Service specification for dementia:
mental health liaison service for
general and community hospitals
DH INFORMATION READER BOX
Policy
HR / Workforce
Management
Planning /
Performance
Clinical
Estates
Commissioning
IM & T
Finance
Social Care / Partnership Working
Document Purpose
Best Practice Guidance
Gateway Reference
16035
Title
Dementia Commissioning Pack
Author
DH
Publication Date
21 Jul 2011
Target Audience
PCT CEs, SHA CEs, Local Authority CEs, Directors of Adult SSs, GPs
Circulation List
#VALUE!
Description
Commissioning Packs are tools to help commissioners improve the quality of
services and minimise unwarranted variation in service delivery. Each Pack
provides a tailored set of guidance, templates, tools and information to assist
commissioners in commissioning services from existing providers or for use in
new procurements.
Cross Ref
Superseded Docs
Action Required
N/A
N/A
N/A
Timing
N/A
Contact Details
Gill Ayling
Quarry House
Leeds
West Yorkshire
LS2 7UE
0113 25 46359
www.dh.gov.uk
For Recipient's Use
Dementia Commissioning Pack
Handbook
Commissioning Framework & Assessment Tool
2. Care at home / care home
3. Care in hospital
5. Patient
information
4. Cost / benefit tool
3. Specification
2. Action Plan /
Inserts
1. Case for change
1. Early diagnosis
Procurement templates and guidance
4. Antipsychotic medication
Contents
A.
B.
Key service outcomes
Purpose of the service
B1 National and local context
B2 Note for commissioners
B3 Aims and objectives
Scope
C.
C1 Patients
C2 Target groups
C3 Equity of access to services
C4 Geographical coverage/boundaries
C5 Requests for support
C6 Interdependencies with other services
C7 Location of service
C8 Days/hours of operation
Service delivery
D.
Stage 0 – Organisational and service level prerequisites
Stage 1 – Assessment and diagnosis
Stage 2 – Supporting good clinical care
Stage 3 – Discharge support
Indicators
E.
Dashboard
F.
Activity
G.
G1 Activity plan
G2 Individual patient agreements (cost per case)
Finance
H.
Annex 1: Service accountabilities
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User note
This specification has been designed to assist commissioners in the delivery of a service to support general and community
hospitals to deliver better care to people with dementia. The text within square brackets [ ] in this document should be completed
by the commissioner in order to reflect local needs and help inform responses from the Provider(s).
The specification should be read in conjunction with the ‘Action plan to improve care for people with dementia in hospital’ as the
mental health liaison service is designed to be one of the priorities in the action plan to support training and organisational
development objectives.
The specification is not mandatory and the commissioner should review the whole of the specification in order to ensure that it
meets local needs and, once agreed with the Provider, it should form part of either a renegotiated contract or the relevant section of
the NHS Standard Contract.
The Dementia Commissioning Pack should be used in conjunction with:
Call to Action:
Reducing inappropriate use of antipsychotics for people with dementia
Together with the Dementia Action Alliance, the NHS Institute for Innovation and Improvement has launched a Call to Action to
work together in a way that will unite us in our common cause to improve the quality of life of people with dementia and their carers
by reducing the inappropriate use of antipsychotics.
To find out more and access resources which will support this Call to Action please visit:
www.institute.nhs.uk/qipp/calls_to_action/dementia_and_antipsychotic_drugs or you can email C2ADementia@institute.nhs.uk
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A. Key service outcomes
Expected high-level outcomes of the service are:
No.
Outcome
1
Reduction in the average length of stay in hospital for patients with dementia
2
Reduction in the number of people with dementia discharged directly from hospital
to care homes as a new place of residence
3
Increase in the number of patients with dementia and their carers who have a
positive experience of hospital care
4
Reduction in the number of people discharged from hospital on antipsychotic
medication and increase in the number of people having a plan to review use of
antipsychotic medication post discharge
Guidance on measuring outcomes is provided in Section E.
4
Related NICE
Quality Standard
NHS Outcome
Framework
1,3,4,8
2,4
B. Purpose of the service
B.1 National and local context
Up to 70% of hospital beds are currently occupied by older people1 and up to half of these may be people with cognitive
impairment, including those with dementia and delirium.2 In too many cases, mental health needs will remain undetected and a
mental health assessment will not be made, with the result, in some cases, that appropriate treatment is not initiated.3 The National
Audit Office found that some general hospital services even worked hard not to make a diagnosis of dementia for fear it would
delay discharge.4 Failure to diagnose dementia is an independent predictor of a poor outcome for the patient and for the service.
People with dementia often have complex problems and may stay in hospital for longer than other people who go in for the same
condition. There is often a lack of co-ordination between the hospital and care providers at the point of discharge. The longer length
of stay may worsen symptoms of dementia and be detrimental to the individual’s well-being. Discharge to a long-term residential
care home becomes more likely and antipsychotic drugs are more likely to be prescribed.5 Although there are examples of good
quality general hospital care, where the challenges of dementia are recognised and addressed, there are also widely reported
cases of substandard or neglectful care.6
1
Audit Commission (2006), Living Well in Later Life: A review of progress against the National Service Framework for Older People.
2
Royal College of Psychiatrists (2005), Who Cares Wins: Improving the outcome for older people admitted to the general hospital.
3
Arden M et al, Cognitive impairment in the elderly medically ill: how often is it missed? International Journal of Geriatric Psychiatry, 1993; 8: 929–937.
4
National Audit Office (2007), Improving services and support for people with dementia. London: TSO.
5
Alzheimer’s Society (2009), Counting the Cost: Caring for people with dementia on hospital wards. London: Alzheimer’s Society.
