Guidance for commissioners of liaison mental health services to acute hospitals 1VolumeTwo:Practicalmental healthcommissio...
Joint Commissioning Panelfor Mental HealthCo-chaired
2 Practical Mental Health CommissioningContentsExecutivesummaryIntroduction04What areacute liaisonservices?Why is acutelia...
Guidance for commissioners of liaison mental health services to acute hospitals 3Executive summary•	 Physical and mental h...
The Joint Commissioning Panelfor Mental Health (JCP-MH)( is a newcollaboration co-chaired bythe Royal Colle...
Guidance for commissioners of liaison mental health services to acute hospitals 5What are acuteliaison services?An acute l...
6 Practical Mental Health CommissioningWhy is acute liaison important to commissioners? (continued)Physical illness increa...
What do we know about thecurrent provision of acute liaison services?There is currently no single,uniform model for liaiso...
8 Practical Mental Health CommissioningWhat do we know about the current provision of acute liaison services? (continued)M...
Guidance for commissioners of liaison mental health services to acute hospitals 9What would a good liaison service look li...
10 Practical Mental Health CommissioningWhat would a good liaison service look like? (continued)StandardsCommissioners wil...
Guidance for commissioners of liaison mental health services to acute hospitals 11RAID is a new model for acute liaisonser...
Supporting the delivery of the mental health strategyThe JCP-MH believes thatcommissioning that leads togood acute liaison...
Guidance for commissioners of liaison mental health services to acute hospitals 13Liaison Expert Reference Group Members•	...
14 Practical Mental Health CommissioningResourcesThe Joint Commissioning Panelfor Mental Health (JCP-MH)www.jcpmh.infoThis...
Guidance for commissioners of liaison mental health services to acute hospitals 159 Reid, S., Wessely, S., Crayford, T.,Ho...
Guidance for commissioners of liaison mental health services to acute hospitals 17A large print version of this document i...
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Guidance for commissioners of liaison mental health services to acute hospitals


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This guide describes what ‘good looks like’ for a modern acute liaison service. It should be of value to Clinical Commissioning Groups (who will be commissioning secondary services, both specialist mental and acute).

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Guidance for commissioners of liaison mental health services to acute hospitals

  1. 1. Guidance for commissioners of liaison mental health services to acute hospitals 1VolumeTwo:Practicalmental healthcommissioningGuidance for commissioners ofliaison mental healthservices to acute hospitalsJoint Commissioning Panelfor Mental
  2. 2. Joint Commissioning Panelfor Mental HealthCo-chaired
  3. 3. 2 Practical Mental Health CommissioningContentsExecutivesummaryIntroduction04What areacute liaisonservices?Why is acuteliaison importantto commissioners?05 05What do weknow about thecurrent provisionof acute liaisonservices?07What woulda good liaisonservice look like?09Supportingthe deliveryof the mentalhealth strategy12Resourcesand references14
  4. 4. Guidance for commissioners of liaison mental health services to acute hospitals 3Executive summary• Physical and mental health areinextricably intertwined. Long-termconditions (LTCs), such as diabetes,are associated with high rates of mentalillness. Some 70% of NHS spend goeson the treatment of LTCs, a great dealof which currently involves treatmentin acute hospitals.• Psychological stress is often expressedas physical symptoms, which are anexample of medically unexplainedsymptoms (MUS).• The mental health needs of a patientin a physical health care setting oftenremain undiagnosed and thereforeuntreated. To optimise the physicalhealth care of patients, it is essentialthat their mental health and wellbeingare addressed at the same time.• Liaison services should be providedthroughout the acute hospital, includingin A&E departments. Services shouldbe provided to meet the needs ofpatients with a mental disordersecondary to their physical disorder,or a physical disorder alongside theirmental disorder, and for patients(particularly those with MUS) whereit is impossible to separate the two.• Acute liaison services operate withinexisting (often ad hoc) local networksof other generic and disorder-specificclinical health psychology andmultidisciplinary services. This shouldbe mapped out by commissioners sothat acute liaison becomes a primarypartner in the effective managementof the emotional and adjustment/behavioural needs of all patientspresenting to acute services.• A liaison service should be an integralpart of the services provided by acutehospital trusts – trusts that haveincorporated a liaison service havedemonstrated much better cost-effectiveness.• Commissioning of acute liaisonservices should be universally includedin contracts for the provision ofacute hospital services and concordto standards set by professional andregulatory authorities.• Acute liaison services should have theresources and skills needed to supportall age groups.• Liaison services may, over time, extendtheir remit to help primary mental healthcare to manage people with LTCs andMUS, in order to avoid unnecessaryadmissions to secondary care.
