1. Is Liaison Psychiatry the saviour of our NHS
Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician), Birmingham. Professor of Old Age Liaison Psychiatry, University of Warwick Visiting Professor of Mental Health and Ageing, Staffordshire University 1

2. What is wrong with us? What is wrong with Liaison psychiatry?
What is wrong with our hospitals?
What is wrong with the system?
What can we do about it?
What is your answer?
What is going to be covered?
Literature
RAID from the beginning till now
RAID in the future

3. Recent evidence: Older People
Up to 70% of hospital beds are occupied by older people. Audit commission, 2006, Living Well in Later Life.
“The trend is likely to continue with major implications for the use of hospital resources” Government Actuary Department, 2002
, hospital stay for increased by 50%, over 75 by 66%. Hospital Episode Statistics,
Mental disorder in older adults is a predictor of:
Increased Length of Stay (LOS)
Poorer outcomes
Institutionalism (impacting on performance and efficiency)
The majority of mental co-morbidity in acute hospital affecting older people is due to three disorders: Dementia, Depression and Delirium. Case for change- Mental Health liaison Service for Dementia Care in Hospitals., Strategic Commissioning Development Unit (SCDU), 21st July 2011.

4. Evidence for need: Older people
Older adults and a typical 1000 bed DGH
700 beds occupied by older adults
350 will have dementia
480 for non-medical reasons
440 with co morbid physical and mental disorder
192 will be depressed
132 will have a delirium
46 will have other mental health problems.
500 beds hospital would have 5,000 admissions/annum, of whom 3,000 will have or will develop a mental disorders. Who cares wins, 2005.
70% of older people referrals to liaison services are not under the care of mental health services.
In a typical acute hospital (500 beds), failure to organize dementia liaison services leads to excess cost of £6m/year

5. Alzheimer’s society: Counting the cost (2009)
Concerns from Nursing staff :
managing patients with challenging or difficult behaviour,
communication difficulties,
not having enough time to spend with patients and provide care.
Concerns from Families:
nurses not recognising or understanding dementia,
lack of personal care,
patients not being helped to eat and drink,
lack of opportunity for social interaction,
the person with dementia not being treated with due dignity and respect.

6. GPs and community dementia care
Only 47% of GPs had sufficient training in dementia management,
A third were not confident in diagnosing dementia.
10% of GPs aware of the National Dementia Strategy.
Only 58% of GPs believe that providing a patient with a diagnosis is usually more helpful than harmful.
Significant numbers of dementia related admissions are directed to acute hospitals through GPs referrals.
It also could be due to lack of coordination between primary and secondary care.
National Audit Office (2010) Improving Dementia Services in England – an Interim Report. Report by the Comptroller and Auditor, General HC 82SesSIon 2009–2010, 14 January 2010.

7. Evidence for need: Alcohol and Substance Misuse
Alcohol consumption increased over the last decade
88% of adults in the UK drink alcohol,
with 38% of men and 16% of women recognized as having an alcohol use disorder (Alcohol Needs Assessment Research Project, 2005).
15-20% of adult inpatients are alcohol dependent.
12% of A&E attendances are alcohol related
7-20% acute admissions have alcohol problems
Annual healthcare cost of £1.7 billion National Indicators for Local Authorities and Local Authority Partnerships (2009)
NI 39 (2009) Aim: Reduce trend in alcohol related admissions.

8. Evidence for need: Self Harm
In the top five reasons for admission in the UK.
Rates in the UK are among the highest in Europe.
170,000 admissions per annum in UK
If training is inadequate it may lead to negative attitudes and poor care
Patient non-engagement and repeated self-harm behaviour can lead to suicide
Drains resources with little positive outcomes
Kripalani et al, (2010) Integrated care pathway for self-harm: our way forward. British Medical journal, 27:
Kapur, N (2006) Self Harm in the general hospital. Psychiatry, 5 (3) 76-80
National Institute for Clinical Excellence (2010) Guidelines for Self harm.

