Is Liaison Psychiatry the saviour of our NHS?: The Birmingham RAID Experience. George Tadros Consultant in Old Age Liaison Psychiatry, ( RAID Lead Clinician), Birmingham. Professor of Old Age Liaison Psychiatry, University of Warwick Visiting

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Is Liaison Psychiatry the saviour of our NHS?
The Birmingham RAID Experience.George
TadrosConsultant in Old Age Liaison Psychiatry,
( RAID Lead Clinician), Birmingham.Professor of
Old Age Liaison Psychiatry, University of
WarwickVisiting Professor of Mental Health and
Ageing, Staffordshire University
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What is wrong with us?

• What is wrong with Liaison psychiatry?
• What is wrong with our hospitals?
• What is wrong with the system?
• What can we do about it?
• What is your answer?
• What is going to be covered?
• Literature
• RAID from the beginning till now
• RAID in the future

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Recent evidence Older People

• Up to 70 of hospital beds are occupied by older
  people. Audit commission, 2006, Living Well in
  Later Life.
• The trend is likely to continue with major
  implications for the use of hospital resources
  Government Actuary Department, 2002
• 2000-2010, hospital stay for 60-74 increased by
  50, over 75 by 66. Hospital Episode Statistics,
  09-10.
• Mental disorder in older adults is a predictor
  of
• Increased Length of Stay (LOS)
• Poorer outcomes
• Institutionalism (impacting on performance and
  efficiency)
• The majority of mental co-morbidity in acute
  hospital affecting older people is due to three
  disorders Dementia, Depression and Delirium.
  Case for change- Mental Health liaison Service
  for Dementia Care in Hospitals., Strategic
  Commissioning Development Unit (SCDU), 21st July
  2011.

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Evidence for need Older people

• Older adults and a typical 1000 bed DGH
• 700 beds occupied by older adults
• 350 will have dementia
• 480 for non-medical reasons
• 440 with co morbid physical and mental disorder
• 192 will be depressed
• 132 will have a delirium
• 46 will have other mental health problems.
• 500 beds hospital would have 5,000
  admissions/annum, of whom 3,000 will have or will
  develop a mental disorders. Who cares wins, 2005.
• 70 of older people referrals to liaison services
  are not under the care of mental health services.
  
• In a typical acute hospital (500 beds), failure
  to organize dementia liaison services leads to
  excess cost of 6m/year

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Alzheimers society Counting the cost (2009)

• Concerns from Nursing staff
• managing patients with challenging or difficult
  behaviour,
• communication difficulties,
• not having enough time to spend with patients and
  provide care.
• Concerns from Families
• nurses not recognising or understanding dementia,
  
• lack of personal care,
• patients not being helped to eat and drink,
• lack of opportunity for social interaction,
• the person with dementia not being treated with
  due dignity and respect.

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GPs and community dementia care

• Only 47 of GPs had sufficient training in
  dementia management,
• A third were not confident in diagnosing
  dementia.
• 10 of GPs aware of the National Dementia
  Strategy.
• Only 58 of GPs believe that providing a patient
  with a diagnosis is usually more helpful than
  harmful.
• Significant numbers of dementia related
  admissions are directed to acute hospitals
  through GPs referrals.
• It also could be due to lack of coordination
  between primary and secondary care.
• National Audit Office (2010) Improving Dementia
  Services in England an Interim Report. Report
  by the Comptroller and Auditor, General HC
  82SesSIon 20092010, 14 January 2010.

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Evidence for need Alcohol and Substance Misuse

• Alcohol consumption increased over the last
  decade
• 88 of adults in the UK drink alcohol,
• with 38 of men and 16 of women recognized as
  having an alcohol use disorder (Alcohol Needs
  Assessment Research Project, 2005).
• 15-20 of adult inpatients are alcohol dependent.
• 12 of AE attendances are alcohol related
• 7-20 acute admissions have alcohol problems
• Annual healthcare cost of 1.7 billion National
  Indicators for Local Authorities and Local
  Authority Partnerships (2009)
• NI 39 (2009) Aim Reduce trend in alcohol related
  admissions.