  5. 5. The Joint Commissioning Panelfor Mental Health (JCP-MH)( is a newcollaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists,which brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• Service users and carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• Afiya Trust• British Psychological Society• Representatives of the EnglishStrategic Health Authorities• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.The JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health.1IntroductionThe JCP-MH has two primary aims:• to bring together service users, carers,clinicians, commissioners, managers andothers to work towards values-basedcommissioning• to integrate scientific evidence, serviceuser and carer experience and viewpoints,and innovative service evaluations inorder to produce the best possible adviceon commissioning the design and deliveryof high quality mental health, learningdisabilities, and public mental healthand wellbeing services.The JCP-MH:• has published Practical Mental HealthCommissioning,2a briefing on the keyvalues and principles for effective mentalhealth commissioning• provides practical guidance and adeveloping framework for mental health• will support commissioners of publicmental health to deliver the bestpossible outcomes for communityhealth and wellbeing• has published a series of short guidesdescribing ‘what good looks like’ invarious mental health service settings.Who is this guide for?This guide describes what‘good looks like’ for a modernacute liaison service. Itshould be of value to ClinicalCommissioning Groups (whowill be commissioning secondaryservices, both specialist mentaland acute).How will this guide help you?This guide has been writtenby a group of acute liaisonexperts in consultation withpatients and carers.The content is primarily evidence-based butideas deemed to be best practice by expertconsensus have also been included. By theend of this guide, readers should be morefamiliar with the concept of acute liaisonand better equipped to:• understand what a good quality,modern, acute liaison service looks like• understand why a good acute liaisonservice delivers the objectives of themental health strategy and the Quality,Innovation, Productivity and Prevention(QIPP) challenge – not only in itself butalso by enabling changes in other parts ofthe system.This guide also addresses issues relatingto the commissioning of acute liaisonservices. It describes:• the benefits of liaison services• the optimum liaison psychiatry team• the mental health needs in acute caresettings that a liaison service addresses• why a liaison service is important forcommissioners of acute hospital services.This guide draws on, and refers to,previously published guidance including:• the Royal College of PsychiatristsCollege Centre for Quality ImprovementPLAN standards3• the Royal College of PsychiatristsCCQI Mental Health PolicyImplementation Guide for LiaisonPsychiatry and Psychological Medicinein the General Hospital4• the Royal College of Psychiatristsbriefing No Health without MentalHealth: the Supporting Evidence5• the NHS Confederation briefingHealthy Mind, Healthy Body.64 Practical Mental Health Commissioning
  6. 6. Guidance for commissioners of liaison mental health services to acute hospitals 5What are acuteliaison services?An acute liaison serviceis designed to provideservices for:• people in acute settings (inpatient oroutpatient) who have, or are at riskof, mental disorder• people presenting at A&E with urgentmental health care needs• people being treated in acute settingswith co-morbid physical disorders suchas long-term conditions (LTCs) andmental disorder• people being treated in acute hospitalsettings for physical disorders causedby alcohol or substance misuse• people whose physical health care iscausing mental health problems• people in acute settings with medicallyunexplained symptoms (MUS).The service aims to increase the detection,recognition and early treatment ofimpaired mental wellbeing and mentaldisorder to:• reduce excess morbidity and mortalityassociated with co-morbid mental andphysical disorder• reduce excess lengths of stay in acutesettings associated with co-morbidmental and physical disorder• reduce risk of harm to the individual andothers in the acute hospital by adequaterisk assessment and management• reduce overall costs of care by reducingtime spent in A&E departments andgeneral hospital beds, and minimisingmedical investigations and use ofmedical and surgical outpatient facilities• ensure that care is delivered in theleast restrictive and disruptive mannerpossible.Why is acute liaison importantto commissioners?The problems acute liaisonaddresses are common:• mental disorder accounts for aroundfive per cent of A&E attendances, 25%of primary care attendances, 30% ofacute inpatient bed occupancy and 30%of acute readmissions7• self-harm accounts for between150,000 and 