A recent report highlights the extent of the gap between physical and mental health care in acute hospitals, where patients’ co-existing mental health conditions are often ignored
The National Confidential Enquiry into Patient Outcome and Death looked at how acute general hospitals manage mental health problems in patients admitted for a physical health issue. Its report, Treat as One, shows that co-existing mental health conditions are often overlooked or neglected in acute hospital settings.
Citation: Muir D (2017) Neglect of mental health problems in acute general hospital inpatients. Nursing Times [online]; 113: 6, 48-49.
Author: David Muir is practice educator in critical care, Hull and East Yorkshire Hospitals Trust; postgraduate research student, University of Hull; and was a case reviewer for the Treat as One report.
The acute care pathway is an important part of healthcare experienced by people with mental health conditions. However, the National Confidential Enquiry into Patient Outcome and Death undertook a study into the management of mental health problems in patients admitted to acute hospitals for physical health problems. Its 2017 report on the study, Treat as One: Bridging the Gap Between Mental and Physical Healthcare in General Hospitals, confirms long-standing concerns about the disparity between the treatment of mental and physical health conditions, and the undue emphasis, in healthcare, on physical health (NCEPOD, 2017).
When patients with a mental health disorder are admitted to acute general hospitals, their mental health problems are often overlooked, misunderstood or neglected; the NCEPOD study gives insights into the scale of the problem.
People with a physical health problem are 2-3 times more likely to have a mental illness than the general population (Parsonage et al, 2012). The most common mental health problems experienced by acute hospital inpatients are self-harm, depression, delirium, dementia, adjustment reactions and alcohol-related disorders (Royal College of Psychiatrists, 2013).
Patients in acute general hospitals who have mental health problems require psychiatric intervention or review, normally provided by liaison psychiatrists. They also need adequate multidisciplinary discharge planning. Liaison psychiatry (LP) services are not always available in acute general hospitals to assess and manage patients with mental health problems, and there is variation in roles and organisational structure where they are available.
NCEPOD conducted a retrospective analysis of data from hospital records of patients admitted for a physical health problem who also had a known mental health problem and/or were detained under mental health legislation. Case reviewers then reviewed the quality of care. The study found shortfalls in liaison, treatment and discharge planning.
Questionnaires were sent to acute trust hospitals, liaison psychiatrists and representatives of healthcare organisations across the UK. Those sent to acute hospitals asked which clinician was responsible for identified patients at time of discharge from the general setting. Information was collected on patients’ care, past medical history and mental health condition, mode of admission into hospital and initial management, mental capacity assessment, consent and communication, interventions, escalation in care and end-of-life or discharge planning. Of 1,064 questionnaires distributed, 782 (73.5%) were completed.
A total of 346 liaison psychiatrists completed clinical questionnaires about assessment and review by the psychiatric liaison team and input from the mental health team. Organisational questionnaires were sent to the medical directors of hospitals where patients with a mental health problem may be treated for a physical condition; 231 were returned completed.
Data collection was restricted to a one-month period. Children, pregnant women and patients having day surgery were excluded from the study.
From the data, 11,950 adults who had a physical illness and co-existing mental health condition were identified. Around five case notes from each of the 200 hospitals involved were selected. A typical case mix comprised:
- One patient who self-harmed during their hospital stay;
- One patient who was admitted to critical care or died during their hospital stay;
- One patient who had been admitted from, and/or was discharged to, a mental health hospital;
- Two patients who had stayed in hospital for more than 72 hours.
Case reviewers were able to assess 552 cases. The remainder of the notes and questionnaires were either incomplete or returned after the deadline.
Of 552 admissions examined, 351 (63.6%) had occurred through the emergency department (ED), while 80 (14.5%) patients had been referred by their GP and 57 (10.3%) transferred from a mental health hospital or another general hospital. The remainder were either referred by outpatients or an unknown admission process was used.
