What is Liaison Psychiatry?

Recently, I was asked by a reader "what is liaison psychiatry?" Liaison psychiatry is a unique specialty providing psychiatric treatment to patients attending general hospitals, dealing directly at the interface between mental and physical health. Specific liaison psychiatry services were set up in the 1970's and in 1997 liaison psychiatry was recognised as a distinct Royal College of Psychiatry Facualty.

The requirement for liaison psychiatry is evident from the high prevalence of psychiatric disorders within the general hospital setting. In fact, the prevalence of psychiatric disorders amongst general hospitals patients is much higher than the general population[1]. Epidemiological studies have revealed that the prevalence of mental disorders in general hospital inpatients range from 41.3% to 46.5%[2]. It has been reported that unless a specific liaison psychiatry service exists within the general hospital, a significant proportion of psychiatric co-morbidity remain undetected and untreated[3]. To add to this, advancements in medical technology such as, intensive care treatment, organ transplantation and cardiac surgery[2] have had an important knock on effect, increasing the workload for liaison psychiatry.

[1] Department of Health 1994
[3] Mental Disorders in General Hospital Patients Rothenhausler HB. Psychiatr Danub. 2006 Dec;18(3-4):183-92.
[3] Business Case For Consultation-Liaison Psychiatry Service Southampton (Peveler, Kenwood, Martin; August 1995)

Knowledge Brokers - A Welcome Role?

It is well known that advancements in medicine bring challenges to ethical and legal boundaries as to how to apply the new medical knowledge. This week the High Court ruled that a woman in persistent vegetative state (pvs) could be given an experimental treatment, contrary to her family’s wishes. The 53 year old woman had been diagnosed with pvs after she suffered a brain haemorrhage during a holiday in August 2003. The experimental treatment involved the drug zolpidem - a frequently prescribed medication for insomnia. There are a small number of case reports with the unexpected finding that this medication has brought people round from pvs for a few hours, just 20 minutes after administration. One theory is that if pvs victims awake, even temporarily, they can be asked what further care they would wish.

The High Court decided to give the go-ahead for a zolpidem trial, believing that it may offer a glimmer of hope for recovery. This was despite her family being concerned that if she awoke she may be very upset upon learning about her condition. Her family’s preferred option was for her not to undergo any experimental treatment. Unfortunately, in her case, zolpidem did not increase her responsiveness, in fact, it seemed that it had its normal intended effect causing her to become even more sleepy. Following this report the Dignity in Dying chief executive Deborah Annetts said the decision was deeply troubling as "the human rights of the woman at the centre of this case are being ignored, and she is effectively being treated as a guinea pig."

Coincidentally, this week the British Medical Journal (Jonathan Lomas BMJ 20/01/07) discussed the need for the latest research to be made more accessible and more understandable. “In the case of research, accumulating sequential processes reveal…often haphazard cycles of discovery and validation.” To aid communication the idea of ‘knowledge brokers’ was mooted.

With research becoming ever more diverse, it is perhaps increasingly important to be aware of new advancements and consequences before applying new techniques to new situations. In the modern age of an increasingly democratic media, the often mysterious world of research arguably needs to respond with greater transparency. The proposal for knowledge brokers is therefore a welcome one, and if implemented thoroughly it could have wide-ranging effects. Not only would it help to bring together the various strands of learning and research into a more cohesive, interdependent body, it could also be used to good practical effect on a day-to-day basis.

Cases such as the one discussed above, highlight the need for a comprehensive review of all the literature and research available. 'Knowledge brokers' may have been extremely well-placed not only to review the research material but also to explain it to the health providers, family and the court.

Thought of the Week

The death of a child is always sad. Last week mother Rosalind Ponomarenko-Jones buried her 19 year old daughter who died from anorexia. She said "burying a child is probably the hardest thing any parent has to contemplate."

This news comes in a week when some fashion shows are not following the advice that models should have a body mass index (BMI) over 18. Rosalind pointed out "When I was a child, smoking was seen as glamorous, but now we all know that it kills. It is hardly seen in films and never promoted in other media. I think the same should be true of emaciated women. Thinness should carry a health warning just like obesity."

A Life Dedicated to the Safety of Others

Samuel Plimsoll (born 1824)

Upon the side of ships you will find the ‘Plimsoll mark’: a circle with a horizontal line across it to guarantee that no ship is loaded so heavily that the line is submerged under water. His symbol spelled the difference between life and death for untold thousands of sea merchants.

It seems incredulous that ships were actually sent out to sea overloaded and not seaworthy, but heavily insured. The men who sailed in these ‘coffin ships’ were doomed, no trade unions were there to defend them; no laws gave them any protection. However, Samuel Plimsoll devoted his life to championing their cause and fought for change via the House of Commons.

