Competencies for all psychiatrists

As specified for all doctors, plus the following.

• Full biopsychosocial assessment of patients, across the age range, with physical health problems, physical symptoms and mental health symptoms or psychological distress, including:

1. • somatisation/medically unexplained symptoms

2. • adjustment disorder

3. • the interrelationship of depression and anxiety on chronic medical conditions, for example diabetes, asthma, chronic obstructive pulmonary disease.

• Mental state examination in difficult circumstances:

1. • intensive care units

2. • breaking bad news

3. • variable conscious level

4. • lack of privacy.

• Assessment of self-harm across the age range, including children

• To advise competently on the treatment of patients with chronic mental health problems while in the general hospital

• Knowledge of medical and surgical treatments and conditions that have an impact on mental state

• Anxiety, depression and psychotic states in in-patients in medical and surgical settings

• Assessment of general medical and surgical admissions

• Demonstrate knowledge of management of alcohol and substance misuse problems in medical and surgical settings

• Diagnose psychiatric symptoms in the presence of confounding severe physical illness and biological symptoms (e.g. cancer, renal disease, severe trauma)

• Implementation of appropriate management plans, including the use of basic psychological, social and environmental interventions as well as psychotropic use from the British National Formulary

• Use risk assessment to advise management plan

• Review notes and drug cards, including investigations and results

• Awareness of medical, surgical and nursing assessment and management plan in the general hospital and its interaction with mental state

• Assessment of patient in A&E

• Identification of medically unexplained symptoms

• Identification, investigation and advice on the immediate management of delirium

• Basic management of patients with eating disorders in medical and surgical settings

• Criteria for referral and signposting to other mental health services including liaison

• Management of behavioural disturbance in medical and surgical settings including:

1. • assessment

2. • environmental measures

3. • use of appropriate drug treatments

4. • management of delirium tremens

5. • management of other drug withdrawal states.

Developing clinical services is challenging. This is especially the case for liaison psychiatry where, at the time of writing, there are no direct requirements for services to exist, knowledge about the functions of liaison psychiatry is generally limited among both managers and other clinicians, and service models vary significantly. However, there have been many successful developments. This chapter aims to give an outline of how such developments may be achieved.

The chapter is based on the expansion of an existing liaison psychiatry service in an acute hospital for adults over 18 years of age in England that takes referrals from all areas of the hospital. However, the principles should apply to services in other countries, covering other ages or service models and be applicable even if there are changes in specific drivers for service development. The chapter also applies to setting up a service from scratch, although this is generally harder unless there is already considerable local demand. It should also be valuable for those needing to defend the service against cuts, although in this case it would be especially important to identify local support and areas of resistance to, or concerns about, the service and to address these in a final report.

Summaries of relevant data and successful business cases are available on the Royal College of Psychiatrists website established to support liaison psychiatry service development (www.rcpsych.ac.uk/specialties/faculties/ liaison/members/servicedevelopment.aspx). In addition, the Academy of Medical Royal Colleges document No Health without Mental Health (2009) provides the case on need and also gives specific illustrated examples of improved outcomes.

General principles of service development and stakeholder involvement

Service development is generally not a linear process and involves a series of discussions and repeated work over several years. However, for clarity, the principles will be described as if they are sequential.

The first task of service development involves engaging stakeholders by increasing their awareness and knowledge of what a liaison psychiatry service does, what clinical areas it addresses, what skills are needed in the team and how should it lead to clinical, financial or other benefits. It is important not to underestimate this work. Personal relationships and, if present, the reputation of your team's existing work are likely to be as crucial as more factual evidence in determining successful development.

Biopsychosocial assessment of patients

Carry out a full biopsychosocial assessment of patients, in medical and surgical settings, with physical health problems, physical symptoms and mental health symptoms, impaired mental well-being or psychological distress, including:

1. • systematic documentation of the chronology of the patient's medical history, including use of timelines

2. • working with other clinical members of the liaison team

3. • know the epidemiology and common presentations of psychological problems in medical and surgical settings

4. • use of appropriate questionnaires in medical & surgical settings and recognise their limitations.

Guidance

The trainee should be observed interviewing a patient who is not previously known to them. This competency will usually be assessed using an Assessed Clinical Encounter (ACE); however, subcomponents may be assessed using a mini-ACE (e.g. in the context of a patient review).

Construct

The trainee should be able to take a history in a physically ill patient or in a patient with medically unexplained symptoms, exploring aspects such as previous medical problems, family illness and associated life events or ongoing stressors. Trainees should focus on the importance of timelines and illness chronology, as well as exploring the patient's understanding of their illness. Trainees should utilise the full range of available information, such as patient notes, informants, carers and staff on the ward. They should also be able to suggest, initiate and interpret appropriate investigations, including physical investigations and collecting corroborative information.

Mental state examination

Carry out a basic mental state examination identifying specifically:

• mood

• psychosis

• delirium

• insight

• understanding.

Guidance

This could be done with a new patient or during a ward review, most commonly using a mini-ACE. Several workplace-based assessments will be required to cover the range and depth of psychopathology.

