Liaison News

Newsletter of the Liaison Faculty

Royal College of Psychiatrists
Spring / Summer 2008
Page

Regulars
1.

Editors comment

2.

Chairs Report

3.

Finance Officers Report

4,

Academic Secretarys Report

5.

Faculty Executive Feedback

6.

National & Regional Feedback

7.

TNC Report

8.

Feedback from Other Activity Areas

i.

Diabetes UK

ii. TNC Annual Conference

10

iii. College

12

9.

New Research Update

13

10.

It all happens in Liaison Outpatients

i.

Cases from the JISC mail Liaison Group

28

11.

Upcoming meetings & courses

30

12.

Book Reviews

32

13.

Faculty PBR Project

15

14.

Quality Standards in Liaison Psychiatry

16

15.

Darzi Review & Liaison Submissions

19

16.

New Service Approaches ICATS

24

17.

Health Care Commission Review

25

18.

Chronic Pain Commissioning Pathway

27

Features

1.

A word from the Editor

At last the rather late spring/summer newsletter! Apologies for the delay but as most of you know and
have been involved in (and those who dont will see from the newsletter!) there has been rather a lot
going on recently, and from March onwards when I was set to go forward with the release of the
newsletter, another suggestion came forward and things were happening that were worth waiting for!
Weve another pretty packed newsletter with feedback from all corners of the UK and can safely say
that were not England centric with this episode!!! Thanks to all whove contributed both regulars and
for the features (thank-you for not getting annoyed with me pestering for your submissions!). New for
this issue Ive added cases of interest from the JISC mail discussion group as I feel they highlight
some of the really interesting cases that we see in Liaison, and it is always interesting seeing
colleagues take on things and to remind us all that if at a wall in treating a patient ask a colleague, and
in this case worldwide! In addition to this Ive also tried to include up-coming meetings and book
reviews. I would especially draw everyones attention to the Prague meeting in March 2009. As youll
see from our Finance Officers report, this is the Facultys main source of income so, to help us not go
under, we need as many of you there so please get it in your diaries now! If you know of any
meetings or have been on any interesting courses or read any books that you think would be of use /
interest to your colleagues, please let me know so I can add them for the next newsletter planned to
get to you December!
As always any suggestion or even better submissions contact me on Melanie.Temple@TEWV.nhs.uk
Enjoy!!!!!!!
Mel
Mel Temple
Hon Sec & Editor

2.

Chairs Report Else Guthrie

I am pleased to report that we had a successful meeting in Newcastle in March this year, despite
attempts by the weather to derail things. For those of you who attended the meeting, you will
remember that the country was hit by severe storms and several speakers were delayed in getting to
the meeting. However, we had a good attendance and should have broken even.
Plans are already underway for next year's meeting which will be held in Prague. I am very grateful to
Mathew Hotopf for organizing the last three Faculty Liaison Meetings. They have all been well
attended with a creative mix of scientific and clinical presentations. Mathew is standing down as
Academic Secretary and his position is been taken up by Sanjay Rao. Sanjay has already begun to
plan next year's meeting which we hope will be well attended.
I am also extremely grateful to Paul Gill who is standing down as Chair of the Faculty Education
Committee (FEC). Paul has made an enormous contribution to the Faculty over the last few years,
mainly in his role as secretary and then as Chair of the FEC. Together with Damien, he has been
responsible for developing and revising the Liaison Psychiatry curriculum: a massive task!
There have been some encouraging developments in Liaison Psychiatry in England on a National
level over the last 12 months.
A) I am pleased to report that the DoH has given the go ahead to the PBR project on
developing a tariff for Liaison Psychiatry work in the acute setting. Mel Temple, Damien
Longson, Peter Aitken and others (and me!) are working over the next few months on this
project. There is no guarantee that even if we are successful in producing a tariff that it will be
implemented but at least there will be one available.
B) Many Liaison Psychiatrists across England have been involved in lobbying the various
regional Darzi committees in relation to Liaison Psychiatry. As a result, Liaison Psychiatry is
mentioned in several of the regional reports although we await the publication of the final
document.

C) Paul Gill has been instrumental in producing a college report entitled Managing Urgent
Mental Health Needs in the Acute Trust: A guide by practitioners, for managers and
commissioners in England and Wales which will be launched on 28th May 2008 at the College.
This report arose out of the concerns expressed by Prof George Alberti re mental health
services in the Emergency Department. Paul has worked with the President of our College and
Prof Alberti to produce an excellent report.
D) The Royal Academy of Medical Colleges has funded a programme of work by the Research
Unit at the RCPsych to develop standards for the accreditation of Liaison Services.
E) Finally, we have had great support from our President, Sheila Hollins, who has lobbied
vociferously on behalf of Liaison Psychiatry.
I hope that the next 12 months is as productive!
I also hope that people will read the piece I have written about ACCEA awards and act accordingly.
Can I also remind people to think about the Fellowship of the College. There are many liaison
members who are eligible for the fellowship but as far as I am aware very few have applied. The
process has recently been streamlined and it now requires only 2 nominees.
I am aware that my report will seem somewhat Anglocentric! Liaison Psychiatry seems to be strong in
Scotland, developing slowly in Wales, and I am aware of some development in Northern Ireland. I
have had an invitation from Eugene Cassidy for one of the next Faculty Residential Meetings to be
held in Cork. I have responded positively to this and hope that we will be able to organize a meeting
in Cork in the next 2-3 years.
On a final note, I will be standing down in the summer of 2009 and we will be seeking nominations for
Chair of the Liaison Faculty at the Prague Meeting in March 2009. If you would like to stand for Chair
you will need to get a nomination into the College prior to the meeting or at the AGM at the Prague
Meeting. I am happy to let people know what the post involves. I can honestly say that it is enjoyable
and interesting work!
Have a great summer!
Else Guthrie

3.

Finance Officers Report Peter Aitken

Dear faculty,
I want to give an early indication of our financial position for the year by reporting on our main income
generating event, the annual residential meeting in Newcastle. I won't be able to get a proper outturn
for the annual residential meeting until next month but I can make an early estimate about
the financial outcome. Our numbers were just over break even numbers. We managed just over the
target of 65 full paying delegates each day, but missed out on our target of 25 half paying delegates.
Unfortunately we didn't actually attract any exhibition.
Fortunately in some areas we underspent, the director of conferences didn't attend, staff expenses
were lower, speaker expenses were lower, and we didn't have to use our contingency. This
underspend is about the same as what we didn't make in exhibition income so my sincere thanks to all
those who tightened their belts or made minimal claims from the faculty funds.
Overall, I think the meeting will make a very small surplus, but this surplus will be in the hundreds
rather than thousands of pounds. This presents us with quite a financial management challenge and I
look to faculty members to use every other route to managing expenses they can find.
Peter Aitken
Faculty Finance Officer

4.

Academic Secretary Report Sanjay Rao

The 2008 Liaison Conference in Newcastle had a wide array of presentations ranging from conceptual
understanding of suffering to life course and epidemiology, highlighting the diversity of streams within
the practice of consultation liaison psychiatry. The presentation on medicine and popular alternate
health nostrums was an informative and entertaining stand up act. The crises of transport and rain
lead to last minute changes but the organisers managed to contain the effects of the disruptions. The
attendees feedback indicated need for more clinical content and has been taken into account for the
next conference.
The next meeting of the CL faculty will be held in Prague which has excellent conference facilities
close to the city centre and truly offers business and pleasure at a reasonable price (which will help us
keep the conference fees down). Liaison faculty members can rest in the fact that other faculties have
provided very positive feedbacks about the venue. This conference will be held over 2 days and will
have a strong clinical/academic focus with topics ranging from transplant psychiatry, eating disorders,
sleep, factitious disorders, palliative care and early dementia management. A variety of workshops
will be available. There will be a session on new service ideas and the poster presentations will be
followed by a best poster certificate crowning ceremony! We have no doubts that attendees will
continue into a long weekend break and the conference office will liaise with local tourism to help
attendees with making bookings.
Sanjay Rao
Academic Secretary

5.

Faculty Executive Feedback

Most of the feedback for this newsletter is contained within the minutes from the AGM so will leave you
to peruse those and not anything more!
Liaison Faculty AGM
12 March 2008, Newcastle Assembly Rooms
1.

Attendances & Apologies Noted.

2.

Countrywide Issues
i.
Feedback for the President Breakfast Mtg with Ministers
The president is shortly to have a meeting with Ministers in relation to the integration of
medical and mental health services following issues related to this being raised. The president
is looking for evidence and service examples of the impact in 1ary and 2ary care. Members
raised Wayne Kaytons work and Managed Care in US and Service examples and studies
from Australia. Ministers have stated they will fund the service providers / authors to attend to
present. Else requested that any suggestions were passed to her asap.
ACTION: All
ii.
NHS Confederation Meeting
Faculty reps have been lobbying the NHS Confederation in respect of achieving Liaison
Services as a topic within one of their meetings that are run for Trust & StHA chief execs. Prof
Peveler has been successful in this and we are hoping to raise / present 3 topics as part of
this to raise the profile of services and their impact. Possible dates are June / Nov. Members
were requested to contact Else if interested.
ACTION: All
iii.
Quality Standards Project
The president and Else have successfully engaged sponsorship of the Academy of Royal
Colleges ( 1.5 million provided by DoH for specific project work on improving services
available to bid for) for a project run by the College Research Unit into Quality Standards for
Liaison Services akin to the Better Services for Self Harm project. The CRC will work over the
next year on this with feedback from the faculty, which will include literature reviews and
developing standards, and finally a package that services can sign up to to assess where they
stand in relation to these. There will be a session within the Annual Meeting on this and the
summary of that session will feed into the project. An update will be put in the newsletter for
info and feedback details.

ACTION: CRC Dr Temple

iv.
Emergency Care Report
This DoH report is headed up by Prof Alberti and Paul Gill as the Faculty Rep with the
document launch due end May. Jt report RCN, Royal Colleges and DoH. Provides
suggestions around service standards for mental health input into emergency care. Is
essentially an English document for political reasons but is proving very useful for Wales
though the Scottish situation is not felt to be well represented.
3.

Project Updates
i.
England
PBR
Explanation of the project was given and the fact that the DoH have supported the project
whos aim is to develop a PBR tariff for acute and outpatient Liaison work with the sponsorship
of NE StHA and support from the DoH Mental health PBR group. Phase one of the project is
looking to attempt to identify proxy measures which can be recorded for patients seen by
service that will allow the patients to be split into two groups or currencies namely low and
high complexity and Phase two will then look at the interventions (i.e. every thing that we do
with them and that is involved in managing them) that are received by each of these groups at
the sites and attempt to cost them and come up with a tariff for the high and low.
Nine sites across the country have support to be involved which should hopefully ensure the
generalisability of the projects to all settings.
The data collection sheet is currently in production and trial with a view to the first data trawl in
June/July.
Darzi Review
The members were reminded of the Darzi review of services which currently underway and
were informed of the work that the faculty have been doing in relation to ensuring that Liaison
is on the map for services within the final Darzi report which is to be published in June/July.
Faculty Members in all the Darzi Regional Areas have been feeding into the Acute and Mental
Health care workstreams alongside the main college response. We have been successful in
several of the regions so far in getting liaison services into their final reports so we are hopeful
of inclusion in the final report which is to be collated from the regional recommendations. If
successful this may finally be the hook / target to get services commissioned on.
ii.
Scotland
Scottish Executive are looking at MH Integrated Care Pathways and Liaison has been
identified as one of these. Awaiting more feedback from Scottish members
4.