9. Evidence for Need: General Psychiatry
25% of patients with a physical illness also have a mental health condition.
60% of over 60s
A&E work is primarily with younger people coming with DSH, Alcohol problems and acute psychosis.
Depression & Anxiety - 2 to 3 times more common in those with physical long-term illness.
Neuropsychiatry
Postnatal psychiatry
Eating disorders
MUPS:
long term disability and dissatisfaction.
Present in most hospital specialities.
Care costs estimated at £3.1 billion per annum

10. The Parameters Mental Health Substance Misuse Older Adult Mental
Physical
morbidity
Psychological
Deprived
area
Inner city
PROCESS 10

11. The product: Rapid Assessment Interface Discharge
BOUNDARY
FREE
TRAINING
COMMUNITY
FOCUS
EARLY
INTERVENTION
SINGLE
POINT OF
CONTACT
RAPID
RESPONSE
24x7 SERVICE
RAID 11

12. The pre-RAID (traditional) service (Cost 0.6m)
Consultant
Liaison Psychiatrist
1.0 WTE
Currently Funded
Specialist
Doctor
1.0 WTE
Currently Funded
Band 7
Nurse
MHOP
1.0 WTE
Currently Funded
Band 7
Social Worker
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Social
Worker
Admin
Band4
1.0 WTE 12

13. The upgraded RAID service (cost £1.4m)
Consultant Psychiatrist
Mental Health of Older People
Consultant
Psychologist
Mental Health of Older People
RAID
Team
Manager
Consultant
Liaison Psychiatrist
1.0 WTE
Currently Funded
Consultant
Psychiatrist
Substance Misuse
Band 7
Nurse
MHOP
1.0 WTE
Currently Funded
Specialist
Doctor
Band 7
Nurse
Liaison
1.0 WTE
Currently Funded
Band 7
Social Worker
1.0 WTE
Currently Funded
Lead Nurse
Substance Misuse
Specialist
Doctor
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
MHOP
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
Liaison
1.0 WTE
Currently Funded
Band 6
Nurse
Substance misuse
1.0 WTE
Currently Funded
Admin
Band4
1.0 WTE
Admin
Band4
1.0 WTE
Assistant Research
Psychologist 13

14. RAID evaluation
RESPONSE
COST
QUALITY

15. Referrals Steadily increasing referrals 300+ monthly referrals
Origin of referral
Number of referrals
16-64 years
65 years +
Mean age
Accident and Emergency (A&E)
833
96% 4%
36.4 years
Poisons Unit
517
34.6 years
Wards
675
41%
59%
65.6 years
Steadily increasing referrals
300+ monthly referrals
Only 30% patients known prior to RAID. 15

16. Top 7 reasons for referral

17. A&E Response

18. Ward Response

19. Teaching and evaluation
158 hospital staff trained: All completed the evaluation
‘A lovely insight from a very experienced practitioner’ 19

20. Practice improvement 20

21. Medical diagnosis coding
Comparing pre-RAID and RAID period
RAID diagnosis 21

22. Patient satisfaction: Feedback
Range
Mode
Median
Mean
0 to 5 5 4
4.2 22

23. Staff satisfaction: Feedback
Range
Mode
Median
Mean
2.5 to 5 5 4
4.2 23

24. RAID evaluation
RESPONSE
COST
QUALITY 24

25. RAID evaluation
RESPONSE
COST
QUALITY 25

26. Areas of savings Reducing Length of Stay Increasing diversion at A&E
Increasing rates of discharge at MAU
Rate of discharge from wards
Destination of discharge
Reducing rates of re-admissions
Many other areas not in this study
Use of security
Staff Retention and recruitment
Complaints
Use of antipsychotics 26

27. 3 Groups for the study 1. Pre- RAID group (control group)
December July 2009
No changes/confounders between pre and post!!
2. RAID_ influence group
December July 2010
RAID did not see patients, but had influence through training and support
3. RAID group
RAID patients
Matched groups:
Matched age, gender, mental health code, medical diagnosis, healthcare resource group (HRG)
RAID patients were the most complex
RAID: average 9 different diagnostic codes
RAID_ influence 3 different diagnostic codes 27

