Liaison psychiatry: a brief history

Aitken et al suggest that it was the bringing together of the alienists (asylum doctors) and academics that ‘enabled’ liaison psychiatry to be recognised as a subspecialty by the newly founded Royal College of Psychiatrists. ¹ However, I would argue that change in the practice of psychiatry prior to that date was much more determined by the Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency ² that led to the 1957 Mental Health Act. Foremost among its recommendations were:

1. (1) to place mental illness and mental deficiency on the same footing as other illnesses or disabilities

2. (2) to abolish special designation of psychiatric hospitals

3. (3) to expand community services.

Subsequently, W. S. Maclay gave an academic address to the 1st Canadian Mental Hospitals Institute entitled Experiments in Mental Hospital Organisation, in which he outlined the likely future progression of these recommendations based on developments in the Manchester region. As early as 1948 the medical administrative staff of the Manchester Regional Hospital Board had begun to address how best to serve the care of psychiatric patients. It was agreed that psychiatric care should be as far as possible analogous to that of all healthcare – community facilities together with primary medical services, and secondary medical provision within local general hospitals. Psychiatric units of 100 to 200 beds were developed within district general hospitals (DGHs) and a consultant psychiatrist and support staff appointed to each unit from 1954.

Initially, there was little or no support from the large hospitals or academic psychiatric departments of the region. However, the regional clinical research committee requested a review of such units in 1960. This was carried out by Dr Stanley Smith, the superintendent of a large mental hospital. It is worth quoting the final paragraph of his ‘Review of Psychiatric Units Associated with General Hospitals in the Area of the Manchester Regional Hospital Board’:

‘In my view they (these units) may well be the most significant social development in British psychiatry today’.

The existing DGHs of the Manchester region were based on the needs of individual communities (‘ecologies’). They were built physically and conceptually from the provision made available by central and regional health services, local government and the community and charitable resources of each area. ‘Liaison’ was implicit to successful provision of overarching healthcare in such facilities.

Services continued to evolve in the DGH psychiatric unit in which I had my longest experience – and which served 200 000 people. These included in-patient beds for people with acute illness, those with chronic illness and elderly patients. A number of beds on the general wards were assigned to psychiatry; they were used for investigation of mental illness and for drug withdrawal. Additionally, beds were held on medical wards for the direct admission of patients who had attempted suicide by drug overdose – these were seen by consultant psychiatrists and social workers before discharge. The average duration of stay of all in-patients was 3 to 4 weeks throughout those 30 years.

Progress in modes of psychiatric treatment was readily acknowledged by the hospital management. The advent of behaviour therapy led to the establishment of a clinical psychology department in 1966 – probably the first of its kind in a DGH. Psychiatric social workers were attached to each consultant team. The laboratory biochemical facilities were extended to allow monitoring of drug therapy and substance misuse.

Before the formal role of community psychiatric nurse was established, nurses from the hospital used to visit patients in their homes if this was felt appropriate. Readily available links to psychiatric assessment were made with the police, the large local Salvation Army hostel and local organisations that dealt with homelessness. A drug team was jointly established with the local authority. An industrial unit served those with work maladjustment. An Alcoholics Anonymous group held its meeting within the hospital. There was a well-recognised postgraduate teaching centre within the DGH which organised regular seminars that included psychiatric topics.

Consultant numbers grew from one to four, enabling a duty consultant to cover intra-hospital consultations and out-of-hours emergency calls from whatever source, in addition to requests from primary care and community organisations. All waiting list referrals were seen within 4 weeks. All the intervention categories that Aitken et al describe were part and parcel of the service.

Guthrie et al commented that one of the most difficult aspects of any provision is that of measuring outcomes. ³ The DGH model aimed to give ‘comprehensive’ healthcare to a district, defined as the smallest population for which such healthcare could be satisfactorily planned, organised and provided. This required the greatest possible co-ordination between health services and the local authority, particularly social services. The majority of districts were expected to serve a population of less than 250 000.

Owing to the closed population and ready liaison with groups and individuals, outcomes could easily be measured. Follow-up clinics, re-referrals and community responses, together with statutory and non-statutory data collection, ensured awareness of changing needs. The importance of early clinical intervention and continuity of care became apparent and data were used to sustain appropriate staffing, bed numbers and budgeting in the DGH.

Lastly, it is my personal view that the Mental Health Act 1983 and the establishment of mental health trusts have hugely emphasised the dichotomy between mental and physical healthcare. I believe that liaison – intimate communication – with both the individual and his or her ‘ecosystem’ is necessary to all good quality care and cannot be prescribed. It is not particular to psychiatric practice; it is the hallmark of good doctoring in all specialties.