotrealisethatthementalillnesscouldbetreatable.

box 1: Mental disorders can increase mortality rates, for example:

• Theriskofdepressedpatientswithcoronaryheartdiseasedyingin thetwoyearsaftertheinitialassessmentistwiceashighasitisfor non-depressedpatients16

• PeoplewithChronicObstructivePulmonaryDisease(COPD)anddepressionhaveanincreasedrateofmortality17andwhenfacedwithend-of-lifedecisions,theyaremorelikelytooptfor‘donotresuscitate’18

• Depressioninstrokepatientsisassociatedwithincreaseddisability andmortality.19

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General practitioners (Gps) have a key role in helping people cope

GPsareideallyplacedtofacilitateanaturalpsychologicaladjustmenttophysicalillnessintheirpatients.GPsalsoneedtorecognisewhenpatientswithphysicalillnessarebecomingdepressedandtreatthemaccordingly.Inprimarycare,briefscreeningfordepressionincertainchronicdiseasegroups(diabetesandcoronaryheartdisease)isestablishedundertheQualityandOutcomesFramework(QOF).25 Thechallengeinprimarycareistoextendsuchscreeningtoalllongterm conditionsandtoprovideorrefertoappropriateinterventionsforpeoplewhendepressionisdetected.

Briefmentalhealthassessmentsshouldalsobemaderoutineforpeopleadmittedtoacutehospitalbedstoidentifythosewithmentaldisordersorthoseathighrisk ofdevelopingthem.Careplanscouldthenincludestrategiesforpreventionandpromptmanagementoftheseconditions.

Some people have physical symptoms which cannot be fully explained

Medicallyunexplainedsymptoms(MUS)accountfor20%ofnewpresentationstoprimarycareandforupto30%-40%ofnewlyreferredmedicaloutpatients.26Oftenthepatientsconcernedexperienceahighdegreeofsuffering.Inmostcases,noobviousphysicalreasonisidentified,butasmallproportionofMUSareeventuallyfoundtohaveanunderlyingorganicdisorder.Psychologicalfactorsarecloselyassociatedwithmedicallyunexplainedsymptoms27andresearchsuggeststhat themorebodilycomplaintsreported,thegreatertheirdegreeofpsychologicaldistress.28Also,themorecomplaintsreported,thegreaterthedegreeofimpairmentandthemorefrequentuseofhealthcareservices.29Over40%ofoutpatientswithMUShaveananxietyordepressivedisorder.30

Mental health problems increase the cost of physical healthcare

Patientswithdepressivedisorderaretwiceaslikelytouseemergencydepartmentservicesasthosewithoutdepression.31Indiabetes,totalhealthexpenditureisfourandahalftimeshigherforindividualswithdepressionthanforthosewithoutdepression.32Inchronicheartdisease,depressedpatientshavehigherratesofcomplicationsandaremorelikelytoundergoinvasiveprocedures.33,34Peoplewithchronicobstructivepulmonarydisease(COPD)whoarealsodepressedhavelongerhospitalstaysandincreasedsymptomburden.35Thepresenceofdementiaanddeliriumincreasesthelengthofstayofolderpeopleingeneralhospitalsby uptotendays.36

box 2: Long term conditions are associated with a high emotional burden.32,40,50

For example in diabetes, depression is linked to:

• Poorselfmanagement• Poorqualityoflife• Poorcontrolofbloodglucoselevels• Morediabeticcomplications• Increasedriskofdying• Delayoravoidanceofdiabetestreatment• Increasedcosts.


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3.2 Awareness of physical disorders in people with mental illness

people with mental illness have reduced life expectancy

Onaverage,peoplewithmentalillnessdiefivetotenyearsyoungerthanthe generalpopulation.37Theboxbelowshowsthestandardisedmortalityratiosfordifferenttypesofmentaldisorder.38

people with mental illness are more likely to have poor physical health

Thephysicalhealthproblemsassociatedwithmentalillnessincludeseriousconditionssuchasrespiratoryandcardiovasculardiseases,diabetes,cancer andepilepsy.

box 3: Standardised Mortality Ratios relating to Common Mental health Disorders

Mental disorder SMR Comments

Allformsofmentaldisorder 1.5Schizophrenia 1.6 Unnaturalcauses:9xmorecommonBipolardisorder 1.7Depression 1.4Panicdisorder 1.7Eatingdisorders 5.4 Self-starvationcaused65%ofdeathsAlcoholabuse/dependence 1.9Substancemisuse 4.9Personalitydisorders 1.8 Unnaturalcauses:in52%ofdeaths

box 4: Example of physical health problems associated with mental illness:

• Peoplewithbipolardisorderhavehigherlevelsofphysicalmorbidityandmortalitythanthegeneralpopulation39

• Majordepressiondoublesthelifetimeriskofdevelopingtype2diabetes40

• Depressionisariskfactorfordevelopingheartdisease41 • Peoplewithschizophreniaarethreetofourtimesmorelikelytodevelop

bowelcancer42

• Peoplewithschizophreniahavea52%increasedriskofdevelopingbreastcancer.42

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The increased morbidity is due to factors that often occur in combination…

Social deprivation

Peoplewithmentaldisordersaremorelikelytoliveinpoverty,beunemployed,havepoorhousing,tobehomelessortoliveinaninstitutionsuchasnursinghome,penalestablishment,orsecurepsychiatricfacilities.43,44,45Theyaremorelikelytodependonstatebenefitsforincome,andsocialisolationcompoundstheirdifficulties.45

Lifestyle factors

Comparedwiththegeneralpopulation,peoplewithamentalillnessaremorethantwiceaslikelytosmoketobacco,46eatlessfruit,arelesslikelytoexerciseregularly,47 havehigherratesofobesity(70%)andmoreoftendevelopthemetabolicsyndrome.48Somealsoarguethatpeoplewithmentalhealthproblemsaremorelikelytobecomephysicallydisabledasaresultofaccidentsorattemptedsuicide.49

Adverse effects of medication

Inparticular,thelongtermuseofantipsychoticdrugsincreasestheriskofdevelopingmetabolicsyndromewhichischaracterisedbyweightgain,highbloodlipidlevels,highbloodpressureandglucoseintolerancewhichcanleadtodiabetes.50Theriskofsuddendeathinschizophreniaincreasesincrementally witheachadditionalpsychotropicmedicationtaken.51

poor access to services

Peoplewithmentalhealthproblems,comparedtothosewithout,receivepoorerqualityhealthcare.37Theyarelesslikelytoseekmedicalhelpanddonotreceive thesamestandardofphysicalhealthcareineitherprimaryorsecondaryhealthservicesasthegeneralpopulation.TheymaynotregisterwithaGPordentist (ormaylosetheirregistration),andcanexperiencedifficultymakingandkeepingappointments.Peoplewithseverementalhealthproblemsarelesslikelytotake partinhealthscreeningsuchasmammographyandcervicalcytology.37Thepresenceofamentaldisordermay‘overshadow’therecognitionandtreatment ofphysicalhealthproblems.Thisovershadowingcanresultinareductioninthequalityofphysicalhealthcareprovidedbyhealthprofessionals.

box 5: patient viewpoint on taking medication for both physical and mental health problems:

‘Itakepsychotropicmedicationformentalhealthaswellasmedicationforphysicalhealth.Thiscanbeproblematicbecauseofthecontraindications– inmyexperience,neithergroupofspecialistscaredabout(orexplainedto me)theeffectsthesemedicationscanhaveoneachother.Ihadtoborrow aBNF[BritishNationalFormulary]andlookitupmyself.’

(Serviceuser,London,2008)


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3.3 Awareness of physical disorders in people with learning disabilities

Ausefulmatrixofgeneticdisordersandthepotentialphysicalandpsychologicaldisorderslinkedtoeachdisorderisavailableonwww.rcpsych.ac.uk/nohealth

There are many barriers to meeting the health needs of people with learning disabilities

TheDisabilityRightsCommissioninvestigationofequaltreatment37confirmed majordeficitsinthephysicalhealthcareofpeoplewithalearningdisabilityandtheMencapreport ‘Death by Indifference’60highlightedthetragicissueofunnecessaryandavoidabledeathsresultingfromunacceptablecare.