Admissions via the ED
Of the 351 patients admitted via the ED, 55 (15.7%) were referred to LP and 32 were seen within an hour – as recommended by the Royal College of Emergency Medicine (2013). The lack of LP input in the ED affected the overall quality of care of 20 patients.
Quality of care
Having an LP team, especially one accredited by the Psychiatric Liaison Accreditation Network (PLAN) (Box 1), was associated with better quality of care. Good practice in mental health care was demonstrated in:
- 40.8% (20 out of 49) of cases in hospitals without an LP team;
- 46.2% (97 out of 210) of cases in hospitals with a non-PLAN-accredited LP team;
- 59.8% (58 out of 97) of cases from hospitals with a PLAN-accredited LP team.
Box 1. The Psychiatric Liaison Accreditation Network
The Psychiatric Liaison Accreditation Network improves the quality of mental health care provided in general hospitals by ensuring liaison psychiatry teams meet standards and engage in quality improvement. About a third of acute general hospitals in the UK have a PLAN-accredited liaison psychiatry team, and over 50 are currently working towards accreditation.
Multidisciplinary discharge planning was noted in 209 (49.4%) out of 423 discharged patients. Discharge management plans were changed following multidisciplinary team (MDT) meetings in 45 out of 107 patients for whom an MDT meeting was documented, demonstrating the value of these meetings in discharge planning. However, LP was only involved in 20 (18.7%) MDT meetings. Delayed discharge occurred for 65 (15.4%) out of 423 patients. Case reviewers considered the mental health condition to have contributed to delays in 25 of the 65 delayed discharges.
Discharge summaries omitted the mental health diagnosis in 95 (27.9%) of 340 patients. From the group of 347 discharge summaries available to case reviewers, three were found to be non-applicable and four contained insufficient data. Details of mental health medications were omitted in 90 patients. None of the discharge summaries were copied to the relevant out-of-hospital psychiatry consultant.
Treat as One reveals a larger-than-anticipated divide between physical and mental health care. A large group of acute hospital patients have significant mental health conditions, but not all receive adequate care for them. The report makes six key recommendations (Box 2) and 21 further recommendations; most can be addressed by organisations but some require national initiatives.
Box 2. Key recommendations
- Mental health conditions should be documented and assessed in referral letters and in emergency department and admission documentation
- National guidelines on the management of mental health conditions should be developed for general hospital staff
- Liaison psychiatry reviews should provide documented plans for the general hospital notes
- All hospital staff in contact with patients should receive training in mental health conditions
- Liaison psychiatry should be fully integrated into general hospitals
- Record sharing between mental health settings and general hospitals needs to be improved
Source: Adapted from National Confidential Enquiry into Patient Outcome and Death (2017)
Integrated LP departments are the most effective link between services in general hospital; national guidelines are required to guide the referral process and establish a national approach to LP.
Mental health problems should be documented for all patients and early referrals made when needed. Nursing documentation may need to be redesigned to include mental health assessment and management. Treat as One will hopefully lead to more mental health training and education for general nurses at both undergraduate level and in continuing professional development.
- Co-existing mental health problems of patients admitted to acute hospitals with a physical ailment are often overlooked, misunderstood or neglected
- Not all acute hospitals have a liaison psychiatry service to manage patients’ co-existing mental health issues
- A recent report found shortfalls in liaison, treatment and discharge planning for acute hospital patients with co-existing mental health issues
- Improvements are needed in documentation, referrals, discharge planning and record sharing
- A national approach towards liaison psychiatry, and better training of staff in mental health issues, are also needed
National Confidential Enquiry into Patient Outcome and Death (2017) Treat as One: Bridging the Gap Between Mental and Physical Healthcare in General Hospitals.
Parsonage M et al (2012) Liaison Psychiatry in the Modern NHS.
Royal College of Emergency Medicine (2013) Mental Health in Emergency Departments: A Toolkit for Improving Care.
Royal College of Psychiatrists (2013) Liaison Psychiatry for Every Acute Hospital: Integrated Mental and Physical Health.