Faculty Business
i.
Treasurer Feedback
Peter Aitken was unable to attend to provide feedback but Else reported that Faculty was
just in Black at 2000 approx. Main income for the faculty is the annual meeting and
members were therefore asked how attendance at this might be boosted to increase this.
It was noted that sign up this year had been lower than previous even with a lower price.
ii.
Academic Secretary Post
Matt Hotopf stood down from the post after this meeting and Sanjay Rao was voted into
post. Matt was thanked for all his work in the annual meeting organisation
iii.
CEC Feedback
The Colleges Central Executive Committee is the min decision body for the college and is
made up of each of the chairs of the faculties and the Colleges Snr Officers. Most
relevant issues for the faculty currently are the fact that the College finances are in a poor
state primarily due to a reduced income from exams and publications.
iv.
Faculty Education Committee
Paul Gill has decided to step down as chair after considerable work for the faculty and
indeed the college in this area. Damien Longson has agreed to take over. The FEC has
been working on the new curriculum in relation to the multiple changes to the medical and
specialist education system. The Liaison Curriculum produced and provided to the college
Education Committee was very well received and put forward as an example to the rest of

the faculties. Once all the rest of the Faculties have submitted their versions a new
overarching Psychiatric Curriculum will be presented to PMetB by the college for their
approval and sign off.

6.

National & Regional Feedback

England
Within England there are lots of projects on-going most of which are detailed in this newsletter and will
hopefully aid services across England. Feedback illustrates that the pressure is still very much on
services at present with Foundation Trust applications, service reviews and financial deficits.
Fortunately the loss of services and posts seems to have slowed but a further consultant post has
been lost in Worthing. On the positive however, a substantive FT post has been established in North
Harringay, London, and Justin Shute, who fought to develop this, has been appointed into the post.
Sarah Burlinson in Oldham has pulled off a real scoop by turning round a threat of service loss to the
situation where the PCT is now funding a new FT post, which brings the compliment to 2 WTE. In
Manchester, Damien Longson has been pivotal in the opening and running of a new 24 hr Emergency
Psychiatry Unit based within A&E, with beds for crisis admission of up to 24hrs before onward
management. This unit complements the existing Liaison Psychiatry service within the hospital.
There have also been 3 sessions of an Old Age Liaison Psychiatry post created in Portsmouth and
Fareham no-one appointed as yet.
This issue we have feedback from the West Country whove developed into an active, organised and
lively area for Liaison Services.
News from the West Country:
After a long and difficult birth, Liaison Psychiatry appears to be developing slowly but surely in the
South West, although there are still notable blank spots.
In the Bristol Royal Infirmary, the lonely team of John Potokar, Consultant Senior Lecturer and a
Clinical Fellow, have expanded to include 2.5 FTE nursing staff, a FTE Staff Grade, and an AF2 Dr as
well as an ST3 and ST4-6 Drs. Johanna Herrod has also joined John as a part time consultant initially
on 6 sessions, now on 7 (and counting!). The team see 1200 new patients per year including self
harm, in-patient and out-patients. The latter include specialist Hepatitis C/interferon and (separate)
Genitourinary medicine service clinics. The Acute Trust have been especially supportive and have
also appointed 2 WTE specialist substance misuse nurses and a specialist alcohol nurse who work
closely with the Liaison team.
Elsewhere in Bristol, Frenchay Hospital has a team of Acute Trust employed Liaison nurses but no
formal medical input, and Southmead (soon to be a super) Hospital relies on a rota of general adult
Psychiatrists it is hoped that more robust dedicated services will be commissioned soon and a PCT
led initiative is happening as you read
In Bath, Bill Bruce-Jones has been working with the Liaison Team at the Royal United Hospital for the
last 10 years and for the last 2 years has had 5 dedicated sessions. The team comprises a
Consultant Nurse (Anthony Harrison) and 2 FTE nursing staff, as well as input from medical trainees.
The Bath team has developed an integrated care pathway for self-harm and a triage system based on
a Mental Health Assessment Matrix. An evaluation of the use of the Matrix by Dr Anish Patel (SpR) is
about to be published. In the near future the team will begin to provide a commissioned CL service to
the brain injury unit at the Royal National Hospital for Rheumatic Diseases. Bill and Anthony are also
involved in trying to develop Liaison services throughout Avon & Wiltshire Partnership Trust; a mental
health trust that covers a huge geographical area including Bath, Bristol, Swindon, Salisbury and
Weston-super-Mare. Difficulties include the multiplicity of commissioning PCTs and a sensitive
debate around whether Liaison services should be generic or age specific.
In Somerset, the Mental Health Foundation Trust, Somerset Partnership, provides liaison services to
the two main general hospital Foundation Trusts: Musgrove Park Hospital in Taunton, serving a
population of 340,000, and Yeovil District Hospital serving a population of 180,000. The services were
established in 2000 with new money from the then Health Authority, and were initially set-up as Self
Harm Services. Over time, they have developed into small but integrated Psychiatric Liaison Services
offering a first point of contact with mental health services, and a range of departmental services
encompassing advice, training and policy development. The Taunton team is multidisciplinary with a
Team Manager/Nurse Clinician, 1.4 WTE Registered Mental health Nurses, 0.6 WTE ASW, 1.0

Team/Medical Secretary, and 0.7 WTE Consultant Psychiatrist, and 0.2 WTE Honorary Specialist
Registrar. The Yeovil Team is Nurse Consultant Lead.
Further west, Exeter welcome Dr Joanna Bromley, appointed Consultant Liaison Psychiatrist at the
Royal Devon & Exeter (4PA) from June 2008. In the English Riviera, news from Peter Aitken is that a
business case has been accepted by the commissioners for a new service to Torbay Hospital to begin
October 2008 with a full time consultant post to be advertised mid summer 2008, as well as four full
time band 6 and 7 nursing posts.
At RCHT Treliske in Cornwall, Adrian Flynn has 7 consultant sessions. There is a band 7 team
manager and 2 other full-time nurses operating a 9-5, 7days a week service. A full-time Liaison ST2
doctor is attached to the team and an F1 post has been approved to start in August 2008. Approval
for ST4-6 training has been sought. There is a full-time drug and alcohol liaison nurse. The older
persons service has 3 wte nursing posts and 2 consultant sessions.
Any news of further developments (eg ?Gloucester, Plymouth and Barnstaple) please let John know
(john.Potokar@bristol.ac.uk) and hopefully the next report will be even more comprehensive and
inclusive!
John Potokar
Liaison Faculty Rep RCPsych SW Division
Wales
Developments continue in Wales with an F/T Cons Old Age Liaison Psych post being available in
Cardiff.
Readers will probably be aware that sadly a large number of young people, particularly in the
Bridgend area of South Wales, have died from suicide over the last year. This has resulted in the
Welsh Assembly Government preparing a Suicide Prevention Action Plan for Wales which aims to
provide strategic direction for the statutory and voluntary sectors. Two projects to help prevent suicide
have recently been awarded large sums of money by the Big Lottery Fund. One is a Lets Talk
project, aimed at reducing stigma and improving public awareness of mental health issues across the
Bridgend and Neath/Port Talbot areas, and another one has been awarded to MIND Cymru to train
13,000 people in suicide prevention skills and to develop a website for anyone concerned about
suicide.
Liaison Psychiatry Services are contributing to work on the Suicide Prevention Action Plan and it is
hoped that Liaison Psychiatry will play a pivotal role in this in the future.
The Welsh Assembly Government have launched a consultation paper Well Being and Mental
Health Service Fit For Wales. This was requested by Edwina Hart MBE, AM, the Minister for Health
and Social Services. Its principal recommendation is that a statutory body responsible for Mental
i
Health and Well Being is established in Wales called Iechyd Meddwl Cymru - a mental health and
well being service for Wales (IMC). It is suggested that eight mental health liaison groups should be
formed to establish joint working protocols with the NHS Trust for the area. It is also recommended
that IMC will provide psychiatric liaison services. Agreements will be reached for a liaison service from
physicians in general medicine and relevant specialties to mental health in patients. This document
can be downloaded from the following link.
http://new.wales.gov.uk/consultation/dhss/iechydmeddwl/iechydmeddwlcymrue.doc?lang=en
Best wishes
Tayeb
Dr Tayyeb Tahir, Consultant Liaison Psychiatrist, University Hospital of Wales, Cardiff.
Jon
Dr Jonathan I Bisson
Senior Lecturer in Psychiatry, Department of Psychological Medicine
Monmouth House, University Hospital of Wales
Heath Park, Cardiff
CF14 4XW
Tel. +44 (0) 29 20744534 Fax. +44 (0) 29 20747839

Northern Ireland
There are currently still only three nominated Liaison Psychiatrists in Northern Ireland, myself with 5
sessions and two others with 2 apiece. Services to a number of small general hospitals which dot
Belfast in particular are patchy with a variety of input being provided, principally for self-harm via a
Liaison Nurse and Crisis Response Team. At present, however, Psychiatric Services in the Belfast
Trust are undergoing a massive change program which will include a review of Liaison Services
provision.
A long-term Liaison Psychiatry plan for NI is in place as part of the Bamford Review. This group was
chaired by myself, and the report will be the model for Mental Health Services of the future, although
there are many deficiencies in all sectors currently. Of concern is the tendency to deal with general
hospitals and regional services purely on the basis of self harm rather than the whole liaison picture
with a number of hospitals setting up self-harm services. This, in the longer term, could detract from
the overall provision of comprehensive services. A working group has also been set-up to look at
services to A&E Departments. This has principally been driven by waiting times but could have
benefits in terms of re-organization and manpower. I have been asked to be involved in this group
also in relation to my input into my own hospital and also links to the Faculty.
Chris Kelly
Consultant Liaison Psychiatrist
Rosemary.rush@belfasttrust.hscni.net
Ireland
There are major changes occurring in Psychiatry in the Republic of Ireland at present. In January
2009, a new professional body, The College of Psychiatry of Ireland, will come into being. The
College will be an amalgamation of the Irish College of Psychiatrists, the Irish Psychiatric Training
Committee and the Irish Psychiatric Association. An Extraordinary Annual General Meeting of the
th
Irish College of Psychiatrists is due to be held on the 20 June. A resolution will be put forward to
dissolve The Irish Division of the Royal College of Psychiatrists from the Royal College of Psychiatrists
st
on 31 December 2008.
The Royal College of Psychiatrists has supported and assisted the development of the new College of
Psychiatry of Ireland. Irish members of the Royal College will automatically become members of the
st
European International Division of the Royal College from the 1 January 2009. It is likely, therefore,
that Irish psychiatrists will be members of both the Royal College and the College of Psychiatry of
Ireland.
The new College of Psychiatry of Ireland will continue the link with the Northern Ireland Division of the
Royal College under the aegis of the All-Ireland Institute of Psychiatry.
John Sheenan
Scotland
New services have been developing with a new F/T post in the Ayr Hospital on the west coast which
brings the total to two WTE consultant posts. The Scottish Executive is currently actively looking at
pathways into care which include Mental Health Pathways, and Liaison Psychiatry is hoping to feature
as its own pathway.
There will be a joint meeting of the Scottish Sections of General Adult and Liaison Psychiatry on the
7th and 8th November in Crieff. There is a varied and interesting programme focusing on topical and
controversial subjects relevant to both General Adult and Liaison Psychiatrists. Speakers include Dr
Raj Persaud on "Confessions of a Media Psychiatrist", Professor Ian Reid on Antidepressant use in
Scotland, Dr Stephen Potts on "Psychiatry in The Emergency Department - Whose Business?",
Professor David Owens "From CATIE to Kansas Via CUtlass - are atypicals losing their lustre? and
Dr Chris Williams "CBT, how does it work and is it really that good?". Further details from the Scottish
Division section of the RCPsych website or from acurrie@scotdiv.rcpsych.ac.uk
A major research trial in Liaison Psychiatry has just begun. Psychological Medicine Research in
Edinburgh has a CR-UK funded trial of depression management in cancer patients (SMaRT oncology
2). This trial will recruit 500 cancer outpatients with major depression in Edinburgh and Glasgow and
compare Liaison Psychiatrist supervised nurse management (collaborative care) with usual care. The

previous trial SMaRT oncology 1 will be published in the Lancet in the next couple of months. The
responsible Consultant Liaison Psychiatrists are Professor Mike Sharpe for Edinburgh and Dr Tom
Brown for Glasgow.
Best wishes
Jude
7.