Healthchecksforpeoplewithlearningdisabilityinvolvingsystematicquestioningandstructuredphysicalexaminationhavebeenshowntodiscoverhighlevelsofunmetneed135,136andthatthebenefitsofsuchinterventionsaresustained.137 Therecentintroductionofprimaryhealthcarechecksforpeoplewithalearningdisability,asadirectlyenhancedservice(DES)intheUnitedKingdomis,therefore, awelcomedevelopment.Specialistlearningdisabilityservicescanplayanimportantroleinfacilitatingthisprocess,includingtheprovisionofrelevanteducation,guidanceand,wherenecessary,practicalsupport.

box 6: Many of the causes of learning disabilities can predispose a person to physical health problems

Learningdisabilitiesarisefromarangeofgeneticconditionsaswellasadverseeventsinthepre-natal,peri-natalandpost-natalperiodsandcanpredispose thepersontoarangeofconcurrentphysicalhealthproblems.Forexample:

• PeoplewithDown’sSyndromehavehighratesofcongenitalheartdisease,thyroiddisorder,sensoryimpairmentsanddementia.52,53Asaresult,theyhave alifeexpectancywhichisshorterthanthatofthegeneralpopulation52

• ThefoodseekingbehaviourofpeoplewithPrader-WilliSyndromemeans thattheyareatagreaterriskofobesityandtype2Diabetes54

• Peoplewithcerebralpalsyexperiencearangeofmusculoskeletal deformitiesandhighratesofdysphagiaandassociatedrespiratoryproblems55

• Therateofepilepsyis20%inthelearningdisabilitypopulation,risingto 50%inthosewithmoreprofoundlearningdisabilities59

• Peoplewithlearningdisabilitieshavelowerbonedensitythantheaveragepopulation56

• Respiratorydiseaseisthemostcommoncauseofdeath(46%-52%)forpeoplewithlearningdisabilities57

• Unmetphysicaldisorderscancontributetochallengingbehaviours, especiallyinindividualswithmoreseverelearningdisabilities58

• Peoplewithlearningdisabilitiesaremorelikelythanthegeneralpopulation toexperiencementalhealthproblemsandtheassociatedrisks.59

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Several factors can contribute to unequal access to healthcare, including:

Difficulties in communication

ThedeliveryofhealthcareintheUKlargelydependsonthepatientseekinghelp.Peoplewithlittleornomeansofverbalcommunicationoftencannotdothis.Eventhosewithmoremildorhiddenlearningdisabilitiesmaystruggletonegotiateasystemwhichassumescompetenceinareassuchasliteracy.Informationisrarelypresentedinaformthatistailoredtoindividualneeds,andindividualsmaybeunabletoprovideinformationintheformthathealthcareprofessionalsrequire.

Somepeoplewithlearningdisabilitiesmayalsohavesensoryimpairmentssuch asdeafness,andshouldnotbedeniedaccesstogoodqualitymentalhealth caresimplybecausethehealthserviceisillequippedtocommunicatewith them.Whenseekingorreceivinghealthcareinanysetting,deafpeoplehavetherighttobeassessedbyatrainedworkerwhohasdeaf/deafblindawareness andskillsinworkingwithpeoplewiththewholerangeofhearingrelated communicationneeds.61

Side effects of medication

Peoplewithlearningdisabilitiesareparticularlysusceptibletothephysicalandpsychologicalsideeffectsofmedication.Thiscanbefurthercompoundedbyatendencytoacquiesceandareducedcapacitytorecogniseandcommunicateproblemsrelatedtosideeffects.

Diagnostic overshadowing

Cliniciansmaydismissbehavioursthataremanifestationsofpainordeliriumasbeingintrinsictotheperson’slearningdisability.Similarly,hearingorvisionproblemsmaygoundetectedbecausehealthcareprofessionalswronglyattributelowlevelsoffunctioningtothelearningdisabilityitself.62

Carersmaybeunawareofthesignificanceofhealthdeficitsormayviewthem asanintrinsicaspectoftheindividual’scondition.Theymayalsoassumethat thehealthproblemisnotamenabletotreatment.

Challenging behaviour

Thismayresultfromthefactthatmanypeoplewithlearningdisabilitiesfindclinicalenvironmentsfrighteningandthreatening.Itisimportanttolookbeyondthepresentingproblemtoidentifypotentialphysical,psychologicalandenvironmentalcauses.Thesedifficultiescanthenbeminimisedthroughcarefulplanning andpreparation.63,64

Attitudes among professionals

Professionalswhoareunfamiliarwiththeneedsofpeoplewithlearningdisabilitiescanbeundulypessimistic,withinappropriatedecisionsbeingmadebaseduponill-foundedopinionsabouttheirqualityoflifeandvaluesascitizens.65


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poorly developed links

Peoplewithlearningdisabilityhaveequalrightstoaccessgenerichealthcareservices.Thismayrequireadditionalinputfromspecialistlearningdisabilityservicestofacilitatethisprocess.However,thelinksbetweenthesespecialistservicesandgeneralhospitalservicesareoftenpoorlydeveloped.Somerecentlydevelopednetworksintheformofliaisonlearningdisabilityserviceshaveshownpromisingresults.66

The importance of making reasonable adjustments

Itisimportanttoallowthetimerequiredtospeaktotheindividual.Aneffectiveconsultationdependsonanumberoffactorsincluding:

• Providingaccessibleinformationinastylethatsuitstheindividual (thismayincludetheuseofcommunicationaids)

• Checkingforunderstanding• Offeringappropriatesupport• Seekingbackgroundinformationfromsomeonewhoknowsthepatientwell• Assessingthepersoninanoptimumenvironment• Preparingtheindividualforanyassociatedphysicalexamination• Establishinganeffectivetherapeuticalliance.

For further advice, please see the ‘Top Ten Tips on Effective Consultation’, at http://www.intellectualdisability.info/values/top_ten_tips.htm. This checklist has been written primarily for GPs but can be usefully applied to a general hospital setting.67

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Thissectionwillexploretherolethatliaisonpsychiatrycanplayinbridgingthegapbetweenphysicalandmentalhealthinthegeneralhospital.

Admission to hospital can be a distressing experience

Inadditiontothedistressarisingdirectlyfromtheirphysicalillness,peopleadmittedtohospitalenteranunfamiliar,stressfulenvironment.Manyolderpeople,whoareorientatedintheirownhomemaybecomeconfusedwhenplacedinanewandstrangeenvironment.Thisiscompoundedifpatientsaremovedfromoneclinicalareatoanother.Patientsoftensharetoiletandbedroomfacilitieswithstrangers,giveuptheirnormalclothesandpersonalbelongings,anddressinnightclothes.Theyhavetointeractwithmanydifferentnurses,doctorsandotherhealthprofessionals.Atthesametimetheiraccesstorelativesandlovedonesisrestricted.Thosewhosmokeheavilyordrinkalcoholmightfindtherestrictionsimposedbyhospitaladmissionparticularlydifficult.

hospital clinicians may find it difficult to deal with fear, worry and other strong emotions in a hospital setting

Nursesanddoctorsinhospitalsareoftenwhollyoccupiedbythephysicalillnessandmightnothavetimetoenquireaboutemotionaldistress.Theymightalsofeeluncertainabouthowtomanagedistressifpatientsbecomeupset.68Notallhospitalwardshaveinterviewroomswherepatientsandtheirfamiliescanbeseeninprivateandpersonalconversationsoftentakeplacebehindacurtaindrawnaroundthepatient’sbed.

