Origins of a Section: liaison psychiatry in the College

Why has liaison psychiatry been slow to develop in the UK? The asylum mentality and the current flight into the community have focused psychiatric resources on chronic psychotic illnesses, neglecting the psychological problems of general hospital patients. Nevertheless, there is abundant evidence that medical and surgical patients have a high prevalence of psychiatric disorder that can be effectively treated with psychological or pharmacological methods.

Until the 1970s specific liaison psychiatry services were virtually unknown in Britain. The separation of psychiatric services from university and district general hospitals made it difficult to provide an effective service. Patients referred from other medical specialities were seen as ward consultations by general psychiatrists, or allocated to general psychiatry out-patient clinics. A small number of specialised consultant posts were established but there was no officially recognised body to represent liaison psychiatry.

Inception and early development

Informal discussions between interested clinicians took place in the early 1980s and a consensus emerged that liaison psychiatry would be served best by establishing a group within the College. A letter to the Bulletin drew a response that indicated there was considerable enthusiasm for establishing a national group to provide a forum for clinical, research and teaching interests in the field of consultation and liaison psychiatry (Mayou et al, 1982). A preliminary meeting was held during the College quarterly meeting in Oxford in 1983, followed by a further meeting during the Annual General Meeting in Edinburgh in 1984. The College was then persuaded to recognise liaison psychiatry as a special interest group, although there was opposition from some senior Fellows who did not regard liaison psychiatry as a distinct clinical activity. A survey of members of the group (Mayou & Lloyd, 1985) indicated that there was substantial clinical and academic activity but respondents complained there was insufficient time to carry out all aspects of the work satisfactorily. Services appeared to have developed haphazardly and few districts had given priority to developing liaison psychiatry. Most of the services were provided by general psychiatrists, some of whom had a special interest in liaison psychiatry. Only nine full-time liaison posts were identified in adult psychiatry and one in child psychiatry. Little had changed by the time a second survey was undertaken 5 years later (Mayou et al, 1990).

Richard Mayou, who had been the prime mover in establishing the group, was elected chairman and served in this capacity until 1989. Subsequently the chair has been taken by Francis Creed (1989-1993), Christopher Bass (1993-1997), Allan House (1997-2000) and Geoffrey Lloyd (2000-). Rachel Rosser, Geoffrey Lloyd, Charlotte Feinmann, Trevor Friedman, Allan House, Robert Peveler and Elspeth Guthrie have held the post of secretary. The first residential meeting was held in Oxford in September 1987. Its success was vital to the development of the group and the annual residential meeting has now become an established event in the College's calendar.

The increased recognition and status of liaison psychiatry have led to the creation of a growing number of consultant posts and a handful of university chairs. By 1996 there were 86 consultants in England, Scotland and Wales who carried out specific liaison work, 43 of whom had either full-time or half-time posts in liaison psychiatry (Guthrie, 1998). Sixteen new posts had been created during the previous 2 years but staffing levels still fell below the College's recommended guidelines of 0.4 fulltime equivalent posts per 100 000 population. Many large general hospitals now have a distinct liaison psychiatry service and these developments have enabled more trainees to acquire relevant experience, although training opportunities are not evenly distributed (Burlinson & Guthrie, 2001). The College has recognised this by elevating the group to the status of a Section in 1997.

Training and education

Members of the Section have advised the College on the desirable content of training posts at senior house officer and specialist (senior) registrar level, emphasising the need for regular supervision by a consultant with a special commitment to liaison psychiatry (House & Creed, 1993). College representatives on advisory committees for consultant appointments should ensure that candidates have fulfilled the training requirements before an appointment is made. Recommendations have also been made to improve undergraduate education and the psychological and psychiatric aspects of general patient care (Sharpe et al, 1996).

The section has been keen to hold joint meetings with other organisations, thereby involving other medical specialists and non-medical professionals who treat similar patients. Several meetings have been held with the British Diabetic Association and biennial meetings with the Society for Psychosomatic Research. Joint meetings have also been held with liaison psychiatrists from Holland, Portugal and the Nordic countries. Building on the success of these international meetings, members of the Section have been active in the recent establishment of the European Association for Consultation—Liaison Psychiatry and Psychosomatics.

Of crucial importance has been the development of links with other Royal Colleges. Two joint conferences with the Royal College of Physicians of London were held on medically unexplained symptoms (Creed et al, 1992), and psychiatric aspects of physical disease (House et al, 1995). These facilitated the establishment of a joint working party on the psychological care of medical patients, whose report made recommendations on the provision of a liaison service in each general hospital and on the training of medical and other staff in recognising and managing psychological problems in medical patients (Royal College of Physicians & Royal College of Psychiatrists, 1995). The report further recommended that purchasers of health care should expect providers to meet the psychosocial needs of patients attending general hospitals; acute services that failed to make such provision should not be purchased (Royal College of Psychiatrists & Royal College of Physicians, 1995). A joint working party with the Royal College of Surgeons published a similar report on the psychological care of surgical patients (Royal College of Surgeons & Royal College of Psychiatrists, 1997). This underlined the importance of training clinicians to recognise psychological problems in surgical practice. Surgical teams working in areas of high psychiatric morbidity, for example, breast care, pain control, cancer and cosmetic surgery, should identify staff members who would be trained in the delivery of effective psychological care. For help with the management of problem cases every surgical team should have rapid access to a consultant-led liaison psychiatry team. A joint working party with the British Association for Accident and Emergency (A&E) Medicine (Royal College of Psychiatrists, 1996) made recommendations on the provision of safe and secure assessment facilities in all A&E departments and on the availability of appropriate educational facilities for relevant staff. Like the other documents, this report stressed that a high quality psychiatric service depends on an adequately staffed multi-disciplinary liaison psychiatry team. A further report is being prepared with the Royal College of Obstetricians and Gynaecologists.

Members of the section have made major contributions to Council Reports on the management of chronic fatigue (Royal College of Physicians et al, 1996) and deliberate self-harm (Royal College of Psychiatrists, 1994) and to the College seminars series (Guthrie & Creed, 1996). There have also been publications on the planning, organisation and management of services (Benjamin et al, 1994), including specialist settings (Peveler et al, 2000).

The future

With a current membership in excess of 1500, the liaison psychiatry section has obviously met a need of College Members. It has helped develop criteria for training and encouraged the establishment of liaison services with specific consultant appointments. It is the only national body to represent liaison psychiatry in the UK. Its future will be intimately linked with the development of liaison psychiatry as a specific area of psychiatric practice and research and it is uniquely placed to shape this development. The regrettable separation of psychiatry from the rest of medicine, embodied in the establishment of separate community mental health trusts, will increase the need for a psychiatric service dedicated to the psychological needs of medical and surgical patients in general hospitals. The funding and management arrangements for such a service needs to be clarified and agreed nationally. With mental health trusts moving their resources into community facilities it would be appropriate for liaison psychiatrists to look to general hospital trusts for financial support. The further development of liaison psychiatry will largely depend on the ability of its exponents to convince purchasers that this element of medical care is an essential component of a high quality health service.