Construct

The trainee should be able fully to differentiate between overvalued ideas, delusions, illusions and hallucinations, and explore the patient's health beliefs, expectations and understanding. The trainee should be able to diagnose delirium (acute confusional state), using appropriate history-taking and examination, including cognitive testing. Trainees should explore all perceptual areas and use appropriate questions in order to determine mood disturbance in physically ill patients.

Capacity

Be able to determine capacity, based on an understanding of the concepts.

Biopsychosocial assessment of patients

Carry out a full biopsychosocial assessment of patients, in medical and surgical settings, with physical health problems, physical symptoms and mental health symptoms, impaired mental well-being or psychological distress, including:

Guidance

The trainee should be observed interviewing a patient who is not previously known to them. This competency will usually be assessed using an Assessed Clinical Encounter (ACE); however, subcomponents may be assessed using a mini-ACE (e.g. in the context of a patient review).

Construct

The trainee should be able to take a history in a physically ill patient or in a patient with medically unexplained symptoms, exploring aspects such as previous medical problems, family illness and associated life events or ongoing stressors. Trainees should focus on the importance of timelines and illness chronology, as well as exploring the patient's understanding of their illness. Trainees should utilise the full range of available information, such as patient notes, informants, carers and staff on the ward. They should also be able to suggest, initiate and interpret appropriate investigations, including physical investigations and collecting corroborative information.

Mental state examination

Carry out a basic mental state examination identifying specifically:

Guidance

This could be done with a new patient or during a ward review, most commonly using a mini-ACE. Several workplace-based assessments will be required to cover the range and depth of psychopathology.

Construct

The trainee should be able fully to differentiate between overvalued ideas, delusions, illusions and hallucinations, and explore the patient's health beliefs, expectations and understanding. The trainee should be able to diagnose delirium (acute confusional state), using appropriate historytaking and examination, including cognitive testing. Trainees should explore all perceptual areas and use appropriate questions in order to determine mood disturbance in physically ill patients.

Developing clinical services is challenging. This is especially the case for liaison psychiatry where, at the time of writing, there are no direct requirements for services to exist, knowledge about the functions of liaison psychiatry is generally limited among both managers and other clinicians, and service models vary significantly. However, there have been many successful developments. This chapter aims to give an outline of how such developments may be achieved.

The chapter is based on the expansion of an existing liaison psychiatry service in an acute hospital for adults over 18 years of age in England that takes referrals from all areas of the hospital. However, the principles should apply to services in other countries, covering other ages or service models and be applicable even if there are changes in specific drivers for service development. The chapter also applies to setting up a service from scratch, although this is generally harder unless there is already considerable local demand. It should also be valuable for those needing to defend the service against cuts, although in this case it would be especially important to identify local support and areas of resistance to, or concerns about, the service and to address these in a final report.

Summaries of relevant data and successful business cases are available on the Royal College of Psychiatrists website established to support liaison psychiatry service development (www.rcpsych.ac.uk/specialties/faculties/ liaison/members/servicedevelopment.aspx). In addition, the Academy of Medical Royal Colleges document No Health without Mental Health (2009) provides the case on need and also gives specific illustrated examples of improved outcomes.

General principles of service development and stakeholder involvement

Service development is generally not a linear process and involves a series of discussions and repeated work over several years. However, for clarity, the principles will be described as if they are sequential.

The first task of service development involves engaging stakeholders by increasing their awareness and knowledge of what a liaison psychiatry service does, what clinical areas it addresses, what skills are needed in the team and how should it lead to clinical, financial or other benefits. It is important not to underestimate this work. Personal relationships and, if present, the reputation of your team's existing work are likely to be as crucial as more factual evidence in determining successful development.

Competencies for all psychiatrists

As specified for all doctors, plus the following.

• Full biopsychosocial assessment of patients, across the age range, with physical health problems, physical symptoms and mental health symptoms or psychological distress, including:

• Mental state examination in difficult circumstances:

• Assessment of self-harm across the age range, including children

• To advise competently on the treatment of patients with chronic mental health problems while in the general hospital

• Knowledge of medical and surgical treatments and conditions that have an impact on mental state

• Anxiety, depression and psychotic states in in-patients in medical and surgical settings

• Assessment of general medical and surgical admissions

• Demonstrate knowledge of management of alcohol and substance misuse problems in medical and surgical settings

• Diagnose psychiatric symptoms in the presence of confounding severe physical illness and biological symptoms (e.g. cancer, renal disease, severe trauma)

• Implementation of appropriate management plans, including the use of basic psychological, social and environmental interventions as well as psychotropic use from the British National Formulary

• Use risk assessment to advise management plan

• Review notes and drug cards, including investigations and results

• Awareness of medical, surgical and nursing assessment and management plan in the general hospital and its interaction with mental state

• Assessment of patient in A'E

• Identification of medically unexplained symptoms

• Identification, investigation and advice on the immediate management of delirium

• Basic management of patients with eating disorders in medical and surgical settings

• Criteria for referral and signposting to other mental health services including liaison

• Management of behavioural disturbance in medical and surgical settings including: