DATE: 20 May 2013
RESPONSE OF: The Royal College of Psychiatrists in Scotland
RESPONSE TO : CRII8 Liaison psychiatry for every acute hospital:
integrated mental and physical healthcare
We are pleased to respond to this consultation. This consultation was prepared
by the Royal College of Psychiatrists in Scotland. For further information please
contact: Karen Addie on 0131 220 2910 e-mail kaddie@rcpsych.ac.uk
The Royal College of Psychiatrists is the leading medical authority on mental
health in the United Kingdom and is the professional and educational
organisation for doctors specialising in psychiatry.
The College in Scotland welcomes the opportunity to comment on this report and
several Liaison psychiatrists and those from the other faculties have contributed
to this response.
The document works well as a summary of what Liaison Psychiatry has to offer
and the “key points” sections will hopefully render it accessible to the target
audience of senior managers/budget holders. However we are not assured the
report works as standard-setting document. In relation to service design and
governance it is far too prescriptive, and a high proportion of the large number
of standards appear arbitrary, unrealistic and lacking an evidence base.
Furthermore, in attempting to set clinical standards across the whole of liaison
psychiatry it is going way beyond its remit.
Perhaps Sections 1-3 which are good, helpful and well-referenced summaries
could be retained with Sections 4 & 5 repositioned as examples of good practice
rather than standards that must be met, and Section 6 could be discarded
altogether or be rewritten it as list of reputable guidelines, (perhaps offering a
brief summary of each together with a link to the original).
The foreword might wish to make more explicit reference to the different
management and commissioning arrangements in Scotland. Liaison Psychiatry
remains an issue for individual NHS Boards not clinical commissioning groups as
in England. Few NHS boards accept a college (any college) recommendations re
staffing profiles without challenge, so the fact that these are included in the
document is interesting but the recommendations cannot be seen as mandatory
At page 11 the report states that it "aims to make recommendations for services
applicable across the United Kingdom, whilst acknowledging that differences in
service funding and organisation or legal frameworks may mean some details
do not apply or require modification for individual jurisdictions."We suggest that
this sentence should appear at the very beginning, and be strengthened by
substituting the word sections for details. The differences between the NHS in
England and Scotland are much broader than matters of detail, and services are
going to diverge even more in the years ahead. RCPsychIS is happy to
contribute to discussions about which sections of the report do and do not apply
north of the border.
There are some gaps in the report including those patients who are in a number
of very specialist services in acute hospital settings but who have significant
mental health needs and require support from psychiatry and psychology. These
include patients who are having transplant surgery and gender reassignment
surgery; patients in rehabilitation with a spinal injury or loss of a limb requiring
fitting of an advanced prosthetic. Also, mental health specialists are often
required to help manage a child with a cleft lip; a facial disfigurement or indeed
any one of a wide range of metabolic disorders that leads to the child being
isolated from a peer group. In relation to children and young people this
document fails to be clear about its applicability across the age range. It would
be helpful if there were a statement early on in the paper that paediatric liaison
psychiatry has many points in common with the adult services but there is a
different history and a different service structure. Developmentally children do
not discriminate mind and body as adults do.
Thus the document has many points that are useful across the age range but
there are specific child and adolescent issues that require a further paper,
particularly the challenges posed by adolescents.
Concern has been expressed regarding the membership of the working group
that produced this report in that it consists of specialists who work in large
cities/hospitals or in specialised areas. A model adopted in such areas may not
be feasible in more rural areas which may need to have different time
commitments, skill mix and specialisation. On page 30 we note the statement:
core principles of service standards “organisational needs of the acute hospital,
such as delays to discharge, should influence response time to referrals in
addition to clinical need and risk”. This may difficult to deliver in District General
Hospitals in Scotland, particularly out of hours when there are limited medical
respources and the assessment requires a doctor’s input. Delays in transport
often contributes to delays in response time, particularly when psychiatric wards
are not located in the acute hospital and ambulances are needed to provide
transport. Also, DGHs would potentially find it hard to meet time scales specified
(page 33), especially where there is only very limited liaison input and
psychiatry is not on an acute hospital site. Page 31 specifies a “minimum of 12
hours a day on site provision for emergency departments”. It would be helpful
this could be clarified we are not sure what “on site” means? , is that located
within the emergency department or acute hospital? For a small service that
may not be feasible or desirable
Improved care for delirium is mentioned as well as provision of expertise in
complex incapacity assessments. The acute on chronic delirium patients we have
found are the ones who are catered for least well as, once the acute phase is
treated, they may have ongoing deficits needing assessed and catered for with
occupational therapy, social work and housing provision but who do not have
mental health problems requiring admission to a psychiatric bed.
We hope that the points raised here are helpful contributions to the ongoing
development of this document.