The present state of consultation and liaison psychiatry

RICHARD MAYOU, Clinical Reader in Psychiatry, University Department of Psychiatry, Wameford Hospital, Oxford OX3 7JX (correspondence); HELEN ANDERSON, Senior Registrar in Psychiatry, Dykebar Hospital, Paisley, Renfrewshire PA2 7DE; CHARLOTTE FEINMANN, Senior Lecturer, Eastman Dental Hospital, Gray's Inn Road, London WCIX 8LP; GAIL HODGSON, Senior Registrar, Gloucester House, Southmead General Hospital, Bristol BSIO 5NB; and PETER L. JENKINS, Consultant Psychiatrist, St Cadoc's/Royal Gwent Hospital, Caerleon, Newport, Gwent NPI 6XQ

Although referral by general hospital doctors is a major pathway to specialist psychiatric care, and there is known to be much clinically unrecognised psychiatric morbidity among general hospital patients, consultation and liaison• services have received much less emphasis than community care.A 1984 survey found that consultation liaison services were haphazard (Mayou & Lloyd, 1985).Despite recent evidence of increasing clinical and academic interest, few local strategic plans refer to consultation and liaison services; even when mentioned they are given a lower priority than community developments (Kingdon, 1989).This further survey is in two parts: a national survey of liaison psychiatrists; and comprehensive reports of all consultation and liaison within Scotland, Wales and three English regions.

National survey
.Questionnaires were returned by psychiatrists in 52 districts of the United Kingdom (see Table I).The general picture remains as described by Mayou & Lloyd (1985): haphazard care largely provided by duty doctors or sector teams, with services varying greatly between areas with similar resources.Very few districts keep systematic records of general hos-tory, with better organisation ofemergency and conpital referrals, and most were unable to provide more sultation work.Even so, the majority ofDGH Units than guesses at the numbers of patients seen, usually were unable to specify particular staff as having conin the range of 1-3 referrals per week.sultation responsibility.Most districts have psychi-Teaching hospitals reported the most elaborate atric out-patient clinics based in the general hospital, services.Several respondents commented that shar-some receiving high proportions ofreferrals from the ing liaison responsibilities between a number of con-general hospital.Few ofthese ofTer any special expersultant teams made for difficulties in co-ordinating tise in the problems of medical patients or in functraining, student teaching and the management of tional somatic symptoms.Very few districts have any attempted suicide and other emergencies.A num-in-patient facilities for those with both medical and ber of teaching hospitals separate Accident and psychiatric illness.Emergency Department care entirely from the General hospital consultation by psychiatric subconsultation-liaison service.
specialties was often unsatisfactory.Psychogeriatric Services provided by District General Hospital liaison was often well developed; liaison by substance Psychiatric Units were generally the most satisfac-abuse services was usually unsatisfactory.Few districts have any special liaison for obstetrics.Many general hospitals have no child psychiatry consultation for emergencies.
Only two respondents said they were "very satisfied" with the present situation, 21 were reasonably satisfied with services ranging from very elaborate to minimal and 29 were very dissatisfied.Reasons for dissatisfaction included: (a) lack of organisation and co-operation in emergency and consultation services to general hospitals (b) inadequate supervision ofjunior staff (c) the difficulties caused by sectorised services and service provision by emergency teams (d) poor professional staffing together with minimal administrative resources.Reports of local plans provide modest encouragement.Several areas have either recently appointed consultants with designated liaison sessions or hope to do so in the future.There was evidence ofrecent or imminent improvements in 28 districts, but changes were thought unlikely in the foreseeable future in the other 24 districts

