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Liaison mental health care has a key role in a mental health emergency and bridge physical and mental health in acute general hospitals. One year on from the launch of the Five Year Forward View for Mental Health and with NHS England’s national transformation programme supporting the development of liaison mental health services across the country, consultant liaison psychiatrist Alex Thomson and colleagues James Hughes and Genevieve Holt, from CNWL discuss how a focus on outcomes allows its staff and patients to work together to improve services.
Over the past decade there has been increasing awareness of the benefits when acute general hospitals have comprehensive liaison mental health departments working alongside other medical specialties. This has resulted in expanded and improved services supported by commissioning guidance from Mental Health Partnerships, a programme of transformation funding from NHS England and its work with the NICE and the National Collaborating Centre for Mental Health to develop an evidence-based treatment pathway for urgent and emergency liaison mental health services.
Evidence from the Centre for Mental Health showed how specialist liaison mental health services can deliver substantial savings to the overall healthcare system. It’s crucial too to keep in mind that as well as savings, services must ensure they are really helping people and offer value for money. But measuring outcomes in fast-moving liaison mental health services is difficult. In one day, a department might see a teenager who’s self-harmed, an elderly woman whose pneumonia has caused her to start hallucinating, and a middle-aged man who has brain or liver damage caused by alcohol dependence. Given that most patients might be seen once for an hour or so, it’s very difficult to evaluate how that intervention might have made a difference to their overall health and wellbeing.
In 2015 the Royal College of Psychiatrists published the Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP). This is designed to be as simple to use as possible and includes four main elements: patient experience, clinician-rated outcomes, feedback from other medical specialties and information about activity and response times.
In Central and North West London NHS Foundation Trust we have been working over the past six months to embed outcome measurement in routine practice through the Psychological Medicine Clinical Network. Eight of our liaison mental health departments meet regularly to share ideas and learn from each other’s successes and failures. From this we’re identifying the factors needed to support effective use of the FROM-LP, and the benefits this kind of information can bring both to our patients and our services.
Our starting point was to engage service users. As doctors and nurses, we needed advice on asking about what matters to patients as well as on how and when to ask for feedback. We also recognised we need help from service users to actually collect feedback. At the moment we have service user representatives as members of our trust-wide clinical network group and are developing an approach to co-production in line with the National Survivor User Network’s 4Pi Framework. Our aim is to ensure all our liaison mental health departments have service users attending team meetings, that clinical staff have had training in co-production and that this work is properly funded.
We are also ensuring that our services have the infrastructure and support to make best use of outcomes reporting. Outcome measures are integrated into the electronic records, and we are using and developing online systems supplemented by paper forms to collect feedback on patient and carer experience.
Most crucial of all is what we do with all this information and how this can help us to improve our services. Our aim is to ensure that all staff understand why this is important, that they have direct access to the feedback on how their service is experienced by patients, and that this is regularly discussed in supervision and team meetings and used to plan and evaluate service improvements.
We also need to show patients that they can trust us to listen and act on what they tell us. As well as working with local user groups, organised by Mind, we will be displaying information about how we’ve responded to feedback at all of our hospital sites.
The reception from staff has been really good. Receiving positive comments makes staff proud and motivates us to continue to do the very best we can for patients. Criticism is also valued and used to make changes and improve our services. Many people have told us they valued the opportunity to reflect and find hope for the future when talking to us. A few people have said that they felt “left in the dark” when waiting for the next stage in their care and so we are making changes to ensure that patients are kept informed about what is happening. We’ll continue to monitor this.
Because liaison mental health is just one piece of people’s overall health care, we’ve also received feedback about other aspects of hospital experience. This highlights the role that liaison mental health services have in ensuring the hospital as a whole is welcoming and accommodating for people with mental health needs, and we work closely with our acute hospital partners to respond to this feedback too.
Adopting the Framework for Routine Outcome Measurement in Liaison Psychiatry has transformed the reports we are sending to commissioners and managers. Instead of a ‘sea of numbers’, we’re now able to analyse what we’re doing, whether we’re helping, and include patients’ own words to describe their experiences. This will help to ensure that new liaison mental health services move well beyond saving money into demonstrating the value to the people they serve.
We are still at the beginning of a journey but this greater understanding will help us understand what we need to change to improve liaison mental health services, and also help us test what difference these changes make in practice.