TNC Report

TNC Business Meeting

Assembly Rooms Newcastle Upon Tyne
12 March 2008
The Annual TNC Business Meeting took place during the Faculty Residential Meeting. Attendance
was limited by the difficulties caused to train journeys by the inclement weather. The agenda was
shortened as a result
The Bristol TNC meeting was discussed. The feedback from delegates was very good. Although
there are one or two matters still outstanding, the conference appears to have made approximately
1000 profit. The role of industry sponsorship was briefly (hurrah!) discussed.
TNC offices were discussed. This meeting marked the switchover with Max Henderson standing down
as Chair, and Thirza Pieters stepping up from Secretary. One person had expressed an interest in the
position but was stuck on a train. Twp further people expressed an interest during the meeting. All
was eventually resolved the following day when despite encouragement to stand for election, two of
the potential candidates decided to withdraw. As a result Hosakere Aditya was confirmed as the new
Secretary of the TNC. Adrian Flynn has done an excellent job as the TNC Finance Officer. He is
willing to continue and the meeting unanimously agreed. Further discussions will be held at the next
TNC meeting but in all likelihood there will be an election for the Finance Officers post at the next
Faculty meeting
Thirza arrived part way through the meeting. There was discussion about the venue for the next TNC
meeting. Non-mainland options are prohibitive for a number of reasons. Thirza is actively
investigating the possibility of Sheffield and Edinburgh and will keep the group updated via Jiscmail.
The meeting adjourned and the group re-gathered for dinner at El Torero. An excellent evening was
had by the 30 or so attendees.
The TNC remains in excellent health!

8.

Feedback from Other Activity Areas

i.

Liaison Faculty & Diabetes UK

Body, Mind and Science:
Liaison Psychiatry at the Diabetes UK Annual Professional Conference 2008.
Rob Peveler r.c.peveler@soton.ac.uk
Peter Trigwell peter.trigwell@leedsth.nhs.uk

Thanks to the sterling work of Dr Khalida Ismail, who was a member of the conference organising
committee for the 2008 Diabetes UK Annual Professional Conference, this meeting had an
extraordinarily high psychological and psychiatric content. The Diabetes UK Annual Pofessional
Conference is the third largest diabetes professionals meeting in the world, after the American
Diabetes Association and the European Association for the Study of Diabetes meetings, and almost
every session of the three day meeting in Glasgow had something of interest for the Health
Psychologist or Liaison Psychiatrist.
On the first day, the professional discipline meetings included a session for what are euphemistically
termed Psychological Wellbeing Professionals. This group has recently produced a position
statement on psychological wellbeing for Diabetes UK, and they were tasked with producing three new
pieces of work to take forward in the forthcoming year. An important issue raised in this meeting was
that of drawing a distinction between psychological support and treatment, which will be important
progress.

Later in the afternoon, Dr Peter Trigwell (Leeds) chaired a very interesting session on Depression and
Diabetes: a double-edged sword. The presenters at this session were Dr Ismail, Dr Allan Jacobson
from Boston and Dr Frank Petrak from Dortmund. Finally, at the end of the first day in a session
entitled Is obesity a brain disorder?, Professor Janet Treasure (IOP) gave the first of three talks at
the meeting on the topic of eating disorders.
On the second day a session on Management Dilemmas in Childhood Diabetes included a second
talk on eating disorders and type 1 diabetes (Robert Peveler). In the afternoon there was a further
session on psychological problems and diabetes which included a presentation on diabetes-related
coping by professor Frank Snoek (Amsterdam), a further presentation on eating disorders from
Professor Gary Rodin (Toronto), and a very practical session on improving psychological wellbeing
and metabolic control by Melanie Temple from Darlington. On the final day Professor Allan Jacobson
from Boston was involved in a meet the Professor session on Psychological Aspects of the Person
with Diabetes. There was also a presentation on the psychological benefits of physical activity in
people with type 2 diabetes from Judy Barnett from Dundee. In addition to these presentations in the
main programme, the short oral presentations and poster presentations throughout the meeting
included a significant component of psychology and psychiatry. Indeed, so strong was the theme that
one had to pinch oneself to remember that this was a diabetes meeting, and not a Liaison Psychiatry
meeting!
Since what was then the Liaison Psychiatry Special Interest Group began its joint meetings with what
was then the British Diabetic Association in 1992, the relationship between the two organisations has
flourished. The plan now is for the isolated meetings to be consolidated into the Annual Professional
Conference and we do expect the significant contribution of psychology and psychiatry professionals
to continue to increase. Dr Ismail is certainly to be congratulated on a fine job with this years
programme. It is also encouraging that both she and Dr Deborah Christie from University College
London will be on the conference organising committee for 2009. Dr Peter Trigwell and I remain
members of the Professional Advisory Council for Diabetes UK. A message to members of the
Liaison Psychiatry Faculty is that this is a really good opportunity to get involved. Anyone interested in
presenting their work at the Diabetes UK Annual Professional Conference 2009 should make
themselves known to Dr Ismail at the earliest possible opportunity. Contributions can range from
plenary presentations to posters or short oral communications.
Comment..
We now have long established and fruitful links between the Liaison Faculty and Diabetes UK and this
conference, with so much psychological / psychiatric content, illustrates the importance of
psychological and psychiatric work in diabetes. Liaison Psychiatrists, especially those in newly
developing services, should be encouraged to consider exploring and even developing a particular
focus on this interesting area.
Please help us to keep the momentum up! Anyone interested in becoming involved should contact
Khalida, Peter or Rob for more information.
ii.

TNC Annual Liaison Conference

th
6 Annual TNC Liaison Psychiatry Conference, Bristol 9-10 November 2007
th

th

th

The 6 Annual TNC Meeting took pace in Bristol on the 9 and 10 of November 2007. 70 people
including the speakers attended, much in line with previous years. This year saw a much welcome
expansion in the number of Liaison Nurses attending.
The Friday session began with Steve Reid (London) talking about the service he runs providing
Liaison Services to the HIV clinic at St Marys. His wide ranging talk discussed the neuropsychiatric
presentations of HIV and aspects of anti-retroviral pharmacology, but also included much on the
psychosocial aspects of what is becoming a chronic disease. He was followed by Al Santhouse
(London) on working with renal medicine. Rarely has an academic talk included Bananarama and
Dostoevsky as well as sensitive observations as to the ethical issues surrounding renal transplants! Al
also took the opportunity to show of his new Apple Mac!
After a break, John Morgan (Leeds) presented a powerful case for a role for Liaison Psychiatry in the
fast expanding world of obesity, most notably obesity surgery services. The last talk of the morning
was Peter White (London) who roamed freely across the concept of psychosocial medicine, whilst
making references to Voltaire and introducing us to a new word metaphysico-theologo-cosmolo-

10

nigologist. Highlighting the limitations of the biomedical approach, he made a powerful argument for
additional attention to be paid to the psychological and especially social factors in assessment and
management of our patients. He concluded by drawing attention to some of the challenges this
approach will have to overcome if it is to be more widely accepted.
After lunch there were parallel workshops. Matthew Hotopf (London) discussed the assessment of
capacity in the general hospital, whilst Charlotte Wilson-Jones and Jane Hutton (London) described
their highly successful mental health link worker scheme. Informal feedback from both sessions
suggests they were both popular and very well received. The final presentation of the day was from
Simon Wessley (London) who gave a fascinating overview of his work on chronic fatigue syndrome.
He described his early involvement seeing patients at Queens Square followed by work defining the
condition, and then setting up effective clinical trials culminating in the dissemination of the NICE
guidelines. He brought the conference down to earth, however, with a glimpse of the down side of this
journey the vitriolic response of a small but very vocal group of patients which brought the
requirement for a wider adoption of the biopsychosocial approach into sharp focus!
After the TNC business meeting the conference adjourned to the Bordeaux Quay restaurant for the
conference dinner. The strong social side of the TNC was again in evidence as the delegates
continued to enjoy the hospitality of Bristol late into the night..
A little bleary eyed, and a smidgeon after the advertised starting time, Day 2 started with the Stalwart
Tayyeb Tahir (Cardiff) talking about the meticulous and focused efforts he put into being in a position
to take up a consultant post and how he has faired since. The New Consultant talk is a well
established part of the TNC conference and Tayyebs talk was up there with previous excellent
presentations. Tayyeb was followed by Anne Hicks (Plymouth) who is a consultant in Emergency
Medicine who, in absence of a Liaison Service at Derriford, has nonetheless established a nurse led
Liaison Service which she is keen to expand. She is also the British Association for Emergency
Medicine representative to the Prof Alberti Group examining the provision of Mental Health Services to
Emergency Medicine. Her witty and acutely observed view from the other side was hugely
successful, not least exposing some of the foibles in the structure of psychiatric services.
After a much needed caffeine break, Johanna Herrod (Bristol) described the plethora of Liaison
Services which are being developed in Bristol and the support for Liaison Services demonstrated by
the Avon and Wiltshire Trust. Watch this space!. In the final talk, Malcolm Cameron (Kilmarnock)
described his work in trying to improve the assessment and management of alcohol problems in the
general hospital. We were all reminded that despite excellent committed work by Liaison Psychiatry,
real change requires all professional groups to come on board and perhaps more importantly to stay
on board! Perhaps the greatest compliment to the morning speakers was the size of the audience
remaining until the end of the conference over 40 enthusiastic delegates!
The conference was enjoyable and well attended. This was, in part, as at 125 all in, it represented
great value. It should be noted, perhaps more widely within the College, that even at this rate 18
delegates (a third) were entirely self-funding. Time and financial support for study is now in short
supply and cost is a major factor in conference attendance, especially for trainees and nurses.
No conference is organised by a single person and this meeting was no exception. I was very
fortunate to enjoy the support and experience of a number of individuals whose contribution I am keen
to acknowledge. The most recent TNC chairs Alex Mitchell and Tayyeb Tahir provided me with
unstinting support and advice, gently steering me away from areas where I might have become
unstuck. Thirza Pieters (secretary) and Adrian Flynn (Finance Officer) were always available to
bounce ideas and plans off, and contributed far more than they realised. Finally, every speaker
contributed their time and expertise willingly and with great enthusiasm for the TNC. There would
have been no conference at all without them and I am grateful to them all.
Delegate Feedback
40 forms received
Responses 1 (poor) 5 (Excellent)
Recommend to colleagues 1 (no Chance) 5 (definitely)
1.
2.
3.
4.
5.

Organisation
Venue
Hotel
Day 1 content
Day 2 content

4.5
4.2
3.9
4.8
4.5

11

6.
7.

Value
Recommend

4.7
4.9

Max Henderson
Chair TNC & Conference Organiser

iii.

ACCEA Awards & Fellowship of College

Prof Else Guthrie
Professor of Psychological Medicine & Medical Psychotherapy,
Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL
Fax: 0161 273 2135

Dear All
Please find below the details of the ACCEA and Fellowship processes which I would encourage
people to consider applying for. The 2007 Bronze Top Ten include three Liaison members Damien
Longson, John Holmes and Jon Bisson, and our congratulations are extended to them. (I would also
th
like to congratulate Else for her 4 Ranking in the Silver List Ed.)
The ACCEA Awards process begins again in June this year. The Awards are open for any consultant
to apply, although its unlikely that sufficient experience and achievements will have been reached
without several years in post. Ten years is a good rule of thumb but there is no hard or fast rule.
If you wish to apply please email a completed application to Sue Duncan at the College. Dont send it
to me. The deadline for this is.. You will need to use last years form as this years will
not be available until later in the year.
The process is as follows. Sue Duncan will sort the forms and then send them on to the Chairs of the
relevant Faculties and Divisions. You can only submit to one Faculty and be a member of one
Division.
Once I have received all the liaison forms, I distribute them to all the members of the exec unless of
course they happen to be applying themselves. The forms are rated on each of the 5 domains and a
total is calculated for each person. These scores go back to the College with a ranking order. This
info is then passed on to the divisions to inform their ratings. So if you are a member of the NW
Division, your ranking according to the Liaison Faculty will be passed on the division members who
then do their own ratings. Those scores are then returned to the College.
The forms are then re-rated in the following way. All the applications are distributed to all the Officers
of the College, the Chairs of Divisions and the Chairs of Faculties. We all rate everyones application,
regardless of division or faculty. We are given the previous ratings from the Faculties and Divisions to
st
rd
help inform our ratings. For instance, someone might be rated 1 by the Forensic Section and 3 by
th
th
his/her Division, or 10 by his/her Faculty and 14 by his/her Division. The totals for each person are
then collated by Sue Duncan and average scores calculated.
There is then a meeting at the College in October 2008. A list of everyone who has applied is
distributed together with their average scores. The individuals with the highest ratings are
automatically referred to the DoH (the cut off is somewhere between 20-30). The next 20-30
individuals are then discussed at the meeting. For each person the Chair of their Faculty and Division
is each allowed -3 mins to support them. At the end of this process, these 20-30 people are re-rated
and the top x % are supported by the college and referred to the DoH.
The DoH clearly take note of the College rankings but it does not automatically follow that support
from the College ensures an award. Our Faculty had three people in the top 10 last year, only one of
whom actually got an award. Some people who actually receive quite low ratings by the College also
receive awards. The DoH, of course, also receive a report from your local manager, which the College
does not see, and I understand that this can be very influential. It is possible to apply through
different routes (e.g. via your Deanery), although I am not actually aware of the details.
In my opinion the rather lengthy process I have described is fair, and by and large the very best
people rise to the top of the rankings. To do well you really need support from your Faculty and
Division and, of course, your Trust.