North East Thames (Charlotte Feinmann)
North East Thames differs from the other regions in having four teaching hospitals and a high proportion of urban districts with large general hospitals.
The four teaching districts have the greatest commitment of consultation-liaison.All have organised services for attempted suicide, day and night-time emergencies, and ward and out-patient consultation.The City and Hackney (St Bartholomew's) has consultant and junior staff sessions with secretarial support, but specialist liaison is for teaching purposes only.Bloomsbury (UCH and Middlesex) has a supervised consultation service and liaison by consultants with a number of specialised units including neurology, oral surgery, ear, nose and throat, gynaecology and oncology.Hampstead (Royal Free) provides specialist liaison to the ward for HIV patients and to the Liver Unit.Tower Hamlets (London Hospital) has a general consultation service with limited specialist liaison.
The City and Hackney and Bloomsbury districts have special in-patient facilities for management of patients with medical and psychiatric problems.The City and Hackney, Bloomsbury and Hampstead all have nurses working for liaison teams.A particular interest in Bloomsbury has been the development of a service for breast cancer, head and neck cancer and obstetric units in which nurse counsellors are supervised by psychiatrists.
Two non-teaching districts, Islington and West Essex and Hackney also have well established con-sultation seryices.Islington has recently changed its semce so that one registrar assesses all referrals to the Whittington Hospital under consultant supervision.West Essex has one registrar who deals with liaison referrals and another who deals with alcoholrelated problems, both being supervised by consultants.The development in West Essex ofan academic department ofhuman development and aging can be expected to increase the extent of liaison.
The other 10 of the 16 districts in the region provide much less organised consultation, usually limited advice on ward referrals and emergencies being seen by duty or sector teams.
Psychogeriatric consultation in general hospitals is widely available.The region has no specialised inpatient facilities for mother and baby problems, substance abuse or psychiatric problems relating to HIV.There are out-patient facilities for these specialist problems in all areas.Bloomsbury provides a regional drug and alcohol service and is developing services for HIV and drug-related problems.Child psychiatrists are not generally available for emergency care but provide routine out-patient services.

Oxford Region (Richard Mayou)
The only organised consultation and liaison service is in Oxford which has a full-time NHS consultant and an honorary consultant with a special interest.One other district, West Berkshire, has a half-time post established in 1988.Two Buckinghamshire districts share an elaborate mother and baby unit which has well established liaison with obstetric units.
Most districts have simple systems for emergencies and ward referral.There are a small number ofliaison attachments.A number ofgeneral consultants in the Region, especially those in the few general DOH units, report good working relationships with their medical and surgical colleagues.Services to smaller and to more specialised general hospitals are much less satisfactory than in the DOHs.
The service in Oxford city is probably the largest in Britain and the first to have a full-time liaison consultant.A multidisciplinary team manage attempted suicide and other Accident and Emergency Department patients.Ward consultations are seen by two supervised SHO/registrars and one general practice trainee.There are several liaison attachments and a specialist out-patient clinic.
The extent of liaison by consultants in the subspecialties varies throughout the region.Some psychogeriatricians work closely with medical colleagues, but in other areas psychogeriatric consultation is relatively disorganised and there is dissatisfaction both on the part ofthe general hospital and of the psychiatrists.The Regional Alcohol Unit is in Oxford and the consultant is expanding liaison links with the departments in the Oxford general hospitals.There is no consultation for alcohol problems outside Oxford and no consultation for drug offenders in the Region.
Oxford is the only one of the five rotational training schemes in the Region to offer a consultation and liaison placement.The Regional Higher Training Scheme has a liaison placement in Oxford; there are also opportunities in several districts for senior registrars to undertake sessional liaison attachments to general hospital services.The University Department of Psychiatry has a major programme of research.