6
Age Concern (2006), Hungry to be Heard. London: Age Concern.
5
Better management of mental health problems has major implications for the quality of care of people, the efficiency of general and
community hospitals and the efficient utilisation of health and social care resources. When established, specifically commissioned
services to improve the care of older people with mental health problems in hospital not only improve the quality of care but also
have the potential to release savings:7
 A hospital mental health liaison service for older people in Leeds contributed to a reduction in hospital length of stay of four
days per admission for people with dementia.
 The National Audit Office estimates the excess cost of inappropriate care in an average general hospital to be around £6 million
per year.
The National Dementia Strategy (2009) states improved care in general hospitals as one of its objectives8 and specialist liaison
services are advocated both in the National Dementia Strategy and in the National Institute for Health and clinical Excellence
(NICE)/Social Care Institute for Excellence (SCIE) guideline on dementia.9
The service to be commissioned in this specification is a service to support general and community hospitals to deliver better care
for people with dementia and will:
 support and advise on making the diagnosis of dementia and other mental health conditions. This includes providing a second
opinion in cases of diagnostic doubt
 support and advise on management and care planning, including discharge planning for people with confirmed or suspected
mental health problems. This includes requests for urgent attention or response to patient behavioural management difficulties
to support hospital clinicians and provide a link to community services, including specialist dementia services where appropriate
 contribute to mental health education and training for hospital staff
7
National Audit Office (2007), Improving services and support for people with dementia. London: TSO.
8
Department of Health (2009), Living well with dementia: A National Dementia Strategy. London: TSO.
9
National Institute for Health and Clinical Excellence/Social Care Institute for Excellence (2006), Dementia: Supporting people with dementia and their carers
in health and Social Care.
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 contribute to the governance, audit and development of policies and procedures for good quality mental health care.
Local context
[The commissioner should insert relevant information on local factors that influence the way the Provider delivers the service, e.g.
issues linked with:
 Joint Strategic Needs Assessments (JSNA), Health and Well-being Boards’ Strategic Plans
 demographics
 epidemiology
 the organisations commissioning the services – and any other existing services.]
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B.2 Note for commissioners
The aim of the mental health liaison service is to provide expert mental health skills to support good quality care of patients in parts
of the hospital where these skills are not already available. The responsibility for providing good quality care remains with ward
staff. In some parts of the hospital, where good skills already exist, input may be low, be mainly advisory in nature and relate to
more complex cases only. Where mental health skills do not exist in sufficient quantity, part of the initial function of the service may
be to provide more direct support to ward staff where required and to help establish procedures, protocols, governance and audit
arrangements for good quality mental health care. The service will contribute to training and education to meet skills gaps in
provision so that staff become competent to deal with routine cases.
As a result of these interventions, over time the nature of the support service may change to become increasingly an advisory
service for more complex mental health cases. This is shown in the diagram below:
Higher level of service maturity and
mental health skills
Commencement of service
Low level of service maturity and
mental health skills
Time
More routine liaison work
More complex liaison work
Assessment and diagnosis
Management and care planning
Discharge support
Intervention is characterised more in terms
of direct support and modelling of good
care for ward staff
Support service is characterised much more
as an advisory service for more complex cases
as protocols are embedded and ward staff
become competent to handle routine cases
Contribute to training and education and protocols, governance and audit
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B.3 Aims and objectives
The aim of the mental health liaison service is to advise on the diagnosis of people with suspected organic and functional mental
health problems and to provide expert advice and support on the delivery of good clinical care, care planning and discharge
planning, as required. The service shall develop the competencies of existing staff to deliver good quality mental health care and
care of people with dementia and shall assist in putting in place procedures, protocols, governance and audit arrangements to
support the delivery of good mental health care and the care of people with dementia. In so doing, the service shall support the
efficient use of existing resources to improve standards of care.
The objectives of the service are:
Support and advice on assessment and diagnosis
 To advise and support high-quality accurate diagnosis of dementia and other mental health problems. This may mean providing
advice or support in more complex cases or more routine cases as required.
Support and advice on care planning, optimum care and response to behaviours that challenge
 To provide timely advice and support to staff to manage behaviours that challenge during the designated hours of the service
as requested, and only after ward staff have followed the local protocol as appropriate and in line with NICE Clinical Guideline
103 (delirium). This includes providing urgent response advice to emergency departments and acute medical admissions units
on cases where non-hospital management options might be possible.
 To provide advice on care planning and delivery of optimum care and to advise ward staff, patients and carers in making
decisions about timely discharge and appropriate place of discharge, resulting in fewer people waiting for community discharge
plans to be put in place or waiting for residential or care-home placements. This includes advice on options for support in the
community, intermediate care, reablement and referral to local dementia services in order to promote early discharge
opportunities.
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Advice on other available specialist support
 To provide links and sharing of information with other resources that can support independent living and well-being for patients
with mental health needs and their carers, including GPs, community mental health services, specialist dementia services,
social care, intermediate care and memory services.
Contribute to training and organisational development
 To provide knowledge transfer to ward staff, improving their competences and confidence in dealing with patients with organic
and functional mental health needs with the result that the patients’ symptoms are less likely to deteriorate and become
problematic.
 Where a protocol for the management of behaviours that challenge or a capacity framework do not exist, or are not being
followed, to help ward staff to develop and implement them and to contribute to putting in place governance and audit
arrangements.
 To support education and training on good clinical care for patients with mental health problems, particularly dementia, in order
to promote a dignified and person-centred experience for the individual and their carer, which minimises distress and ensures
that the patient is discharged without losing more functionality.
