Model Service
Specifications for
Liaison Psychiatry
Services - Guidance
1st edition, February 2014
Title:
Model Service Specifications for Liaison Psychiatry Services - Guidance for
Edition:
1st edition
Date:
February 2014
URL:
http://mentalhealthpartnerships.com/resource/model-service-specificationsfor-liaison-psychiatry-services
Commissioner: Strategic Clinical Network for Mental Health, Dementia and Neurological
Conditions South West
Editors:
Dr Peter Aitken, Dr Sarah Robens, Tobit Emmens
Devon Partnership NHS Trust, Dryden Road, Wonford House, Exeter, EX2
5AF
www.devonpartnership.nhs.uk
Preface
This service specification describes four models of hospital based
liaison psychiatry service, which have evidence for cost and quality
effectives impacting on emergency and unplanned care. Each model
builds on the level previous one.
This document uses the current (January 2013) Department of
Health Service Specification Template.
This service specification is part of a suite of four related documents,
each with increasing levels of detail:
•
•
•
•
Liaison Psychiatry Services - Guidance - sets out the key
consideration to be made when commissioning liaison
psychiatry services.
An Evidence Base for Liaison Psychiatry - Guidance - sets
out the evidence gathered from lay people, professionals,
commissioners and the literature about what is needed from
liaison psychiatry services.
Developing Models for Liaison Psychiatry Services Guidance - provides the technical information needed for
commissioning liaison psychiatry services.
Model Service Specifications for Liaison Psychiatry
Services - sets out exemplar service specifications for four
models of liaison psychiatry.
The guidance was commissioned by the Strategic Clinical Network
for Mental Health, Dementia and Neurological Conditions South
West.
1
With thanks and appreciation
We would like to recognise and appreciate the contribution of the
following people for their work in putting together this guidance:








