An integrated model of care is tearing down traditional barriers between physical and mental health care at acute hospitals in Oxford.
Psychiatrists and psychologists have been directly recruited to specialist acute teams at the Oxford University Hospitals NHS Foundation Trust as part of an integrated psychological medical service.
It was launched by the trust in 2013, and is led by University of Oxford professor of psychological medicine Michael Sharpe.
Starting with palliative care, general medicine and geratology, the service now has staff integrated into many of the trust’s high-need acute units.
So far, 10 psychiatrists, 30 psychologists and several medical nurses with specialist mental health training have joined acute teams, caring for patients, sharing expertise, and supporting work to improve the flow of patients.
Together, they are identifying patients’ mental health needs earlier, putting in place appropriate support in hospital, including helping people to prepare for radical and life-changing treatments, and liaising with community services so that help is available after people leave hospital.
Professor Sharpe, who has researched how best to integrate mental and physical care, was consulted to advise on how to improve mental health provision at the trust before being asked to lead the new fully integrated service.
“Before we started, the mental health service to the acute hospitals in Oxford had become quite limited and focussed largely on patients who had self-harmed,” he said. “The clinicians and management in the acute trust wanted to develop their capability to deliver comprehensive patient care in wards and clinics and made the radical decision to set up their own trust wide integrated psychological medicine service.
“What’s been achieved is truly amazing. The psychiatrists and psychologist are fully integrated into medical teams, in contrast to traditional liaison mental health services which are only able to link separate physical and mental health services.
“It’s fascinating to see what happens when you fully integrate mental and physical care. It cuts out all those boundary issues arising from different services with different priorities and different clinical records and allows care to be delivered around the patient’s needs.”
Benefits identified by acute trust medical staff include better care for the large number of patients with co-morbid physical and mental illness, the earlier identification of potentially complex cases, improving care and reducing the numbers of delayed discharges.
There’s also no need for managers to reconcile payments between organisations as the inpatient service is paid for and delivered in-house by the trust.
Professor Sharpe added: “By supporting, advising and educating medical and nursing staff, the new service is also starting to have effects that you couldn’t possibly achieve with a visiting liaison type service. For example, it has had a huge effect on attitudes in the organisation and has effectively abolished the stigma that, as we know, all too often dogs mentally ill people and those who care for them.
“The attitude to psychiatry and mental health among physicians, nurses and surgeons is now quite different with much greater acceptance. For example, the psychological medicine service was awarded acute trust ‘team of the year” in 2014.
“The trust is also increasingly interested in making sure its nursing and medical staff are well supported; providing them with essential psychological and psychiatric expertise when it is needed takes away the stress they feel when coping with situations that are often beyond their expertise. It also helps them to learn how to do it better in future. We didn’t realise how much it would help the staff themselves when we started, but it’s emerging as a major benefit.”
Annual costs to have integrated psychological medicine average around £100,000 a year for a large clinical unit such as the regional trauma service, the precise amount depending on the size of the service. This cost is, however, potentially offset by savings, for example by reducing the length of stay for complex patients.
Prof Sharpe said: “We’ve had a number of clinical units come to us to and discuss having psychological medicine in their teams, go away, then come back later saying that they’ve released money from their budget to do it. I think that’s amazing. They’re effectively saying, we could spend this money on another physician or surgeon like us, but instead we’re going to spend our limited funds on developing psychological medicine so that we can better serve our patients.”
Director of Clinical Services Paul Brennan was the driving force behind the service’s development.
“I had come at this on the basis there was clearly a real unmet need to manage what can be quite challenging and distressed patients who present with a medical condition but actually have a psychological need as well,” he said.
A survey of senior referring clinicians from acute general medicine and geratology showed their satisfaction with assessment and management of patients mental health needs more than doubled over the first nine months of the service. Further evaluations are being done as the integrated service develops.
Mr Brennan added: “Colleagues say having the team has helped them to manage those patients that get admitted, reduces their length of stay, and helps the ambulatory care teams to ensure that they don’t have to be readmitted.
“There are always needs for better psychological care and I’m positive we will continue to develop the services into clinical areas beyond those we have already established in acute medicine and geratology, children’s, obstetrics, neurosciences, cancer, palliative care, renal and trauma services.”
Tim Kendall, NHS England’s national clinical director for mental health, said: “Oxford’s experience demonstrates that is not just patients and families who can benefit through integrated care which considers the mind and body as a whole.
“A change of focus, such as that which led to the creation of Oxford’s psychological medicine service, can also transform working relationships and attitudes to deliver a culture-change in care which puts people first.”