NHS leaders now agree that for too long healthcare has been provided in silos, much to the detriment of overall patient care. Integration of physical and mental health is crucial in redressing this balance and inequality. Liaison psychiatry services, such as ours in Sunderland, are integral in promoting partnership working and restoring parity of esteem to those with complex problems.
Liaison psychiatry can be thought of as a sub-specialty which provides psychiatric treatment to patients attending general hospitals, whether they attend outpatient clinics, Emergency Departments (EDs) or are admitted to inpatient wards. It therefore deals with the interface between physical and psychological health.
There is a great cost of long-term illnesses such as cardiovascular disease, diabetes, chronic obstructive pulmonary disease (COPD) and musculoskeletal disease such as osteoarthritis, both to the patient, but also to carers and families. The rates of co-morbid (i.e. present at the same time) common mental illness such as depression and anxiety in these patients is high, about 2-3 times that of the general population. Not recognising these illnesses worsens the prognosis of the underlying condition, leads to poorer overall quality of life, impairs adherence with treatment and, ultimately, ends up costing the NHS extra money in repeated hospital admissions and GP and ED attendances.
Furthermore, presentations of mental distress and illness such as self-harm, suicidal thoughts, depression and anxiety are common in the ED, making up at least 5% of all ED attendances nationally. Compelling evidence exists however that this is likely to be a huge underestimate; a large proportion of those frequently presenting to both EDs and hospital outpatient clinics have undiagnosed, co-morbid mental illnesses and psychosocial problems which are either masked by physical symptoms such as pain, or perpetuate the underlying illness.
We also know that up to 45% of UK hospital inpatients suffer with cognitive impairment or dementia, often with high levels of impairment and frequently present alongside a multitude of physical illnesses and functional problems.
In Sunderland we are fortunate to have a well-resourced, multidisciplinary liaison psychiatry service embedded within a large general teaching hospital, Sunderland Royal. We comprise senior nurses, support workers, peer support (leading on service user and carer engagement), a psychologist and therapist, an occupational therapist and doctors (psychiatrists). We operate 24 hours a day, 7 days a week and can quickly respond to referrals from the ED (within one hour) and from the wards (within 24 hours).
We see patients across the age range, from 16 and above, and are able to offer whole person psychosocial assessment and treatment of a range of problems. The majority of referrals from the ED tend to be about those who have presented following acts of self-harm or with suicidal thoughts, and we are often able to enable rapid discharge home with appropriate care packages, and without the need for stressful and unnecessary hospital admission. The nature of ward referrals is varied, but common themes include patients with dementia and behavioural disturbance, confusion, depression and anxiety. There is also a cohort of patients whose physical symptoms, such as pain or weakness, cannot be wholly explained by the traditional ‘medical’ model, and who often have co-morbid mental illness. These patients suffer with considerable ongoing distress and our assessment and management often leads to greater understanding of the underlying problems and improved quality of life for the patient and their carers.
It was however, not always so. During my time with the team, a little under two years, I have witnessed a transformation in our relationships with our acute hospital colleagues and, consequently, their level of understanding of the complex nature of these problems. This has been achieved by promoting partnership working, education (both formal and informal), flexibility in our approach to assessment and treatment and, ultimately by placing the patient and their carers at the centre of decision-making.
This is now borne out in our integrated care pathways. If you suffer a stroke, maintaining your psychological wellbeing will be regarded as a vital facet of your recovery; if you have COPD, practitioners will recognise the symptoms of anxiety which worsen your breathing and act appropriately; if your memory is failing, you will have access to timely assessment and care planning.
Partnership working has also led to enhanced care within obstetrics, gynaecology, nephrology, neurology, medicine and more. There is, of course, much work still to do, but our focus remains to educate, encourage and support our colleagues in the pursuit of fully integrated, patient and carer-centred, whole person care.
Dr. Vishaal Goel, Consultant Liaison Psychiatrist
Sunderland Psychiatric Liaison Team