There are many different kinds of mental health problems in the general hospital setting

Self-harm

Self-harmisoneofthemostcommonreasonsforadmissiontoanacutemedicalbedandaquarterofpeoplewhoself-harmandattendemergencydepartmentsreportexperiencingnegativeattitudesfromstaff.71NICErecommendsthatpeoplewhoself-harmshouldreceivethesamestandardofcareasotherpatientsandthat adetailedpsychosocialriskassessmentbeundertaken.72Thisisimportantbecausepeoplewholeavetheemergencydepartmentorhospitalwithoutanadequatepsychosocialassessmentarelesslikelytobeofferedfollowup73andmaybemorelikelytorepeatself-harm.74Despitethis,notallpatientsarecurrentlyoffereda

4. LiAiSON pSyChiATRy SERviCES

box 7: More than one-quarter of general hospital patients have a mental disorder

• Twenty-eightpercentofconsecutivepatientsadmittedtoanacutemedicalsettingwerefoundtohaveapsychiatricdisorderthatmetdiagnosticcriteriaandafurther41%hadsub-clinicalsymptomsofpsychologicaldistress.69

• Depressiveandanxietydisordersaretwiceascommoninhospitalpatients astheyareinthegeneralpopulation70

• Thefiguresareevenhigherforolderpeople,whooccupytwo-thirdsofNHSbeds.Sixtypercentofpeopleovertheageof65whoareadmittedtoageneralhospitalhaveorwilldevelopamentaldisorderduringtheiradmission.Upto40%havedementia,53%depressionand60%havedelirium.15


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psychosocialassessmentandevenwhentheyare,somepatientsreportdissatisfactionwiththis.71Manygeneralhospitalprofessionalsreportalackoftraining,supportandsupervisionregardingworkingwithpeoplewhoself-harm.129

Alcohol

Alcoholisresponsibleforabout10%ofunselectedattendancesatemergencydepartments,andahigherpercentageofattendanceswithtrauma.75Whilstmanypatientsattendtheemergencydepartmentasadirectandobviousresultofalcohol(forexampleafteradrinkingbinge,orinastateofwithdrawal),approximately 20%ofpatientsadmittedtohospitalforillnessesunrelatedtoalcoholareregularlyconsumingunsafelevelsofalcohol,representing‘the future burden of alcohol misuse on hospital services.75Alcoholproblemsoftengounrecognised,76althoughthereisgoodevidencethatforpeoplewhoaredrinkingabovesafelimits,detectionfollowedbyabriefalcoholinterventionresultsinsignificantreductionsinalcoholconsumptionpostdischarge.77

Disturbed behaviour

Thisisdefinedasbehaviourthatinterfereswithaperson’scareorsafety,orthe careandsafetyofothers.About4%ofgeneralhospitalpatientsdisplaydisturbedbehaviour,anditismorecommoninmalesthanfemales.78Inmostcasesaggressivebehaviourisdirectedtowardsstaffratherthanotherpatients.Althoughanuncommonoccurrence,disturbedbehaviouronageneralhospitalwardcanconsumeadisproportionateamountofresources,particularlystafftime.78There areproventechniquesinpreventing,de-escalatingandmanagingdisturbedbehaviour;79theuseofsedativemedicationinphysicallyunwellpeopleisriskyandrequiresexpertise.

Dementia

Dementiaaffectsapproximately30%ofelderlypeopleadmittedtoanacutegeneralward.15Patientswithdementiaareparticularlyvulnerableingeneralhospitals.Theyarehighlysusceptibletoenvironmentalchangeandmayfinditdifficulttocommunicatetheirneeds,forexampleregardingtoiletingorpainrelief.Bettermanagementofdementiainhospitalcanresultinimprovedfunctionanddecreasedlengthofstay.80

Delirium

Deliriumoccursin15-20%ofallgeneralhospitaladmissionsandratesareconsiderablyhigherinelderlypatients(upto60%)especiallythosewithdementia.15 Thesedisordersoftengoundetectedinthegeneralhospital;forexample,acutestaffmaynotrecognisedeliriumin50%ofcases.81Verylittleisknownatpresentabouthowtoidentifypatientsathighriskofdevelopingdelirium,althoughthosepatientswiththreeormoreriskfactorsareninetimesmorelikelytodevelopdeliriumduringtheirhospitalstaythanpatientswithout.15Havingdementiaincreasestheriskofdeliriumfivefold.15

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Liaison psychiatry services improve the care of patients with such problems

Table1summarisesthewaysinwhichliaisonmentalhealthservicescanhelpwithsomeofthecommonproblemsassociatedwithmentaldisorderamongpatientsinthegeneralhospital.Manyliaisonmentalhealthteamsincludepsychologistsornurseswithexpertiseincognitivetherapyandotherpsychologicaltherapies.Aswellasprovidingdirectpatientcare,liaisonstafftrainandsupportgeneralhospitalstaffinthebetterdetectionandtreatmentofmentalhealthproblems.Thiscanresultinmorepositiveattitudestowardsmentalillhealthandgreaterconfidenceinaddressingemotionaldistressexpressedbypatientsorpatients’relatives.Healthpsychologyandclinicalpsychologyalsoprovidespecificpsychologicaltreatmentforpeoplewithdepressionandanxiety,butdonotcoverthewholerangeofmentalhealthproblemsthatpresentinageneralhospital.

box 8: Risk factors associated with developing delirium during a hospital stay

predisposing factors precipitating factors

•Visionimpairment •Useofphysicalrestraints•Severeillness •Malnutrition/dehydration•Cognitiveimpairment •Morethanthreemedicationsadded•Raisedbloodurea/creatinine •Useofbladdercatheter •Anyiatrogenicevent(harmful

consequenceofaprocedure orintervention


23

24


CONDiTiON OR pRObLEM DiFFiCuLTiES FACED iN ThE hOSpiTAL

WhAT CAN LiAiSON pSyChiATRy SERviCES DO?

psychological reaction to physical illness

Somepatientswilldevelopmajordepressionoranxietyasa consequenceoftheirphysicaldisorder.

Theliaisonservicecantreatdepression,leadingtoreducedhealthcarecosts(e.g.indiabetes).

Delirium Failuretodetectandmanageproperly. Theliaisonservicecanimprovepatientoutcomeanddecreaselengthofstay.

Dementia Failuretodetectandmanageproperly. Theliaisonservicecanimprovepatientoutcomeanddecreaselengthofstay.

Disturbed behaviour Placesthepatientandothersatrisk andisdifficulttomanageintheacutesetting.

Liaisonserviceshavetheexpertise andskillstohelphospitalstaffmanagepatientswithverydifficultand disturbedbehaviour.

Self-harm Oneofthemostcommonreasonsforadmissiontoanacutemedicalbed.Thosepatientswhoareadmittedarethosewhohavemadethemostseriousattemptstokillthemselves.Someprofessionalsinthegeneralhospitalfindworkingwithpeoplewhoself-harmtobestressful.

Liaisonservicescaneffectivelyassessandtreatself-harm,resultingindecreasedpsychologicalsymptomsanddecreasedrepetitionofself-harm.Theycanalsoprovidesupportandtrainingtoacutecolleagues.

Medically unexplained Symptoms Thesepatientsrequirehighusageofhealthresources.

Liaisonpsychiatryinterventionscanimprovepatientoutcomesandreducecosts.

TAbLE 1: COMMON pRObLEMS MANAGED by LiAiSON pSyChiATRy SERviCES


25

WhAT iS ThE EviDENCE bASE?

Asystematicreviewconcludedthat,comparedwithconsultation,theliaisonapproachforolderpeopleingeneralhospitalsresultsinmorespecialistassessments,morereferralswithdepression,betterdiagnosticaccuracy,morementalhealthreviewsandincreasedadherencetorecommendationsformanagingthementaldisorder.82Depressionintheelderlyphysicallyillcanbetreatedwithaliaisonpsychiatryintervention83andtreatmentofdepressioninolderadultsimprovesphysicalfunctioning.84Arandomisedtrialfoundthatmedicalpatientswithvariousmentaldisordersweretwiceaslikelytoreturntoindependentlivingiftheyreceivedspecialistmentalhealthmultidisciplinaryliaisonthanthosereceivingusualcare.85 Depressioncanbesuccessfullytreatedinpatientswithdiabetesusingcollaborativecare.86Intype2diabetespsychologicaltreatmentsimprovelongtermglycaemiccontrol.87Asystematicreviewhasconcludedthatantidepressantsareofbenefitin thephysicallyillwithdepression.88

Arandomisedtrialofolderpeoplewithhipfracturereceivingdailyproactivegeriatricconsultationfoundthatthisreducedepisodesofdeliriumbyonethirdandseveredeliriumby40%.89Quasicontrolledtrialsofperioperativecare90 and interpersonalandenvironmentalnursinginterventions91inhipfracturehavebeenassociatedwithareductionofdelirium andlengthofstay.Thereisgoodevidencethatbothtypicalandatypicalantidepressantsareeffectiveintreatingdelirium.92

Inacontrolledtrial,routinementalhealthliaisonforolderpeoplewithhipfracturewasassociatedwithareducedlengthofstay.Theinterventiongrouphadameanlengthofstayoftwodayslessthantheusualcaregroup.Thecostoftheservice wasoffsetbyshorterdurationofadmission.80Arandomisedcontrolledtrialofintensivespecialistmultidisciplinaryrehabilitationofolderpeoplewithhipfractureachievedareducedlengthofstayforpatientswithmildormoderatedementiaandthosewithmilddementiawereassuccessfulreturningtoindependentlivingaspatientswithoutdementia.Furthermore,patientswithmildandmoderatedementiafromtheinterventiongroupweremorelikelytobelivingindependentlythreemonthsafterfracturethantheusualcarecontrolgroup.93

Thereareprovenandrecommendedtechniquesforthede-escalationofviolenceanddisturbedbehaviour,79whichmentalhealthteamsaretrainedtodeliver.