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C. Scope
C.1 Patients
The mental health liaison service is designed for patients with symptoms of organic and functional mental health problems.
The heterogeneity of symptoms prior to diagnosis will mean that the service shall provide advice and support for patients with a
range of mental health needs including depression, delirium and/or dementia. The service shall also be accessible to people with
learning disabilities.
The majority of patients who are in contact with the mental health liaison service will be elderly and a significant proportion of these
will have dementia or some other cognitive impairment. A Provider shall ensure that sufficient resources and skills are in place to
meet the specific needs of this target group.
C.2 Target groups
It is not the role of the support service to carry out the functions of ward staff; the role of the service is to provide additional support
and advice on diagnosis, care planning, good clinical care and discharge support. This means, for example, that ward staff should
follow established pathways or protocols that relate to good mental health care prior to contacting the support service.
C.3 Equity of access to services
[Describe the Provider’s required policy and practices for ensuring that its services are accessible to all, regardless of age,
disability, gender reassignment, pregnancy and maternity, race, religion or belief, sex or sexual orientation, and deal sensitively
with all service users and potential service users and their family/friends and advocates. Explain policies and practices to actively
engage with, and provide culturally sensitive services to, minority groups in the population served]
C.4 Geographical coverage/boundaries
[Include details of any required geographic coverage/boundaries or geographical restrictions.]
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C.5 Requests for support
The Provider shall accept requests from all parts of the hospital
C.6 Interdependencies with other services
[Describe any relationships between the service and other Providers of health, social care and other services in which a
relationship of ‘dependency’ exists. The commissioner should consider any other existing relevant services, which may include, for
example: existing support arrangements in A&E; on-call arrangements for out of hours services; services for adults; services for
people with learning disabilities; and intermediate care services. The commissioner should discuss governance arrangements for
the support service with the Provider, including the inter-relationship with the management of the NHS trust and reporting
requirements.]
C.7 Location of service
[The service should be located in the general hospital with the greatest need – where a commissioner would like alternative
arrangements, they should describe them here.]
C.8 Days/hours of operation
[Include full details of times at which the Provider offers services.]
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D. Service delivery
The following diagram sets out a pathway for a mental health liaison service. It shows four stages in the pathway and certain
elements may take place in parallel rather than in series. Not all patients will require all components of the service (1–3). Stages 1
to 3 reflect the delivery of the commissioned service. Stage 0 is included in the service specification to confirm the obligations to be
placed on the Stage 0 Provider by the commissioner. This is important because Stage 0 reflects the prerequisites that should be in
place for Stages 1 to 3 to be effective.
The Provider shall contribute to establishing procedures, protocols, governance and audit arrangements and education and training
where needed in order to support good quality mental health liaison services and promote the efficient use of existing resources –
although overall responsibility for this remains with the hospital NHS trust.
A high-level service description is set out below.
Service level
1
Advice on
assessment and
diagnosis
Patient
presentation
0
Confirm patient
eligibility & contact
support service
2
Advice on good
clinical care
3
Patient discharged
Advice on
discharge
Provider identifying and contacting wards where advice / support / training may be required
Organisational level
Assistance in establishing procedures, protocols, governance and audit arrangements
Assistance in delivering education and training to support good quality mental health care
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Stage 0 – Organisational and service level prerequisites
Service level prerequisites
Patient
0.1
Confirm patient
eligibility
0.2
0.3
Contact the
support service
Share
information about
the service
Patient presents at
hospital
Provider identifying and contacting wards where advice / support / training may be required
Organisational level prerequisites
Assistance in establishing procedures, protocols, governance and audit arrangements
Assistance in delivering education and training to support good quality mental health care
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Request for
advice or
support from
support service
Overview
Stage 0 describes the prerequisites that should be in place for the mental health liaison service to be effective. Prerequisites need to be in
place at an organisational level and a service level.
Organisational level
In order to use mental health liaison service resources efficiently and to improve capability of staff across the hospital, the NHS trust shall be
responsible for putting in place procedures, protocols, governance and audit arrangements at ward level to support the delivery of good quality
mental health care. The NHS trust shall also have responsibility for developing and delivering staff education and training to meet the mental
health needs of patients. The mental health liaison service shall assist in the development and delivery of these objectives but shall not be
responsible for them.
Service level
Support or advice may be requested from health professionals in relation to:
 assessment and diagnosis of a suspected mental health problem
 good health and social care for patients with a mental health problem, including care planning or discharge planning. This may include
urgent response or advice on managing behaviours that challenge
Staff should follow appropriate mental health procedures or protocols, prior to contacting the support service. Although the service is primarily
request led, the Provider shall also have responsibility for identifying and contacting parts of the hospital where advice and support may be
needed and also have responsibility for identifying training requirements and escalating issues to the Executive Board where performance fails
to improve within a reasonable time period.
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Indicators
Outcomes
There is no specific indicator for Stage 0
This stage contributes to:
Outcomes 1 – 4
The text below describes the infrastructure that needs to be in place at an organisational level in order to help ensure that a mental
health liaison service is effective:
Establishing procedures, protocols, governance and audit arrangements
The NHS trust shall ensure that procedures, protocols, governance and audit arrangements are put in place across the hospital to
enable staff to respond more effectively to patients with mental health problems and to help ensure that resources from the mental
health liaison service are used efficiently.
Where procedures and protocols do not already exist, the Provider shall assist in establishing them to support the delivery of good
quality mental health care. These procedures and protocols shall include, but not be limited to:





managing behaviour that challenges, in line with NICE guidelines on delirium and dementia
assessing capacity within the Mental Capacity Act (2005)
deprivation of liberty safeguards
dementia-friendly care pathways
appropriate use of antipsychotic medication for people with dementia.