170,000 A&E attendancesper year in England8• MUS may account for up to 50% ofacute hospital outpatient activity9• 13–20% of all hospital admissions andup to 30% of hospital admissions viaA&E at weekends are related to alcohol10• in England, alcohol-related hospitaladmissions doubled in the 11 years upto 2007, and alcohol-related deaths alsodoubled in the 15 years to 200611• one quarter of all patients admitted tohospital with a physical illness also havea mental health condition that, in mostcases, is not treated while the patient isin hospital6• most patients who frequently re-attendA&E departments do so because of anuntreated mental health problem6• two thirds of NHS beds are occupiedby older people, up to 60% of whomhave or will develop a mental disorderduring their admission.6Mental and physical healthare closely linked Mental illness increases riskof physical illness andcomplicates its management.Depression is associated with:• reduced life expectancy of 10.6 yearsin men and 7.2 years in women12• increased risk of coronary heart disease13• four-fold increased risk of myocardialinfarction (MI) and four-fold increasedrisk of death within six months ofmyocardial infarction14• two-fold increased risk of type 2diabetes15• three-fold increased risk of non-compliance with treatmentrecommendations.16Schizophrenia is associated with:• reduced life expectancy of 20.5 yearsin men and 16.4 years in women17• three-fold increased death rate fromrespiratory disease18• two-fold increased risk of obesity, twoto three-fold increased risk of smoking,two-fold increased risk of diabetes,two to three-fold increased risk ofhypertension, five-fold increased riskof dyslipidaemia and two to three-foldincreased risk of metabolic syndrome.19Substance use disorder is associatedwith 13.6 year reduced life expectancyfor men and 14.8 years for women.12Smoking is the main cause of preventabledeath in the general population. Peoplewith a mental disorder smoke much morethan people without a mental disorder:they consume 42% of all tobaccoconsumed in England.20
  7. 7. 6 Practical Mental Health CommissioningWhy is acute liaison important to commissioners? (continued)Physical illness increases the risk ofmental illness. Depression is more commonin those with a chronic physical illness.21Risk of depression is doubled for peoplewith diabetes, hypertension, coronaryartery disease and heart failure, andtripled in those with stroke, end-stagerenal failure and chronic obstructivepulmonary disease.22Depression is more than seven timesmore common among people with twoor more chronic physical conditions.23One in five people newly diagnosed withcancer or first hospitalised with a heartattack will develop depression or anxietywithin one year.24Children with physical illness are atincreased risk of emotional or conductdisorder.25Integrated mentaland physical health careThe close links betweenmental and physical healthhighlight the importance ofan integrated approach totreating physical and mentalillness. However, traditionallymental and physical healthcare have been commissionedseparately; it is rare that theneeds of patients with mentaland physical health problemsare provided for through asingle funding stream.Mental health and physical healthare closely linked. Liaison servicesprovide commissioners with a means toaddress this in the acute hospital setting.Liaison services can significantly reduceincidence of mental illness associatedwith physical illness and vice versa,thereby reducing the burden on bothprimary and secondary care. The focusof Improving Access to PsychologicalTherapies (IAPT) has been extended tocover psychological interventions forLTC co-morbidity and MUS.Mental illness can frequently causeor aggravate physical disorder. Thesedisorders are seen and treated in acutehospital settings. The commissioners ofacute hospital services should thereforebe responsible for commissioning acuteliaison services to meet this need.Liaison services are important in facilitatingcollaborative care approaches to bothmental and physical health conditions.Closer working between primary andsecondary care staff is particularlyimportant in improving the confidenceof specialist mental health staff inidentifying, preventing and interveningearly with physical health problems, andvice versa (see the companion primarymental health care commissioning guide).The quality and productivitychallenge (QIPP)Commissioners are requiredto improve quality whileat the same time increasingproductivity (QIPP). Liaisonservices provide an excellentopportunity to do this by:• improving clinical outcomes• reducing admissions to and lengths ofstay in acute settings• ensuring patients with co-morbid long-term conditions receive better treatmentwhile using fewer health care resources• treating and reducing costs for patientswith MUS• reducing psychological distress followingself-harm, and reducing suicide.