people with an experience of our services, commissioners
and commissioning supporters
the Faculty of Liaison Psychiatry at the Royal College of
Psychiatrists
the Academy of Emergency Medicine
the National Clinical Director for Mental Health
the Centre for Mental Health
the Strategic Clinical Network for Mental Health, Dementia
and Neurological Conditions South West
the research and development team at Devon Partnership
NHS Trust, and
Dr William Lee, Reader in Psychiatric Epidemiology,
Plymouth Peninsula Schools of Medicine and Dentistry.
Dr Peter Aitken's time was funded by the National Institute for Health
Research (NIHR) Collaboration for Leadership in Applied Health
Research and Care for the South West Peninsula (PenCLAHRC).
The views and opinions expressed in this paper are those of the
authors and not necessarily those of NHS England, the NIHR or the
Department of Health.
2
Summary of liaison psychiatry service models
The four models of hospital based liaison psychiatry service described in this specification
are:
•
•
•
Core Liaison Psychiatry Services
•
Comprehensive Liaison Psychiatry Services (Enhanced with inpatient and outpatient
services to specialties at regional and supra regional level)
Core 24 Liaison Psychiatry Services
Enhanced 24 Liaison Psychiatry Services (Enhanced with adjustments to fill local
gaps in service and some outpatient services)
Table 1: High level summary of differences between models
Core
Core 24
Enhanced 24
Comprehensive
c 500
c 500
c 500
c 2000
2
2
4
5
0.6
2
2
2
2 Band 7
6 Band 7
3 Band 7
6 Band 6
7 Band 6
7 Band 6
Other Therapists
0
4
2
16
Team Manager Band 7
1
1
1
3
Clinical Service manager
Band 8
0.2
0.2 - 0.4
0.2 - 0.4
1
Admin Band 2, 3 and 4
2.6
2
2
12
0
1
1
1
Total Whole Time Equivalent
14.4
25.2 - 25.4
22.2 – 24.4
69
Hours of Service
9-5
24/7
24/7
24/7
Age
16+
16+
16+
16+
Older Person
Yes
Yes
Yes
Yes
Drug and Alcohol
No
Yes
Yes
Yes
Out Patient
No
No
Yes
Yes
Specialities
No
No
No
Yes
£0.7M
£1.1M
£1.4M
£4.5M
Example Number of Beds
Consultants
Other Medical
Nurses
Business support (band 5)
Approx Costs
2 Band 8b
17 Band 6
10 Band 5
3
Detailed descriptions on these models and their differences in terms of staff size and skill
mix can be found in document 3, ‘Developing Models for Liaison Psychiatry Services Guidance’. An example of further defining the optimal service for your local context can be
found in appendix 3 of document 2, ‘An Evidence Base for Liaison Psychiatry Services Guidance’.
How to use this template service specification
The italicised (coloured or black) text represents the four different service models. This text
can be modified or deleted in line with the guidance to create a service specification suitable
for local needs. To help determine which level of service is most appropriate to your local
need please read document 3, ‘Developing Models for Liaison Psychiatry Services Guidance’.
We recommend that you consider the whole care pathway being designed and how it will be
completed with the addition of a liaison psychiatry service.
To help decision with regard to choice of model of service the commissioner is
recommended to identify:
•
•
•
•
•
•
•
•
Urban or rural setting.
Emergency and unplanned care pathways in your local context.
The presence and pattern of existing rudimentary services for mental health
presentations serving Emergency Departments (ED) and the acute care hospital in and
out of working hours.
Number of beds in the hospital.
That ED is present but limited or no out of hours demand.
That ED is present with out of hours demand and adequate outflow care pathways.
That ED is present with out of hours demand but gaps in supporting pathways.
Regional or supra regional services present or academic teaching hospital.
4
It is also important to consider the detail of surrounding service pathways specifically:
•
•
•
Local pattern, volume and timing of demand on ED and acute care hospital.
Out of hours services other than mental health creating demand.
Any need to serve community or virtual hospital wards that will take staff away from the
ED site.
Considering these points in conjunction with reading document 3, ‘Developing Models for
Liaison Psychiatry Services - Guidance’ should help commissioners select the optimum
model for their local context.
Example for scaling models to meet local need
A rural or provincial 750-bed hospital with a 24 hour Emergency Department might not have
sufficient volume of work to warrant a Core24 Liaison Psychiatry Service and therefore the
number of nurses could be reduced from 13 towards Core depending on identified demand.
A hospital with less than 500 beds will still require a team that meets the Core Liaison
Psychiatry Service Staff Specification to provide sufficient working hours coverage. This level
of staffing will enable sufficient headroom to support other areas, for example, community
hospitals and virtual wards.
An urban hospital with 500 beds and a 24-hour Emergency Department is likely to benefit
from 24 hour, seven day services due to the volume of walk in referrals.
A hospital with more than 1000 beds is likely to need a comprehensive service due to the
volume of referrals especially if it provides regional or supra-regional services.
There is limited scope to reduce the overall number of staff below the level described in the
models. Fewer staff in either the Core or Core24 model will be unable to provide adequate
cover when taking into account annual leave, training, sickness, or unplanned leave.
Diagram 1 on page 6 is a guide to identifying the best model to start from when designing
the most appropriate service for your local context.
5
Diagram 1: Scaling models to meet local need
6
Broadly speaking the minimum and maximum commissioning envelope should be
Number of Beds
Model
Minimum
Maximum
Per 500 beds
Per 500 beds
<500
Core
£0.6M
£0.7M
>500
Core24
£0.7M
£1.4M
>1000
Enhanced24 /
Comprehensive
£1.1M
£1.4M*
*Depending on level of enhancements required for regional and supra-regional services.
Therefore, a large urban 1000 bed hospital would require a commissioning envelope
between £2.2M and £2.8M and would provide an Enhanced24 or Comprehensive Service.
Scaling the base model to meet local context
We recommend that commissioners consider the whole care pathway being designed and
how it will be complemented with the addition of a liaison psychiatry service. The base model
will be scaled according to hospital bed numbers served, adequacy of surrounding care
pathways, 24 hour demand, presence of regional or supra-regional services and urban or
rural location.
We recommend that the project group work through P26 and P27 of document 3 ‘Developing
Models for Liaison Psychiatry Services – Guidance’ and appendix 3 from document 2 ‘An
Evidence Base for Liaison Psychiatry - Guidance’.
7
Notes on local modifications
A hospital with less than 500 beds will still require a team that meets the Core Liaison
Psychiatry Service Staff Specification to provide sufficient working hours coverage. In this
situation the Core model can support other areas, for example, community hospitals and
virtual wards.
A rural or provincial 750 bed hospital with a 24hour Emergency Department may still not
have sufficient night time activity to warrant a Core 24 Liaison Psychiatry but instead scales
up the size of the Core model to meet office or extended office hours.
An urban hospital with 500 beds and a busy 24-hour Emergency Department is likely to
benefit from Core 24 service due to the volume of walk in referrals.
An urban hospital of any size hosting regional and supra-regional services may need an
enhanced or comprehensive model.
Reducing staffing below the levels described in the models means that they will be unable to
provide adequate service cover when taking into account annual leave, training, sickness, or
unplanned leave. This reduces the models to ‘rudimentary’ for which there is no evidence of
effectiveness.
8
Service Specification Template
Department of Health, updated January 2013
Service Specification No:
Service:
Commissioner Lead:
Provider Lead:
Period:
Date of Review:
1. Population Needs (Mandatory)
1.1.
National/local context and evidence base
Liaison psychiatry, also known as Psychological Medicine, is the medical specialty
concerned with the care of people presenting with both mental and physical health
symptoms regardless of presumed cause. The specialty employs the bio-psychosocial model
being concerned with the inter-relationship between the physiology, psychology and
sociology of human ill health.
Liaison psychiatry services are designed to operate away from traditional mental health
settings, in the main in acute care hospital emergency departments and wards, and medical
and surgical outpatients.
Liaison psychiatry teams are multidisciplinary, clinically led by a consultant liaison
psychiatrist who will have higher specialty training in general adult psychiatry with sub
specialty endorsement in liaison psychiatry. Many liaison psychiatrists will also have higher
specialty training in general medicine or general practice.
Liaison psychiatrists as well as being in a position to diagnose and prescribe can also
formulate and deliver brief psychotherapeutic interventions most commonly cognitive
behavioural therapy or psychodynamic interpersonal therapy.
The multidisciplinary liaison psychiatry team will typically include specialist mental health
nurses, clinical psychologists, occupational therapist and social workers.
9
Liaison psychiatry services hold expert knowledge on the safe operation of the mental health
act in general health settings and provide expertise to capacity assessments.
25% of all patients admitted to hospital with a physical illness also have a mental health
condition, and in most cases this is not treated whilst the patient is in hospital.
25 – 33% of patients with a long-term physical health problem also have a concurrent mental
illness which increases the risk of physical health complications and increases the costs of
treating the physical illness.
Mental disorders account for 5% of all Emergency Department attendances. These
presentations are often resource heavy and labour intensive.
Chronic repeat attenders at Emergency Departments accounts for 8% of all Emergency
Department attendances. The most common reason for frequent attendance is an untreated
mental health problem.
Self-harm accounts for 150,000 – 170,000 Emergency Department attendances per year in
England.
95% of acute hospital admissions for people with dementia occur in an emergency, with over
60% of these coming through Emergency Department. Emergency admissions for people
with dementia account for nearly 10% of all hospital admissions. 25% of all emergency
presentations in people with dementia are preventable.
Liaison Psychiatry services should respond to need as it presents in the Emergency
Department / ward and not restrict on the basis of age, presenting symptoms or underlying
condition or health state.
Descriptive evidence shows a list of benefits including decreased length of stay, reduction in
psychological distress, improved service user experience, improved dementia care and
enhanced knowledge and skill of general hospital clinicians.
“The status of liaison psychiatry should change. It needs to be recognised as an essential
ingredient of modern health care and not an optional extra which is merely nice to have.”
(Parsonage, Fossey and Tutty 2012: 6)
A more detailed summary of the literature, essential reading, references and lay,
commissioner and professional views can be found in the documents 2 and ‘3: An Evidence
10
Base for Liaison Psychiatry Services – Guidance’ and ‘Developing Models for Liaison
Psychiatry Services. Guidance’.
2. Outcomes
2.1.
NHS Outcomes Framework domains and Indicators
Domain 1
Preventing People from dying prematurely