The Provider shall support the development of governance arrangements for the implementation and review of these procedures
and shall support the implementation of audit arrangements in relation to the Royal College of Psychiatrists National Audit of
Dementia Care (core audit and the enhanced audit).
Although the mental health liaison service shall support the development and implementation of these actions, the overall
responsibility for delivery remains with the Trust.
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Education and training to support good quality mental health care
The scale of resources available in the mental health liaison service and the scale and profile of the training challenge will mean
that the Provider cannot be responsible for the delivery of all education and training to support good quality mental health care. The
Trust shall be responsible for ensuring that a strategy is in place, together with sufficient resources and management supervision to
deliver education and training, and the Provider shall assist in training and education as required, in relation to:
 establishing protocols and procedures for good mental health care
 training and education requirements arising from routine support requests from hospital wards or as a result of feedback
from the National Audit of Dementia, other surveys or from patients and carers.
Education and support should enable ward staff to handle the vast majority of routine issues relating to mental health care and over
time the mental health liaison service should provide an advisory service rather than direct support.
[The commissioner should note that dementia training for hospital staff may be delivered through the ‘Action plan for improved care
in hospital’ which should be considered with this specification.]
The text below describes the process that needs to be in place at a service level to help ensure that the support service is effective:
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0.1 Confirm patient eligibility
Hospital staff shall consider contacting the mental health liaison service for any adult where there is uncertainty about diagnosis or
treatment for a mental health problem, including dementia.
Because of the complexity and heterogeneity of symptoms, it is not possible to provide an exhaustive list of eligibility criteria.
Instead, the request for advice or support is a clinical decision based on the possibility or knowledge that the individual has
dementia or other mental health problems and expert mental health support or advice is required. This will be on the basis of
presenting symptoms, a review of past history or collateral history from an informant.
A request to the support service may relate to:
 a request for advice or support for assessment and formal diagnosis where there is uncertainty of diagnosis
 a request for advice in relation to care planning or addressing care needs or discharge planning advice where the patient has a
diagnosed or suspected mental health problem and where staff are uncertain about the best treatment. This may include
requests for urgent support or response to managing patients’ behaviours that challenge.
Hospital staff shall identify patients that meet the criteria for advice or support from the mental health liaison service. Eligible
patients are those who meet the general criteria set out below. Hospital staff may contact the mental health liaison service by
telephone to check whether further advice or support is required.
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Inclusion criteria
 The patient is presenting with symptoms of suspected mental health needs and advice on diagnosis is required.
 The patient has a diagnosis of mental health need and advice is required in relation to care planning, meeting good clinical care
standards or discharge planning.
 Urgent support or response to patient behavioural management difficulties is required in cases with a known or suspected
mental health need.
Exclusion criteria
 It is not the role of the mental health liaison service to carry out the functions of ward staff nor to duplicate existing skilled
provision; the role of the mental health liaison service is to provide advice and support on diagnosis, care planning, good clinical
care and discharge planning. This means, for example, that ward staff should follow established protocols or procedures
relating to mental health care prior to contacting the support service.
0.2 Contact the support service
Hospital-based health professionals shall make contact with the service by secure email, telephone, fax or IT system, following
standard arrangements that are in place in the hospital.
The Provider shall respond within [one] working day of the request being made. Where a request is made for urgent attention, the
Provider shall prioritise this request and respond within [one] hour.
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0.3 Share information about the service
Hospital-based health professionals shall, where relevant and where possible:
 provide information to the patient and carer about the service
 advise the patient that the support service may need to speak to the patient and another point of contact (e.g. family carer,
person who resides with the patient or another person who has frequent contact with the patient)
 ask permission from the patient to speak to another point of contact. If the patient lacks capacity, contact a family carer or other
appropriate person in line with the requirements of the Mental Capacity Act (2005).
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Stage 1 – Assessment and diagnosis
Advice and/or support
1.3
History taking
Patient
Patient
continues to
assessment
1.1
Receive request
and confirm
eligible patients
1.2
Initial review of
presenting
symptoms
1.4
1.7
1.6
Cognitive &
mental state
examination
1.5
Other
appropriate
investigations
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Make the
diagnosis
Communicate
the diagnosis
Advise on
good clinical
care [2]
Overview
At this stage, the Provider shall deliver advice to ward staff on assessment, diagnosis and/or sharing the diagnosis. For more complex cases,
or cases where there is uncertainty, the Provider upon request shall provide direct support in undertaking assessment, diagnosis and/or sharing
the diagnosis.
Where the initial indicators are those of delirium or other mental health need, the Provider shall follow the relevant NICE guidelines on
assessment, diagnosis and treatment. The Provider shall:
 provide advice or support for more complex cases where there is diagnostic uncertainty or provide advice where a second opinion is
requested.
A diagnosis of dementia shall only be made after a comprehensive assessment by a suitably qualified professional, including, where
appropriate (NICE/SCIE Clinical Guideline 42):
 history taking
 cognitive and mental state examination
 physical examination as needed and other appropriate investigations
 a review of medication.
As required, the Provider shall see the patient within [one] working day of receiving the request and shall complete the diagnosis within [five]
working days.
Indicators
Outcomes
Indicator 1
This stage contributes to:
There will be a reduction in average length of stay in hospital for
people with dementia of [x] days
Outcome 1. There will be a reduction in average length of stay in
hospital for people with dementia
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1.1 Receive request and confirm eligible patients
The Provider shall check the request and confirm eligible patients within [one] working day of receiving it and shall confirm a date
and time to provide advice or support.