  8. 8. What do we know about thecurrent provision of acute liaison services?There is currently no single,uniform model for liaison servicesacross the country. Where suchservices exist, they are oftenprovided by the local mentalhealth trust within the estate ofthe acute hospital trust, whichmay present logistical andoperational challenges.Liaison services are commonlycommissioned by the commissioners ofmental health services (rather than thecommissioners of acute hospital care).This is despite the fact that the acute trustshould be providing them, and the qualityand productivity benefits that derive fromthe service are realised within the acutehospital setting.Most acute liaison servicescould provide the following:• advice, training and coaching onthe management of mental healthproblems to other professionals inthe acute hospital• biopsychosocial assessment,formulation and diagnosis for peopleidentified by acute hospital staffas experiencing impaired mentalwellbeing or whose physical symptomsare unexplained• brief interventions, advice andsignposting to services in a rangeof agencies for patients in acutehospital settings• participation in Mental Health Actand Mental Capacity Act assessments,and performing risk assessments forharm to self and others• expert advice on capacity to consentfor medical treatment in complex casesinvolving both physical and mentalhealth problems• acting as a Responsible Clinicianunder the Mental Health Act for peopledetained under the Act, and receivingcare in the acute hospital• rapid response to requests forassessment in the A&E department andon acute hospital wards (assessment andmanagement of people who have self-harmed forms a significant proportionof this responsibility)• development of care planspost-assessment• arranging appropriate follow-uppost-discharge• assessment of people with MUS• management of people with MUSwho require a higher level of inputthan can be provided by lowerintensity services such as IAPT – inassociation with primary care, specialistmedical teams and other specialistmultidisciplinary teams (eg. chronicfatigue syndrome/ME services)• contributing to the managementof people with long-term physicalconditions in collaboration with primarycare and specialist physical healthmultidisciplinary teams (eg. diabetespsychology and dietetics)• assistance with the managementof people with long-term physicalconditionsGuidance for commissioners of liaison mental health services to acute hospitals 7• assessment, management andsignposting of patients with alcohol andsubstance misuse disorders.The service could bring thefollowing benefits:• increased mental health care capacitywithin the acute hospital throughcollaboration• improved wellbeing of staff in acutehospital settings, by relieving the anxietythese staff sometimes feel when dealingwith patients with complex needs –this may in turn help reduce levelsof sickness absence• improved patient self-managementof their care• improved physical care of peoplewith mental disorder• reduced stigma associated withmental health care.
  9. 9. 8 Practical Mental Health CommissioningWhat do we know about the current provision of acute liaison services? (continued)Models of acute liaison servicevary greatly, from those thatprovide a ‘core’ adult mentalhealth liaison service to thosethat cater for more complexneeds (learning disability,dementia, children and youngpeople). However there is aconsiderable body of work thatdescribes what liaison servicesshould do, how they should beorganised and what standardsthey should achieve.Liaison psychiatry provision is often patchy,despite its core role in risk managementand in facilitating good physical healthcare. The picture is further complicated bythe range of other services that providebehavioural input to physical healthcare. Liaison services have a unique andessential role in providing broad coveracross health care settings, and in theircapacity to handle the most severe andrisky mental health problems. However,commissioners will also need to considerthe range of other services that provideevidence-based talking therapies andrehabilitation for physical health problems,including MUS and LTCs. These include:• clinical health psychology embeddedin medical teams, such as oncology,diabetes, renal, rheumatology orrespiratory teams and providingspecialist talking therapies, assessment,consultation, training and research• chronic pain management teams andchronic fatigue teams, operating over awider area than a single acute hospital• cancer network of psychosocial supportprofessionals, organised to supportsophisticated training arrangements formedical and nursing oncology staff (andoften including liaison psychiatrists)• cardiac and pulmonary rehabilitationteams.Existing liaison services tend typically tobe for adults with mental health needs,and not for children and young people.An important development would befor commissioners to commission liaisonservices that are age-inclusive. The liaisonneeds of children and young adults maydiffer in some respects from those ofadults and older people but the principlesand benefits are applicable across all ages.This all-age approach will presentchallenges to the way in which servicesare currently organised but is importantif the ambition of the English mentalhealth strategy is to be realised throughthe commissioning process.Furthermore, the current patchy natureof liaison services commissioning leadsto patchy provision. There should beuniversal agreement to commission liaisonservices as part of the acute hospital carecommissioning process.What do we know about the current provision of acute liaison services? (continued)
  10. 10. Guidance for commissioners of liaison mental health services to acute hospitals 9What would a good liaison service look like?Model of service deliveryA good liaison service functionsbest as a discrete, specialised,fully integrated team comprisingmulti-professional health carestaff, under single leadershipand management.A core service should be based on thefollowing principles:• staff members sole (or main)responsibility is to the acute liaison team• the team includes adequate skill mix• the team has strong links with specialistmental health services and good generalknowledge of local resources• there is clear and explicit responsibilityfor all patients in the acute hospitalsetting• there is one set of integratedmulti-professional healthcare notes• consultant medical staff are fullyintegrated.Key components of the serviceA comprehensive liaison servicewill have the following features:• ability to work closely with the acutehospital through integrated governance,open (pre-referral) discussion with thehospital’s principal referring units, asingle point of referral and the capacityto serve the agreed hospital population• provision of comprehensive assessmentand formulation, including riskassessment and joint assessment whereappropriate, using recognised formalinstruments to provide diagnosis andformulation that leads to an agreed planthat is communicated in a timely manner• capacity to engage effectively withthe patient in a safe place that allowsa positive therapeutic relationship tobe built• provision of a range of interventionsincluding signposting, support,psychosocial interventions, therapeuticinterview, brief psychotherapeuticinterventions, and pharmacotherapy• effective liaison with other parts ofthe health system, including generalpractice, crisis and in-patient teams,specialist mental health teams, socialservices, emergency services and non-statutory agencies• broad capacity building across the healthand social care system so that mentalhealth is much more readily recognisedas a concomitant to physical health(liaison clinicians should be able to assessphysical health as well as mental health,manage mental health issues, recognisethe remit of their capabilities, and referto psychiatric services when appropriate)• provision of supervision, liaison anddirect clinical activity outside the acutesetting and into primary care when carepathways for patients with MUS, LTCsor other issues require consistency ofcare in order to avoid deterioration orre-admission• all-age inclusive services, includingliaison services for children, older peopleand adults with dementia• holistic and culturally responsiveservices.
  11. 11. 10 Practical Mental Health CommissioningWhat would a good liaison service look like? (continued)StandardsCommissioners will need tocommission liaison servicesthat can demonstrate that theymeet the recognised standardsfor the service.These are set out in the Royal Collegeof Psychiatrists College Centre forQuality Improvement (CCQI) Planstandards,3against which liaison servicesmay be accredited. These are notcurrently mandatory. It is suggestedthat the PLAN accreditation processbecomes a commissioning requirement,with the joining fee included in thecommissioning process.The optimum liaison teamTo provide the breadthof services set out above,a range of staff operatingwithin a multidisciplinaryteam is essential.Table 1 sets out the absolute minimumstaff requirements to provide an adultcare liaison service working office-hours within an acute hospital with 650beds, as described in the Royal Collegeof Psychiatrists Mental Health PolicyImplementation Guide.4additional staffing requirementsIf liaison professionals are toprovide teaching, training andsupport to colleagues withintheir team and throughout thegeneral hospital, the staffingratios above would need to beincreased to allow for this.Similarly, a greater number of staff will beneeded to provide a comprehensive officehours liaison service for:role grade time commentMedical Consultant Whole time Consultant involvement is essential,including managing risk, providingsupervision and training, and offeringexpertise on psychopharmacologicaltreatment, complex patients, capacityand the Mental Health Act.Nursing Band 8 Whole time One of the nursing roles should be asteam leader.Nursing Band 7 3 xwhole timeThe nurses operate as autonomouspractitioners, undertaking assessments,and brief treatment interventions, andliaising with mental health teams inprimary care. Those working with olderadults will become involved in detaileddischarge planning.ClinicalPsychologyBand 8 1 May be provided from healthpsychology team, but should bean integral part of a liaison teamto provide supervision, trainingand delivery of brief psychologicaltreatments.Team PA Band 4 1.5 xwhole timeCore to referral management,information gathering andcommunication.Table 1: Examples of levels and skill mix for a team serving a generalhospital with 650 beds and 750 new self-harm patients per year.(Mental Health Policy Implementation Guide, 2008)• adults with complex needs• older-age adults –all senior staff will needexperience in older people’s mental health,and all teams should have the necessaryrequirements to allow training of juniorsand students for all professional groups• CAMHS – child and adolescent mentalhealth services to general hospitals shouldbe provided by specialist multidisciplinaryCAMHS liaison teams, but currentprovision is patchy and further investmentis required.The model of acute liaison servicesoutlined in this guide will require a numberof additional therapists with experienceof working with people with MUS. Thesetherapists may come from a variety ofbackgrounds, including social work,occupational therapy and physiotherapyFor examples of guidance on appropriatestaffing levels for older-age adults andother population groups please seereferences26-31,as well as the existingJCP-MH series of guides on commissioning(
  12. 12. Guidance for commissioners of liaison mental health services to acute hospitals 11RAID is a new model for acute liaisonservices developed by Birmingham andSolihull Mental Health Foundation Trustand the University of Staffordshire. Ithas been piloted at Birmingham’s CityHospital, an inner city general hospitalwith some 600 beds.31The service offers consultation and liaisonto A&E, the medical assessment unit andthe medical, maternity and surgical wards,with response targets of one hour for A&Eand 24 hours for inpatients.RAID builds on existing liaison services,adding health and social care capacity tothe liaison team, plus specialist skills inolder adults and addictions – as such, it isa complete, all-age mental health servicewithin an acute trust.RAID is viable at a cost of circa £1 millionfor a hospital of circa 600 beds.Economic evaluation of RAID, undertakenby the London School of Economics, hasdemonstrated that it can achieve thefollowing outcomes, over and abovetraditional liaison services:• reduce admissions, leading to areduction in daily bed requirementof 44 beds per day, saving the NHS£3.55 million per annum throughdecommissioning acute beds• reduce discharges to institutional carefor elderly people by 50%, saving localauthorities £3 million per annum incontributions to residential care• produce a consequent cost-to-returnratio of £1 to £4.Quality indicators have confirmed goodpatient feedback on improved holistic carein acute care settings. Staff feedback hasconfirmed that the team is popular and hasbuilt capacity and confidence in managingpatients with mental health issues,reduced violence and improved morale (asevidenced in the annual staff survey).In terms of hospital efficiency, waitingtimes for mental health patients in A&Ehave been reduced by 70%, which isreflected in an overall improvement inA&E waiting times.The service is to expand across theBirmingham acute care health economyto cover five acute hospitals with 3,600beds in total. Throughout this expansionit will be subject to ongoing evaluation.OutcomesThe quality outcomes ofliaison services include:• improved service user experienceand care outcomes• improved access to mental health carefor a population with high morbidity• reduced emergency department waitingtimes for people with mental illness• reduced admissions, re-admissionsand lengths of stay• reduced use of acute beds by patientswith dementia• reduced risk of adverse events• enhanced knowledge and skills ofacute hospital clinicians• improved compliance of acute trustswith legal requirements under theMental Health Act (2007) and MentalCapacity Act (2005)• improved compliance with NHSLitigation Authority Risk ManagementStandards and the Clinical NegligenceScheme for Trusts (CNST).RAID: an example ofservice innovationThe Rapid Assessment Interfaceand Discharge (RAID) service isan age-inclusive, drugs/alcoholinclusive, consultant-led servicethat is fully integrated into thestructure and function of anacute hospital in Birmingham. Ithas shown dramatic reductionsin bed use,particularly use ofacute/elderly ward beds bypatients with dementia.
  13. 13. Supporting the delivery of the mental health strategyThe JCP-MH believes thatcommissioning that leads togood acute liaison services,as described in this guide,will support the delivery ofthe mental health strategy1in a number of ways.Shared objective 1:More people will havegood mental health.Commissioning acute liaison services willincrease the number of people receivingappropriate care and support and reducethe number developing mental illness. Thisis because they provide early identification,diagnosis, and either treatment or referral,for people with mental health needsadmitted to acute hospital.Shared objective 2:More people with mentalhealth problems will recover.A patient’s road to recovery is oftenmade more difficult by the co-morbidityof physical and mental health needs.By commissioning a liaison service thataddresses both physical and mentalhealth needs together, the prospectsof recovery are enhanced.Shared objective 3:More people with mentalhealth problems will havegood physical health.Ensuring that a person’s mental healthneeds are also addressed when they arein an acute hospital for treatment for theirphysical health needs removes one ofthe potential barriers to provision ofgood physical health care. Liaisonservices can reduce the risk of self-harmand suicide while also addressing thelong-term conditions and medicallyunexplained symptoms with whichmany patients present.Shared objective 4:More people will have a positiveexperience of care and support.By addressing both physical and mentalhealth needs together, acute liaisonservices can improve the likelihood ofpatients experiencing more holistic andpositive care in acute hospital settings.Shared objective 5:Fewer people will sufferavoidable harm.One of the key components of agood liaison service is to assess therisk of self-harm and harm to others.Commissioners should look to a liaisonservice to both provide short-terminterventions and appropriate onwardreferral and signposting. Reducingoutpatient attendance, hospital admissionsand readmissions protects patients fromavoidable harm.Shared objective 6:Fewer people will experiencestigma and discrimination.By commissioning services that recognisemental and physical health as inseparableand inter-related, commissioners will beactively addressing the stigma that derivesfrom the artificial separation of physicaland mental health and increasing publicand professional understanding of theirfrequent coexistence.12 Practical Mental Health Commissioning
