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Patient feedback on liaison mental health care in A&E

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VOL: 98, ISSUE: 21, PAGE NO: 34

Patrick Callaghan, PhD, MSc, RMN, is a senior lecturer, Department of Mental Health and Learning Disability, City University, London;Sarah Eales, BSc, RMN, is a research assistant, City University, London;Tim Coats, MD, is a senior lecturer and A&E consultant, University of London and the Royal London Hospital;Len Bowers, PhD, MSc, RMN, is professor of psychiatric nursing, City University, London;Jennie Bunker, RMN, DipHE, is manager, Emergency Mental Health Assessment and Liaison Service, Royal London Hospital

Liaison mental health nursing was developed in the 1960s in the USA (Roberts and Taylor, 1997; Robinson, 1982). Liaison nurses were regarded as clinical specialists who acted as an educational resource and whom colleagues could consult about the care of patients experiencing mental health problems. They also provided specialist psychological care to patients and their families, and liaised with other disciplines (Nelson and Schilke, 1976).

Liaison mental health nursing was developed in the 1960s in the USA (Roberts and Taylor, 1997; Robinson, 1982). Liaison nurses were regarded as clinical specialists who acted as an educational resource and whom colleagues could consult about the care of patients experiencing mental health problems. They also provided specialist psychological care to patients and their families, and liaised with other disciplines (Nelson and Schilke, 1976). Liaison nurses focused on the interpersonal problems between nurses and patients, in contrast to ‘liaison doctoring’, where the emphasis was on the diagnosis and treatment of an illness (Robinson, 1987). In the UK, liaison mental health services developed in response to the increasing number of people with mental health problems who were accessing services via A&E (Tunmore, 1997; Ryrie et al, 1997). They are now an integral part of many A&E departments (Watts, 1997) and are likely to remain so, given current government policy as outlined in the National Service Framework for Mental Health (Department of Health, 1999). Empirical evidence shows that A&E liaison mental health services reduce the demands made on general health services (Storer et al, 1987). Most studies on A&E liaison mental health nursing simply describe the service (Loveridge et al, 1997; Putman, 1998), although Storer et al (1987) and McEvoy (1998) reported some evaluation. However, none systematically elicited the views of service providers, users or stakeholders on the value of the service. This paper evaluates the work of a liaison mental health service in East London. The specific aims of the study were: - To describe referrals to the service during a one-year period; - To investigate service users’ views on the service; - To investigate users’ satisfaction with the service.

The liaison mental health service
The service at the hospital began with three liaison mental health nurses in 1998. The team currently includes mental health nurses, social workers and psychiatrists. It operates 24 hours a day and takes referrals from the police, GPs, community psychiatric nurses and other community groups. It also accepts self-referrals. The liaison team provides mental health services to the A&E department and inpatient wards.

Research methods
The researchers assessed the nature of clinical and non-clinical referrals to the service, from April 1 2000 to March 31 last year, using specially designed forms that were completed by the members of the liaison team. Non-participant observation took place over six days to enable the researchers to describe and understand the work of the service. Semi-structured interviews were conducted with all stakeholders in the service. Data was collected from all those (n=423) seen by the liaison mental health service during the research period. The researchers also interviewed a random sample of 17 users and assessed the level of user satisfaction by means of a postal questionnaire (n=71 respondents).

Data-collection measures
Part one: audit of referrals The first stage involved collecting information on clinical and non-clinical referrals (associated with the liaison service’s role in teaching and research). Information on client demographics was also collected - whether clients were known to A&E and mental health services, time of arrival, waiting time, duration of contact, and whether the client was regarded as an emergency (seen immediately), urgent (seen within an hour) or non-urgent referral (seen within a day). Data on ethnic origin was recorded using categories provided by the Commission for Racial Equality, and ethical approval for the study was obtained. The presenting problem of each referral was assessed using the Health of the Nation outcome scale (HoNOS) (Wing et al, 1996). This assesses 12 categories of symptoms, each scored from 0 (no problem) to 4 (severe to very severe problem). The diagnosis of each referral was reported using the World Health Organization’s International Classification of Diseases (ICD-10) categories (1992). Each client’s risk of violence and suicide was assessed using the Violence and Suicide Risk Assessment Scale (VAS), which identifies 10 categories of risk. The mean VAS score is calculated by adding up the scores for each category and dividing by 10. A score close to zero represents the lowest risk, with a score close to four indicating the highest risk (Feinstein and Plutchik, 1990). Part two: semi-structured interviews Using random sampling, the researchers interviewed 17 clients who had used the service in the one-year period. Part three: user-satisfaction survey Questionnaires were sent to all clients to measure seven aspects of satisfaction: efficacy; professional skills and behaviour of staff; access; overall satisfaction; information given; type of intervention and relatives’ involvement in care. Qualitative data was generated by open-ended questions about each client’s experience.