Domain 2
Domain 3
Domain 4
Domain 5
Reducing premature death in people with serious mental
illness
Enhancing quality of life for people with long-term
conditions

Ensuring that people feel supported to manage their
condition

Enhancing quality of life for people with mental illness
Helping people to recover from episodes of ill health or
following injury

Improving outcomes from planned treatments

Improving outcomes from injuries and trauma
Ensuring people have a positive experience of care

Friends and Family Test

Improving peoples experience of out-patient care

Improving access to primary care services

Improving experiences of healthcare for people with
mental illness
Treating and caring for people in safe environment and
protecting them from avoidable harm

Patient Safety Incidents Reported

Reducing the incidence of avoidable harm
11
2.2.
Locally defined outcomes
Example LIAISON PSYCHIATRY SERVICE PERFORMANCE INDICATORS
Performance indicator
Indicator
details
Weekly
target
Monitoring
Acute hospital activity targets
Minimum reduction in mental
health related A&E waiting
times breaches
Month 1 weekly
target
3
Month 2 weekly
target
5
Month 3 weekly
target
6
30 % Reduction in
emergency re-admission
rates for patients accepted
by the team
30% of all
patients seen
by the team
Weekly activity
reporting
Audit of patients
under the care of
the team
Attendances at Emergency
Departments for self-harm
per 100,000 population
Percentage of attendances at
Emergency Departments for
self-harm that received a
psychosocial assessment.
Quality measures
Total number of
assessments
undertaken by
the team
100%
Weekly activity
reporting
Total number of
patients
100%
Weekly activity
reporting
12
Performance indicator
Indicator
details
Weekly
target
Monitoring
accepted under
the care of the
team
Prevention of discharge to
institutional care e.g.
residential placements
Age, sex,
source of
referral,
97% of all
patients seen
by the team
Monthly activity
reporting
Audit of
discharge
location and
length of stay of
patients under
the care of the
team
Provision of rapid access to
psychiatric assessment
ICD-10 coding
80%
of mental health
conditions
completed for all
patients seen by
the team
Monthly activity
reporting
1 hour response
time ED referral
80%
Weekly activity
monitoring
24 hour
response time
ward referral
80%
Weekly activity
monitoring
90%
Monthly activity
reporting
All patients 65+ with a
diagnosis of dementia, under
the care of the team to have a
review of antipsychotic
medication
Improved referrer, patient
and carer satisfaction
Baseline survey
of satisfaction of
patients, carers
and referrers
13
3. Scope (Mandatory)
3.1.
Aims and objectives of service

To provide Emergency Departments and Acute Care Hospital Inpatient units with
24hour rapid access to specialist mental health assessment within 1hour and 24hours
respectively aimed at avoiding unnecessary admission.

To provide effective mental health interventions in Emergency Departments and
Acute Care Hospital Inpatient Wards to optimise the time the patient spends in these
environments aimed at reducing length of stay.

To provide connection with community services for mental health, addictions, housing,
care support and primary care to accelerate the onward care of people into a
community setting.

To train and supervise general hospital staff in the recognition and management of
common mental health presentations including depression and anxiety, self-harm,
alcohol and addictions, personality and eating disorders, psychosis, delirium and
dementia.

To provide advice and action in support of hospital staff in respect of the safe
operation of the mental health act and complex capacity assessments.

To provide to regional and supra-regional specialist units where they are present.

To help hospital services meet NICE guidance criteria for managing mental health
and psychological conditions and those co-morbid with long-term conditions.
3.2.
Service description/care pathway

Services should be all-age (including those under 16 and those over 65).

Services should be delivered 7 days a week, and beyond office hours, but this will
depend on local context, in support of emergency and unplanned care pathways.

If there is no 24hour liaison psychiatry service then there should an alternative service
to provide support to ED and avoid mental health admissions out of hours.

For hospitals without an emergency department the liaison psychiatry team can
operate to support community hospitals and virtual hospital wards in the community.

The Liaison Psychiatry team will be in or very close by to the acute care hospital it
serves.

The Liaison psychiatry service will be supported by business and administrative
support enabling effective communication and information exchange with surrounding
agencies.

The Liaison Psychiatry service will have a single point of access for referrals.
14

As well as the Core set of consultants (Including expertise in self-harm, older people
and addictions) and nurses, liaison psychiatry teams should be multidisciplinary,
depending on the model being implemented, include social workers, occupational
therapists, STR workers, drug and alcohol workers and learning disability nurses.
These decisions will be informed by pre-commissioning needs assessment.

The liaison psychiatry service should have access to professional expertise in
psychological therapies.