The Provider shall respond to all requests relating to adults with suspected mental health problems.
The Provider shall accept or reject the request for advice or support based on a telephone query or based on information provided
in the hospital’s standard service request arrangements.
In some instances, advice may be provided by telephone.
1.2 Initial review of presenting symptoms
The Provider shall provide advice or support on the initial review of presenting symptoms. Advice or support on the initial review
shall be by a suitably qualified and trained professional who is able to determine whether presenting symptoms or indicators are
likely to be those of dementia or another mental health problem such as delirium. Where the presenting symptoms or indicators are
those of another mental health need other than dementia, the Provider shall follow the appropriate NICE guidelines on assessment,
diagnosis and treatment.
Where dementia is suspected and where further advice or support is requested, the Provider shall follow the process and timelines
set out below. If the initial review indicates that an assessment should take place in the community, this recommendation shall be
made to the patient’s GP. This action may be appropriate in instances where the patient is likely to be discharged before the
diagnosis is complete or where there are other complicating factors, such as delirium, that mean a diagnosis is not likely to be
possible until a later follow-up meeting. The numbers of recommendations to GPs for community assessments shall be recorded
and shared with the commissioner.
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1.3 History taking
At the date and time agreed with the person who has made the request, the Provider shall advise on or undertake the assessment
with the patient. History taking shall be undertaken by a suitably qualified and trained professional and shall include, but shall not
be limited to:
 a subjective and objective assessment of patient’s life, social, family and carer history, circumstances and preferences, as well
as their physical and mental health needs and current level of functioning and abilities, including an interview with an informant
to generate a collateral history
 assessment of history and impacts of impairments of vision, hearing and mobility
 assessment of history and impacts of impairments of medical co-morbidities
 assessment of key psychiatric and behavioural features, including depression, wandering and psychosis
 risk assessment covering all areas appropriate to the individual, e.g. falls, risk to self, childcare or carer responsibilities, driving,
and financial and legal issues
 carer assessment including stress, health and function.
In undertaking the assessment, specialist input may be required from geriatricians or specialists in stroke or falls, or a wide range
of other disciplines including specialist nurses, therapists, pharmacists and social workers. Appropriate quality assurance shall be
in place, including appropriate supervision and quality control.
The Provider shall note NICE/SCIE Clinical Guideline 42 and confirm whether the patient wishes to know the outcome of the
diagnosis and with whom the diagnosis should be shared. The Provider shall also explain the process and timelines for making
and communicating the diagnosis.
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1.4 Cognitive and mental state examination
The Provider shall advise on or undertake a cognitive and mental state examination. The cognitive and mental state examination
shall be undertaken by a professional with specialist expertise in diagnosis and sub-typing and shall include an examination of
attention and concentration, orientation, short and long-term memory, praxis, language and executive function.
The Provider shall be qualified to undertake and interpret formal detailed cognitive testing using standardised instruments.
However, in undertaking these tests, the Provider shall also have experience of taking in to account other factors known to affect
performance (educational level, skills, prior level of functioning and attainment, language and any sensory impairments, psychiatric
illness or physical/neurological problems).
1.5 Other appropriate investigations
The Provider may need to advise on or arrange further investigations to inform diagnosis or sub-typing and these shall include, but
not be limited to:
 review of medication in order to identify and minimise the use of drugs that may adversely affect cognitive functioning. This
should be a shared responsibility with physicians
 ECG/EEG
 structural imaging (magnetic resonance imaging, MRI or computer tomography)
 formal neuropsychological testing where appropriate
 other investigations as appropriate.
Where there is a high likelihood that the patient will be discharged before investigations are complete, the Provider shall inform the
patient and, if appropriate, the carer that the patient’s GP will contact them to let them know the outcome of the investigations. The
Provider shall forward results from investigations to the patient’s GP, together with recommendations for future care.
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1.6 Make the diagnosis
A diagnosis of dementia and its sub-type shall be made by health care professionals with expertise in differential diagnosis of
dementia using international standardised criteria in line with NICE/SCIE Clinical Guideline 42.
1.7 Communicate the diagnosis
Wherever possible, the Provider shall contact the carer within [two] working days of the diagnosis having been made in order to
organise a time to communicate the diagnosis to the patient and the carer together, although in some instances the diagnosis may
need to be shared separately with a carer, for example by telephone.
The Provider shall note the importance of a carer being present wherever possible to provide support to the patient when the
diagnosis is communicated. The Provider shall follow NICE/SCIE guidelines on sharing information with patients and their families.
The Provider shall also ensure that relevant hospital health care professionals are informed of the diagnosis before it is shared with
the patient or carer because this should inform their care planning and discharge planning.
Where the patient has been discharged before the Provider is able to share the outcome of the diagnosis, the Provider shall contact
the patient’s GP to request that they contact the patient and carer to communicate the diagnosis in person. The GP may choose to
make a referral to the memory service or community mental health team to provide specialist advice and support.
The Provider shall share the diagnosis with the patient’s GP and where appropriate provide recommendations on further means of
support, such as the memory service, mental health services or specialist dementia services.
The Provider shall communicate the diagnosis to the patient and carer in simple, direct language avoiding use of medical jargon
and shall communicate in a warm, caring and respectful manner. Diagnoses and actions fall in to five categories:
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Diagnosis
Action
1. No organic or functional mental
health problem
Communicated to requesting clinician and GP
2. Other mental illness (including
depression or delirium)
Advice communicated to requesting clinician including the initiation of urgent treatment or
referral to other services – GP informed
3. Dementia (no medication)
Talk through support available via local support organisations or via the community mental
health team if needed – GP informed
4. Dementia (medication)
Talk through available medication and support available via local support organisations and
arrange follow-up by community mental health team if needed – GP informed
5. Possible dementia
Communicated to requesting clinician and GP with advice to refer to memory service, if
available, if symptoms persist or increase
1. No organic or functional mental health problem
Where the diagnosis is one of no organic or functional mental health problem, the patient and the requesting clinician shall be
notified of this outcome and this information shall be shared with the patient’s GP.
2. Other mental illness (including depression or delirium)
The Provider shall share the diagnosis with the patient and requesting clinician and where appropriate the Provider shall advise on
the initiation of urgent treatment or referral for physical or mental disorder if required. The Provider shall give the requesting
clinician advice on further treatment needed and shall share this information with the patient’s GP.
27
3. Dementia (no medication)
The Provider shall inform the requesting clinician and give a clear and full explanation to the patient and carer of:
1. The diagnosis
2. The prognosis
3. The treatment plan/next steps.
The Provider shall address any initial concerns or requests for information from the patient or the carer. The diagnosis shall be
shared with the patient’s GP.
4. Dementia (medication)
Where medication is indicated, the Provider shall follow the same process as that outlined above, but shall discuss medication as
part of the treatment plan.
5. Possible dementia
Where the diagnosis is unclear, the Provider shall share the information with the requesting clinician, the patient and the patient’s
GP. The patient shall be discharged to their GP who shall be encouraged to refer the patient to the memory service, if available, if
the clinical picture changes or if the recommendation is that issues relating to delirium are complicating a possible diagnosis of
dementia.
[The commissioner should note the importance of a protocol being in place with GPs to ensure that communication of diagnosis
takes place, when required.]
28
Stage 2 – Supporting good clinical care
Advice on optimum clinical care (2.1)
Advice on care
planning
Check medication
& use of
psychotropic
medication
Urgent response &
support for patient
behavioural
management
difficulties
29
Advice on capacity
decisions and
Mental Capacity
Act
Overview
The Provider shall provide timely support and advice to requesting clinicians to help deliver good clinical care of patients with dementia and
other mental health needs where there is uncertainty around the optimum treatment. This advice shall include, but not be limited to:
 care planning
 checking medication and advising on appropriate use and the use of alternatives to prescribing antipsychotic drugs
 urgent response and support for patients presenting with behaviours that challenge
 advice on capacity decisions and the Mental Capacity Act (2005).
In most instances, the Provider shall have an advisory role; however, in some cases (e.g. in relation to urgent response) the Provider may
provide more direct support to ward staff, if required.
Indicators
Outcomes
This stage contributes to indicators 1–4
This stage contributes to:
Outcomes 1–4
2.1 Advice on optimum clinical care
One of the roles of the mental health liaison service is to build skills in other health care professionals and improve the standard of
care for people with mental health problems and their carers. The service shall respond to requests for advice and support within
[one] working day of the request being made and in some cases advice may be given over the telephone. Where urgent attention is
requested, the Provider shall respond as soon as possible and within [one] hour.
The Provider shall model good clinical care that is patient focused and ensures positive patient experience, including promoting
dignity and privacy. The Provider shall comply with good practice from available evidence and policy, including:
30
 NICE Clinical Guidelines for dementia/depression/delirium
 Living Well with Dementia: A National Dementia Strategy (Department of Health, 2009)
 Who Cares Wins: Improving the outcome for older people admitted to the general hospital (Royal College of Psychiatrists,
2005)
 The Use of Antipsychotic Medication for People with Dementia: Time for action (Banerjee S, 2009)
 National Service Framework for Older People (Department of Health, 2001)
 Discharge workbook Ready to go? (Department of Health, 2011).
Health professionals may seek advice and support from the Provider in relation to:
Care planning
The Provider shall provide advice on care planning to ensure that mental health needs of patients are addressed and to ensure that
outcomes of assessments are incorporated into care plans. The Provider shall be available to advise on optimum patient care as it
pertains to mental health and shall provide care plans to address and help manage issues that shall include but not be limited to:
 inappropriate behaviour
 low mood
 self-harm
 psychosis.
31
Checking medication and advising on appropriate use of psychotropic medication in discussion with physicians
Older people are particularly susceptible to the effects of combinations of medication. The Provider shall be available to check
medications and their combinations and to provide advice on the possible effects, prior to initiation. This includes all psychotropic
medications (antipsychotic, anti-depressant and mood stabilisers).
In cases of poor reaction or lack of efficacy, the Provider shall provide recommendations regarding changes to medication
prescribed for a mental health need, if safe to do so, and advise on alternative strategies as appropriate.
The Provider shall give advice on the initiation, maintenance and cessation of psychotropic medication, in line with NICE guidelines.
This shall include advice as to whether usage should be reviewed, reduced or stopped post discharge. The Provider shall ensure
that the patient’s GP is informed of any decisions made and shall advise the patient’s GP about any review of medication, post
discharge, where appropriate.
Urgent response and support for patients presenting with behaviours that challenge
The Provider shall offer advice and support to staff to help manage behaviours that are ‘out of character’ or behaviours that
challenge and which may relate to symptoms of a mental health problem. Ward staff are expected to follow local protocols for deescalation in line with NICE guidelines for dementia and delirium, prior to calling the mental health liaison service.
The Provider shall respond to requests from hospital staff and offer advice and support as appropriate, in line with NICE guidelines
for dementia and delirium.
The Provider shall prioritise these requests for support and shall respond within [one] hour.