Results
Part one: audit of referrals The clients referred to the service during the study period had an average age of 33; 57% were men and 43% were women. Urgent referrals (seen within the hour) accounted for 53%; emergency referrals (seen immediately) accounted for 30%; and non-urgent (seen within 24 hours) for 17%. Emergency referrals waited an average of 17 minutes, urgent referrals waited an average of 35 minutes, and non-urgent referrals were seen within 75 minutes. Most referrals (60%) were known to A&E 57% were known to adult mental health services. More than half (53%) of those referred were single, 21% were married and 26% were divorced, cohabiting, separated or widowed. Most (67%) had no formal education, 13% had completed secondary school, and 20% had further and/or higher educational qualifications. More than half (58%) were of white ethic origin and 17% were Bangladeshi. There was a small number from black Caribbean, black British and black African backgrounds. Most lived locally, mainly in permanent accommodation (75%), 20% lived in temporary housing and 5% had no fixed abode. The diagnoses of the clients referred are shown in Table 1. Analysis of the data from the HoNOS and VAS scores showed that: - 13% of clients were physically aggressive; - 8% were seriously suicidal; - 14% were incapacitated by substance use; - 22% reported symptoms of schizophrenia; - 19% had severe depression; - 56% had relationship difficulties; - 14% experienced severe social isolation. The typical violent and suicidal person was 26 years old, male, single, white, lived in permanent accommodation and had no formal education. The typical violent person had a history of mental illness, whereas the typical suicidal person had no history of mental illness. Part two: semi-structured interviews Interviews took place either in people’s homes, while they were inpatients or at the university. The median age was 31; 59% were men and 41% were women; about half (47%) were single, lived in permanent accommodation (65%), were unemployed (53%) and described their ethnic origin as white (59%). Three themes emerged. The first concerned the practicalities of providing a liaison service in A&E. For many of the participants it was the first time they had used mental health services and they were glad to have had access to a specialist mental health professional. Most found the waiting time (median=30 min) acceptable, but some said it was too long. Similarly, views on the comfort of the surroundings varied. Privacy was an important issue and several users felt the liaison service should be sited away from A&E. The second theme involved the staff profile. Clients valued the fact that staff were qualified in mental health and knew about mental health issues. Their knowledge of local mental health support services and consideration for clients’ carers was also important to users, as was their ability to offer a different perspective on the client’s experience or suggest ways of dealing with this experience. The third theme related to the level of service. Clients raised issues such as staff knowing their background/history, and having the time to talk and make a thorough assessment. Access to a psychiatrist, receiving a diagnosis, the importance of transparency, follow-up and liaison with other services were also mentioned. Having an action plan and clear outcomes were important. One client said: ‘The second assessment was less helpful. Largely, I think, because it was indeterminate. I didn’t get any sense of where my case was going; any idea of who I might see next.’ The aspects of the service which users found most useful were: - Being seen in private by a professional trained in mental health care; - Being taken seriously, which helped clients understand their problems; - The knowledge that they could come back if they had further problems. The last point was exemplified by one client, who said: ‘It gave me a greater insight into my state of mind. It was only through talking to [the mental health nurse] that I began to grasp I might have a problem with my mental health. It was a bit of a shock but it was broken to me quite gently.’ Users were also asked to identify the strengths and weaknesses of the service. Their views are listed in Table 2, but no single strand emerges. Clients also made suggestions on how the service could be improved. These included: - Making changes to the environment: move the service out of A&E and improve privacy for people seen on the wards; - Offering clients an explanation of the outcome of the assessment and providing them with a clear plan; - Sending a follow-up letter or making a follow-up telephone call to each client; - Using hospital security rather than the police when there are problems; - Making more staff available. Part three: user-satisfaction survey Seventy-one out of 262 questionnaires were returned (27%). Quantitative responses showed a high level of satisfaction (see Fig. 1 overleaf), but the replies to the qualitative questions were not as complimentary. Although 24 people rated staff attitudes as positive, three rated them as negative. In addition, although 10 people felt positive about the listening skills of staff, six felt they were ‘not understood’. Waiting times produced the most dissatisfaction: 18 people said these were unsatisfactory, with only four being satisfied.

Discussion
The median age of referrals in this study concurs with previous data. The ethnic mix of clients reflects the ethnic breakdown of people living in the area served by the study hospital (East London and the City Authority, 1999). The service is provided mainly to people living in the catchment areas of the hospital and mental health trust, but some clients reside in temporary accommodation or have no fixed abode, creating difficulties for follow-up. The study found that the main diagnosis was depression (Table 1), a finding similar to that of previous research (Ryrie et al, 1997). Beech and Valiani (2000) found that self-harm was the most common primary and secondary reason for referral, but it did not rate highly in the reported diagnoses in our study. Most referrals were seen in A&E and not on the wards, suggesting that the liaison service needs to publicise the fact that it is available to inpatients. For most clients the outcome was referral to various community services, a finding that supports the results of previous studies (Ryrie et al, 1997; Loveridge et al, 1997). Beech and Valiani (2000) reported an admission rate of 42% for those seen by the liaison mental health service, but in this study the admission rate was much lower. A significant number of clients were new to mental health services, suggesting that the liaison service is an important first step towards care and support for people who might otherwise be overlooked. This directly addresses Standard 4 of the National Service Framework for Mental Health. However, most clients were known to adult mental health services, suggesting an additional level of support to that they may already be receiving in the community. Views on privacy varied. Clients clearly expect privacy while being assessed. Identifying how best to acknowledge and meet this need could lead to greater satisfaction with the service. They also indicated that follow-up would be helpful, so how this might work in relation to the 25% of people who live in temporary accommodation or have no fixed abode should be considered. Our findings support the contention that the evaluation of users’ reports of dissatisfaction with services depends on the methods used to analyse the answers. The quantitative data showed high levels of satisfaction but the qualitative data offered a different perspective. The quantitative measure may have overestimated satisfaction.

Conclusion
This study is the first attempt to comprehensively evaluate a liaison mental health service. The data collected offers an insight into a service that is a first point of contact for people with mental health needs that also meets the goals of the National Service Framework for Mental Health. The best method of assessing client satisfaction (that is, one that produces most benefit for least cost) has not been determined, but we have shown that the way data is collected affects results. Future work will concentrate on investigating why this occurs. - The study was funded by the NHS R&D levy

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