1. IMPROVING THE INDIVIDUAL EXPERIENCE

2. Who are we? Acute and Community Hospital Mental Health Liaison Teams Started as 2 year project 2004-06 Acute – 3 WTE Band 6 nurses (7 days 8am-10pm) + 7 psychiatrist sessions/week. Gloucester Royal and Cheltenham General Hospitals. Community - 2 FTE Band 6 nurses for rural Gloucestershire and 9 community hospitals. Access to psychiatrist opinion via CMHT’s. Mon-Fri 9-5pm

3. Figures 70% of beds in acute hospitals occupied by older people Likely higher numbers in community hospitals 60% 65years or over have or develop mental health problems when admitted to hospital-general hospital staff increasingly exposed Co-morbid mental health problems raise total health care costs by at least 45% for each person with a long-term condition (King’s Fund 2012)

4. Influencing factors National Service Framework 2001Standard 4 Everybody’s Business 2005 Counting the Cost NICE standards National Dementia Strategy 2009 South West Dementia Partnership No Health Without Mental Health 2011

5. What we do Sometimes don’t need to do a lot to make a difference-detectives! Communication. Objectivity. 3 D’s mainly Acute – 4hr urgent response time. Usual for routine referrals 2 days. Community – Approx. weekly visits. Flexibility – No referral inappropriate. Complex discharge planning and longer term management in increasingly complex presentations Seen as experts – involved in planning Training and supervision often in corridor Challenge labels and normalising Modelling approaches to care-sometimes working alongside Extensive partnership work

6. What’s worked well? Acceptance by different organisation into their setting, meeting of cultural differences, relationships. Ownership – 2 years ago ‘One of yours’! Integrating into routine practice e.g. tools, Living Well Handbook, care plans, routine bloods, CT heads, histories, pathways …… Increased referrals-embodied into wards. Ward Dementia Champions + Dementia Link Workers- on-going advocacy Involved in mental health training to all mainstream staff Liaison in community hospitals ‘unique’ Increase in people referred for Memory Assessment Support from key players

7. The challenges Spread very thinly - Not in non-ward areas, not regularly able to sit on MDT’s, handovers and staff shadow, advance care planning Reactive.v. pro-active Pace not sensitive to needs of people with Dementia e.g bed management Environmental issues – signage, moves, privacy and dignity, reduced opportunity to explore Do we ‘do’ or do we ‘enable’? Fostering dependency? Knowing when to stop. Knowing what we can influence. Whose patient is this?

8. Cont…. Person being in right place at right time with purposeful occupation How demonstrate useful – tension between different agendas, targets are NOT liaison Burnout/isolation, professional growth, ‘Square peg in round hole’ The institutional and professional separation of mental and physical health care – IT systems, values……..

12. Case examples ST – discharge planning VL – psychotic depression NOT dementia

13. Overarching principles Integrating mental health care into everyday workings with good interface between clinicians and senior managers Providing better mental health training for mainstream staff Develop liaison service as most complete and desirable service model Work collaboratively to increase awareness and provide support and supervision

14. Cont……. Rapid assessment of older people with suspected mental health problems who present to A&E Promoting routine assessment of mental health problems of all admissions and better management of straightforward mental health problems Providing rapid access to specialist assessment and management of complex mental health problems Facilitating good practice in discharge planning

15. Liaison figures Good economic as well as clinical case for liaison psychiatry RAID services recently found that benefits in terms of reduced inpatient bed use within the acute hospital exceeded the costs of the service by a conservative factor of more that 4:1 – through promotion of quicker discharge from hospital and reducing rates of re- admission. Also some evidence that more elderly people discharged to independent living rather than to institutional settings