32
Advise on capacity decisions and the Mental Capacity Act (2005)
The Provider shall give advice on capacity decisions and compliance with the Mental Capacity Act, where required. Where
appropriate the Provider shall reinforce the message that a diagnosis of dementia does not mean that a patient does not have
capacity. In most instances, ward staff should be competent to make capacity decisions and shall follow their own framework to
assess capacity before contacting the mental health liaison service. However, help and advice may be sought from the Provider,
where:
 the level of capacity is genuinely unclear, or
 a significant decision is to be made (e.g. a change in relation to the place of residence).
Where the decision is likely to be in relation to a new place of residence, the Provider shall engage with health professionals,
patient and carers in a timely manner in order to try and ensure that discharge is not unduly delayed.
In most instances, ward staff should be able to make ‘best interest decisions’ on behalf of the patient and shall only seek advice
from the mental health liaison service for more complex cases where there is doubt and as required, for example in relation to:
 risk issues
 safeguarding issues.
Where requested to do so by a patient or carer, family member or health or mental health professional, the mental health liaison
service shall provide advice on sources of independent advocacy support.
The Provider shall assist the Trust to develop, implement and review protocols for Deprivation of Liberty Safeguards.
33
Stage 3 – Discharge support
3.1
Review
information
3.3
3.2
Advise patient &
carer(s)
Request for
advice or
support
34
Advise health
and social care
professionals
Patient discharged
3.4
Contact patient’s
GP
Overview
Planning for discharge should start as early as possible and the Provider shall reinforce this message as part of their contact with health care
professionals. This is particularly important for patients with dementia and other mental health problems. The Provider shall provide advice on
effective discharge arrangements to patients, carers and health and social care professionals on a request basis. The Provider shall promote
Department of Health guidance on discharge: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate
care (Department of Health, 2010).
Discharge planning remains the responsibility of the ward staff and adult social care and the mental health liaison service shall advise and
contribute to discharge planning as necessary and appropriate.
Indicators
Outcomes
Indicator 2
This stage will contribute to:
There will be [x] fewer people discharged directly to a care home
as a new place of residence
Outcome 2. There will be a reduction in the number of people
with dementia discharged directly from hospital to care homes as
a new place of residence
Indicator 4
There will be [x%] of people who are on antipsychotic medication
at point of discharge who have a plan to review use post
discharge
Outcome 4. There will be an increase in the number of people
having a plan to review the use of antipsychotic medication post
discharge
Page 35
3.1 Review information
Discharge planning and support should start as early as possible in the hospital stay. In order to advise on discharge planning, the
Provider shall review all relevant information relating to each patient’s (and carer‘s) needs and preferences. The Provider shall
review the most recent patient notes and shall consult with hospital professionals for their views and also with patients and carers
to understand their needs and preferences. The Provider may also contact community mental services or social services if
required.
3.2 Advise patient and carer(s)
The Provider shall consult with the patient and carer(s) to ascertain their needs and preferences and shall provide advice to ensure
that decisions comply with the Mental Capacity Act (2005). The Provider shall share information that gives the patient and their
family an accurate overview of strengths, needs and relative risks, promoting independence and choice. Patients and carers shall
be assisted to achieve a timely discharge back to familiar surroundings wherever possible.
3.3 Advise health and social care professionals
The Provider shall provide advice from a mental health perspective regarding the recommended place of discharge. Advice shall
enable health and social care professionals to take risks and manage risk as appropriate in relation to where the patient should be
discharged to and shall provide information about relevant services to facilitate timely discharge. This may include, but shall not be
limited to services provided in:
 social care, community support, housing, primary care
 intermediate care
 reablement
 step-down care.
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The Provider shall reinforce the message that intermediate care or rehabilitation pathways are appropriate for and should be
accessible to people with dementia and shall always be considered where the patient is at risk of admission to long-term residential
care.
3.4 Contact GP
The Provider shall ensure that a letter summarising the main points of the care plan, together with a copy of care plan, is provided
to the patient’s GP and, if appropriate, that the care plan is copied to other relevant mental health services.
Page 37
E. Indicators
When reporting progress against outcomes, the commissioner may wish to consider the measures and indicators set out below:
Outcome
There will be a
reduction in
average length of
stay in hospital for
patients with
dementia
There will be a
reduction in the
number of people
with dementia
discharged
directly from
hospital to care
homes as a new
place of
residence11
Expected
outcomes
Yr 1 Yr 2
Yr 3
TBA
TBA
TBA
TBA
TBA
TBA
Indicator
description
Indicator
threshold
Measurement
Remedy
Annual average
length of stay in
hospital for patients
with dementia
compared with
annual average in
baseline year
[TBA]10
(x) average length of stay in hospital for
patients with dementia in operational year
Conversation at quarterly review
Annual number of
people discharged
directly from hospital
to care homes as a
new place of
residence compared
with baseline year
[TBA]12
(y) average length of stay in hospital for
patients with dementia in baseline year
[Commissioners to insert any bespoke
consequences to apply in accordance with
Clause 31.6 of the NHS Standard Contracts.]
(x) – (y) = change in average length of stay
in hospital for patients with dementia
(x) number of people discharged directly to
care home as a new place of residence in
operational year
(y) number of people discharged directly to
care home as a new place of residence in
baseline year
(x) – (y) = change in number of people
discharged directly to care home as a new
place of residence
10
Indicator thresholds should be set annually at the expected outcome target.
11
Commissioners should note issues around data availability and consider how these may be overcome.
12
Commissioners will need to determine a baseline position prior to agreeing expected outcome measures.
Page 38
Conversation at quarterly review
[Commissioners to insert any bespoke
consequences to apply in accordance with
Clause 31.6 of the NHS Standard Contracts.]