Liaison psychiatry services should have strong links with Health Psychology.
Evidence-based model of liaison psychiatry service for local context
Guided by the colour coded text, please select from:
1. Core: Liaison Psychiatry Services, operate working or extended hours only.
2. Core24: Liaison Psychiatry Services, operate twenty-four hours, seven days a week.
3. Enhanced24: Liaison Psychiatry Services, operate twenty-four hours, seven days a
week with extensions to fill local gaps in service and some outpatient services.
4. Comprehensive: Liaison Psychiatry Services operate twenty-four hours, seven days a
week, enhanced with inpatient and outpatient services to specialties at large hospitals
with regional and supra-regional services.
15
Core Liaison Psychiatry Services
These services have the minimum specification likely to offer the benefit suggested by the
literature. Core will serve acute health care systems with or without minor injury or
emergency department environments where there is variable demand across the week
including periods of no demand where a 24hour staffed response would be uneconomical.
Core24 Liaison Psychiatry Services
These services have the minimum specification likely to offer the benefit suggested by the
literature where there is sufficient demand across the 24 hours period to merit a full service.
Typically these acute health care systems are hospital based in urban or suburban areas
with a busy emergency department.
Enhanced24 Liaison Psychiatry Services
These services have enhancements to the minimum specification to fit in with gaps in
existing pathways and services. Often they have additional expertise in addictions psychiatry
and the psychiatry of intellectual disability. Demography and demand may suggest additional
expertise with younger people, frail elderly people or offenders, crisis response or social
care. This may extend to support for medical outpatients.
Comprehensive Liaison Psychiatry Services
Comprehensive services are required at large secondary care centres with regional and
supra-regional services. These services include Core24 level services but will have
additional specialist consultant liaison psychiatry, senior psychological therapists, specialist
liaison mental health nursing, occupational and physiotherapists. They support inpatient and
outpatient areas such as diabetes, neurology, gastroenterology, bariatric surgery, plastic and
reconstructive surgery, pain management and cancer services. They may include other
condition specific elements such as chronic fatigue and psychosexual medicine teams.
Some may include specialist liaison psychiatry inpatient beds. Comprehensive services run
over office and extended hours supported by the core service running twenty four hours,
seven days a week.
16
Core Liaison Psychiatry Services - a working-hours model.
The service operates weekday office hours with out-of-hours cover provided by a duty
psychiatrist on-call and out of hours services.
These services have the minimum specification likely to offer the benefit suggested by the
literature. Core will serve acute health care systems with or without minor injury or
emergency department environments where there is variable demand across the week
including periods of no demand where a 24-hour staffed response would be uneconomical.
The model mainly serves emergency and unplanned care pathways.
The Core model sets out three main areas of work for a liaison psychiatry service:
1. Direct patient care (assessment, diagnosis and provision of mental health care for
patients referred to the team),
2. Support and training to general hospital staff relating to mental health needs,
3. Interfacing with other parts of the health and social care system.
This model has five main functions:
1. To provide a timely response to all mental health presentations in the emergency
department within one hour and acute hospital inpatient wards within 24-hours.
2. To use time to listen to the people referred, collect information from multiple sources
and make a bio-psychosocial formulation, psychiatric diagnosis, risk management
plans and contribute to appropriate treatment and discharge plans, working in
partnership with agencies in primary care and community services.
3. To offer brief evidence based psychological interventions as inpatient or short-term
follow up of up to 5 sessions.
4. To work with acute care hospital teams to optimise length of stay and accelerate care
to out-of-hospital pathways.
5. To consult with hospital staff regarding the care and management of their patients,
provide advice regarding medicines management, behavioural management, alcohol
related issues, eating disorders, access to mental health services, the management of
frequent attenders, use of the mental health act and provide expertise to capacity
assessments and Safeguarding.
The team should work in close relationship with any health psychology services within the
hospital, to ensure collaborative working and clear pathways.
17
Table: Core Liaison Psychiatry Services summary
Core Liaison Psychiatry Service
Summary
Example Number of Beds
c500
Consultants
2 wte
Other Medical
0.6wte
Nurses
2 Band 7 (TL)
6 Band 6
Other Therapists
0
Team manager
1 Band 7
Admin (Band 2, 3 and 4)
2.6
Clinical Services Manager
0.2 Band 8
Business support (band 5)
0
Total Whole Time Equivalent
14.4
Hours of Service
9-5
Age
16+
Older Person
Yes
Drug and Alcohol
No
Out Patient
No
Specialities
No
Approx Costs
£0.7M
The consultants should have expertise in self-harm, addictions, the care of older people and
medically unexplained symptoms. The team manager runs the service. The band 7 nurses
are clinical leaders for each of the adult and older people sub-teams.
18
Training
A comprehensive range of training should be offered for students and substantive members
of staff. Subjects taught will include: suicide and self-harm; drug and alcohol misuse;
psychiatric emergencies; Mental Health Act; cognitive impairment; delirium; capacity; asthma
COPD; mental health; somatoform disorders; confusing diagnoses; personality disorder and
Safeguarding.
What is needed to make it work well

A suitable location on-site near ED with safe clinical space for the work.

Appropriate information, record keeping and communication infrastructure to enable
capturing and sharing of patient-specific data and communication with general
practice within 24 hours of the person being seen.