Participantsrandomisedtobriefpsychodynamicinterpersonaltherapyhadasignificantlygreaterreductioninsuicidalideationatsixmonthfollowupcomparedwiththoseinthecontrolgroup.Theyweremoresatisfiedwiththeirtreatmentandwerelesslikelytoreportrepeatedattemptstoharmthemselvesatfollowup.94Psychosocialtreatmentfollowingself-harmresultsinreduceddepression,hopelessnessandimprovementinproblems.95Specialistself-harmteamssignificantlyimprovethequalityofpsychosocialassessment.96Emergencydepartmentandambulancestaffwhoreceivesupportandexpertise fromliaisonmentalhealthcolleaguesarelesslikelytoreportlowmoralewhenworkingwithpeoplewhoself-harm.97

Liaisonpsychiatryinterventionscanimprovepatientoutcomesandreducethecostsassociatedwithmedicallyunexplainedsymptoms.98Systematicreviewsoftheefficacyofantidepressantsandpsychologicaltreatmentfortreatingpatientswithmedicallyunexplainedsymptoms,suggestbothapproachesarebeneficial.99

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CONDiTiON OR pRObLEM DiFFiCuLTiES FACED iN ThE hOSpiTAL

WhAT CAN LiAiSON pSyChiATRy SERviCES DO?

Alcohol Abuse Thereispoormanagementofalcoholwithdrawalstatesresultinginincreasedlengthofstayorunnecessaryadmissions.

Briefliaisoninterventionscanbeeffectiveinthereductionofalcoholusebypatientsidentifiedashavingalcoholproblemsinthegeneralmedicalsetting.

people who attend the ED regularly (‘frequent attenders’)

Thesepatientsarehighusersofhealthresourcesandmorelikelytoexperiencepoorermentalhealth.

LiaisonpsychiatrycanhelpEDstaffmanagepatientsappropriatelyandensurepatientsareofferedappropriatecommunitybasedservices.Casereviewscanalsobeundertakenwhereappropriate.

Lack of mental capacity TheMentalCapacityActandtheAdultswithIncapacity(Scotland)Acthighlighttheneedforrapidassessmentsofcapacitytoconsenttomedicaltreatmentinthegeneralhospitalsetting.FailuretoimplementtheseActsappropriatelymaydisadvantagethepatient.Itcanalsoresultinlegalaction.

AnexperiencedConsultantLiaisonPsychiatristmightbebestequippedtomakeaninformedjudgementaboutcapacityforpatientswithcomplexphysicalandmentalhealthproblems.

Severe mental illness Asmallproportionofmedicalin- patientshaveseverementalillness (e.g.schizophrenia).Thesepatientscausegreatanxietyingeneralhospitalstaffandthereareoftenmajorriskissueswhichneedtobemanaged.

LiaisonServicescanrespondrapidlyandprovideacontinuityofservicebetweencommunityandhospitalwhilstthepatient’sphysicalneedsarebeingattendedto.

All mental health problems Generallackofknowledgeandskillsamongstgeneralhospitalstaffinthedetectionandmanagementofanymentalhealthproblem.

Educationandtrainingdeliveredbyliaisonservicesimproveknowledge,skillsandattitudesamongstgeneralhospitalstaff.

TAbLE 1: COMMON pRObLEMS MANAGED by LiAiSON pSyChiATRy SERviCES CONT.


27

WhAT iS ThE EviDENCE bASE?

Heavydrinkerswhoreceiveabriefalcoholinterventionaretwiceaslikelytomoderatetheirdrinkingsixto12monthsafteraninterventionwhencomparedwithheavydrinkerswhoreceivenointervention.100Inthegeneralhospitalsetting,heavydrinkerswhoarecounselledabouttheirdrinkinghaveasignificantlybetteroutcomethancontrolswhenfollowed-up12monthslater.77

50%ofpatientswhofrequentlyattendtheEDhavementalhealthproblems.91LiaisonmentalhealthstaffcanhelpEDstafftounderstandtheneedsofthisgroupandthereasonswhytheyuseservicesfrequently.102Thereareveryfewcontrolledstudiesofpsychiatricinterventioninthisgroupofpatients.ArecentstudysuggeststhatmultidisciplinarycasemanagementhasapositiveeffectonpsychosocialfactorsforfrequentattendeesbutincreasesEDutilisation.103

40%ofacutemedicalpatientsdonothavementalcapacitytomakeinformeddecisionsaboutmedicaltreatment,andclinicalteamsrarelyidentifypatientswhodonothavecapacity.104LiaisonpsychiatristsreceivemandatorytrainingintheassessmentofcapacityinrelationtotheMentalCapacityActinEnglandandWales.SomeliaisonpsychiatristswillalsobetrainedtoprovideassessmentsundertheDeprivationofLibertySafeguards(DOLS):thenewlegalframeworktosafeguardtherightsofpeoplewholackcapacityandneedtobedetainedinasafeenvironment.

NICEhaspublishedclinicalguidelinesonthetreatmentandmanagementofschizophrenia105andbipolardisorder.106

NICEhaspublishedguidanceonthetreatmentandmanagementofmostmentalhealthandbehaviouralconditionsincludingin2009aguidelineondepressioninchronichealthproblems(www.nice.org.uk).Psychiatrictreatmenthasshowntobeeffectiveintreatingpatientswithcomplexphysicalandmentalhealthproblems.107

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Liaison psychiatry services are not limited to a general hospital setting

Integratedclinicalassessmentandtreatmentserviceshavebeensetupasaway ofmanagingreferralsintosecondarycareandprovidingpatientswithrapidaccesstoassessmentandtreatment.Liaisonpsychiatryservicescanbeembeddedintothesenewservicessothatpsychologicalproblemsandtreatablementalillnesscanbeaccessedinparallelwithphysicalhealthtreatment.Liaisonservicescanalso linkmorecloselywithprimarycaretoprovidesupervisionforprimarycarepractitionersforcomplexcasesandprovidegreatercontinuityofcareforpatientswithlongtermconditions.

box 9: providing mental health services to emergency departments (ED)

Inmanyareas,mentalhealthinputtotheEDisprovidedbyCrisisResolution andHomeTreatmentTeams(CRHTs),asystemwhichhastheadvantageofproviding24hourcover.However,theseteamsareexpectedtoprioritisepatientsinthecommunity,withamajorfocusonhometreatment,meaningthattheyarenotalwaysabletorespondpromptlytopatientsintheED.LiaisonpsychiatryoffersanalternativewayofprovidingmentalhealthprovisiontoEDs,eitherthroughliaisonteamsbasedentirelyintheEDorpreferablyviateamssetup tomanageurgentmentalhealthneedsthroughoutthewholeofthehospital. Thiswouldhelpensureequalaccesstomentalhealthcareforallgeneral hospitalpatients.

box 10: Links between liaison psychiatry and primary care

Therearetwokeyareaswhereliaisonmentalhealthservicescandirectlysupporttheworkofprimarycarepractitioners:

• Thecareofpeoplewhohavepsychologicalreactionstophysicalillness• Thecareofpeoplewithmedicallyunexplainedsymptoms.

InformationaboutthedetectionandmanagementofboththesehealthproblemsisavailableinarecentjointreportbytheRoyalCollegeofGeneralPractitionersandtheRoyalCollegeofPsychiatristsentitled‘TheManagementofPhysicalandPsychologicalProblemsinPrimaryCare:Apracticalguide’.ThetwocollegeshavealsorecentlyestablishedaForumforMentalHealthinPrimaryCare.Theaimsoftheforumaretoguideandpromotegoodpracticeinmentalhealthcare,actasanexpertresource,andinfluencenationalpolicyandstrategy. (www.rcpsych.ac.uk/college/mentalhealthinprimarycare.aspx)

Mentalhealthservicesshouldestablisheffectiveliaisonwithlocalprimarycareteammembersandotheragenciestoprovideonwardcarepathways.


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Links with community learning disability services

Inmostareas,communitylearningdisabilityservicescanofferaccesstoarange ofprofessionalswhoareskilledinworkingwithpeoplewhohavelearningdisabilities.Theseprofessionalscanhelppatientsaccessprimaryandsecondarycare.Thiscanbeahelpfulresourceforpatients,generalhospitalstaffandliaisonmentalhealthteams,asthelearningdisabilityprofessionalwilloffersupportregardingassessmentandtreatment,andwherenecessary,anyconcurrentchallengingbehaviour.

box 11: providing mental health liaison to maternity services

Psychiatricdisorderisaleadingcauseofmaternalmorbidityandmortality, yetlessthanhalfofmentalhealthtrustsintheUKprovidespecialised perinatalpsychiatricliaisonasrecommendedbythematernaldeaths enquiries.108,109,110

Perinatalliaisonservicesareideallyplacedto:

• Provideexpertadviceandsupporttomaternityprofessionalsonthe individualriskandbenefitsofpsychiatrictreatmentduringpregnancy andbreastfeeding

• Seeindividualpatientsincrisisandconductassessments.

Mentalhealthprovisiontomaternityservicesshouldideallyoccurwithinanetworkwhichincludesaccesstospecialisedinpatientmotherandbabyunits ifnecessary.108,109Thisensuresthatthemostseriouslyillwomencanquicklyaccesstheappropriatelevelofcarewithoutunnecessarilybeingseparated fromtheirbabies.

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Thissectionaddressestwoaspectsofpatientengagement;theimportanceofinvolvingpatientsintheirowncare;andthebroaderissueofinvolvingpatientsandcarersinservicedesign,deliveryandimprovement.

To be actively engaged in their care, patients need to be better informed

TheNationalInstituteforHealthandClinicalExcellence(NICE)andtheScottishIntercollegiateGuidelinesNetwork(SIGN)emphasisetheimportanceofprovidinginformationthatenablespatientstoexercisechoiceintheircareandtreatment.NICEhasrecentlyproducedaguidelineonMedicinesAdherence111thatis ‘about enabling patients to make informed choices by involving and supporting them in decisions about prescribed medicines’.

Many patients would like to be more involved and better informed

Asurveyofmorethan50,000inpatientsinEnglishgeneralhospitals112demonstratedthatalthoughmostweregenerallysatisfiedwiththecaretheyreceivedfromtheNHS,manyexpressedconcernsaboutlackofchoiceandinformationabouttreatmentandcare.Otherpatientandcarersurveysrevealsimilarfindings.113

Well informed patients experience less anxiety and better outcomes

Patientswhoarewellinformedaboutprognosisandtreatmentoptionsaremorelikelytoadheretotreatmentsandhavebetterhealthoutcomes.114Theyarealso lesslikelytoexperienceanxietyinrelationtohealthscreening115andoperativeprocedures.116Communicationisalsoimportant.Forexample,whenworkingwithpatientsforwhomEnglishisnottheirfirstlanguage,staffneedtomakesufficienttimeavailableforanindividualtoexpressandexplainthemselvesfully.Thisalsoallowstimetogainabetterunderstandingofculturalnormsandvalues.

box 12: Survey of over 50,000 adult inpatients

• Threequartersofthosewhoseadmissiontohospitalwereplannedin advancewasnotgivenachoiceofadmissiondates

• Halffeltthattheywereinvolvedindecisionsabouttheirdischarge,30% saidthattheywereinvolvedtosomeextentand17%feltthattheywere notinvolved

• Halfofthepatientswhotookmedicinehomewerenotgiveninformation aboutthepossiblesideeffects

• Duringtheirhospitalstay,only6%wereaskedtogivetheirviewsonthequalityoftheircare

• Athirdsaidthatstaffdidnotgivetheirfamilyorcareralltheinformation theyneededtohelpcareforthem

• Halfofpatientsdidnotreceivecopiesofletterssentbetweenhospital doctorsandtheirfamilydoctor.

5. ENGAGiNG pATiENTS AND CARERS


31

Engagement includes taking account of mental distress

Somepeoplewithmentalandphysicalhealthproblemsfeelthatgeneralhospitalstaffdonottaketheiremotionalwellbeingintoaccount.Forexample,manypeoplewhoattendhospitalfollowingself-harmreportthatstaffdonotaskabouttheiremotionaldistressandonethirdofemergencydepartmentstaffreportedthattheyshowedlessrespectandofferedlesssupporttopeoplewhoself-harmcomparedwithotherpatients.117Theattitudeofprofessionalscanhaveaprofoundimpactonpatientsandcarers:

“The nurse made such a difference to me just by taking the time out to chat and being sensitive to how mixed I was feeling about the situation” –Adultattendingtheemergencydepartmentfollowingself-harm,2007

patients can be supported to self-manage long term disease

TheExpertPatientsProgramme118isauser-ledself-managementprogrammespecificallyforpeoplelivingwithlongtermconditions.Theaimoftheprogrammeistosupportpeoplebyincreasingtheirconfidence,improvingtheirqualityoflifeandenablingthemtobettermanagetheircondition.Havingbeensuccessfullypiloted,theExpertPatientsProgrammecurrentlyoffersaround12,000courseplacesayear.Itisbeingmadeavailablethroughprimarycaretrustsandpartnerorganisations.Workisunderwaytoadaptcoursesforpeoplewithmentalhealthproblems,andforcarers.Feedbackfromaround1,000patientswhocompletedthecoursebetween2003and2005indicatesthattheprogrammeisachievingimprovedhealthoutcomesforpatientsandreducingthedegreetowhichtheyusehealthcareservices.

box 13: What do people with physical and mental health problems want from services?

A2004study113foundthattwothirdsofrespondentshadproblemsaccessingmentalhealthservicesbecauseoftheirphysicalimpairment.Asimilarproportionhaddifficultiesusingphysicaldisabilityservicesbecauseoftheirmentalhealthneeds.Whenaskedwhattheywantedfromservices,keyfactorswere:

• Forgeneralhospitalstafftotakeaccountofpatients’mentalhealthneeds,withoutmakingnegativejudgementsorbehavinginaderogatorymanner

• Forstafftotakeseriouslythepatient’sownviewoftheirhealth,andnottointerpretphysicalimpairmentspurelyasamanifestationofmentalillness. Oneperson,forexample,saidthat,whenhewasinhospital,‘the fact that I said I had [asthma and arthritis] was seen as an aspect of mental illness’

• Formentalhealthstafftohaveagreaterunderstandingofphysicalhealthneeds,withouthavingnegativeattitudesorlowexpectationsofthepatient

• Forallhealthcareprofessionalstohaveagreaterunderstandingoftherelationshipbetweenmentalandphysicalhealth

• Forstafftotreatthepatientasawholepersonandnotadisease• Formentalhealthprofessionalstotakeaccountofaccessneedsrelating

tophysicalimpairment,andviceversa• Clearcommunicationandpositiveattitudesfromstaff:“He was actually

helpful because he seemed normal and he didn’t use words that were not understandable”.