12

Good luck!
Fellowships
The College is keen for people to apply for Fellowships of the College. The award of a Fellowship is
an indication by the College that you are held in high standing by your professional colleagues. The
application process has been simplified. You contact the College for a form, complete it and seek
support from two other members. Your application will then be considered. There are no specific
rules but I think 10 years post MRCPsych, or several years as a consultant would be expected. The
benefits include a larger subscription fee! It also helps if you are thinking of applying for an ACCEA
Award.

9.

New Research in Liaison Psychiatry and Psychological Medicine - Spring 2008

Alex Mitchell
Type of

Authors

Title

Sakhuja D & Bisson J.

Liaison Psychiatry services in Wales

Research
Service study

Psychiatric Bulletin
(20 08), 32, 134-136.
Comment: It is nice to see a service description paper even if the conclusion if theres not
sufficient. 27% of trusts in Wales have no dedicated liaison psychiatry and only 13% had a fulltime consultant liaison psychiatrist. No team had a clinical psychologist and only two (25%)
provided a psychological treatment service.

Primary

Nuyen J et al.

Comorbidity was associated with neurologic and

(epidemiological)

Journal of Clinical

psychiatric diseases: A general practice-based

Epidemiology 59

controlled study

(2006) 12741284

Comment: This cross-sectional study used morbidity data recorded by Dutch general practitioners
that included 6,641 patients with lifetime depression. They examined both mental and physical comorbidities. Common comorbid conditions with depression included psychotic disorders, anxiety
disorders, substance abuse, and Parkinsons disease. It is a useful paper to clarify both physical
and psychological comorbidity effects.

Primary

Anne E Rhodes and

Suicidal Ideators Without Major DepressionWhom

(epidemiological)

Jennifer Bethell

Are We Not Reaching?

Can J Psychiatry
2008;53(2):125130

Comment: Data were drawn from the Canadian Community Health Survey involving 36 984
Canadian household residents aged 15 years or more. Almost one-half (47.9%) of those with
suicidal thoughts did not have major depression and had no mental health service contact in the

13

previous year. Individuals in this group were younger and exhibited greater morbidity than their
nonsuicidal counterparts . see also related publication: Rhodes A, Bethell J, Bondy S. Suicidality,
depression and mental health service use in Canada. Can J Psychiatry. 2006;51(1):3541.

Editorial

Strain and

Challenges for ConsultationLiaison Psychiatry in the

Blumenfield

21st Century

Psychosomatics.2008;
49: 93-96
Comment: I dont have access to this editorial but list it anyway for those that do!

Review

Wei LA et al

The Confusion Assessment Method: A Systematic

J Am Geriatr Soc

Review of Current Usage

2008

Comment. There are now numerous methods to assess delirium. This review examines the CAM.
There were 10 validation studies, 16 adaptations of the original, 12 translations, and 222
applications of the CAM in studies. From the best seven high-quality studies (N 51,071), the CAM
had a sensitivity of 94% (95% confidence interval (CI) 59197%) and specificity of 89% (95% CI
58594%).

Adaptations were interesting. The CAM-ICU was specifically for use in mechanically ventilated
ICU patients provides a brief nonverbal assessment to score the CAM algorithm. For rapid
evaluation of delirium in the Emergency department setting a simplified version has been
developed. Emergency department physicians diagnosed delirium in only 17% of these CAMidentified cases!

Primary study

Artero S et al

(prognosis)

Risk profiles for mild cognitive impairment and

progression to dementia are gender specific
J. Neurol. Neurosurg. Psychiatry published 1 May
2008; online only

Comment This study provides impressive data on risk of cognitive decline in 6892 participants
who were over 65 and without dementia were recruited from a population-based cohort in three
French cities. 42% of the population were classified as having MCI at baseline.

Risk of MCI was linked with depressive symptomatology and to be taking anticholinergic drugs.
Risk of progression from MCI to dementia was associated with were ApoE4 allele, stroke, low
level of education, loss of Instrumental Activities of Daily Living (IADL), and age. Given most
factors were irreversible the authors conclude that intervention programmes should focus on
stroke, depression and anticholinergics.

Primary study

Himelhoch S et al

Access to HAART and utilization of inpatient medical

14

(quality of care)

hospital services among HIV-infected patients with

co-occurring serious mental illness and injection drug
use
General Hospital Psychiatry 2007; Volume 29, Issue
6: 518-525

Comment. This study is the latest in a series of about 20 examining quality of medical care in
those with psychiatric disorders. A review is currently in press with Br J Psychiatry. Among HIVinfected individuals, they looked at whether serious/severe mental illness (SMI) and injection drug
use (IDU) effects (a) receipt of highly active antiretroviral therapy (HAART), and (b) utilization of
inpatient HIV services. Those with co-occurring SMI and IDU and those with IDU alone
(AOR=0.64; 95% CI=0.580.85) were significantly less likely to receive HAART than those with
neither SMI nor IDU. Those with co-occurring SMI and IDU were more likely to use any inpatient
medical services (AOR=2.22; 95% CI=1.643.01) and were significantly more likely to use them
more frequently (incidence rate ratio=1.33; 95% CI=1.131.55) than those with neither SMI nor
IDU, SMI only or IDU only.

Secondary

Gilbody S, Sheldon T,

Screening and case-finding instruments for

(Meta-analysis)

House A. CMAJ

depression: a meta-analysis

2008;178:997-1003.
Comment: This is a useful update to the authors previous Cochrane review tackling a
controversial topic, that is what merit is screening (or case-finding)? Tools were associated with
modest increase in the recognition of depression by clinicians (relative risk [RR] 1.27, 95%
confidence interval [CI] 1.02 to 1.59). The authors discuss in what circumstances tools might work
and what additional resources are necessary.

Feature Articles
13.

PBR Project

Liaison Psychiatry PBR Tariff National Pilot Project

Lead: Dr Melanie Temple
Sponsor: Jonathan Storey, NE StHA
A. What is the problem being solved?
Liaison Psychiatry services provide specialist mental health input to the general hospital and A&E
setting for patients presenting with primary, co-morbid and complex mixed mental health & physical
health presentations. The services suit within and are delivered in the general hospital and therefore
fall outside of normal mental health services but currently dont come under the acute PBR system
within acute health. This causes considerable difficulties in financing services with confusion over
where the monies should be derived from given the provision within acute health but by mental health.
The project aims to develop a tariff within the PBR system which will allow for clear funding streams
for services which will also allow expansion of the specialist outpatient services into GP practices
utilising PBC.
B. If you intend to create a new tariff or currency for a service currently outside the scope of
PbR, how do you propose to do this?
Two waves of real time prospective data collection at multiple sites across the country, the first to
establish collecting data proxy measures which sit presentations seen into proposed currency

15

streams of low/med/high followed by second collection establishing pathways for each currency and
their average cost for the tariff.
C. Has it been approved by the trust Director of Finance/Chief Exec etc?
Yes at all sites involved in the project as detailed in the proposal submitted.
D. If a provider project, is the relevant commissioner on board, and vice versa?
Yes at all sites.
E. Has it been discussed with the SHA and do they support in principle?
Yes at all sites.
F. In what way will the learning be transferable across the country?
National project with sites across the country so should readily be transferable.
G. Have they piloted any other innovative ideas recently? Were they successful?
All sites involved have effective and efficient liaison services which have been developed over the
years to meet patient need and also meeting various targets and NICE guidance.
H. Do they have buy-in from other organisations e.g.: Professional bodies, DoH branches,
Charities etc?
Yes as per proposal RCPsych, RCP, RCS, DoH Acute & Mental Health PBR groups, RCPsych
Patient forum, Prof Alberti & Prof Appleby.
PBR Project: DATA-set development & collection Phase One
Aims:
The aim of the dataset is to produce a measurable set of proxy measures which allows patients to be
put into three categories of complexity and likely associated expense
e.g. Low / High complexity for A&E/inpatients and Low/High for outpatients
The measures must be those likely to be already collected by liaison services or easily accessible to
avoid increased workload where teams are already collecting data for trust purposes
Outcomes:
A readily measurable dataset that places patients into groupings that will then allow progression onto
Phase Two of the project (developing costings for each group)
Proposed Measures:
A&E and Inpatients
Psychiatric Diagnosis Top level ICD code i.e. F10, F20, F31, F32, F41, F43, F60 etc. or No
psychiatric illness
MHA or MCA assessment
Number of direct contacts with patient (face to face and tel. Calls with patients)
Time taken for completion of assessment and management plan
Number of liaison professionals involved in case (e.g. nurse, Dr + Nurse, 2 nurses)
Follow-up required other than GP/primary care
Very high Intensity Service User (VHIU) as per DoH defn. >= 6 admissions in year
Outpatients
Psychiatric & Physical Diagnosis if present
Time for initial assessment (patients may take 1-3 appointments to complete assessment,
formulation and agree management plan)
Time for follow-up assessments (i.e. patients with medication monitoring take less time than
those completing therapeutic intervention 30 mins versus 1hr appt)
Actions:
1. All participating centres to run dataset collection over one month (June 2008) period to assess
applicability and ability to place into either low or high
2. Centres to feed back to Melanie for collation of data and then discussion with support
StHA/DoH Mental health PBR group for processing onto Phase 2.

16

14.

Quality Standards and Accreditation Programmes for Liaison Psychiatry Services &
Royal College Research Unit Project & Feedback from Annual Meeting Session
Mel Temple, Hon Sec Liaison Faculty
Lucy Palmer, College Research Unit

As part of the Annual Meeting a session was held for all members to discuss and air their views on the
concept of Quality standards, what they are and how they might be applied to Liaison Psychiatry
Services. The need for the development of these standards by the Faculty was highlighted by several
members following their service being requested to provide evidence of quality service provision. This
discussion was also timed to provide feedback into the CRC project.

A.

Annual Meeting Feedback

Consensus view of meaning of quality standards:

Is this person better of for seeing this service How?

What elements of the service achieve this change?
How do we measure the presence of those elements?
What are the aims of liaison psychiatry services and how do we show that were achieving them
Not necessarily about numbers of members of staff etc. more about what the team does / should be
doing / deliver and measures of that. They will however by the nature of looking at what should be
being delivered guide the make-up of teams/services
It was felt to be important that these were in relation to patients and not commissioners so not mixed
with performance standards that might be applied to Liaison services e.g. 4 hour waits A&E, Lengths
of stay, % SH patients of assessment etc.
It was felt that there should be a set of core standards that would be applicable to all settings but that
some larger complex settings e.g. large inner city teaching hospitals may have more that apply than
smaller DGHs due to nature and complexity of the patients seen in that setting.
B.

Areas Faculty Members Felt To Be Important:

Outcome Measurements:
Variable types can be used and lots of debate about how useful but all agreed need an objective
measure of the services showing specific improvements for patients
Examples specific scores / measures
Questionnaires and surveys stakeholders / service users
Evidence of Integration of Mental Health Care into the General Hospital / Acute Health Care Setting
One of the aims of a Liaison Psychiatry / Psychological Medicine Service is to ensure the provision of
a whole person approach to care
Examples of this integration might include:
Location of liaison service offices within the acute care setting i.e. general hospital!
Regular training/teaching of acute care staff in mental health issues
Liaison Outpatient clinics within the general hospital outpatients
Joint outpatient clinics
Joint service access and care pathways and integrated care pathways for patients
Screening for mental health problems as routine part acute health care
Joint care planning
Suitable room provision for assessments and interventions
Basic level knowledge of MH issues and their management by acute staff
Basic level interventions by acute staff e.g. specialist nurses in diabetes / respiratory /
palliative care
All levels of psychological interventions and required care available to patients in the acute
care setting as they need it tier 1-IV
Cross trust/pct/directorate/clinicians meetings and steering group to set, plan and review
standards etc.
Patient & Service User Involvement
Design / delivery of services
Care plans

17

Availability of Appropriate Care at all levels of complexity and risk

Risk Assessments and joint planning
Availability of Consultant Level Input
Availability of medication and psychological approaches
In-patient options Crisis 12-24hrs
- Complex cases longer stay co-morbidity / severe somatisation /
conversion disorders etc.
Appropriate Responsiveness to patient need and stakeholder responsibilities
Identified and agreed response times to different areas in the acute care setting with agreed key areas
being:
- A&E
- SH assessments
- Acute on-ward consultation assessments
- Mental Health Emergencies in the acute setting
It was felt that the 18 week referral to treatment should apply to OPC services incl. provision of
psychological therapies given the co-morbidities and importance of time issues in some physical
conditions.
CRC Project for Academy of Royal Colleges Quality Standards for Liaison Services
Establishing an accreditation programme for liaison mental health services in the UK
The Colleges Centre for Quality Improvement (CCQI) currently runs over a dozen programmes
designed to help specific mental health services measure and improve their performance against
agreed standards over a period of time. Specific programmes have been designed to cater for a
diverse range of services including therapeutic communities, ECT clinics, community based CAMHS
and many more. However, aside from the Better Services for People who Self-Harm programme,
none of these programmes relate specifically to liaison mental health services. Whilst the Better
Services programme enjoyed some success in bringing together emergency care staff, service users
and mental health teams to effect positive changes, its remit is limited, and many staff are now telling
us that what they really want is a quality improvement initiative dedicated to the whole of the liaison
team, not just self-harm services.
An accreditation programme is therefore being developed. Known as the Psychiatric Liaison
Accreditation Network (PLAN), the programme will provide:

A set of agreed, national standards for liaison/psychological medicine services. Liaison

teams and service users will be asked to help develop these standards from the offset, and
the standards will be heavily informed by relevant reports produced by the liaison faculty and
similar, including the forthcoming papers on urgent mental health needs and the mental
health policy implementation guide. The standards will also be mapped to any relevant
existing targets, such as those produced by the Healthcare Commission, NICE and so, to
help teams demonstrate compliance with those. The complete set of standards will be
aspirational; no service could be expected to meet every one. To support benchmarking and
accreditation, the standards would be categorised into three types: type 1 - standards that are
essential to safety or the quality of patient experience; type 2 - standards that a good liaison
service should meet and type 3 standards that an excellent service would meet.
A robust accreditation process that uses established review methods, such as service user
surveys, staff feedback, case note audits and peer-review visits where service users and staff
visit another liaison team for the day. The results of the self- and peer-review will be
considered by an accreditation advisory committee (AAC) comprised of nominated
representatives of the key professional bodies. Services that are struggling to meet
accreditation criteria are given some time and support to help them reach an acceptable
standard, and assistance is provided as far as possible, including help arguing for better
resources where a lack of funding is holding teams back.
The option of increased networking opportunities (if this is desired) to share examples of
best practice, e.g. through newsletters, an online discussion group, and an annual forum
where services come together to share success stories and offer each other advice on how
best to overcome difficulties.
A set of change interventions, such as online training exercises, information leaflets for
patients, training material for acute staff to improve their understanding of mental health, and

18

so on. The interventions will be designed by liaison experts and service users and made
freely available to all members.
Help to raise the profile of liaison mental health services by demonstrating how valuable
they are to service users, other mental health services and acute staff (for example, the selfharm project elicited the views of hundreds of acute staff, many of whom stated the need for
a greater mental health presence in the ED this type of feedback could be used to inform
commissioners, managers and so on).

The programme will be designed and guided by a steering group made up of liaison mental health
professionals, service users, and acute staff. Care will be taken to ensure that the programme
compliments (but does not duplicate) existing work taking place around Payment By Results, the Darzi
Review and so on. The central project team at the Centre for Quality Improvement would manage and
deliver the content of the programme, and report back regularly to its steering group and membership.
Early discussions with a number of liaison services indicate that a modular approach would be
preferred, to take into account different service configurations and ensure that smaller teams are not
discriminated against. This approach would allow teams to sign up to one or all of the following
modules:
Module 1: Meeting emergency mental health needs throughout the hospital, which is likely to
include services to people who self-harm, people brought in under Section, people who may be
psychotic, and people on general wards who develop urgent mental health needs.
Module 2: Meeting mental health needs throughout the general hospital, which is likely to include
people admitted to general wards who have a psychological reaction to physical illness or injury,
people with medically unexplained symptoms and people where psychological factors may be
affecting their capacity to consent or refuse medical treatment.
Module 3: Providing mental health input to outpatient and specialist services, such as oncology
services, diabetes services and so on.
We know that many teams are not large enough to provide the types of services listed in module 3, or
even module 2, but all teams will be able to participate in some part of the programme. Funding has
been secured to help develop the programme, but trusts that sign up will also need to pay a
subscription fee to help meet the costs of this not-for-profit programme. In terms of timescales, we
plan to develop standards over the summer, devise and pilot the tools late 2008, and then recruit
trusts to begin work in early 2009.
We warmly welcome your views on this programme (positive or negative!) If you wish to comment,
please email me on lpalmer@cru.rcpsych.ac.uk or call me on 020 7977 6642.
Best wishes, Lucy Palmer, Royal College of Psychiatrists Centre for Quality Improvement

15.

Darzi Review

I doubt anyone working in the NHS in England or indeed the UK generally are not aware of the
recently published Darzi Review (spear headed by the surgeon Lord Darzi hence the Darzi Report!).
This is an overarching review of NHS services looking at how they are delivered in England and is to
be the driver behind the next big shake up in service design and provision. Following the initial review
regional StHA wide groups were set up to look at service provision and how it might work with an
emphasis on Pathways of Care, Access, Seamless interfaces and challenges to the 1ary and 2ary
care boundaries. Within each StHA, Group Acute Care streams and Mental Health Streams have
been tasked with reviewing service provision in their area and making recommendations around care
needs and appropriate pathways. Each of these regional reports were delivered to the central DoH
Darzi Review Group for collation into a final set of recommendations which were published July.
Further information on the Darzi Review can be found at
http://www.dh.gov.uk/en/Healthcare/OurNHSourfuture/index.htm
The faculty exec and local regional representatives needless to say saw this as a prime opportunity to
get liaison onto the map as it were with the adage that if youare not in Darzi you are not going to be in
a service! To this end Faculty members over all StHA regions started lobbying the Acute Care and

19

Mental Health Care Groups in order to get Liaison included into the their regional reports and
recommendations with that hope that if we featured in enough of these reports then we might get
some time in the final version due July 2008. We were successful in some areas with the regional
documents making good reference to the need for Liaison Services and the Colleges own response
(All Royal Colleges were asked to provide feedback into the process) also being very clear about the
need for Liaison Services.
Unfortunately there wasnt the direct reference to Liaison Services we were hoping for within the report
though it was noticed that Lord Darzi started his report with no physical health without mental health.
Despite this at local level there are still opportunities as the work streams are to continue the work
within the StHAs and we would encourage all Liaison Psychiatrists to ensure local representations on
all of the workstreams especially acute care, chronic disease and mental health. Work within the
workstreams alongside hopefully a developed and accepted PBR tariff may make the future brighter
for service in England.
With kind permission of Janet Butler, Consultant Liaison Psychiatrist in Southampton who fed into the
South Central StHA Acute Care Group, below is an example of the cases that were put to the groups
for Liaison Services and could be of use to anyone being asked the Why Liaison Services question
as part of local Darzi Reviews or any other review!
Mel Temple
South Central Health Authority: Acute Care Group
Co-morbidity of mental and physical illness in relation to acute care
Janet Butler
Consultant Liaison Psychiatrist
Mental health problems are very common in general hospitals and Emergency Departments in all age
groups. Those known to community mental health teams due to severe mental illness who present
with an acute physical problem are a minority but may give particular challenges to manage. A larger
group of people have mental illness presenting in acute care services in conjunction with their physical
illness. The scale and seriousness of the problem is reflected in high level reports including those
from the Royal College of Psychiatrists and other agencies. Specific recommendations to address the
issues are being developed in a joint report from The Royal College of Psychiatrists, the Royal College
of Physicians, the Royal College of Paediatric and Child Health, The College of Emergency Medicine
and colleagues working in The Department of Health.
Evidence of need for a new clinical pathway to address mental and physical health comorbidity
Mental health disorders are very common in general hospitals
30% general hospital in-patients (45% of older people), and 30-60% general hospital outpatients have psychiatric disorders. Psychiatric disorder especially prevalent in certain
specialties (e.g.: neurology, gastroenterology, cancer care), in long term conditions and in
those who present frequently in primary or secondary care (Little et al. 2001; Koopmans et al.
2005).
Table 1: Common mental health problems presenting in acute care settings
Emergency Departments
General hospital wards
Self harm and suicidal feelings
Physical and psychiatric co-morbidity (commonly
Alcohol and substance misuse
depression, anxiety, delirium, dementia);
Acutely disturbed people who may be
Medically unexplained symptoms;
psychotic, or have another serious mental
People admitted after self-harm;
health problem.
Alcohol and drug misuse;
People with delirium and/or dementia.
Acute organic disorders and chronic cognitive
Primary physical problem with mental health
impairment;
issues affecting their self care and healthcare
Behavioural problems ( eg non-adherence to
utilisation
treatment, lack of capacity to consent);
Poor self care with long term conditions
Lack of skills to safely manage acute severe mental
illness (psychosis, suicidality, personality disorder)
during general hospital admission.