South West Region (Gail Hodgson)
It is remarkable how much consultation and liaison psychiatry is being carried out in the region, particularly as there are no consultants with a designated responsibility.All general psychiatrists in the South Western Region work, or are about to work, in a sectorised system and most have their bases some distance from colleagues in other specialties.All but two of the 11 districts have the majority of their general in-patient beds in large psychiatric hospitals, often in rural areas remote from the more centrally sitedDGH.
All districts have consultation services, usually based on a rota system or a Sector team.Psychiatric trainees and clinical assistants are usually supervised on request only.
Deliberate self-harm (DSH) referrals and records are generally well organised.Most districts have a defined policy and some have assessment protocols.Ten districts require wards to refer the patients to a central point by a given time each day.In nine districts everyone over 16 is seen and in two districts most are seen, the rest being assessed by house or casualty staff.All school age children are seen by senior child psychiatrists and often followed up by the same individual.Eight districts have a rota for psychiatric assessment for between five and seven days a week.Three districts use sector back-up with the initial assessment done in two districts by medical social workers and in one by a specially employed full-time psychiatric social worker using specially designed assessment forms.
Referral systems are often rudimentary and records are usually limited to letters to GPs.Referrals are usually seen either by an on-call rota system or sent direct to the sector consultant team.In one district where mental health services are largely community based most referrals are made to one consultant.Two districts commented that they felt that DGH teams were not referring because of the obstacles to referrals caused by sectorisation.
Out-patient clinics are sited within the DGH in ten districts.There are no special facilities to care for patients who have combined major medical and psychiatric disorders within any of the district general hospitals.
In one district there is a close and long-standing liaison between the neuroscientists, neurologists, neurosurgeons and neuropsychiatrists.Other liaison services are for radiotherapy/oncology (2 districts), terminal and palliative care (3), chronic pain (2), eating disorders (I), gastroenterology (1) and dermatology (I) clinics. .
Liaison by psychiatric sub-specialties is most highly developed in child/adolescent psychiatry, where close contact with paediatricians is seen as an integral part of the routine clinical work.Psychogeriatric liaison with geriatricians is increasingly seen in the same light, despite a shortage of consultants.
In one district, services are going to merge.Psychogeriatricians find that links with orthopaedic surgeons are less good.Ten out of II districts have or are about to have designated consultants with sessional commitment to alcohol and drug abuse.Eight districts have some service for those infected with HIV virus, two have designated consultants.
There are no facilities in any of the district obstetric units for caring for a newly delivered mentally ill mother, although four districts have mother and baby facilities on acute psychiatric wards and there is one specialist mother and baby unit within a large psychiatric hospital.
Clinical psychologists have shown an increasing interest in DOH patients.At least two districts have between a half and one whole-time equivalent Principal Clinical Psychologists attached to a local DGH.
Most psychiatrists contacted were dissatisfied, and some embarrassed, about their general hospital services.There was considerable concern that hospital consultation-liaison had suffered from the emphasis on community services: at the same time, most felt that their general psychiatric service would improve once they had moved to a DGH site.Greatest satisfaction was expressed by psychiatrists already working from a base in a small DGH where they had regular informal personal contact with their consultant colleagues.Five districts are seriously examining plans for improved liaisons, three would like a consultant with a designated responsibility for liaison, one has two liaison beds planned, three are considering training specialist nurse counsellors.
Fonnal teaching or specialised training is minimal.However, 11 hours ofteaching time has recently been allocated to liaison psychiatry in the Regional MRCPsych Part II course.

Scotland (Helen Anderson)
A recent survey (Anderson, 1989) showed that liaison services have developed little compared with a previous survey ten years ago (Brooks & Walton, 1981), and were similar to those described in a national survey by Mayou & Lloyd (1985).
The typical service is an emergency psychiatric service seeing mainly overdose cases.The number of patients seen is usually small.Teaching is of low priority and although a consultant psychiatrist is usually nominated as having a special interest in liaison work, the service remains largely undeveloped with no specific sessions laid aside.Most liaison and consultation work appears to take place outside psychiatrists' ordinary working hours.Despite the obstacles and lack of training opportunities, respondents to the Scottish survey were generally enthusiastic about this aspect of psychiatry.Psychiatrists working in district general hospitals were generally more satisfied than those with no general hospital base.However, they did not provide a wider range of services or more sessional commitments or more teaching.
As in other areas of the country, no record is kept of the number of patients seen by the service.Since referrals tend to be made by varied means and collected in several places, it is impossible for either psychiatrists or managers to assess the number of patients seen or the resources used.Links have been established with specialist units across the country but these have been haphazard and have been brought about by the enthusiasm of particular individuals.
There are particular difficulties in providing a specialist service for geographically large rural catchment areas with scattered populations.Inevitably, such services tend to be sectorised and all psychiatrists are equally involved in general hospital work.
Three ofthe four university teaching hospitals have liaison services which provide post-graduate teaching and training in liaison psychiatry.Edinburgh remains the most developed service in Scotland with the only full-time consultant in liaison work and the largest number of para-medical sessions.The unit provides training at registrar and senior registrar level.Specialist liaison links and increasing para-medical support are being actively developed.
In Glasgow, the psychiatric services are provided by several psychiatric hospitals around the Glasgow area, as distinct from Edinburgh's more centralised service.The Professorial Unit in Glasgow provided a valuable training post in liaison psychiatry.For some years the psychiatric registrar has attended a medical ward round on a regular basis.All psychiatric staff are involved in an international pain clinic with inpatient and out-patient facilities and staff in the unit also attend a regular clinic at the Glasgow Dental Hospital.In Dundee, the consultation-liaison service is provided by a separate senior rotation to the main general hospital.One consultant has developed a close liaison with the obstetric unit.