Support from hospital leadership, especially for training and raising awareness.
A good example of a working-hours model is the Royal Devon and Exeter Hospital
Core24 Liaison Psychiatry Service
These services have the minimum specification likely to offer the benefit suggested by the
literature where there is sufficient demand across the 24 hours period to merit a full service.
Typically these acute health care systems are hospital based in urban or suburban areas
with a busy emergency department. This model extends the Core Liaison Psychiatry Service
to provide 24hour seven day a week, service, with rapid response to the emergency
department as well as on wards. The model mainly service emergency and unplanned care
pathways.
Key elements

13 nurses working on shifts.

Team consultants available beyond office hours and for some periods at weekends.

Outside of these hours, rapid access to consultant support provided by on-call
services using provision already in place.

Substantial time is given to supporting and training mainstream hospital staff.

There is a single point of contact for all patients (16+) in hospital with diagnosed or
suspected mental health conditions of any severity.

Co-ordination with out-of-hospital care providers and housing services.

Integrated within broader health and social care system.

Single management structure.
19
Table: Core24 Liaison Psychiatry Service summary
Core 24 Liaison Psychiatry Service
Summary
Example Number of Beds
c500
Consultants
2wte
Other Medical
2wte
Nurses
6 Band 7
7 Band 6
Other Therapists
4
Team Manager Band 7
1
Clinical Service manager Band 8
0.2 - 0.4
Admin Band 2, 3 and 4
2
Business support (band 5)
1
Total Whole Time Equivalent
25.2 - 25.4
Hours of Service
24/7
Age
16+
Older Person
Yes
Drug and Alcohol
Yes
Out Patient
No
Specialities
No
Approx Costs
£1.1M
At some sites, at least one of the nurses will be a specialist alcohol nurse and some sites
may choose to replace one of the therapist roles with something context specific e.g.
substance-abuse nurse.
The inclusion of band 7 nurses is crucial so that they can provide leadership and make
discharge decisions.
20
Even if the hospital has fewer than 500 beds, in order to provide a 24/7 service there will still
need to be a team of 13 nurses. This model can only be reduced if the hospital has a limited
hours minor injuries unit or no emergency department at which point it reverts to Core.
This model also includes integration with community provision and local authority teams and
factors in improving communication with GPs and specialists. There is a focus on enhanced
data capture and recording. This model does not, however, include post-discharge follow-up
clinics for patients as with Enhanced24, preferring instead to build links at primary and
community care levels.
A good example of a working-hours model is the North West London Optimal Model.
Enhanced 24 Liaison Psychiatry Services
These services have enhancements to the minimum specification to fit in with gaps in
existing pathways and services. Often they have additional expertise in addictions psychiatry
and the psychiatry of intellectual disability. Demography and demand may suggest additional
expertise with younger people, frail elderly people or offenders, crisis response or social
care. This may extend to support for medical outpatients. The model serves mainly
emergency and unplanned care but extends to support elective and planned care where
mental health problem co-exist.
The key additional elements of this model are:

They have more consultant liaison psychiatry time.

They include follow up clinics, including for self-harm, substance misuse and general
and old age psychiatry.

They develop extensions to manage gaps within existing surrounding pathways of
care.
21
Table: Enhanced 24 Liaison Psychiatry Services summary
Enhanced24 Liaison Psychiatry Service
Summary
Example Number of Beds
c500
Consultants
4wte
Other Medical
2wte
Nurses
3 Band 7
7 Band 6
Other Therapists
2
Team Manager Band 7
1
Clinical Service manager Band 8
0.2 - 0.4
Admin Band 2, 3 and 4
2
Business support (band 5)
1
Total Whole Time Equivalent
22.2 – 24.4
Hours of Service
24/7
Age
16+
Older Person
Yes
Drug and Alcohol
Yes
Out Patient
Yes
Specialities
No
Approx Costs
£1.4M
A good example of this model of care is the Rapid Assessment Interface and Discharge
(RAID) services from Birmingham and Solihull Mental Health NHS Foundation Trust. This
service is for circa 500 beds. This service has been evaluated and found to provide
significant cost savings, as well as positive feedback from patients and staff.
22
Comprehensive Liaison Psychiatry Services
Comprehensive services are required at large secondary care centres with regional and
supra-regional services. These services include Core24 level services but will have
additional specialist consultant liaison psychiatry, senior psychological therapists, specialist
liaison mental health nursing, occupational and physiotherapists. They support inpatient and
outpatient areas such as diabetes, neurology, gastroenterology, bariatric surgery, plastic and
reconstructive surgery, pain management and cancer services. They may include other
condition specific elements such as chronic fatigue and psychosexual medicine teams.
Some may include specialist liaison psychiatry inpatient beds. Comprehensive services run
over office and extended hours supported by the core service running twenty four hours,
seven days a week. This model serves emergency and unplanned care pathways as well as
planned and elective care where mental health problems co-exist.
Table: Comprehensive Liaison Psychiatry Services summary
Comprehensive Liaison Psychiatry Service
Summary
Example Number of Beds
c2000
Consultants
5
Other Medical
2
Nurses
2 Band 8b
17 Band 6
10 Band 5
Other Therapists
16
Team Manager Band 7
3
Clinical Service manager Band 8
1
Admin Band 2, 3 and 4
12
Business support (band 5)
1
Total Whole Time Equivalent
69
Hours of Service
24/7
Age
16+
Older Person
Yes
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Drug and Alcohol
Yes
Out Patient
Yes
Specialities
Yes
Approx Costs
£4.5M
A good example of this model is to be found in Leeds.
Access to Liaison Psychiatry Services
Direct patient care