20

Work has shown up to 50% of the very high utilisers of services known to the community
matrons have a co-morbid mental health diagnosis.
About 5% people presenting to Emergency Departments have a primary mental health
problem, 40% have mental health issues and self harm is one of the most common reasons
for adults to present
Poorly recognised or managed mental health problems and lack of understanding of legislation
creates heightened risk of adverse incidents. An inquiry by the Hampshire and Isle of Wight Strategic
Health Authority into an acute hospital in-patient suicide, highlighted the need for increased mental
health service clinical and educational input into acute trusts and better partnership working..
Mental health problems increase healthcare costs from increased morbidity, mortality and lengths of
stay
Medically unexplained symptoms are especially associated with markedly increased
subsequent healthcare costs (e.g. five times higher in a study of neurology referrals, Hansen
et al. 2005) and form a disproportionate percentage of patients requiring repeated hospital
admissions and investigations (Reid et al. 2001).
Length of stay and re-admissions are known to be higher for people with co-morbid mental
illness (e.g. after hip fracture (Holmes and House, 2001) and have been shown to be reduced
by Liaison Psychiatry teams (Strain et al. 1991).
Depression increases morbidity and mortality and is highlighted as an essential factor to
address in many NSF and NICE guidelines (e.g. COPD, stroke, diabetes, epilepsy, heart
disease, cancer).
Psychiatric problems that may not reach severity for intervention in their own right by existing mental
health teams can still lead to significantly increased morbidity when combined with a long term
condition
E.g. Disordered eating and use of insulin for weight control in diabetes are strongly associated
with microvascular complications such as renal failure (Peveler et al. 2005).
Alcohol related problems are extremely common in general hospitals
Alcohol misuse accounts for 12% of hospital expenditure.
Presentation to acute hospitals presents a key point to identify and reduce harmful levels of
alcohol consumption. Despite severe liver damage or other physical problems many people
are not physically dependant (Sheron 2005).
Common mental health issues in acute care settings are not frequently experienced by community or
crisis/acute mental health teams e.g. delirium, organic psychoses, depression, anxiety or eating
disorders complicating significant physical illness, medically unexplained symptoms and factitious
disorders or complex diagnostic and management problems with medical co-morbidity.
Community and crisis teams rarely have the capacity to respond in a timely fashion or expertise to
facilitate provision of care in a non psychiatric setting.
What does a good care pathway look like?
A specialist mental health service based on the acute hospital site dealing with psychological and
psychiatric issues related to physical healthcare (Liaison Psychiatry Service) is widely recognised as
the best way to improve care (CSIP 2005/6 Self Harm Service mapping exercise, Royal College of
Psychiatrists Council Reports 108 and 118, RCP 2005 Who Cares Wins, DoH 2005, Everybodys
Business CSIP 2005, Securing Better Mental Health for Older Adults, DOH). In addition to direct
clinical work, mental health services specialising in physical and mental health co-morbidity have a
major role in stepped provision of care via education of generalist staff. In acute hospitals, they can
facilitate appropriate application of the Mental Health Act and management of related risks. Although
acute care is generally considered in relation to general hospital presentations, improved pathways
bridging primary and secondary care could reduce acute presentations. This integration of
psychiatric/psychological services with physical healthcare is demanded in many NSFs (long term
conditions, coronary heart disease, renal disease) and NICE guidelines (chronic heart failure, stroke
multiple sclerosis, Parkinsons disease, epilepsy, COPD, cancer, older people).
Local areas need to be able to design the details of a care pathway to fit local need and service
models, however, core components of mental health services need to exist. Services may be
organised on a Hub and Spoke model with a core team in each acute hospital and some out-patient
and educational service provision from a central hospital with a larger team as is needed for larger
acute hospitals with tertiary services. Staffing recommendations exist in various reports (Royal
College of Psychiatrists, College Reports 55, 108 and 118, Who Cares Wins, Department of Health
Checklist: Improving the management of patients with mental illness in emergency care settings,
2004). The joint report mentioned in the introduction should provide further guidance but current

21

recommendations and clinical opinion supports the following features of mental health service
provision to all emergency departments and acute hospitals. The Royal College of Psychiatrists
Liaison Faculty have produced an outline Policy Implementation Guide to assist with this. A report is
also pending from the Emergency Medicine Group under Prof Alberti.
Core clinical and service design issues
Multi-disciplinary mental health team dedicated to the acute hospital to serve all adults aged
over 18 years with teams including those with skills for both working age and older adults. A
separate team for those under 18 years is recommended due to specific issues in childhood
and adolescence.
The core Liaison Psychiatry team needs to operate at least Mon-Sun 9am-5pm to provide
necessary specialist expertise.
Staffing level and skill mix according to the needs, size and working hours of the service and
acute hospital, but needs to include a Consultant Psychiatrist, senior nurse and availability of
specific psychological interventions within the multi-professional team.
A clear route of referral for 24 hour 7 day a week response to the Emergency Department and
for urgent ward referrals. This could occur from extended hours in a Liaison Psychiatry team,
crisis teams or other services, but requires staff with skills to manage acute mental health
problems in general hospital settings and where there is physical health co-morbidity.
Single point of referral for all mental health problems regardless of age (except possibly for
referrals from paediatric wards directly to child and adolescent services).
Assessment of all referrals unless telephone advice meets the referrers needs.
Timely response times to be agreed by the mental health and acute hospital trusts. For
example, within 3 hour to urgent referrals (faster to crises) and within 2 working days to
routine referrals.
Good links between the Liaison Psychiatry team, Community Mental Health services, acute
hospital, primary care and social services to maintain care plans for patients with severe
mental illness admitted for physical problems, facilitate discharges and development of care
plans for frequent attenders. These need to be reflected in both clinical and managerial links.
Expanded core services, such as are likely to be needed in larger general hospitals, could
benefit from a variety of pathway additions such as expanded out-patient services to manage
mental health problems with the aim of improving equity and quality of care and reducing
inappropriate admissions, dedicated mental health specialists and link workers with access to
medical supervision for areas known to have high mental health morbidity (such as alcohol,
gastroenterology, neurology), increased professional mix to include specialist psychologists,
proactive identification of mental health problems on wards and specific funding arrangements
for mental health assessment solely required as part of medical or surgical treatment (such as
advice about depression before prescribing interferon or a pre-surgical psychological
assessment).
Core managerial, clinical governance and service development issues
Stepped care model of service provision (1: education by the mental health team to enable
most mental health problems to be detected and managed by acute hospital staff, (2: mental
health assessment of significant morbidity or risk with follow up on the ward as required, (3:
complex assessments to aid diagnosis or understanding of the patients health behaviour and
ongoing management.
Recognition of the increased time taken for ward assessments compared to those in the
Emergency Department, recognition that self harm is only a proportion of in-patient and
Emergency Department referrals (around two thirds in Southampton and Exeter) and
medically unexplained symptoms are a large proportion of those referred to out-patient
services.
Recognition of education of general hospital staff as an integral component of Liaison
Psychiatry services in line with a stepped model of care provision and improved risk
management.
Designated senior doctor, nurse and managers from both the mental health and acute trusts
to lead service review and developments with a cross trust mental health group in line with
recommendations by the Royal Colleges for Psychiatrists and Physicians.
Plan for how to deliver education to acute and community staff regarding legal and clinical
issues relating to the Mental Health Act, Mental Capacity Act and detection and basic
management of common mental health problems.

22

Clear referral pathways, documentation, risk management policies and joint liaison with
commissioners.
IT and finance department partnership between trusts to facilitate costed need, activity and
outcome data .

What already exists in the South Central StHA Area that meets this description?
There are no services that meet this care pathway description. The provision of mental health
services to general hospitals is patchy and limited, especially for those under 18 and over 65.
Southampton has a multi-disciplinary Liaison Psychiatry team with a full time Liaison Psychiatrist.
Oxford has a similar service though recently much reduced. Both only cover adults of working age
and during working hours. Neither service is specifically commissioned, a fact highlighted recently
with the substantial reduction in services in Oxford in relation to cost saving for other areas. Other
hospitals have mental health cover from a variety of service models, none consistent with care
pathway approaches.
Where are gaps and what are the barriers to implementing an improved pathway?
The current geographical, managerial and commissioning separation of mental and physical
healthcare presents specific challenges to managing this co-morbidity safely and effectively. Major
barriers to an effective care pathway for mental and physical co-morbidity include: exclusion of the general hospital in commissioning for mental health services,
lack of commissioners with knowledge and skills to cover mental and physical health,
lack of clarity and agreement about who is responsible for funding these services,
lack of recognition of the mental health need in acute hospitals,
lack of recognition of mental and physical co-morbidity within mental health and physical
health commissioning and related targets for all ages for unscheduled, general and tertiary
physical health services,
lack of recognition of the impact of mental health problems on self care, healthcare utilisation
and morbidity in physical illness and for medically unexplained symptoms.
What needs to happen to support local implementation?
Agreement between the PCTs & StHA as to commissioning approach and the basic core elements of
pathway and service structure for this group followed by discussion and agreement with the agreed
provider trust.
References
Department of Health CSIP (2005) Everybodys Business - Integrated mental health services for older
adults: a service development guide, London CSIP
Guthrie, E. Lloyd G. (Eds) (2007) Handbook of Liaison Psychiatry, Hardcourt.
Hansen et al. (2005), Mental illness and health care use: a study among new neurological patients.
General Hospital Psychiatry 27:119-124
Holmes J & House A. (2000) Psychiatric illness predicts poor outcome after surgery for hip fracture: a
prospective cohort study. Psychological Medicine 30: 921-29
Royal College of Psychiatrists Council Reports CR108 The Psychological care of medical patients: a
practical guide (2004); CR118 Psychiatric Services to Accident and Emergency Departments(2004);
CR55 Report of the Working Party on the Psychological Care of Surgical Patients (1998)
Who Cares Wins (DoH, 2005)
Strain, J., Lyons, J., et al (1991) Cost offset from a Psychiatric consultation-liaison intervention with
elderly hip fractures. American Journal of Psychiatry 148: 1044-49
Byrne M, Murphy AW, et al. (2003) Frequent attenders to an emergency department: a study of
primary healthcare use, medical profile and psychosocial characteristics. Annuls of Emergency
Medicine 41(3): 309-318
Little P, Somerville J, et al (2001) Psychosocial, lifestyle, and health status variables in predicting high
attendance among adults. British Journal of General Practice 51: 987-994
Koopmans GT, Donker MCH & Rutten FHH. (2005) Length of stay and health services use of medical
inpatients with comorbid noncognitive mental disorders: a review of the literature. General Hospital
Psychiatry 44: 44-56
National service frameworks for long term conditions (2005), coronary heart disease (2000),
National Institute of Clinical Excellence Guidelines for chronic obstructive pulmonary disease (2004),
The Epilepsies (2004), Self Harm (2004), Cancer Networks, Chronic Hear failure, Parkinsons disease
Royal College of Physician Reports and Clinical Guidelines on stroke (2004), Alcohol in the NHS

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16.

Integrated Care Pathway Services A Novel Way Forward for Liaison Psychiatry?

Sarah Burlinson
sarah.burlinson@nhs.net
Integrated Clinical Assessment and Treatment Services
A presentation and workshop on Integrated Clinical Assessment and Treatment Services (ICATS) was
delivered by Dr Alan Nye, Pennine Musculoskeletal Partnership and Dr Sarah Burlinson,
Psychological Medicine Service, Pennine Care. The sessions detailed the ICATS model of healthcare
delivery and funding and advantages to patients, clinicians and the PCT. Developments between the
local ICATS and the Psychological Medicine Service in Oldham were described and suggestions for
how Liaison Psychiatry could develop within the ICATS framework to promote a bio-psychosocial
approach to patient care discussed.
The Pennine Musculoskeletal Partnership ICATS is an NHS body with a primary care contract from
Oldham PCT to deliver musculoskeletal services. This is a 3 year rolling Specialist Personal Medical
Services Contract (SPMS) and all services are defined by a Service Level Agreement. The ICATS is
funded by Payment by Results.
ICATS were developed to try and redesign and improve clinical services, and reduce referrals from
primary to secondary care. The service sits at the interface between primary and secondary care. All
GP referrals for rheumatology and orthopaedics are funneled through this service. Patients are
triaged and either seen and treated within the multidisciplinary ICATS team, or fast tracked to the
appropriate secondary care specialist.
Benefits to patients have included rapid access with over 90% of referrals seen and assessed within 4
weeks, faster referral to secondary care, self referral for joint injections, services closer to home and
the development of new services including an osteoporosis service, a chronic pain service and
community based liaison psychiatry
Commissioners have been pleased with the service and ICATS model as it has helped them meet
targets around 18 week waits, which were particularly relevant to orthopaedics and rheumatology, and
practice based commissioning and has saved money.
Background
The ICATS began as a Tier II service in 2003: this was a pilot project focusing on the rheumatology
waiting list. This was deemed successful and Pennine Musculoskeletal Partnership submitted a
business plan for an ICATS in July 2005 as part of a tendering process. The SLA signed off January
2006 and the ICATS commenced March 2006.
Moving to becoming commissioners rather than providers of clinical services; the PCT was becoming
an 18 week pioneer site and needed to transform clinical pathways; the Tier 2 rheumatology had been
very successful with national awards, significant diversion of clinical work away from secondary care,
good consultant links and an excellent relationship with the PCT.
Interface with Psychological Medicine/ Liaison Psychiatry
When the Tier 2 Rheumatology Service began, the Psychological Medicine Service was asked to
provide assessments and treatments for patients who were felt to be psychologically distressed and/
or who would benefit from a psychological approach to symptoms. The drive behind this development
was to improve the quality of patient care, rather than meeting any specific target. Initially funding was
provided for a 2 year project (50k/year) for more nursing and consultant time. This was extended
and in April 2008 agreement was reached for a considerable expansion of this service (approximately
180k per year). The clinical remit will expand from rheumatology to include orthopaedics and chronic
pain. This will allow for more nurse therapy and consultant time in addition to a new clinical
psychology post and extra administration.

24

As there is no national tariff for Lliaison Psychiatry the contract involves a SLA (block contract)
between the ICATS and Pennine Care NHS Trust, with clear agreements for clinical activity and a
service specification.
The ICATS is in the process of developing contracts with neighbouring PCTs, which may be a vehicle
for further expansion of psychological provision.
Business Planning
ICATS can be developed by any group of clinicians, but considerable business planning experience is
needed. There are 2 ways of tendering; competitive tendering - which is very time consuming and
requires a lot of financial and business knowledge, and a process known as Any Willing Provider
which is said to be quicker and easier. The developments in the Psychological Medicine Service at
Oldham have arisen by piggy backing on existing ICATS developments for musculo-skeletal
conditions within the PCT, and not by clinicians within the service bidding to become an ICATS
provider.
Summary
ICATS are new ways of delivering clinical services and seem to offer opportunities to improve patient
care using an integrated multidisciplinary approach. There appears to be a role for Liaison Psychiatry
Services in these developments. Service redesign in clinical areas affected by the 18 week targets in
particular, could offer real opportunities for a more integrated approach to health care.

Dr Sarah Burlinson
Consultant in Psychological Medicine
Royal Oldham Hospital
Pennine Care NHS Trust

17.

Health Care Commission Review of Annual Health Check

Geraldine Swift. ger@swift.name

Im sure everyone is aware of the Health Care Commissions annual health check which is an annual
review of performance and quality standards that trusts and care providers are required to meet in
order to get their fit for purpose tick in the box. The components of the health check are currently
under review and development for 2008/9 (details on HCC website
www.healthcarecommission.org.uk and downloadable adobe file). We were fortunate to be able
provide input into this via Geraldine Swift who took the opportunity to plug Liaison Psychiatry Issues
with Ian Kennedy at her local Darzi Meeting. This resulted in direct contact from Anthony Deering at
the Health Care Commission asking for Liaison Psychiatry feedback into the process. (Excellent
scoop Geraldine! Ed.). Geraldines excellent response is shown below. Hopefully this should get
more pertinent specific liaison / psychological medicine points being present within the health check
and therefore help with the argument for services.
Response to HealthCare Commission Annual Health Check Review
Liaison Psychiatry is a branch of psychiatry that is traditionally defined as providing psychological care
to people in general hospitals A&E, out-patients and in-patients. The main groups of patients seen
within Liaison Psychiatry include:
Patients who self-harm
Patients with co-morbid physical and mental health problems (depression and renal failure
etc)
Patients with medically unexplained and functional symptoms
Patients with delirium and dementia
Given its wide remit and its location, liaison psychiatrists are interested in the Health Care
Commissions assessments across different sectors and organisations. The Executive Committee of
the Faculty of Liaison Psychiatry welcomes the opportunity to feedback our views regarding Have

25

Your Say Developing the Annual Health Check 2008/2009. We have organised our views
according to the consultation questions.
Consultation Questions 1
Please comment on our proposals for national reviews and studies in 2008/2009 focusing on the
themes set out in section 3.
1. In the review of end-of-life care, we would hope that consideration be given to the access to a
tiered approach to psychological care. Staff who work in end-of-life care are often particularly
skilled at delivering tier 1 and 2 psychological care, such as providing information, support and
reassurance. However, unless they know that they can access extra support and supervision
if required, they may avoid addressing difficult emotional areas, and leaving patients feeling
more isolated. We believe it is therefore very important that palliative care staff should have
access to more specialised psychological supervision and support. We hope that the review
of end-of-life care will look at this provision.
2. In the national study on access to psychological therapies, we hope that the needs of people
in hospital will not be forgotten. Some patients, particularly in rehabilitation type settings, may
benefit from traditional, one hour weekly, formal psychological interventions. Apart from
rehabilitation, many other patients face prolonged stays in hospital for example with endstage respiratory failure or following major surgery. They also benefit from psychological
interventions, although these may need to be briefer and more frequent. We hope that the
study on access to psychological therapies will take their needs into consideration.
3. In the national study on equality of access to services for disabled people, we are conscious
that mental health disability is still perceived as carrying a stigma. Health care staff carry the
same prejudices as the general population and many patients with mental health problems
continue to report that they feel they are treated differently because of their mental health
diagnoses. In their consideration of this issue, we would refer the Health Care Commission to
the Royal College of Psychiatrys campaign in fighting stigma, Changing Minds, particularly
the ebook Every Family in the Land and the leaflet Does it matter if doctors discriminate?.
4. In the survey of patients with long-term neurological conditions, we would ask that the
Commission inquire into the availability of all levels of psychological support experienced by
patients.
5. Aside from the proposed reviews and studies, we are aware that the Commission has already
completed a review of mental health in-patient services. A follow-up review includes a
question on the provision of Liaison Psychiatry Services. We would welcome any comments
from the Commission regarding the patchiness of service provision and the inequality of
service provision between adults of working age and older people (see also under consultation
question 7 below).
Consultation Questions 3 and 14
Q3: Please comment on proposed indicators for primary care trusts, in particular whether they provide
sufficient coverage of key health and healthcare priorities to inform local communities and sufficient
recognition of the move to localism.
Q14: Please comment on whether proposals for the annual health check 2008/2009 will sufficiently
encourage trusts to address health inequalities and to promote wellbeing.
We would welcome a greater emphasis on the issues of self-harm and suicide. Although CPA 7-day
follow-up is an indicator for PCTs as a proxy suicide target, this is only relevant to people with serious
and enduring mental illness. The vast majority of people who self-harm are highly distressed but do
not meet the criteria for referral to secondary care mental health services. Once they leave hospital,
follow-up for people who self-harm is therefore unusual in most parts of England and Wales. People
who self-harm are an appropriate target group for the Health Care Commission as they are a large
group (170,000 presentations to A&E annually, 1 of top 5 reasons for admission to acute hospitals),
vulnerable and there is great potential for improvement in the services they are offered.
We would therefore propose that PCTs should be required to address health inequalities and promote
well-being by developing strategic partnerships with social services, acute trusts and mental health
trusts aimed at reducing self-harm.

26

Consultation Questions 5
Please comment on our proposed indicators for acute trusts.
1. Stroke Care: We welcome the acknowledgement of the need for psychological support for
patients following stroke in the NSF for Older People and in the Sentinel Stroke Audit. We
regret the poor performance across trusts in terms of having a clinical psychologist attached to
the specialist stroke team only 31% in 2006. We suggest a greater emphasis on the need
for a psychological therapist as part of the team. In improving progress towards the goal of
good psychological support and supervision, it may be more helpful to use this broader term of
psychological therapist (which could include nurses, occupational therapists and doctors with
specific training in psychological interventions) rather than restricting local choice by requiring
a clinical psychologist.
2. Patients receiving clinically effective care in A&E: We would expect that this indicator being
drawn up by the Health Care Commission and British Association of Emergency Medicine
should include a measure of the number of patients who receive a psychosocial assessment
after self-harm, in line with NICE guidelines on management of self-harm.
3. Maternity Care: When an indicator is developed in this area, we would anticipate that it will
include the need to ensure that, during pregnancy and while breast-feeding, women and staff
who care for them have access to specialised advice regarding anti-depressant and other
psychotropic medication as recommended in NICE guidelines on perinatal mental health.
4. Experience of patients/users: We are unclear whether patients are routinely asked about their
experience of psychological support while in hospital. We would understand this to mean all
levels of support from all staff such that patients are aware that their mental well-being is of
concern to staff along with their physical well-being. If such areas are not enquired into, we
would recommend that they be considered when the current domains are reviewed.
Consultation Questions 7
Please comment on our proposed indicators for mental health trusts.
In line with the NSF for older peoples emphasis on the need to ensure equity of access, we suggest
that mental health trusts be required to ensure equal access for older people to Liaison Psychiatry
teams. At present the provision of Liaison Psychiatry for adults of working age is patchy but the
provision for older people is generally very poor for example, there is only 1 full-time equivalent
Consultant in Liaison Psychiatry for older people across the UK to our knowledge.
These comments have been discussed by the Faculty of Liaison Psychiatry. Representative members
would be happy to meet with members of the commission and discuss them further.

18.

Chronic Pain Pathway Commissioning Document

I thought in Liaison Psychiatry faculty members may be interested in this new DOH pathway. It is an
18 week commissioning pathway for chronic pain and will be issued by the DOH to PCTs as the 'gold
standard' against which to commission. It aims to set out the best care pathway through primary/
secondary and tertiary care. Dr Nye was the project lead and had several clinical leads (of which I
was one-for the psych bit) working with him to produce it. There was a consensus meeting to enable
a wider audience to contribute, etc, as per standard DOH approaches to pathway development.
I think some of the good things about it, from our perspective, are the biopsychosocial framework and
inclusion of consideration of psychological factors/ treatment/ risks as well as physical. There's also
mention of both psychiatry and psychology. Hopefully ,this pathway will help act as a lever when
trying to engage PCTs in commissioning appropriate psychological/ psychiatric services for patients
with any chronic pain.
In terms of viewing it, there are 'pop up ' boxes of supplementary information behind the flow chart.
This info can be printed off as a whole by clicking on show/ hide menu and supp info, although I've
never had much success printing off the whole chart myself.

27

I imagine it should be on the DOH website though have not yet checked, and that it can be refined, as
necessary, with time.
Pathways for Health DoH 18wks Chronic Pain 2008
Best wishes
Sarah
Whilst on the subject of pain The Clinical Standards Dept of the RCP in conjunction with the British
Pain Society and the British Geriatric Society have produced a set of National Guidelines for The
Assessment of Pain in Older People This is Guideline No 8 of the Concise Guidance to Good
Practice Series which are a good solid series of evidence based guidelines for clinical management
and sensible reading. Very useful for quoting to our physician colleagues at times of disputed
management too! Ed.

10.

Clinical Cases of Interest News from the JISC Mail Discussion Group
Dr Tarra Shaw, CL Psychiatrist, Royal Prince Alfred Hospital, Sydney

Dear all,
My apologies for the long story and grammatical shortcuts which follow; any suggestions very
appreciated:
21 y old girl, lives with parents + brothers (19,16) on an extremely remote farm in New South Wales,
Australia (eg nearest little town is 150km away, nearest kids birthday parties growing up, 90km away)
so schooled via radio school till age 12, then home schooled by mum till finished high school, and at
18 started TAFE courses to improve her poor (dyslexic) English reading/writing/spelling skills. IQ >
100. Her life plan is to live + work on farms.
The home schooling was a geographical necessity. Mum is normal, rational, sensible, eg aware that
the social isolation is a big developmental disadvantage for the kids, tried to maximise social
interactions with other kids eg camps, parties. Medically healthy family, and girl healthy bar childhood
asthma; most of family a bit atopic (seasonal mild asthma), + Dad and a brother also have dyslexia.
She looks mildly dysmorphic. Parents are not related. Always a tough farm girl - the eldest, worked
outside in staggering 45C heat, kept up with Dad + the brothers etc etc.
3 y ago she began to get these "episodes": smell would trigger the episode (lots of smells can trigger eg petrol, perfume, shampoo, deodorant, gum from trees, food smells) then repeated coughing;
nausea; sometimes vomiting; then gets very cold, even in hot summer; then in most cases, excessive
drowsiness and had to sleep - for 3 - 7 hours; hard to rouse sometimes - Mum might have to wake up
3-4 times or so to tell girl dinner is ready; has amnesia for times woken, and for some of the episode/
events around episode. For next 12-48hrs post episode, lacks her usual mental clarity - eg memory
not quite right, thinking not crisp, doesn't always make sense eg might answer a question tangentially
or babble a bit, (sometimes fast but there's no manic feel), movements are slow, amnesia, can't
negotiate complex tasks - actually can't do this early in episode sometimes. Not every episode
progresses to the excessive sleeping, but most do. Some episodes become almost cyclical in cough
excessively-vomit-cough-vomit. Some are just some cough then really sleepy. No hallucinations smell really present tho she is very sensitive and smells the smell long before others can. No
delusions.
Seen at allergy clinic in large Sydney teaching hospital (mine) a yr ago, some skin allergies, put on
food restriction diet, given an Epipen (adrenalin/epinephrine) and family have used it 3 times in last 6
months, and this prevents the sleepiness, and can cut into the cough-vomit cycle. It's a HUGE saga
when she/her mother uses Epipen - ambulance has a 150km drive to the edge of their property, a
parent drives her down to edge to meet ambo, then all go to nearest hospital hours away. They are
hours from medical assistance and fear she'll die in the midst of an attack, if it's anaphylaxis.