Mayouetal.
Because of dissatisfaction with current services, a variety of changes are planned across Scotland.Although only one hospital (Dumfries) initiated a liaison service within five years prior to this survey, several areas hope to appoint consultants with specific interest in consultation-liaison psychiatry over the next few years.There is encouragingevidence that services around the country are set to develop.

Wales (Peter Jenkins)
Arrangements for hospital consultations vary from area to area.Only one district, Gwent, has a specific consultant post with a special responsibility for the development of the liaison service.This post has recently been filled and the service has yet to be developed.In most areas, one or more consultants have some nominal responsibility for aspects of the consultation service, but few have specific sessions or administrative support.No area reported a centralised record of consultations.
The majority of work is concerned with the assessment and management ofdeliberate self-harm, and is normally undertaken by a junior doctor with consultant or senior registrar supervision available on request.The extent of such requests is unknown.Arrangements vary, but the only area with designated beds is Llandough Hospital Poisons Unit, Cardiff.
The majority of ward consultation requests are emergency requests and seen by junior doctors, except in one area, where all consultations are seen by a consultant.In a three-month survey in South Glamorgan, 51 requests were received, of those no follow-up was arranged in about 50% and no notes made in 34°A..It is unlikely that the quality ofservice is significantly higher in other areas.
The University Teaching Hospital, Cardiff, has the most developed service in Wales.Apart from emergencies, between three and five non-emergency ward consultations per week are seen by well supervised junior staff based on the DGH acute psychiatric unit.There are a number of liaison services and a named psychiatrist is available to the Departments of Surgery, and Geriatric Medicine, the epilepsy and bone marrow transplant units, Dental School, adolescent renal unit, and the tinnitus clinic.There is an active research programme.It is hoped to start an out-patient clinic and eventually to appoint a designated consultant.
No area has a medical/psychiatric in-patient unit or specific liaison out-patient clinics.All areas have provision .formothers and babies in specific units.Child and adolescent services are relatively underdeveloped in terms of in-patient treatment as are alcohol and drug treatment units.There is close liaison between geriatric medicine and psychogeriatric services throughout Wales.
Many large general hospitals have no child psychiatry service for urgent referrals, obstetric liaison is uncommon and for substance abuse unsatisfactory.Lack of resources is a very substantial obstacle to providing adequate care to distressed people in general hospitals.Greater medical in-put and improved para-medical support are necessary to make a major impact on this time-consuming, but largely undocumented, aspect of psychiatric care.However, it is also apparent that lack of awareness and poor organisation of what is already available are both important factors.Our survey showed that a number ofdistricts are able to use modest resources to provide efficient and innovative consultation and emergency services.
It is essential for the welfare of patients and the reputation ofpsychiatry that all health districts audit their consultation and liaison services, improve their use of present resources and make detailed plans for better emergency, out-patient and in-patient care.There can be no single plan suitable for all areas.Teaching hospitals require skilled senior staffto provide a clinical service to train psychiatrists and to offer teaching to medical and other students.Specialists may be inappropriate in rural areas where general practitioners cover large catchment areas.The Liaison Group and the Royal College must set out guidelines for the organisation and staffing of consultation and liaison services.