Faculty of Liaison Psychiatry – Royal College of Psychiatrists
JISC UPDATE May 2013
A lot of useful content this month – much to think about….
Child and Adolescent Mental Health Liaison services
A question was raised about hospitals’ experiences of paediatric liaison input to the
general hospital – as this seems to vary so widely.
Lucy Palmer from the Royal College told us that there had been a special interest
group for paediatric liaison and they developed some (draft) standards - see below.
1) The majority of liaison professionals are satisfied with the length of time they are
able to spend on each assessment (including face to face time, reading notes and
writing up notes)
2) The majority of young people (or carer, if present) is satisfied with the length of
time spent on the mental health assessment
3) The peer review team (or Accreditation Committee) agrees that the majority of
care plans are well constructed
Note: Care plans should:
*
Consider young person's level of functioning and communication needs;
*
Consider the young person's family and community needs and context;
*
Demonstrate that the assessor has made efforts to access past notes;
*
Include a clear formulation of diagnosis;
*
Indicate a care/discharge plan which aims to address problems and build on
the service user's (and carer's) strengths and needs
4) If the young person presents with a companion, the assessor offers them the choice
of having the companion present during the assessment .
Note: this should only happen after the assessor has spent some time alone with the
patient, to ensure that the patient can speak privately at first (if applicable). In other
cases, where the companion wishes to speak to the assessor in private, this should also
be facilitated (with the patient's permission).
Young people's and/or their parents/carers involvement with other agencies are
clearly identified during assessment
5) Assessments of individuals' ability to consent are made in accordance with the
relevant legal principles:
*
Under 16s are presumed not to be competent to make decisions about their
treatment unless they are assessed to be Gillick/Fraser competent
*
People aged 16 and over are presumed to have capacity to make decisions
about their treatment unless it is established that they lack capacity (section 1 MCA
2005)
6) All assessments relating to the young person's ability to consent are recorded in
their notes
7) Where young people are not able to give consent, their views are ascertained as far
as possible and taken into account
Note: consent from someone with parental responsibility is obtained or recorded in
accordance with the MCA 2005.
8) Staff must be clear on who holds parental responsibility (if applicable) and this
should be recorded in the case notes
We were told that Anthony Crabb has taken over as chair of the Paediatric Liaison
Network (now officially an RCPsych network) and that there is a survey on national
service provision pending.
Samaritans
A Liaison Team has just developed a Samaritans link with A+E at Frimley Park
Hospital. As this is a new service, they have gone through rigorous preparation;
induction of volunteers and A+E staff, in-house public relations, document and policy
development, scrutiny by the acute hospital clinical governance committee etc and
they are more than happy to share the experience and documentation with other
departments that may be interested in similar work with the third sector. The links
with the psychiatric teams need developing as this is primarily an acute hospital
initiative driven by a superb Head of Corporate Affairs and fully supported by the
A+E manager. In addition to the presence of two Samaritans in A+E (very limited
time slot at present) there is the facility for referral at any time during the week of
individuals who consent and wish to have subsequent follow-up telephone support.
Experience of working with the Samaritans in this area has been very good so far.
Professor White is one of a number of consultants who advise and support the
Samaritans; ‘I would second Malcolm’s positive approach to the involvement of the
Samaritans in A & E departments. The UK Samaritans have recently been offering
support to several statutory agencies, including prisons, and I am aware of very
positive feedback received. I would encourage colleagues to follow Malcolm and
Adrian’s examples in making links with local Samaritan branches to enhance services
to patients attending A & E. They are very keen to make these links. Although
volunteers, I can speak to the remarkable capabilities of the Samaritans, their
professional approach to selection, training, and supervision, which I hope will
reassure those of us concerned about clinical governance.
The international equivalent of the Samaritans is “Befrienders Worldwide”.
The Samaritans are a relatively underused resource to help our patients.’
Durham and Darlington have similarly been involved with service development for
many years; Samaritans offer follow up sessions (1to1 or telephone) after self harm
assessment if they refer (a simple form); something they developed as part of the
RCPsych Self Harm Collaborative; also they have been active in their suicide
prevention task force
They ran a suicide risk management training for mental health teams and the
Samaritans helped with role play; MH staff commented 'I’ve forgotten how to listen
and encourage like that' (and be comfortable staying with suicide emotions). This
clinician calls them 'the calm amongst the storm'.
Bristol has an arrangement where they can ask their local Samaritans to offer a
follow-up phone call to anyone seen once they have left the A&E dept.
‘Specialling’
A Liaison service is trying to help the general hospital address the large scale use of
RMN 1-1 'specialling' for patients who need to remain in the hospital because of their
physical condition; but who have behavioural disturbance. They have developed a
risk assessment tool to help decide whether an RMN is warranted; and follow up
patients to give advice on RMNs continued use. Are there any liaison psychiatry
services that employ nurses as part of their teams to provide this? Or are there any
other solutions?
A respondent said that their service employs a specialist mental health nurse with a
background in teaching who provides specialist assessment of those on 'specials' with
development of individualised plans; and also both classroom (mainly mental health
1st aid) and 1:1 'at the time' teaching of the RGNs. It seems to work really well.
The Chelsea and Westminster Hospital has a lead nurse for mental health who works
with liaison – ‘he is involved with us in deciding when to special patients on the
wards. The acute trust pays for this, and the lead nurse has created a bank of RMNs,
to reduce expense.
His name and contact: paul.morris@nhs.net
An initiative being tried in North West London is to use the dementia CQUIN funds
to employ a nurse specialist who will be responsible for both the CQUIN targets; and
also aim to reduce 1:1 use in the elderly with delirium/dementia by providing ward
nurses/HCAs with training.
Psycho-oncology
Does anyone have experience in setting up such a service?
Their oncology service funds psychology and use their general liaison service for
inpatients. However referrals are rising and are often time consuming and
challenging; in addition to increased acute medicine referrals.
This struggle to cover this work was echoed from Southampton.
A Bristol colleague suggested contacting Dr Alex Mitchell at Leicester ; who has a
brilliant business plan for Psycho-oncology.
Interview rooms in the ED
Below are some good examples of assessment rooms which meet PLAN standards.
1. This shows an observation window and sturdy seating. Nothing else is in the
room which can potentially cause harm.
2. – Below - An example of 2 doors in an assessment room.
3. – See below - This room has a strip alarm and enough room for four people to sit
comfortably. The bright sofa’s make the room more welcoming.
4. Below is an example of how lightweight canvas pictures can add warmth to an
assessment room, but they need to be securely and safely attached to the wall.
5. Below - This shows a room with 2 doors which open both ways, and has an
observation panel whilst also ensuring privacy. Also again, a strip alarm is clearly
visible.
6. Below demonstrates a room which has frosted, toughened glass for privacy and
safety, sturdy furniture and is also a good sized room.
The Royal College has guidance (through PLAN) on what is an acceptable standard
for our interview room.
The standard set out in PLAN is ‘Can the liaison team access facilities and equipment
for conducting high risk assessments’? PLAN requires the following:
1. Be located to, or within, the main Emergency Department or Acute medical
Unit
2. Have a door which opens both ways and is not lockable from the inside
3. Have an observation panel or window
4. Have a panic button or alarm system (unless staff carry alarms at all times)
5. Only include furniture, fittings and equipment which are unlikely to be used to
cause harm
6. Ideally, the facilities should also include two doors
On further discussion with Lucy Palmer, another sensible requirement is around size
of room – and a room that can accommodate 4 people seated with comfort is
recommended.
Jackie Gordon
Worthing