28

She tried to individuate last yr, + moved out of home w support from family, into a house 100m away
on the property. This rekindled memories of child sexual abuse from a male cousin which occurred
age 4 in that house, +she had some of the episodes, feared cooking inside with cooking smells
triggering the episodes, so couldn't cope... got depressed, slight OCD symptoms, suicidal,
worrying ideas re shooting self with one of the many guns on the property...informal regular support
from a friend + venlafaxine improved all of this and she moved back home and now looks happy.
TAFE involved her travelling far away for week-long spells, every 2 mo, 2 y ago, and she had some
anxiety re this (mild social anxiety); smells of perfumes etc in the teenagers' boarding house also
triggered episodes. Completed most of course but mum had to collect her once (plane trip).
Now is an inpatient under resp physicians, a planned booked admission (it's a 10h trip to
this hospital!) who are convinced this isn't asthma and are trialling her not using salbutamol/adrenaline
during an attack. She is having daily attacks in hospital, and freq at home was about one every 3
weeks. Mum is with her most/all of the time in hospital, but v happy to leave the room for psych
interviews, investigations etc.
I was prepared for an enmeshed dependant relationship, but they are as normal as can be,
considering the circumstances and lack of individuation.
So far:
basic bloods N, no wheeze on examination, they're repeating allergy tests, IgE normal, CXR N, EEG
prob N awaiting formal report, MRI just done awaiting report, neuro team are considering 24h
telemetry EEG to catch EEG during an episode.
I have to say, to me, it does not have the feel of conversion d/o or similar. I am open to this dx but not
embracing it. There are lots of reasons it could be, but the patient role seems to significantly
disadvantage her and she really does not like it (eg cannot drive into town alone now +wants to, can't
leave the house some days because smells outside trigger attacks, family have to wash before
entering house, and not use certain shampoo, scents, cook, etc; her life is now very restricted, can't
even drive across the property safely (property is 15km across), and she unable to function as cannot
be left alone doing a responsible farm task; none of (tough farming) local community and perhaps
family eg Dad, really understand what's going on, has lost "tough coping" position of respect in family,
and future is...?)
I think she might have a rare organic syndrome ? She has the look of a "funny looking kid" and the
symptoms are so complex and weird
My best contender is Endoxepine Stupor, tho I'm not sure the coughing fits this
Have also considered Paradoxical vocal cord motion disorder to explain the coughing
Kleine-Levin syndrome does not really fit, I think
I'm thinking, to do from here: - EEG during an attack, IV flumazenil during an attack, and a genetic
consult
Does anyone have any other ideas? Investigative, diagnostic,..(ANY!)
Responses Included:
i.
Could this be reflex epilepsy with autonomic discharge causing cough & vomit? Then postictal drowsiness & confusion?
Try a range of olfactory stimuli from the list you've given during the 24hr EEG.
ii.
I presume the studies for a form of epilepsy will prove negative and that she will turn out to be
experiencing major dissociative episodes triggered by powerful reminders of the abuse. The coughvomit-cough can represent the choking on ejaculate from oral sex. There is not much information
about the nature and duration of the sexual abuse, but it would be worth your while getting someone

29

familiar with major dissociative symptoms to explore her trauma history with her. There are few selfprotective repertoires available to a 4 year old other than dissociating from the experience, and
olfactory triggers are very potent in this setting

iii.
I had a patient who had similar episodes with vomiting when she was in a certain room in her
house. She eventually had a generalized seizure and was diagnosed with temporal lobe epilepsy. Her
EEGs were always normal. If telemetry is difficult to get in your part of the world (as it is here) the most
reasonable course of action would be a trial of tegretol. If there is a component of conversion, the
suggestion that these attacks could be treated with the antiseizure medication may help.Prolactin is
sometimes elevated after a seizure but mostly after tonic clonic ones and not necessarily after
temporal lobe seizures. I would think that seizures would really have to be ruled out before you
pursued the whole dissociative attack thing - I'd cross my fingers it was epileptic because treatment of
intense dissociation like this I think would be much more difficult. I also just diagnosed someone with
narcolepsy who has had waxing and waning sleep attacks for years but on careful questioning has
sleep paralysis and cataplexy. Ruling out a sleep disorder and perhaps a sleep study might be helpful
(but again, here those are hard to get).
iv.

Geographically very challenging case (I come from a small country)!

I agree with Dr Clifton that these are probably dissociative. They are not convincingly stereotyped or
brief by the sound of them. Nor are they reflex given multiple olfactory triggers.
Given that she is in at present try provoking attacks on telemetry with usual methods, suggestion
and if necessary a stressful psychiatric interview. Prolactin wont help here. A post-ictal EEG when she
is hard to rouse / supposedly sleeping will also help determine whether dissociative or other.
Get the respiratory team / Allergy clinic to consider whether Adrenaline pen is justified at all here.
Consider in conjunction with them putting her back on a normal diet and family no longer making any
changes to washing / toiletries (ie normalizing home environment in so far as is possible). Is there any
reason why she cant be left alone during a responsible farm task? Ie any dangerous episodes if not
then phased return to this.
Consider teaching her cued distraction and relaxation to use at the very onset of an attack (when she
begins coughing) and if possible teaching her mother to take as much a back seat during an attack
as possible. I would say that her current patient role is a huge advantage to her rather than
disadvantage as suggested. It keeps her in close proximity to her mother it is this attachment along
with the abuse-related traumatic stress that needs to addressed in treatment.
What do you think?...................
11. Upcoming Meetings & Events
Please feel free to let me know of any events youd like to advertise in this section. Ed.
.British Association of Psychopharmacology
The 2008 SUMMER MEETING programme and registration details are available here:
http://www.bap.org.uk/summer_meeting_2008/index.html
BAP has developed a set of MASTERCLASSES IN PSYCHOPHARMACOLOGY. Held in an 18month cycle, the next available dates and topics are listed below
Day A: Wednesday 22 April 2009 / Wednesday 11 November 2009 Topics: Schizophrenia /
Substance Misuse
Day B: Thursday 23 April 2009 / Thursday 12 November 2009 Topics: Bipolar / Perinatal / ADHD
Day C: Friday 24 April 2009 / Friday 13 November 2009 Topics: Depression / Anxiety / Sleep
Feedback from delegates at the April 2008 Masterclasses: Very knowledgeable speakers, Handout
folder very well presented, Overall excellent quality and good value for money,
Lived up to my
expectations both content, speakers and handout were excellent, really couldnt be better
Full details available here: http://www.bap.org.uk/Masterclasses09/masterclasses.html

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Faculty Annual Residential Meeting -

Prague 14-15 March 2009

Liaison Faculty
Annual Residential Meeting
14-15 March 2009
Prague
The hotel offers excellent conference facilities close to the city centre and truly
offers business and pleasure at a reasonable price. Liaison faculty members can
rest in the fact that other faculties have provided very positive feedbacks about
the venue.

This conference will be held over 2 days and

will have a strong clinical/academic focus
with topics ranging from transplant
psychiatry, eating disorders & liaison
psychiatry, sleep, factitious disorders,
palliative care and chronic delirium / early
onset dementia management. As always a
variety of workshops will be available as
part of the programme.
There will be a session on new service ideas
ala Dragons Den and the poster
presentations will be followed by a best
poster certificate crowning ceremony!
We have no doubts that attendees will
continue into a long weekend break and the
conference office will liaise with local
tourism to help attendees with making
bookings.
Put the date in your diaries now!

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12.

Book Reviews

This book is a very welcome addition to Liaison Psychiatry literature. It is the first really
comprehensive textbook of Liaison Psychiatry by authors predominantly working in the UK; however,
the inclusion of a number of eminent international contributors greatly enhances it. Although the
editors state that it is aimed at clinicians from a variety of backgrounds, it will principally be read by
practising or aspiring liaison psychiatrists. General adult psychiatrists would, however, greatly benefit
from reading several of the contributions notably those on self-harm, alcohol problems, functional
somatic symptoms and neurology.
Although there are multiple authors, the editors have succeeded in ensuring an evenness of style and
all the contributions combine clinical wisdom with reasonable discussion of the evidence base
underlying the area under discussion. In recent years Liaison Psychiatrists have become more aware
of the need to forge links with primary care, particularly as patients spend less time in hospitals and
more services for physical illness become community based. This is acknowledged by two excellent
chapters on primary care psychiatry. Particular highlights were the assessment section in the
neurology chapter, which could be of benefit to all psychiatrists (although in the same chapter I would
have liked more advice on how to manage behaviourally disturbed brain-injured patients in a general
medical setting), and also the chapters on alcohol problems and psychological treatments.
My criticisms of this book are few. In any multi-author book it is challenging to keep the reference lists
up-to-date and in some of the chapters this was an issue. I would have liked to have seen a chapter
on transplant surgery. The contributions in other chapters, for example those on renal and hepatic
disease, did not cover assessment of both organ donors and recipients as comprehensively as a
single chapter might have. The otherwise excellent chapter on legal and ethical issues could have
made more use of experience already gained in Scotland of incapacity legislation. These are,
however, minor reservations. The editors are to be congratulated on pulling together an excellent
book. Were I to be asked to recommend a single liaison psychiatry textbook for liaison psychiatrists
and trainees it would now be this one.
Tom Brown, Department of Liaison Psychiatry, Western Infirmary, Glasgow G11 6NT,
UK. Email: tom.brown@ggc.scot.nhs.uk
doi: 10.1192/bjp.bp.107.042168

32

Adopt-a-Book
An opportunity to contribute towards the history of psychiatry and the College.

The Adopt-a-Book scheme of the Royal College of Psychiatrists was launched at the 2007 Annual
Conference in Edinburgh.
The scheme is aimed at raising funds for the conservation and repair of the Colleges antiquarian book
collection. The collection consists of rare books dating as far back as the 15th century. It is an
important source of information on the history of psychiatry, mental illness and learning disability.
The collection also contains books written by notable authors such as Daniel Hack Tuke, Forbes
Winslow, Henry Maudsley, John Connolly, Sigmund Freud, and many others.
The appeal for donations is directed at members and fellows of the College, and anyone who is
interested in restoring and conserving the collection to a condition suitable for its use by researchers
and historians, and in its preservation as part of our national heritage.
Since its launch in July, the scheme has received considerable support, mainly from members of the
College. As a result several adopted books have now been sent to the conservator to be repaired.
We would like to thank all those who have generously donated to the scheme so far, and look forward
to your continued support.
To obtain a full list of books to be adopted and a donation form, please go to
www.rcpsych.ac.uk/college/archives/adopt-a-book.aspx or contact:
The Archivist
Royal College of Psychiatrists
17 Belgrave Square
London
SW1X 8PG
Tel: 020 7235 2351
E-mail: archives@rcpsych.ac.uk

STOP PRESS!!!!
Consultant in Liaison Psychiatry for the Psych-oncology Service at Christie Hospital
Foundation Trust
Due to the forthcoming retirement of Dr Penny Hopwood, recruitment for the above post is
commencing. Please expect an advert in the British Medical Journal in August/September for this
exciting post working with an established multidisciplinary team at the prestigious Christie cancer
hospital. If you are interested in finding out more please contact Dr Penny Hopwood (0161 446 8004
or penny.hopwood@christie.nhs.uk). This is a full time post but enquiries from those interested in part
time working or job sharing are welcome.

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