He wrote a book called ‘Our Seamen’, which was an attack on ship owners, for the existence of the extreme evil of coffin boats and for the absence of humane conditions of life at sea. After much political debate, his book rallied the moral force of public opinion and the Merchant Shipping Act was passed. This ensured sea vessels could to be examined and detained if deemed unsafe.

Quotation from Samuel Plimsoll
“I cannot trust myself to say what I think or feel in plain English. I shall therefore put my feeling into my work. And, oh! How I will work!”

In response to Why The NHS Needs People Power, Will Hutton

Will Hutton wrote an interesting article (British Medical Journal13/1/07) suggesting the need for more local involvement in the NHS. However, the institutionalising mechanisms he suggested such as, surveys, citizen juries and focus groups for introducing democracy, may not be sufficient. Once these become more than merely small guides to the direction of public opinion and start to take on the significance of affecting policy, they would have to satisfy certain basic democratic requirements such as fairness, transparency and above all, being open to all. If they were to satisfy all of these, they would stop being focus groups or surveys and instead would be, in effect, the same as local elections. If we are to have local elections, it may be sensible to consider using existing structures.

For example, if the whole structure of the NHS is simplified down to as few layers as possible, perhaps making health authority boundaries coincide with those of local authorities, then many elements of the decision-making process could be handed over to local politicians. For example, with the democratic safeguard, national government could hand over powers to set targets and potentially even budgets. Primary Care Trusts (PCTs) could hand over the power of commissioning to make local authorities in effect into ‘local commissioning bodies’. The local authorities would then be responsible for implementing the will of the people through the mechanism of local politicians. This would not only invigorate local democracy but it would make the NHS far more responsive to local needs.

This has been added as a response to the BMJ article on eBMJ.

Can Gerry Robinson Fix the NHS? – Let’s hope the answer is ‘Yes’.

Management guru Gerry Robinson was the star of a BBC 2 series last night when he was set his ‘biggest challenge’ - to reduce hospital waiting lists. For those of us who work within NHS hospitals, the stories seemed all too familiar. Delays getting patients in and out of theatre (or in reality anywhere), different specialties not working in harmony, committees and sub-committee’s having endless meetings with no conclusions or outcomes…..

He admitted, that after spending just 2 days a week in a hospital environment he returned home feeling “depressed”, “frustrated” and even doubting his own self-belief to make simple changes. Another familiar tale.

So what was his main challenge? He understood that hospital workers were all highly dedicated to their patients, skilled, and often worked long hours under stressful conditions. But what he came to realize, without actually the coining the term, was that his challenge was how to overcome ‘learned helplessness’.

Learned helplessness is a psychological condition, when a human or animal has ‘learned to believe that it is helpless’. It thinks that it has no control over its situation and that whatever it does is futile. As a result it will stay passive when the situation is unpleasant or harmful and damaging.

In an interview with Gerry Robinson he said “It’s actually quite hard to explain, the psyche…you had any number of people saying well we’ve been talking about this for two years, or I’ve brought this up with this committee for the last 10 years.” Historically it has been difficult to take control of a system undergoing rapid regular changes and cutbacks. Often basic questions just never got answered. In simple economic terms it would seem almost impossible to comprehend any business which could not calculate basic supply and demand data. Yet in the case of hospitals, working in the dark and not having access to vaguely accurate patient numbers was common.

So how can we break this cycle? Let’s hope that having people like Gerry Robinson going into hospitals will allow the workers to realize that they are free to be entrepreneurs. He may just be that paternalistic figure who entered Rotherham NHS hospital, and rather than saying "no", said the unmentionable word - "yes"….. this may well be the catalyst to start breaking the 'cycle of learned helplessness'.

More Inspirational Human Stories

Dr. Muhammad Yunus, (DOB June 28, 1940), was the third born of 14 children in Bangladesh. As a banker and economist, he developed of the concept of microcredit, the extension of small loans to entrepreneurs, too poor to qualify for traditional bank loans.

He first got involved fighting poverty during the Bangladesh 1974 famine. He discovered that very small loans could make a disproportionate difference to a poor person. His first loan consisted of $27 US from his own pocket, to a women who made bamboo furniture. Traditional banks had not been interested in offering her such a tiny loan. However, he found that by loaning her money, with a very reasonable interest rate, she was able to finance her entire family. His revolutionary discovery was that by loaning money, rather than just giving money, he discovered the cycle of poverty could be broken.

In 1976, Yunus founded the Grameen Bank (Grameen means "of rural area", "of village") to offer loans to poor Bangladeshis. To ensure repayment, the bank uses a system of "solidarity groups", where small informal groups apply together for loans, and its members act as co-guarantors. As it has grown, the Grameen Bank has also developed other systems of alternate credit that serve the poor. In addition to microcredit, it offers education loans, housing loans, financing for fisheries and irrigation projects, venture capital, textiles, and other activities, along with the other banking services, such as savings. In 2006, he and the bank were jointly awarded the Nobel Peace Prize, "for their efforts to create economic and social development." The Grameen model of micro financing has been so inspiring that it has been emulated in 23 countries.