Referrals are received from both the Emergency Department and acute care wards.

The threshold for referral will change over time as hospital staff experience grows
working with the liaison psychiatry team.
Support and Training

All acute care hospital inpatient teams and ED can make a request to the liaison
psychiatry service for support and training. Management and risk committees may
also request help.

This will be a mixture of formal training sessions on core topics and informal learning
through working alongside the liaison psychiatry team supported by coaching and
mentoring.
Interface with broader health and social care system

The liaison psychiatry team requires regular formal meetings with other parts of the
health system, including general practices, mental health units, crisis resolution
teams, community services, social care and housing team.

Liaison psychiatry involves extensive telephone and email communication by way of
building an accurate picture of the clinical problem and communicating the detail of
the care plan required to address it.

GPs should be informed of their patient’s assessment within 24 hours.
Assessment

Engagement, bio-psychosocial assessment, formulation, diagnosis and initial
management plan for patients with a physical illness or disease, and associated
psychiatric and/or psychological difficulties and distress and continuing care plans.

Create a written record of the assessment based on information from the patient,
carers, other health professionals and health information systems.
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
Provide this information to the patient and their GP in the form of a letter.
Following the assessment

Give advice or signpost to agencies that can help with support of GP.

Make brief intervention by liaison psychiatry team.

Make onward referral to a specialist mental health service.

Use the mental health act and Safeguarding procedures.

Communicate the plan to the patient, their carers and partner agencies and GP.
Review

3.3.
Commissioners will want to agree with providers arrangements for review within the
contracting process.
Population covered
Liaison psychiatry services provide for people accessing Emergency Departments or
admitted to the acute care hospital. In some circumstances outpatient populations are also
serviced.
3.4.


3.5.
Any acceptance and exclusion criteria
People under 16.
Direct referral from general practice.
Interdependencies with other services
Services must work in partnership to ensure safe, planned and joined up care. There must
be smooth transitions between services to avoid people slipping through the net. Service
must adopt and maintain a ‘hands-on’ approach to care with clear lines of accountability with
clearly identified lead clinicians. Information must be shared with people using services and
all those professionals relevant to the care plan where consent has been agreed and risk
considered in line with policy.
The key interdependencies are with:

General Practice, Primary and Community Care and IAPT services.

Acute care providers.

Specialist mental health social workers and social care teams.

Specialist mental health intensive support services.
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
All internal and external access and liaison services

Specialist mental health accommodation and support providers

Third sector information, advice, support and advocacy providers including those for
carers