Outcome
There will be an
increase in the
number of patients
with dementia and
their carers who
have a positive
experience of
hospital care
Increase in the
number of people
having a plan to
review use of
antipsychotic
medication post
discharge
13
Expected
outcomes
Yr 1 Yr 2
Yr 3
TBA
[85%]
100%
TBA
100%
100%
Indicator
description
Indicator
threshold
Measurement
Remedy
Percentage of
patients and carers
surveyed satisfied
with the service
(based on >50% of
people who have had
contact with the
support service
returning the survey)
[85%]13
(x) Number of surveys with satisfactory score
Conversation at quarterly review
Percentage of people
who are seen by the
service and who are
on antipsychotic
medication at point of
discharge who have
a plan to review use
post discharge
(y) Total number of surveys received
[x/y] x 100 = percentage of patients and
carers who are satisfied with the service
[100%]
Number of people seen by the support
service who are on antipsychotic medication
at point of discharge and who have in place
a plan to review use post discharge.
Indicator thresholds should be set annually at the expected outcome target.
Page 39
[Commissioners to insert any bespoke
consequences to apply in accordance with
Clause 31.6 of the NHS Standard Contracts]
Conversation at quarterly review
[Commissioners to insert any bespoke
consequences to apply in accordance with
Clause 31.6 of the NHS Standard Contracts]
F. Dashboard
The Provider shall report performance using the dashboard template below:
Proforma mental health liaison service dashboard report
Activity by ward
Financials
Liaison service
originated
contacts
Savings: Year to date
16
1010
1000
990
980
970
960
950
940
930
920
14
12
£000s
Requests made
in month
£000s
Spend:Year to date
Ward
10
8
6
4
2
0
Budget
Actual
Budget
Spend: Current month
£000s
Ward B
Ward C
510
500
490
480
470
460
450
440
430
420
£000s
Ward A
Budget
Performance
Outcome
Reduction in average length of stay in hospital
for people with dementia
Month
X
Actual
Savings: Current month
Actual
9
8
7
6
5
4
3
2
1
0
Budget
Actual
Provider analysis
Yr to
date
Provide a description of the key performance issues for
the provider. Where possible this information should be
benchmarked. Where relevant, outline contractual levers
being used, e.g. withholding monies
Reduction in number of people with dementia
discharged directly from hospital to care homes
as a new place of residence
Increase in the number of patients with
dementia and their carers who have a positive
experience of hospital care
Reduction in the number of people discharged
from hospital on antipsychotic medication and
increase in number of people with a plan for
review post discharge
Patient complaints:
The commissioner should agree these information requirements with the Provider and these should be inserted into the NHS
Standard Contract.
Page 40
G. Activity
G.1 Activity plan
Item
Activity for period
Assessment and diagnosis (contact)
Assessment and diagnosis (advice only, no contact with patient)
Management and care planning (contact)
Management and care planning (advice only, no contact with patient)
Discharge support (contact)
Discharge support (advice only, no contact with patient)
TOTAL
G.2 Individual patient agreements (cost per case)
Page 41
H. Finance
Annual contract value
Service
Basis of contract
Currency
Price
Cost per case
Total
Page 42
Thresholds
Total annual
expected cost (£)
Annex 1: Service accountabilities
[The service accountabilities of the hospital trust, the Provider and the commissioner are summarised below. Any changes to these
assumptions will need to be reflected in the specification.]
Trust
Governance and reporting
Responsible for establishing scope and boundaries with other services and putting in
place protocols to manage service requests (for example between the mental health
liaison service and any working-age service)
Responsible for establishing management and reporting arrangements between the
support service and the Trust.
Procedures and protocols
Responsible for establishing and implementing procedures and protocols at ward level
to improve mental health care. These procedures and protocols should support good
quality care, but also help ensure that efficient use is made of the resources available in
the mental health liaison service
The mental health liaison service can provide support for this but cannot be responsible
for it
Training and organisational development
Responsible for the delivery of training to meet mental health needs and for promoting
awareness and profile across the hospital
The mental health liaison service can provide support for this but cannot be responsible
for it
Accommodation and infrastructure
Responsible for providing accommodation within the hospital and access to required IT
infrastructure
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Provider
Identifying need and support
The service is based on requests for advice and support; however, the Provider also
has the responsibility for identifying areas of the hospital where advice and support may
be required. It is responsible for identifying training requirements and, where service
remains unsatisfactory for a short period of time, for escalating issues to the
management of the Trust for resolution.
Assessment and diagnosis
Advice and support. The mental health liaison service will provide advice on any
aspect of assessment and diagnosis. Only where there is doubt about optimum clinical
care will the service provide direct support to carry out one or more functions of the
assessment and diagnosis process.
Care planning
Advice. The mental health liaison service will provide relevant care plans and will
provide advice on their implementation.
Checking medication
Advice. The mental health liaison service will provide advice on medication. This
should include contacting the patient’s GP to ensure that review arrangements are in
place for the continuing use of antipsychotic medication, post discharge, where
appropriate.
Urgent response and management
Advice and support. The mental health liaison service will provide advice in relation to
patient behavioural management difficulties and may provide direct support for cases
that require urgent response, as appropriate.
Mental Capacity Act (2005)
Advice. The mental health liaison service will provide advice on the Mental Capacity
Act (2005) for more complex cases where there is doubt about how to provide optimum
care.
Discharge support
Advice. The support service will provide advice to discharge teams and should provide
links and information about other services to facilitate timely discharge.
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Commissioner
GP protocols
For the service to be effective, the commissioner should note that protocols should be in
place with GPs regarding communicating diagnosis, where this is required, and
reviewing the use of antipsychotic medication post discharge from hospital.
Page 45