Consultation-liaison:from dream to reality A systematic approach to developing C-L mental health service delivery

national health care schemes. The decision to become a psychiatrist is probably the most radical choice a doctor can make. It defies the division between mental and general health care. One challenge to C-L psychiatrists is to secure a more formalised position for mental health service delivery within the general health care sector, in both organisation and funding. This would enhance both the quality and quantity of health services to medically ill people with psychiatric comorbidity. The purpose of this article is to increase the awareness of such problems, and to set out strategies to consolidate the professional development and positioning of C-L psychiatrists in the health care field.

A second problem is that negative attitudes of medical specialists and nurses are reinforced by the inappropriate mental health facilities avail able in the medical setting, and the parallel inadequacies of mental health settings. This complicates the transfer of comorbid patients between the general and mental health care, which ultimately can often depend on the perservance of the C-L psychiatrist involved.

The return to theÃŸeld of medicine
Psychiatrists who return to medicine vary considerably in their degree of preparation for the C-L role, depending on the sophistication of the C-L service in their training programme. Three major factors can be blamed for their deficiencies.
First, there is too little data on the effects of psychiatric interventions in the medically ill during general hospital stays. Since a call in the beginning of the 1980s to improve C-L research a series of studies funded by the US National Institute of Mental Health have revealed the formidable difficulties of experimental re search on physical/psychiatric comorbidity (Saravay & Strain, 1994). In addition to randomised clinical trials, various groups are working on audit systems which are eventually to set standards for C-L service delivery (Huyse et ai, 1992). The European Consultation-Liaison Workgroup (ECLW)has conducted a collabora tive study followed by a quality management study (Huyse, 1996a,b). Similar initiatives on a more modest scale have been taken in the US and Australia (Strain et al, 1996).
A second difficulty is to get across to the medical and health care policy community what specific role C-L psychiatrists fulfil in the general hospital and what structural basis is required for their activities. Studies assessing interaction within the medical system, such as those on staff conflicts that interfere with appropriate care and on the degree of staff compliance with C-L psychiatric recommendations, have appeared only in C-L literature.
The third problem is that a return to the medical system entails a change in psychiatrists' strategies towards patients. Becoming a psychia trist involves a sort of estrangement from the medical system -an internalisation of psychotherapeutic principles with their tendency to observation and passivity. Psychiatrists may now find it hard to become active again in the presence of their medical colleagues. More so than patients seen by generalist psychiatrists, those suffering physical/psychiatric comorbidity often find themselves in a personal existential crisis which demands a more active approach. A similar change in activity levels is required for the psychiatrists' relationship to the medical staff. The question arises whether they should explicitly put forward how they see their role on a ward or should they adopt a more psychotherapeutic attitude, seeking openings to introduce their views. Just as in giving psychotherapy, a psychiatrist here must be careful to avoid verbalising problems that are impossible to solve.
Two recent randomised clinical trials, one US study on hip fracture in the elderly (Strain et al, 1991) and another Dutch study on physical/ psychiatric comorbidity in the medical popula tion 75 and older, suggest that management needs to take a more proactive, preventive approach to physical/psychiatric comorbidity. In the latter study. Slaets et ai (1994Slaets et ai ( , 1997 have demonstrated significant clinical and cost effects of admission screening and of treatment by both a psychogeriatrician and liaison nurses. This was evident by a better functional status at discharge and by shorter lengths of stay, includ ing readmission days in a six month follow-up period. Obviously such an active role in mana ging ward personnel requires specific training and skills not likely to be gained in most of today's training programmes.

Strategies
Several different strategies are needed to develop a more formalised basis for the mental health care of patients in general medical settings. These are intended to provide a more secure basis for psychiatrists wishing to establish themselves at this interface. We discuss these strategies here in random order.

Organisations
One requirement for developing the field of C-L psychiatry is a higher level of professional organisation (Huyse, 1991). If this is not achieved then C-L psychiatry will forever be a domain for pioneers trying to find their niche in a hostile environment. The need for better organ isation has already been recognised in the creation of groups such as the Academy for Psychosomatic Medicine, the Liaison Psychiatry Group of the Royal College of Psychiatrists, the Section of Consultation Psychiatry of the Royal Australian and New Zealand College of Psychia trists, and sections or interest groups within several other European psychiatric associations. Several such groups are moving more or less explicitly towards sub-specialisation status through a focus on curricula, fellowship training programmes, funding and research strategies (FordefaÃ®, 1994).
Another approach is the establishment of international organisations like the European Association for Consultation-Liaison Psychiatry and Psychosomatics (EACLPP). Its main focus is on international networking, trying to set up an international forum and a more active exchange between participants. Recently, Mayou & Creed have urged more active participation of repre sentatives of national organisations in the C-L field (personal communication).
This would effectively generate needed information to re inforce national initiatives. A meeting of the EACLPP will be organised as a satellite of the next European Conference for Psychosomatic Research (ECPR) in Manchester September 1998. Ford et al (1994) has reviewed 49 fellowship training programmes and formulated the Acad emy of Psychosomatic Medicine's goals and standards for C-L training. These refer to a knowledge base for diagnosis and treatment, which is to include a full range of consultation and liaison techniques. However, they devote insufficient attention to a number of issues: finding a proper balance between passivity and activity; applying complementary psychotherapeutic strategies: protocollised strategies for patients with common psychiatric comorbidities; treatment of more complex, longer-lasting or fluctuating psychiatric disorders. Furthermore there is the question of the different roles C-L psychiatrists can fulfil in medical teams. There is the role of the 'gatekeeper' who facilitates transfers from the mental to the general health care sector and vice versa, and that of the mentor who furnishes both patients and health profes sionals the information and strategies needed to cope with complex illnesses and ensure con tinuity of care. There are also different roles as care provider, from psychotherapist to case manager. In addition, on the general hospital wards the C-L psychiatrist must collaborate closely with liaison nurses and guide them in observing and containing patients' behaviour. Together C-L psychiatrists and C-L nurses could develop ward programmes to provide more integrated care to specific populations, such as elderly, trauma, oncological, intensive care unit or neurological patients. Residency/registrar training programmes should also be considered, such as the US Rochester dual training model, as well as models of general practitioner training in psychiatry. The question arises as to whether C-L psychiatrists would enhance their credibility and position by helping develop curricula for internal medicine, neurology and general practice.

Organisation and funding
Since the field of physical/psychiatric comorbidity lies between medicine and psychiatry, who will take it in and give it asylum?  (Benjamin et oÃ-, 1994).
An overt strategy towards the general health care system All such issues need to be drawn together as an integrated policy, and a structure needs to be developed to implement it. But is it the respon sibility of psychiatry alone to achieve this? The Royal College of Physicians and the Liaison Psychiatry Group of the Royal College of Psy chiatrists (1995) have formulated a key answer: the joint working party. This is a model of how things should proceed from here. Other medical specialities should be drawn into the planning process to help them see their responsibility for the integrated care of their patients, and to assure them of the sound knowledge base and skilled psychiatric support needed to achieve this. Novel C-L quality management and audit approaches systems need to be integrated into existing hospital systems. This can aid the collection of more reliable and extensive data to evaluate whether interdisciplinary standards have been met. At present in the framework of the Biomedl programme, a practical admission risk screening instrument (Compri) to predict the complexity of hospital care, and a multidimen sional method to assess health service needs (Intermedi are being tested to assess the inte grated health care needs of the patients requiring complex hospital care (Huyse, 1997). There purpose is the early detection of psychiatric comorbidity in high-utilisers and the subsequent provision of appropriate care and referral.