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Evidence for need Self Harm

• In the top five reasons for admission in the UK.
• Rates in the UK are among the highest in Europe.
• 170,000 admissions per annum in UK
• If training is inadequate it may lead to negative
  attitudes and poor care
• Patient non-engagement and repeated self-harm
  behaviour can lead to suicide
• Drains resources with little positive outcomes
• Kripalani et al, (2010) Integrated care pathway
  for self-harm our way forward. British Medical
  journal, 27544-546
• Kapur, N (2006) Self Harm in the general
  hospital. Psychiatry, 5 (3) 76-80
• National Institute for Clinical Excellence (2010)
  Guidelines for Self harm.

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Evidence for Need General Psychiatry

• 25 of patients with a physical illness also have
  a mental health condition.
• 60 of over 60s
• AE work is primarily with younger people coming
  with DSH, Alcohol problems and acute psychosis.
• Depression Anxiety - 2 to 3 times more common
  in those with physical long-term illness.
• Neuropsychiatry
• Postnatal psychiatry
• Eating disorders
• MUPS
• long term disability and dissatisfaction.
• Present in most hospital specialities.
• Care costs estimated at 3.1 billion per annum

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The Parameters
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The product Rapid Assessment Interface Discharge
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The pre-RAID (traditional) service (Cost 0.6m)
Consultant Liaison Psychiatrist 1.0
WTE Currently Funded
Specialist Doctor 1.0 WTE Currently Funded
Band 7 Nurse MHOP 1.0 WTE Currently Funded
Band 7 Social Worker 1.0 WTE Currently Funded
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse MHOP 1.0 WTE Currently Funded
Band 6 Nurse MHOP 1.0 WTE Currently Funded
Social Worker
Admin Band4 1.0 WTE
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The upgraded RAID service (cost 1.4m)
Consultant Liaison Psychiatrist 1.0
WTE Currently Funded
Consultant Psychiatrist Mental Health of Older
People
RAID Team Manager
Consultant Psychologist Mental Health of Older
People
Consultant Psychiatrist Substance Misuse
Band 7 Nurse MHOP 1.0 WTE Currently Funded
Specialist Doctor
Band 7 Nurse Liaison 1.0 WTE Currently Funded
Band 7 Social Worker 1.0 WTE Currently Funded
Lead Nurse Substance Misuse

Specialist Doctor
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse MHOP 1.0 WTE Currently Funded
Band 6 Nurse MHOP 1.0 WTE Currently Funded
Band 6 Nurse MHOP 1.0 WTE Currently Funded
Band 6 Nurse Liaison 1.0 WTE Currently Funded
Band 6 Nurse Substance misuse 1.0 WTE Currently
Funded
Admin Band4 1.0 WTE
Admin Band4 1.0 WTE
Assistant Research Psychologist
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RAID evaluation
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Referrals
Origin of referral Number of referrals 16-64 years 65 years Mean age
Accident and Emergency (AE) 833 96 4 36.4 years
Poisons Unit 517 96 4 34.6 years
Wards 675 41 59 65.6 years

• Steadily increasing referrals
• 300 monthly referrals
• Only 30 patients known prior to RAID.

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Top 7 reasons for referral
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AE Response
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Ward Response
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Teaching and evaluation
158 hospital staff trained All completed the
evaluation
A lovely insight from a very experienced
practitioner
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Practice improvement
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Medical diagnosis coding Comparing pre-RAID and
RAID period
RAID diagnosis
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Patient satisfaction Feedback
Range Mode Median Mean
0 to 5 5 4 4.2
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Staff satisfaction Feedback
Range Mode Median Mean
2.5 to 5 5 4 4.2
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RAID evaluation
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RAID evaluation
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Areas of savings

• Reducing Length of Stay
• Increasing diversion at AE
• Increasing rates of discharge at MAU
• Rate of discharge from wards
• Destination of discharge
• Reducing rates of re-admissions
• Many other areas not in this study
• Use of security
• Staff Retention and recruitment
• Complaints
• Use of antipsychotics