Quotes from Dr Muhammad Yunus
"I was teaching…and feeling helpless. I teach beautiful theories of economics, and people are going hungry," he said. "Forget about those theories. I'm a human being, I can go and touch another person's life.'"
He advocates that by fixing poverty, you are also attacking a root cause of terrorism:

“We must address the root causes of terrorism to end it for all time, I believe putting resources into improving the lives of poor people is a better strategy than spending it on guns.”

Innovative Ideas - Inspiring people

Dr Sam Everington OBE first trained as a Barrister and then as a doctor. He first made his name back in the 1980s when he found novel ways of highlighting the absurdly long hours which doctors worked. He slept outside the Royal London Hospital, creating a media storm. These days Dr Sam Everington is a GP, who attracts nationwide interest for the idiosyncratic ways in which he uses talented people in his practice area, a deprived part of London's east end. Through his innovation the government now uses his “Healthy Living Centre” as a model. His holistic approach to medicine means that education, employment, housing and creativity are all crucial in helping patients get back on their feet.

His centre is no small undertaking it includes over one hundred projects – a church, complimentary therapies, art studios, a nursery, community care projects, garden projects, a community café and a community cinema. It is a unique partnership between the private, public and voluntary sector.

Apparently the first thing former secretary of state for health John Reid said when he came to visit was, "Where's the NHS sign?" But Sam reminded him who the centre belongs to – the patients. When Sam talks about setting up such massive centres, he does not give false hope, but believes in being a "can do" person with a strong belief in the end goal. He strongly encourages other doctors and believes they too have the potential to be great entrepreneurs. What an inspiration.

Why doesn't the NHS profit from its' own data?

To continue with the theme of starting a new year with developing new ideas, this proposal includes:

The NHS should profit from data it has already collected.

Within the NHS, it is well known that there is a divide in the service between medical staff working with patients, and managerial staff working with finances; a sort of ‘them and us’ mentality. It is sometimes difficult for medical staff to see the good results produced by managers, all too often focusing on frequent messages about cuts and targets. Yet indisputably, management is imperative to allow the medical profession to continue the caring role. Is there a way to encourage NHS management to directly aid the NHS budget?

Currently, NHS management collect data - a high value commodity. Increasingly, there is awareness in partnerships between public and private health care providers. Prior to private companies offering a service, they research supply, cost and demand figures. This data is often collected by telephone surveys, with vast quantities of time spent talking to ward staff, taking them away from their primary role of patient care to discuss bed availability. Yet, every good manager already collects this supply and demand data, very accurately, within their hospital. For example, the data may include bed numbers for each specialty and sub-specialty, giving supply data, and then the occupancy of these beds, showing demand data. Another example would be how much it costs to run these beds. My proposal would be to ask mangers to publish this valuable data on a monthly basis, offering the following advantages:

1) Publication of the data already collected by managers would allow interested parties (often private health companies) to buy this data, and in turn provide the NHS with a revenue source.

2) Publication would aid the integration between managers and health care workers, as the importance of the data collated by managers would become evident.

3) Managers and health care workers would be encouraged to work together, in turn, improving the accuracy of the data collected.

4) Publication of data would increase the accountability of managers and increase motivation to illustrate good value for money.

5) Publication would provide valuable NHS data for strategic planning.

The NHS should not be encouraged to be secretive about information, however, why not allow the NHS to collect revenue from the vast quantity of data it has already collected.? Indeed, the Freedom of Information Act 2000 (Section (19) and other provisions) deals with the possibility of charging fees for information intended for publication.

In conclusion, NHS data knowledge could provide a further useful funding source.

New Year Resolutions - New Ideas

As the New Year starts many people have decided to make the 2007 resolution to get fit. This seems an honourable endeavour - yet is there a way of doing this whilst also helping society or the environment?

One idea may be to actually generate energy whilst burning off calories. This could be done using 'alternative fitness centres' with gym equipment that generated electricity whilst people exercised. The quantity of energy produced could be displayed individually or combined in groups to encourage teams representing communities, firms or schools. Currently, most existing gyms have a system whereby to expend calories you are using a machine using electrical energy during operation. Hence using electrical energy to expend human energy, but why not use the human energy and transfer to storable energy?

Simple modification of these gym equipment designs could incorporate small generators that feed into the building energy system. For example, a fitness cycle could be fitted with an alternator via the flywheel instead of using air or magnetic resistance. The gym building could also be designed in a highly energy efficient manner to include power generators such as wind turbines and solar panels incorporated in the construction.

So next time you go to the gym, have a think whilst on the running machine, if there is a way you could burn your calories and help the environment.