  14. 14. Guidance for commissioners of liaison mental health services to acute hospitals 13Liaison Expert Reference Group Members• Paul Gill (ERG Chair)Consultant PsychiatristSheffield Liaison Psychiatry ServiceSheffield Health and Social CareNHS Foundation Trust• Jonathan CampionConsultant PsychiatristSouth London and MaudsleyNHS Foundation Trust• Mike ClarkeLondon School of Economicsand Political Science• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Jeremy Gauntlett-GilbertSenior Clinical PsychologistBath Centre for Pain ServicesRoyal National Hospital forRheumatic Diseases• Rebecca HarringtonAssistant Director(Strategic Planning and JointCommissioning)London Borough of Camden& Camden PCT• Lance McCrackenConsultant Clinical PsychologistBath Centre for Pain ServicesRoyal National Hospital forRheumatic Diseases• Stella MorrisConsultant PsychiatristHumber NHS Foundation Trust• Kieron MurphyDirector of DeliveryJoint Commissioning Panelfor Mental Health• Chris NaylorFellow (Health Policy)King’s Fund• Annemarie SmithCarer RepresentativeDevelopment processThis guide has been written by a groupof liaison care experts, in consultationwith patients and carers. Each memberof the Joint Commissioning Panel forMental Health received drafts of the guidefor review and revision, and advice wassought from external partner organisationsand individual experts. Final revisionsto the guide were made by the Chairof the Expert Reference Group incollaboration with the JCP’s Editorial Board(comprised of the two co-chairs of theJCP-MH, one user representative, onecarer representative, and technical andproject management support staff).
  15. 15. 14 Practical Mental Health CommissioningResourcesThe Joint Commissioning Panelfor Mental Health (JCP-MH)www.jcpmh.infoThis website describes the functionand intended outputs of the JCP-MHQuality standards for liaisonpsychiatry services (2nd ed).Royal College of PsychiatristsCollege Centre for Quality ImprovementPsychiatric Liaison AccreditationNetwork (PLAN) (2010) report sets out standards foracute liaison services.Mental Health Policy ImplementationGuide: Liaison Psychiatry andPsychological Medicine in theGeneral HospitalRoyal College of Psychiatrists (2008) report focuses on the key componentsthat should be in place in a liaison team ifthe service is to operate effectively.No Health without Mental Health:the ALERT summary report.Academy of Medical Royal Colleges(2009) report, produced by the PLANteam with the Royal College ofPsychiatrists Liaison Faculty highlightsthe importance of liaison services andargues that every hospital should haveaccess to these services.Healthy Mind, Healthy BodyNHS Confederation (2009) briefing explains how liaisonpsychiatry services can transformquality and productivity in acutesettings. It sets out some good practiceexamples together with academicevidence to build a business case forliaison psychiatry services.Managing Urgent MentalHealth Needs in the Acute TrustAcademy of Medical RoyalColleges (2008) report outlines the case forinvesting in liaison mental healthservices and sets out a set ofrecommendations and standardsthat should underpin these services.Department of Healthmental health Institute for Healthand Clinical Excellence (NICE) HM Government (2011).No health without mental health:a cross-government mental healthoutcomes strategy for people of all ages.London: Department of Health.2 Bennett, A., Appleton, S., Jackson, C.(eds) (2011). Practical mental healthcommissioning. London: Palmer, L., Dupin, M., McGeorge,M., Soni, M. (eds) (2010). Qualitystandards for liaison psychiatry services(2nd ed). London: Royal College ofPsychiatrists College Centre for QualityImprovement. Aitken, P. (2007). Mental health policyimplementation guide: liaison psychiatryand psychological medicine in thegeneral hospital. London: Royal Collegeof Psychiatrists. Royal College of Psychiatrists (2007).No health without mental health: thesupporting evidence. London: Academyof Medical Royal Colleges/Royal Collegeof Psychiatrists.6 NHS Confederation (2009).Healthy mind, healthy body: how liaisonpsychiatry services can transform qualityand productivity in acute settings. London:NHS Confederation. Royal College of Psychiatrists and BritishAssociation for Accident and EmeregencyMedicine, 2004, Psychiatric services toaccident and emergency departments(CR118) London, Royal College ofPsychiatrists.8 Yeo, H.M. (1993). The cost oftreatment of deliberate self-harm.Archives of Emergency Medicine,10(1), pp. 8–14.