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3 Groups for the study

• 1. Pre- RAID group (control group)
• December 2008- July 2009
• No changes/confounders between pre and post!!
• 2. RAID_ influence group
• December 2009- July 2010
• RAID did not see patients, but had influence
  through training and support
• 3. RAID group
• December 2009- July 2010
• RAID patients
• Matched groups
• Matched age, gender, mental health code, medical
  diagnosis, healthcare resource group (HRG)
• RAID patients were the most complex
• RAID average 9 different diagnostic codes
• RAID_ influence 3 different diagnostic codes

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Retrospective case-by-case Matched Control Study
Sub Control mean 8.4 Sub RAID Inf mean 5.2
Sub Control mean 10.3 Sub RAID mean9.4
359 cases
Control (2873 Patient) Mean 9.3 days
RAID Influence (2654 Patient) Mean 4.74
RAID (886 Patient) Mean 17.6
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RAID sample mean vs. population mean
A confidence level of 95 was obtained.
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1. Length of stay Retrospective Matched Control
Study
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Length of stay Comparing the groups

• P value 0.01

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Cost savings LOS/ all age groups

• All ages
• Saving over 8 months 797 8,493
• 9,290 bed days
• Saving over 12 months 13,935 bed days
• Per day 13,935 365
• 38 beds per day

• Older people only
• Saving over 8 months 414 8,220
• 8,634 bed days
• Saving over 12 months 12,951 bed days
• Per day 12,951 365
• 35 beds per day

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2. Admission Avoidance at MAU Cohort control
study

• All ages
• Control group
• 30 of avoided admission at MAU.
• RAID and RAID influence group
• 33 avoided admission at MAU
• Increase of 9
• Average LOS 9.3 days
• 240X9.3 2,232 bed days
• 2232 365 6 beds/ day

• Older people
• Control group
• 17 of avoided admission at MAU.
• RAID and RAID influence group
• 25 avoided admission at MAU
• Increase of 47
• Average LOS 22 days
• 111 X 22 2442 bed days
• 2442 365 6 beds/ day

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3. Elderly Patient Discharge Destination

• 30 of elderly patients who come to acute
  hospitals from their own homes are discharged to
  care homes (national figures)
• LSE estimated savings to our wider economy of
  60,000/week (Social care cost).

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4. Savings Re-admission
Group Re-admission per 100 patients
Retrospective (3500) 15 (505)
Partial RAID (3200) 12 (408)
RAID (850) 4 (42)
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5. Survival after discharge Survival analysis
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Older People Re-admissions
Group Re-admissions per 100 patients
Control group (pre-RAID) 19 patients
RAID influence 22 patients
RAID 5 patients
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Survival Analysis Elderly
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Savings through increasing survival

• The savings calculated from survival assumes
  patients readmission at same rate of
  retrospective patients
• Over 8 months ? 1200 admissions saved.
• Over 12 months ? 1800 admissions saved.
• Saving 22 beds per day one ward
• Saving 20 beds per day comes out of elderly care
  wards.

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Combined total savings beds/day

• On reduced LOS
• saved bed days/12 months 13,935 bed days
• 365 38 days/day (35 beds/day for the elderly)
• Saved bed days through avoiding admissions at MAU
• Saved bed days 6 beds / day
• Elderly bed days saved 6 beds / day
• Increasing survival before another readmission
• Admissions saved over 12 months 1800 admissions
• Average LOS 4.5 days
• 8100 saved bed days
• 365 22 beds/day
• 20 for the elderly
• Total Saved beds every day
• 38 22 6 66 beds/ day (Maximum) Elderly 59
  beds/day
• 21 22 6 49 beds/ day (minimum) Elderly 42
  beds/ day

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London school of Economics, August 2011

• Very thorough, detailed and vigorous review
• Very conservative estimation
• Total savings
• 3.55 million to NHS
• At least 44 beds/day
• 60,000/week to social care cost
• Money value
• Cost return 1 4
• Recommended the model to NHS confederation

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Number of patients with a Mental Health Diagnosis
Dementia Delirium and Depression
(Retrospective case notes and all screened in
and out)
Please note there may be more than one diagnosis
per person
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Comparison of diagnoses Prospective Data
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What is next?

• RAID Manual
• RAID Engine
• RAID Network
• How to improve the model?
• What works?
• Which bit for which patch!