Housing services,

Drug and Alcohol services

Learning Disability services

Younger Peoples services

Employment services

Generic health and social care locality teams

Tertiary health providers – forensic and independent

Early intervention services

Out of Hours services, inc. GP, Duty Social Worker
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4. Applicable Service Standards
4.1.
Applicable national standards e.g. NICE, Royal College
Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of liaison
mental health services to acute hospitals. Available at www.jcpmh.info
College of Emergency Medicine Toolkit: Mental Health in the Emergency Department
(Feb2013).
Parsonage, M. and Fossey, M. (2011) Economic evaluation of a liaison psychiatry service.
London: Centre for Mental Health.
Parsonage M, Fossey M, Tutty C (2012) Liaison Psychiatry in the Modern NHS. London:
Centre for Mental Health.
4.2.
Applicable standards set out in Guidance and/or issued by a
competent body (e.g. Royal Colleges)
Academy of Medical Royal Colleges (2008) Managing Urgent Mental Health Needs in the
Acute Trust: a guide by practitioners for managers and commissioners in England and
Wales.
Academy of Medical Royal Colleges and Royal College of Psychiatrists (2009) No health
without mental health: the ALERT summary report. London: Academy of Medical Royal
Colleges.
PLAN (Psychiatric Liaison Accreditation Network) CCQI, Royal College of Psychiatrists.
4.3.
Applicable local standards
This will be decided locally, however we recommend that there is a clear contractual
statement about the services contribution to safeguarding.
Safeguarding
The Liaison Psychiatry assessment process may identify safeguarding issues. These
concerns may relate directly to the patient or the welfare and safety of other adults or
children. These adults or children may reside at the patient’s place of residence or may have
regular contact with them.
Local safeguarding policies must be followed involving Multi-Agency Safeguarding Hubs
(MASH) or Multi-agency Public Protection Arrangement (MAPPA) as necessary.
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5. Key Service Outcomes (Mandatory)
Those presenting at the Emergency Department and requiring mental health assessment
are seen within 1 hour (in service hours) - target 90%.
Inpatients medically fit and requiring mental health assessment or where its absence is
preventing discharge or transfer of care are seen within 24 hours of referral – target is 95%.
16-18 year olds presenting at the Emergency Department and requiring mental health
assessment. The hospital liaison psychiatry service liaises with CAMHS team and ensures a
response within 4 hours – target is 90%.
Across all primary diagnoses with a secondary diagnosis of dementia, to reduce average
length and excess bed days from the baseline.
Across all primary diagnoses with a secondary diagnosis of functional mental health (as per
defined ICD10 codes), to reduce average length and excess bed days from baseline.
Reduce readmissions of people with dementia and mental illness.
Patient, carer and staff view that the treatment and support provided enhanced the patient
experience and improved safety and overall quality of care.
Increased numbers of carers identified and carer assessments facilitated.
Reduce Significant Incidents by improvement in risk assessment processes increased
awareness and understanding of functional mental illness and dementia.
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6. Applicable quality requirements and CQUIN goals
6.1.
Applicable quality requirements
The liaison psychiatry service should be accredited by the Psychiatric Liaison Accreditation
Network (PLAN) of the CCQI at the Royal College of Psychiatrists.
6.2.
Applicable CQUIN goals
A range of national levels and drivers exist. Their use is for local determination. These may
include:



Mental health CQUIN targets with incentives for raising awareness, screening and
signposting training, targets related to frequent attending and crisis presentation.
Local AHSNs/ LETBs targets to support training.
Other drivers may include Quality Outcome Framework, Local Enhanced Scheme,
DES targets, currency development and minimum data set requirements.
7. Financial Requirements
These are high-level figures intended to guide the contracting conversation
Expected Contract Values, Details of locally agreed tariff arrangements
Number of Beds
Model
Minimum
Maximum
Per 500 beds
Per 500 beds
<500
Core
£0.6M
£0.7M
>500
Core24
£0.7M
£1.4M
>1000
Enhanced24 /
Comprehensive
£1.1M
£1.4M*
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8. Information Requirements
All information relating to number of people referred / assessed / diagnosed to be provided
at GP practice level for:
i)
Care cluster
ii)
Primary or secondary diagnosis of common mental disorder
iii)
Primary or secondary diagnosis of alcohol or drug use disorder
iv)
Primary or secondary diagnosis of personality disorder
v)
Primary or secondary diagnosis of severe mental illness
vi)
Primary or secondary diagnosis of dementia
vii) Primary or secondary diagnosis of self-harm
viii) Primary or secondary diagnosis of medically unexplained symptoms
ix)
Intellectual disability
x)
No mental health diagnosis
xi)
Open to specialist mental health services
xii) On Care Programme Approach (CPA)
xiii) Frequent attender; more than four ED visits per annum.
xiv) Black and minority ethnic communities
xv) Age
xvi) Gender
Data to be collected separately and also aggregated to give total number of people with
mental illness.
9. Location of Provider Premises (Mandatory)
What is needed to make it work well:

A suitable on-site location near to the Emergency Department.

A safe clinical and administrative space to work as detailed in PLAN.

Appropriate IT infrastructure to enable capturing and sharing of patient-specific data.

Support from hospital leadership, especially for training and awareness-raising.
More detailed guidance on the location and hosting of services can be found in document 3:
Developing Models for Liaison Psychiatry Services - Guidance.
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10. Individual Service User Placement (Non mandatory)
Highly complex situations with medical, surgical and mental health co-morbidity and legal
involvement may need management in a regional or supra-regional unit. Contract agreement
should include contingency for very expensive patients where care costs fall well outside the
average expected for the commission.
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