  16. 16. Guidance for commissioners of liaison mental health services to acute hospitals 159 Reid, S., Wessely, S., Crayford, T.,Hotopf, M. (2001). Medically unexplainedsymptoms in frequent attendees ofsecondary health care: retrospectivecohort study. British Medical Journal322(7289), p. 767.10 Fernandes, A. (2011). Guidancefor commissioning integrated urgentand emergency care. A whole systemapproach. Centre for Commissioning,Royal College of General Practitioners.11 National Audit Office (2008).Department of Health Reducing AlcoholHarm: health services in England andalcohol misuse. Report by the Comptrollerand Auditor General.12 Chang, C-K., Hayes, R,D., Perera, G.,Broadbent, M.T.M., Fernandes, A.C. et al(2011). Life expectancy at birth for peoplewith serious mental illness and othermajor disorders from a secondary mentalhealth care case register in London. PLoSONE 6(5): e19590. doi:10.1371/journal.pone.001959013 Hemingway, H., Marmot, M. (1999).Psychosocial factors in the aetiologyand prognosis of coronary heart disease:systematic review of prospective cohortstudies. British Medical Journal 318, pp.1460–67.14 Lesperance, F., Frasure-Smith, N.,Juneau, M., Theroux, P. Depression and1-year prognosis in unstable angina. ArchIntern Med. 2000, 160(9), pp. 1354–60.15 Fenton, W.S., Stover, E.S. (2006).Mood disorders: cardiovascular anddiabetes comorbidity. Current Opinionin Psychiatry 19(4), pp. 421–27.16 Di Matteo, D., Martin, L., Williams, S.,Haskard, K. (2005).The challenge of patientadherence. Therapeutics and Clinical RiskManagement 1(3): pp. 189–99.17 Brown, S. (1997). Excess mortality ofschizophrenia: a meta-analysis. BritishJournal of Psychiatry 171, pp. 502–8.18 Saha, S., Chant, D., McGrath, J.(2007). A systematic review of mortality inschizophrenia; is the differential mortalitygap worsening over time? Archives ofGeneral Psychiatry 64(10), pp. 1123–31.19 De Hert, M., Dekker, J.M., Wood, D.,Kahl, K.G., Holt, H., Möller, K. (2009).Cardiovascular disease and diabetes inpeople with severe mental illness: positionstatement from the European PsychiatricAssociation (EPA), supported by theEuropean Association for the Study ofDiabetes (EASD) and the European Societyof Cardiology (ESC) European Journal ofPsychiatry. European Psychiatry 24(6),pp. 412–24.20 McManus, S., Meltzer, H., Campion,J. (2010). Cigarette smoking and mentalhealth in England. Data from the AdultPsychiatric Morbidity Survey. London:National Centre for Social NICE (2009). Depression with a chronicphysical health problem: the treatmentand management of depression in adultswith chronic physical health problems(partial update of CG23). Clinical guidance91. London: NICE.22 Egede, L. (2007). Major depression inindividuals with chronic medical disorders:prevalence, correlates and association withhealth resource utilization, lost productivityand functional disability. General HospitalPsychiatry 29(5), pp. 409–16.23 Moussavie, S., Chamnatti, S., Verdes,P., Tandon, A., Patel, V., Ustun, B.(2007).Depression, chronic diseases, anddecrements in health: results from theWorld Health surveys. The Lancet 370,pp. 851–58.24 Burgess, C., Cornelius, V., Love,S.,Graham, J., Richards, M., Ramirez,A.(2005). Depression and anxiety inwomen with early breast cancer: fiveyear observational cohort study. BritishMedical Journal 330: 702 doi: 10.1136/bmj.38343.670868.D325 Parry-Langdon, N. (ed) (2008).Three years on: survey of the developmentand emotional well-being of childrenand young people. Cardiff: ONS.26 Royal College of Psychiatrists. (2005).Who Cares Wins. London: Royal Collegeof Psychiatrists.27 Royal College of Psychiatrists. (2006).Raising the Standard - specialist servicesfor older people with mental illness.London: Royal College of Psychiatrists.28 British Psychological Society. (2008).Briefing Paper No. 27 - Clinical HealthPsychologists in the NHS. London: BritishPsychological Society.29 British Psychological Society. (2006).Briefing Paper No. 5 - CommissioningClinical Psychology Services for olderpeople, their families and other carers.London: British Psychological Society.30 British Psychological Society. (2010).Commissioning ClinicalNeuropsychology Services.London: British Psychological Society.31 NHS Confederation (2011).With money in mind.The benefits of liaison psychiatry.London: NHS Confederation.
  17. 17. Guidance for commissioners of liaison mental health services to acute hospitals 17A large print version of this document is available fromwww.jcpmh.infoPublished February 2013Produced by Raffertys