Liaison psychiatry and general hospital management

In their excellent editorial Lloyd & Mayou (2003) lament the lack of substantial progress in the development of liaison psychiatry. They refer to Scotland's greater cognisance of liaison psychiatry (Scottish Executive Health Department, 2000), before reaching practical conclusions, foremost among which is for liaison psychiatry services to be managed by the acute hospitals they serve. They also refer to Kendell's analysis of the physical–mental divide (Kendell, 2001). I wish to pick up these points.

As a mentor after I took up post in Edinburgh, Bob Kendell impressed on me his view that liaison psychiatrists were ‘ambassadors of psychiatry’ in the general hospital. He pointed out that, for most hospital specialists, liaison psychiatrists would be the only psychiatrists they were likely to encounter – so we had to be available, approachable, helpful, practical, considerate and sensible; we had to be good clinical psychiatrists and we had to resolve problems rather than cause them.

That does not mean liaison psychiatrists cannot bring special skills to the workplace, but it does imply that such skills have to be welded to basic clinical nous and rapport with colleagues. The significance of this is increased in a world in which we tend to be more valued by physicians than fellow psychiatrists – perhaps increasingly so as psychiatry becomes focused on severe and enduring mental illness, and other forms of disability, suffering and resource demand are marginalised.

Next, I made the leap from mental health to general hospital management when trusts were first mooted (without understanding the implications – it just felt right), and this turned out to be a fortuitous decision. Liaison psychiatry at the Infirmary rapidly expanded as I planned with medical colleagues solutions to the clinical problems we faced: some funds came through the Trust Improvement Programme and some from individual directorates seeking to purchase consultant sessions. I do not believe this initiative would, or could, have happened had I remained with the mental health unit. Now the rest of Scotland has progressed as the Executive's intentions have been made good – notably, with the appointment of four consultant liaison psychiatrists and 10.5 liaison nurses in Glasgow.

The consequences of going with the acute trust have been far-reaching. Psychiatry is not regarded as an alien speciality – we are seen as assets. We understand the environment and the pressures and we respond to the needs that arise rather than pursue a purist agenda. Crucially, we appreciate that what the acute hospital requires primarily from its psychiatric service lies in the areas of rapid assessment, immediate management and optimal resource usage rather than the proven areas of effectiveness that are highlighted as the rationale for spending on liaison psychiatry.

As a tangible illustration of our significance and role, the department of psychological medicine in Edinburgh's new Royal Infirmary has not been located up some back alley or on the top floor. We are sited on the ground floor near the hospital's front door because we are recognised as a key constituent in the modernisation agenda that has swept through acute medical care in the hospital. Without ‘going native’ I doubt that much of this progress would have occurred – so seek to make this management leap rather than sticking with tried and trusted strategies that have been found wanting.