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There remains a stigma around mental illness

Manypatientsfeelembarrassedtotalkabouttheiremotionalproblemsforfearof anegativeresponsefromhealthservicestaff,andthereremaindeeplyentrenchedviewsamongstsomecliniciansthatmentalhealthproblemsareshamefulorasignofweakness.Liaisonpsychiatryservicesarewellplacedtochallengestigmatisingviewsofmentalillness,througheducation,trainingandhighvisibilityinacutemedicalsettings.119

involving patients in service development, research and audit can improve mental health care in the acute setting

TheNHSPlan120placespatientsatthecentreofservicedesignanddelivery.Ideallythisinvolvementshouldextendtotheplanningoflocalservices,recruitment,trainingandeducationofstaff,research,clinicalauditandserviceevaluation. Box15illustrateshowthiscanworkinpractice.

box 14: Engaging with carers

Considerationshouldbegiventothesupportneedsofpeoplewhocareforsomeonewithmentalandphysicalhealthproblems.Carersmayfinditdifficult toaccesshealthprofessionalsandthehealthofcarersisalsooftenoverlooked.

box 15: involving service users in the improvement of self-harm services

TheRoyalCollegeofPsychiatrists’‘BetterServicesforPeoplewhoSelf-harm’projectwasestablishedin2005(www.rcpsych.ac.uk/cru/auditselfharm.htm).Peoplewhoself-harmwereinvolvedonmanylevels,includingdeveloping trainingmaterialsandcoursesforclinicians,providingtraining,designingdatacollectiontoolsandwritingreportsandrecommendations.Usersworkedalongsideambulance,emergencydepartmentandmentalhealthstafftoplanserviceimprovementthroughmeetings,workshopsandpeer-reviewvisitstootherhospitals.NHSstaffdescribedtheirinputas‘very helpful’inbringing aboutpositivechangeasdescribed:

“[They gave] an insight of what it is like to receive a service...a good relationship was established, allowing a freedom to share views, even those of a potentially controversial nature. It felt that service users were extremely active and equal partners and played a significant role in the project. For this we thank them.”

Many of the service users involved gained from the experience:

“I have been able to develop training skills which has led to me being invited to join the planning team for student nursing training at a local university. I have gained sufficient confidence in my own abilities to be able to return to work, albeit part time and in a junior position, for the first time in six years.”

“All my trouble with self-harm has finally been put to use and my experiences have been invaluable in helping improve things. I feel useful!”


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BothNICEandSIGNinvolvepatientsandcarersintheprocessofdevelopingtheirclinicalpracticeguidance.InEngland,LordDarziconcludedinhis2008reportthat‘Peoplewantagreaterdegreeofcontrolandinfluenceovertheirhealthandhealthcare’.122Inkeepingwiththis,thefocusintheNHSisshiftingfromtreatmentoutcomesthataredefinedbythecliniciantothosethataredefinedbythepatient.ThisisreflectedintheDepartmentofHealth’sworktodevelopPatientReportedOutcomesMeasures(PROMS)foruseinperformancemanagementofservices.

There are many barriers to involving patients and carers in improving services

Inrealityhowever,theoftenverygoodintentionsofinvolvingpatients‘cansometimesfailtomovebeyondrhetoricintoreality’121andrunstheriskofbeingtokenisticandsuperficial.Severalfactorscanhindermeaningfulinvolvement,includingpracticalbarriersrelatingtorecruiting,supportingandpayingusersandcarers.Someprofessionalsalsodescribedifficultiesinfindingpeoplewhoarerepresentativeofthe‘typicalpatient’butLindow123warnsthatthisshouldnotbe usedasareasontoexcludepatients:

“The most usual strategy to discredit user voices is to suggest that we are too articulate, and not representative…We ask how representative are others on the committee? We point out that as they are selected for their expertise and experience, so are we…We ask, would workers send their least articulate colleagues to present their views, or the least confident nurse to negotiate for a change in conditions?”

Itisequallyimportantthatpeopleshouldnotbedisenfranchisedpurelybecauseofintellectualimpairments.Whengivenappropriatesupportandopportunitypeoplewithlearningdisabilitiesandtheircarersarecapableofgivinginvaluableinsightsintopotentialbarrierstoeffectivehealthcare.63

The value of patient expertise should not be underestimated

‘By definition, no one else, no matter how well trained or qualified, can possibly have had the same experience of the onset of illness, the same contact with services or the same journey through the health system.121

Theseexperiencesareanimportantresourcethatcanhelptoimproveindividualpackagesofcareaswellasservicesgenerally.Wheninvolvingpatientsorcarersinanykindofservicerevieworimprovement,caremustbetakentoprovidetheappropriateemotional,financialandpracticalsupport.

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General hospitals need flexible and responsive liaison mental health services

ThisistheviewoftheRoyalCollegeofPhysicians,RoyalCollegeofPsychiatristsandtheAcademyofMedicalRoyalColleges.70,81ARoyalCollegeofPhysicianstaskforcerecommendsthatacutementalhealthservices,includingthosededicatedtotheneedsofolderpeople,shouldbepartoftheacutespectrumofcare,and thatallfutureacutemedicalunitsshouldhaveasafeareaformanagingpatientswithacutementalhealthproblems,arelatives/carersroomandaroomforprivate orconfidentialinterviews.124

however, there is little incentive for the NhS to develop such services

Thisisbecauselocalmentalandphysicalhealthcareservicesarecommissionedseparatelyandmanagedbydifferentorganisations.Liaisonmentalhealthteamsarethereforenota‘must do’foreithermentalhealthoracuteservices.Asaresult,thereispatchyandinconsistentprovisionacrosstheUK.Whereahospitaldoeshavealiaisonmentalhealthservice,thisisinvariablyprovidedandmanagedbythelocalmentalhealthtrust.

TheDepartmentofHealth’sdriveforintegratedcare,especiallyforlongtermconditions,andtheshiftincommissioningtoprimarycareanddevelopmentof‘Practice Based Commissioning’,presentanopportunityforthedevelopment ofservicesinalessdualisticfashion.125

There are different models of service

However,liaisonpsychiatryservicesworkmosteffectivelywhentheyareembeddedintotheworkofthegeneralhospital.Thisallowsliaisonstafftoworkcloselywithgeneralstafftoimproverapiddetectionandtreatmentofpatientswithmentalproblemsinthegeneralhospitalsetting.Mostservicesincludetrainingandeducationalcomponentstoimprovetheoverallqualityofserviceprovisioninthegeneralhospital.Liaisonserviceswillalsohelpensureappropriateguidelines (e.g.NICEandSIGN)arebeingfollowedandthatclearpathwaysofcarearedevelopedforpatientswithparticularmentalhealthproblems.

Liaisonservicesshould‘map’ontothespecificneedsofanacutehospital.Asacutehospitalsvaryinsizeandservicedelivery,thesizeandmakeupofeachliaisonservicewillalsovary.Forexample,teachinghospitalsrequirelargerliaisonservicesthandistrictgeneralhospitals,becausetheyareusuallylargerandareoftenlocatedininnercityareaswithhighratesofdeprivation.Teachinghospitalsalsomanagepatientswhoaretertiaryreferrals(i.e.peoplewithhighlycomplexhealthproblems).

6. RE-ORGANiSATiON OF SERviCES, COMMiSSiONiNG AND QuALiTy STANDARDS


35

A liaison mental health team requires adequate staffing

Thetablebelowgivesanapproximateguidetotheminimumlevelsandskillmixforabasicteamservingageneralhospital,operatingMondaytoFriday,9am-5pm.126

box 16: Suggested minimum staffing for a team serving a general hospital126

ROLE GRADE TiME COMMENT

Medical Consultant Wholetime Consultantinvolvementisessential,includingmanagingrisk,providingsupervisionandtrainingandofferingexpertiseonpsychopharmacologicaltreatment,complexpatients,capacityandtheMentalHealthAct.

Nursing Band8 Wholetime Oneofthenursingrolesshouldbeasteamleader.

Nursing Band 7 3XWholetime Thenursesoperateasautonomouspractitioners,under-takingassessments,andbrieftreatmentinterventions,andliaisingwithmentalhealthteamsinprimarycare.Thoseworkingwitholderadultswillbecomeinvolvedindetaileddischargeplanning.

ClinicalPsychology Band8 1XWholetime Maybeprovidedfromhealthpsychologyteam,butshouldbeanintegralpartofaliaisonteamtoprovidesupervision,traininganddeliveryofbriefpsychologicaltreatments.

TeamPA Band4 1.5XWholetime Coretoreferralmanagement,informationgatheringandcommunication.

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Thesestaffinglevelsrepresenttheabsoluteminimum,andadditionalcoverwouldalmostcertainlyberequired,dependingonthepopulationserved.Toprovideacomprehensiveliaisonservicewhichspecificallycatersforthespecialneedsofadultswithcomplexneedsanddementia,greaternumbersofthestafflistedabovearerequired.Inaddition,theteamwouldalsorequireatleastonefulltimeoccupationaltherapist,1.5WTEsocialworker,sessionsfromasupportworkerandadditionaladministrativesupport.Thestaffinglevelsrequiredtoprovidealiaisonservicetoolder-agedpatientsareavailableathttp://www.rcpsych.ac.uk/PDF/RaisingtheStandardOAPwebsite.pdf.

Ifliaisonprofessionalsaretoprovideteaching,trainingandsupporttocolleagueswithintheirteamandthroughoutthegeneralhospital;thestaffingratiosabovewouldneedtobeincreasedtoallowforthis.

Finally,thetableabovedoesnotincludechildandadolescentmentalhealthservices(CAMHS)togeneralhospitals.ThisoughttobeprovidedbyspecialistmultidisciplinaryCAMHSliaisonteams,butcurrentprovisioniscurrentlypatchy andfurtherinvestmentisrequired.

Quality Standards WeneedqualitystandardsformentalhealthcareingeneralhospitalsThesewouldclarifytheroleofliaisonservices,andprovideameansbywhich tomeasureandimprovethequalityofcaretheyprovide.Ina2008reportbytheAcademyofMedicalRoyalColleges,127theChairoftheAcademyemphasised theimportanceofsettingsuchqualitystandards(Box17).

The psychiatric Liaison Accreditation Network will support implementation

TheRoyalCollegeofPsychiatrists’CentreforQualityImprovement(CCQI)hasestablishedanationalaccreditationprogrammeformentalhealthservicestogeneralhospitals(www.rcpsych.ac.uk/PLAN).

box 17: The importance of setting standards

“We witness mental distress and mental illness daily, in people of all ages and in many different circumstances. Yet in our society they command less priority than do physical problems….the same standard of assessment, diagnosis and intervention should be provided for mental health care as is expected for physical health care. This requires an extension of current standards to cover practice in these acute services, commissioning of services and assessment of performance.”

-ProfessorDameCarolBlack,Chair,AcademyofMedicalRoyalColleges


37

Figure 1: The quality improvement cycle adopted by pLAN

Aprocessofself-andpeer-reviewwillculminateinadecisionaboutwhether aliaisonservicehasmetessentialstandardsandcanthereforebeaccredited bytheRoyalCollegeofPsychiatrists.Althoughthemainfocuswillbeonthe liaisonteam,participatingteamscanchoosetonominateotherdepartmentsin thehospitalforanadditional‘MentalHealthFriendlyAward’.Forexample,adepartmentofthehospitalwouldreceivesuchanawardifitmetanumberof corestandardswhichdemonstratethatthementalhealthneedsofpatientsare wellmetinthatdepartment.

box 18: The psychiatric Liaison Accreditation Network (pLAN) will:

• Provideassurancetoserviceusers,carers,commissioners,governmentdepartments,regulatorsandthepublicthataccreditedliaisonservicesare ofanacceptablequalityandthatsafetyandqualitystandardshavebeenmet

• Recogniselocalachievementsmeasuredagainstrigorousnationalstandards• Stimulateliaisonservicestoconstantlyimprovethequalityofcarethey

provide• Givecommissionersconfidencetoinvestinaccreditedliaisonservices• Developaprofessionalidentityforaccreditedliaisonservicesandraise

awarenessofthevalueofeffectiveservices.

Figure1describesthequalityimprovementcycle.

1. Agree standards 2. baseline data collection

5. Action planning work, learning events and

interventions

6. Re-audit to measure change

3. peer-review (staff and service users visit

another service)

4. Data fed back through reports. Accreditation

status confirmed.

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Many healthcare professionals would welcome better mental health training

ThelackofintegratedthinkingaboutphysicalandmentalhealthintheNHSmeansthatthereisarealneedforhealthcareprofessionalstoacquireagreaterunderstandingoftherelationshipbetweenmentalandphysicalhealth.However,recentrecommendationsandauditfindingsreflectthefactthatmanyhealthcareprofessionalshavenotbeenprovidedwithadequatementalhealtheducation:

Doctors need better training in the detection and treatment of mental health problems in patients who are physically ill

MostUKmedicalstudentsreceiverelativelylittletraininginmentalhealth,andmostofthatfocusesonthemanagementofsevereandenduringmentalhealth.Medicalgraduatesinitiallybecomefoundationdoctorsfortwoyears,duringwhichtimetheyacquirethemajorityoftheircorementalhealthcompetenciesinanticipationofbecominggeneralpractitionersorhospitalspecialists.132

box 19: Training needs of general hospital staff and Gps

• In2003,theRoyalCollegesofPhysiciansandPsychiatristsrecommendedthatcommissionersensureimprovedtrainingofgeneralhospitalstaffin thementalhealthneedsofolder-agedadults81

• Atthesametime,theChildren’sNationalServiceFrameworkstatedthatliaisonarrangementsshouldprovidefortheeducationandtrainingofallchildren’shealthcarestaffinthementalhealthneedsofchildrenandtheirfamilies110

• In2008,theAcademyofMedicalRoyalCollegesrecommendedbetter mentalhealthtrainingopportunitiesforstaffinemergencydepartments,medical,paediatricandsurgicalwards127

• TheHealthPromotionAgencyforNorthernIrelandsurveyedover500 primarycareprofessionalsin2008andfoundthateightoutof10wanted moretraininginrecognisingmentalhealthproblems,suicide,self-harm andmentalhealthpromotion.Barrierstotrainingwereidentifiedasalack oftimeandalackofaccess.Asuggestedsolutiontothisproblemwas onlinetraining128

• Arecentauditfoundthatmorethanhalfof500emergencydepartment staffwouldhavelikedtheirinitialtrainingtoincludemoreemphasison mentalhealth129

• VariousNICEandSIGNguidelinesstipulatetheneedforbettermental healthawarenessamongstphysicalhealthprofessionals(www.nice.org.uk)

• Traininginrelationtotheneedsofpeoplewithlearningdisabilityisalsogenerallyinadequateleavingmanyhealthcareprofessionalsfeelinguncomfortableandunprepared130

• ThelearningdisabilitycomponentoftheRoyalCollegeofPsychiatrists’curriculumforbasicspecialisttrainingemphasisestheimportanceofrecognisingtheinfluenceofphysicalfactorsonpsychologicalpresentation. Itisessentialthatgeneralhospitalstaffaretrainedaboutnotjustthehighratesofandatypicalpatternsofhealthdeficitsinpeoplewithlearningdisability,butalsothepotentialatypicalpresentationofphysicalsymptoms.131

7. TRAiNiNG AND EDuCATiON


39

Thefoundationcurriculumemphasisestheimportanceofpsychological,socialandculturalfactorsintheassessmentandmanagementofphysicallyillpatients.Morespecifically,foundationdoctorsmustbeabletomanagepatientsfollowingself-harm,withanacuteconfusionalstateandwithpsychosis.Theyarealsorequiredtodeveloppositiveattitudes,inwhichtheymustconsidertheimpactof:132

• Physicalproblemsonpsychologicalandsocialwell-being• Physicalillnesspresentingwithpsychiatricsymptoms• Psychiatricillnesspresentingwithphysicalsymptoms• Somatisation• Familydynamics.

However,thedichotomyofcarebetweenmentalhealthandacutetrustsorNHSboardscanmakeacquisitionofthesecompetenciesverydifficult.Thereareanumberofwaysinwhichmentalhealthstaffcanfacilitatetheprocess:

• Generalhospitalshaveweeklygrandroundswhichshouldbeattendedbymultidisciplinarymembersoftheliaisonpsychiatryteam,whoshouldalsotaketheirturninpresentinganddiscussingcasesandissuesofsharedinterest

• Mentalhealthprofessionalsshouldparticipateintheregularteachingofacutetruststaff–notonlyintheformalsettingofcontinuingprofessional development–butalsoonthewards.Sharingknowledgeandattitudesduringroutinecareofferstheopportunityofinvolvingthepatient’sownperspective andexpectations

• Mentalhealthprofessionalsshoulddevelopworkingrelationshipswithacutecareunitswheretheprevalenceofpsychologicalmorbidityisparticularlyhigh– suchasrheumatologyandgastroenterology.Thedaytodaypresenceofmentalhealthprofessionalsontheseunitspromoteslearningandincreasedawarenessofmentalhealthissues

• Mentalhealthprofessionalscantraincolleaguesintheuseofeasilyimplementedmentalhealthscreeningquestionnaires,whichimprovestaffawarenessforpsychologicalandpsychiatriccomplications.TheHospitalAnxietyandDepressionScaleisawellvalidatedself-ratingscaleforusein thegeneralhospital.133

box 20: All doctors working in a general hospital setting should be able to:

• Elicitpatient’sconcernsaboutillnessinasensitiveandcompetentmanner• Screenfordepressionandanxiety• AssesscognitivefunctionusingtheMiniMentalStateExamination• Carryoutabasicriskassessmentforsuicideandself-harm• Beabletoassessbasiccapacitytogiveconsentformedicaltreatment• Detectdementiaanddeliriumandtreattheseappropriately• Detectsymptomsofdrugandalcoholwithdrawalandtreatthese

appropriately.

40


Competencies need to be checked

‘Knowing Why’and‘Knowing How’,usuallytestedbywrittenandclinicalexams,arenotconsideredtobesufficientevidenceofcompetence.ThecurrentgoldstandardistheWorkplaceBasedAssessment,particularlyasthisincludesfeedbackandreflectivepractice.Twoofthese,currentlyapprovedbythePostgraduateMedicalEducationandTrainingBoard,lendthemselvesparticularlywelltothedevelopmentofintegratedphysicalandmentalhealthskills:

• CaseBasedDiscussion(CBD):IntheCBDthehealthcareprofessionaldiscussesanindividualpatient.Thetrainercanfocustheconversationonaspectsofmanagementthatrequireattentiontophysicalandpsychologicalneeds,andcanhelpidentifypointsofstrengthandareasthatcouldbedevelopedfurther

• Mini-ClinicalExamination(mini-CEX):Inthemini-CEX,whichusuallylasts10-15minutes,thehealthcareprofessionalinteractswithapatientwhilstbeingobserved.Theexercisecould,forexample,betoassessthepatient’smood,theimpactoftheirphysicalillnessontheiremotionalhealth,ortheirunderstandingoftheirillness.Again,thetrainerorsupervisorcanfocusthesubsequentfeedbackanddiscussiononareasrelevanttointegratedcare.

Training in primary care needs to be improved

Therearealsoopportunitiesforteachingandawarenessraisinginprimarycare.Recentdevelopmentssuchasprimarycarementalhealthteams,GPswithspecialinterestsinmentalhealth,theImprovingAccesstoPsychologicalTherapies(IAPT)ProgrammeandtheGatewayWorkersProgrammeraiseawarenessofmentalhealthissuesandaccesstotreatmentsinprimarycare.Theseteamsneedtotrainandsupportactivecasemanagersandpatientswithlongtermconditionstointegratephysicalandpsychologicalcare.Secondarycarementalhealthspecialistsneedtotrain,superviseandsupportprimarycarestafftoacquireandmaintainrelevantmentalhealthskills.

TheRoyalCollegeofPsychiatristsandtheRoyalCollegeofGeneralPractitionersrecentlyrecommendedthatGPsintrainingwouldbenefitfromspendinganattachmentinLiaisonPsychiatry.134Thetypeofmentalhealthproblemsseenbyliaisonpsychiatryservicesaremorediversethanthoseseenbyteamswhospecialiseinthetreatmentofseverementalillness,andtheproblemsaremorerelevanttothosemostfrequentlyencounteredbyGPsintheirdailypractice. Thecollegesalsorecommendedthatmorepsychiatrictraineesshouldspenda sixmonthattachmentinprimarycare.ThenewlyestablishedForumforMentalHealthinPrimaryCarealsoprovidesusefulupdatesaboutpsychologicalaspects ofphysicalhealthandactsasanexpertresource (www.rcpsych.ac.uk/college/mentalhealthinprimarycare.aspx).

Manypatientswithchronicconditionssuchaspainareincreasinglylikelytobeseeninintermediatecaresettings.Newservicesneedtoincludementalhealthspecialistssothatstaffbecomefamiliarwithmanagingtheinterfacebetweenphysicalandpsychologicalcare,andtrainingneedsshouldbeprioritised.

Finally,thenationalguidelinesdevelopedbyNICEandSIGNrelatingtophysicalconditionsvaryintermsofmentalhealthcontent(seewww.rcpsych.ac.uk/nohealthforadetaileddescription).Itisvitalthatnationalguidanceensuresthatmentalhealthissuesreceiveadequatefocus.


41

ItishopedthattheALERTreportwillnotonlyenhanceunderstandingofthe linkbetweenmentalandphysicalhealth,butalsoprovideamuchneededimpetus forthedevelopmentofbetterservicesforthissignificantandlargelyneglectedgroupofpatients.Moresubstantialmentalhealthprovisionacrossthegeneralhospitalsettingwillbenefitpatients,carersandhealthcareprofessionalsfrom allbackgrounds.ItisenvisagedthattheMedicalRoyalCollegesandotherorganisationswillworktogethertomaketherecommendationsinthisreport areality.

8. SuMMARy

42


This report has been compiled by:

professor Else Guthrie ChairoftheFacultyofLiaisonPsychiatry,RoyalCollegeofPsychiatrists.HonoraryProfessorofPsychologicalMedicineandMedicalPsychotherapyUniversityofManchester

Lucy palmer ProgrammeManager,NoHealthwithoutMentalHealthProjectRoyalCollegeofPsychiatrists’CentreforQualityImprovement

Dr paul Lelliott DirectoroftheRoyalCollegeofPsychiatrists’ResearchandTrainingUnit

Dr Carolyn Chew-Graham SeniorLecturerinPrimaryCare,UniversityofManchesterGeneralPractitioner,Manchester.ClinicalChampionforMentalHealth,RoyalCollegeofGeneralPractitioners

professor Derek bell ProfessorofAcuteMedicineatImperialCollegeConsultantPhysicianatChelseaandWestminsterHospitalNHSFoundationTrustRoyalCollegeofPhysicians’representativeonthePsychiatricLiaisonAccreditationNetwork

Deborah Agulnik ProjectWorker,NoHealthwithoutMentalHealthProjectRoyalCollegeofPsychiatrists’CentreforQualityImprovement

With valuable contributions from:

Dave Anderson AssociateMedicalDirector/Consultant,MerseycareNHSTrust

Janey Antoniou ServiceuserAdvisor,RoyalCollegeofPsychiatrists

Roger banks VicePresident,RoyalCollegeofPsychiatrists

Alan Carson ConsultantinNeuropsychiatry,DepartmentofClinicalNeurosciencesandDepartmentofPsychiatry,UniversityofEdinburgh

irene Cormac ConsultantForensicPsychiatrist,RamptonHospital

Chris Dickens SeniorLecturerinPsychologicalMedicine,UniversityofManchester

Melanie DupinProjectWorker,RoyalCollegeofPsychiatrists

Charlotte Edwards HonoraryResearchAssistant,RoyalCollegeofPsychiatrists

ACKNOWLEDGEMENTS


43

paul Gill ConsultantLiaisonPsychiatrist,SheffieldCareTrust

Max henderson MRCResearchTrainingFellow,KingsCollegeLondon,InstituteofPsychiatry

peter hindleyConsultantChildandAdolescentPsychiatrist,StThomas’Hospital

Sheila hollinsProfessorofPsychiatryofLearningDisability,StGeorge’sUniversityofLondon

Khalida ismail ClinicalReader,DepartmentofPsychologicalMedicine,InstituteofPsychiatry

Glyn Jones ConsultantPsychiatrist,DirectorateofLearningDisabilityServices,AbertaweBroMorgannwgUniversityNHSTrust

Damien LongsonConsultantLiaisonPsychiatrist,ManchesterHead,SchoolofPsychiatry,NorthWestDeanery

Jackie Macklin ServiceUserAdvisor,RoyalCollegeofPsychiatrists

Satveer Niijar ServiceUserAdvisor,RoyalCollegeofPsychiatrists

Margaret Oates ConsultantinPerinatalPsychiatry(retired)

Johan Redelinghuys ConsultantPsychiatrist,WestLondonNHSMentalHealthTrust

Guy Sanders ConsultantinEmergencyMedicine,RoyalSussexCountyHospital,Brighton

Geraldine Swift ConsultantinLiaisonPsychiatry,CheshireandWirralPartnership,NHSFoundationTrust

barry Wright ConsultantChildPsychiatrist,HonorarySeniorLecturer,HullYorkMedicalSchool

With thanks to:

Rosie Carlow PublicationsManager,AcademyofMedicalRoyalColleges

James Taylor Designer

44


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