28. Retrospective case-by-case Matched Control Study
Sub Control mean: 8.4
Sub RAID Inf mean: 5.2
Sub Control mean: 10.3
Sub RAID mean:9.4
72 cases
359 cases
Control (2873 Patient)
Mean: 9.3 days
RAID Influence (2654 Patient)
Mean: 4.74
RAID (886 Patient)
Mean: 17.6 28

29. RAID sample mean vs. population mean
A confidence level of 95% was obtained. 29

30. 1. Length of stay: Retrospective Matched Control Study30

31. Length of stay: Comparing the groups
P value= 0.01 31

32. Cost savings: LOS/ all age groups
All ages:
Saving over 8 months= ,493 =
9,290 bed days
Saving over 12 months= 13,935 bed days
Per day= 13,935 ÷ 365 =
38 beds per day
Older people only:
Saving over 8 months= ,220 =
8,634 bed days
Saving over 12 months= 12,951 bed days
Per day= 12,951 ÷ 365 =
35 beds per day 32

33. 2. Admission Avoidance at MAU: Cohort control study
All ages
Control group;
30% of avoided admission at MAU.
RAID and RAID influence group;
33% avoided admission at MAU
Increase of 9%
Average LOS= 9.3 days
240X9.3= 2,232 bed days
2232 ÷ 365= 6 beds/ day
Older people
Control group;
17% of avoided admission at MAU.
RAID and RAID influence group;
25% avoided admission at MAU
Increase of 47%
Average LOS= 22 days
111 X 22= 2442 bed days
2442 ÷ 365= 6 beds/ day 33

34. 3. Elderly Patient Discharge Destination
30% of elderly patients who come to acute hospitals from their own homes are discharged to care homes (national figures)
LSE estimated savings to our wider economy of £60,000/week (Social care cost). 34

35. 4. Savings: Re-admission
Group
Re-admission per
100 patients
Retrospective (3500)
15 (505)
Partial RAID (3200)
12 (408)
RAID (850)
4 (42) 35

36. 5. Survival after discharge: Survival analysis36

37. Older People Re-admissions
Group
Re-admissions per 100 patients
Control group (pre- RAID)
19 patients
RAID influence
22 patients
RAID
5 patients 37

38. Survival Analysis: Elderly

39. Savings: through increasing survival
The savings calculated from survival assumes patients readmission at same rate of retrospective patients
Over 8 months → 1200 admissions saved.
Over 12 months → 1800 admissions saved.
Saving 22 beds per day = one ward
Saving 20 beds per day comes out of elderly care wards. 39

40. Combined total savings: beds/day
On reduced LOS
saved bed days/12 months= 13,935 bed days
÷ 365 = 38 days/day (35 beds/day for the elderly)
Saved bed days through avoiding admissions at MAU
Saved bed days = 6 beds / day
Elderly bed days saved= 6 beds / day
Increasing survival before another readmission
Admissions saved over 12 months =1800 admissions
Average LOS 4.5 days
= 8100 saved bed days
÷ 365 = 22 beds/day
20 for the elderly
Total Saved beds every day
= = 66 beds/ day (Maximum) {Elderly: 59 beds/day}
= = 49 beds/ day (minimum) {Elderly: 42 beds/ day}
2010: City Hospital has already closed 60 beds. 40

41. London school of Economics, August 2011
Very thorough, detailed and vigorous review
Very conservative estimation
Total savings:
£3.55 million to NHS
At least 44 beds/day
£60,000/week to social care cost
Money value
Cost : return = £1: £4
Recommended the model to NHS confederation

42. Please note there may be more than one diagnosis per person
Number of patients with a Mental Health Diagnosis – Dementia Delirium and Depression (Retrospective case notes and all screened in and out)
Please note there may be more than one diagnosis per person

43. Comparison of diagnoses Prospective Data

44. What is next? RAID Manual RAID Engine RAID Network
How to improve the model?
What works?
Which bit for which patch!