Monday, 13 September 2010

Liaison Psychiatry

Nurse Anne has a point. She usually does. Working on an acute ward, delivering hands on nursing care, she's insight into what works well on wards, what's necessary and what works badly.

It's frustrating and bewildering that both cogent, articulate views and intuitively sensible cathartic rants, whilst all true and meaningful, seem to be ignored. A manager who I've a lot of time for was lamentting how intellectual explanation or common sense experiences are all too often brushed aside by management structures if the views aren't, "aligned with the corporate direction of the organisation." She then went to talk about EBITDA and cost pressures and totally lost me. But the message was clear that if you say what managers like, you're listened to. Say what managers don't like and you're not listened to. Oh, you're heard, it's noise that is sometimes attended to, but then discounted. Not every good idea can be progressed, so this managerial self selection of what to attend to is the best that consultation/clinical engagement can feign to date.


In mental health, we're usually more fortunate. I work with a number of managers, but actually have a decent relationship with them. I don't get what I want all the time, obviously, but I get good enough resources to deliver an excellent service, which really is what I want managers to deliver for me. Just give me the tools and then pretty much leave us alone, then we can deliver.

In Nurse Anne's world it's much, much worse. Outside of mental health, acute Trusts have pressures and tend to cut costs through removing/not replacing frontline qualified staff. Our local Trust has a lot more HCAs and a lot less nurses (on the wards) than it did 10 years ago. Oh, it has more nurses in management (as matrons, Champions and project managers in a whole slew of initiatives) but lamentably the clinical areas have fewer clinicians, despite increased activity, increased process and increased technical interventions compared to a decade ago. If you're doing more work, and more complex work, and dealing with iller people, and need folk to deliver technical/complex care, wouldn't you want more nurses? Before you even look at the triage, surveillance, assessments and formulations ward nurses undertake, the documentation and process has increased in volume and complexity with MUST nutritional screening, Waterlow scores, falls assessments, Abbey Pain Scale ratings, medicines reconcilliation and so on, much more than just the TPR that used to be done. What of extended roles, Non-Medical Prescribing, First Contact Practitioner, Nurse led Clinics, Nurse Consultants running wards (in Cumbria, even running mental health wards in place of medical Consultants).

Undeniably, nurses now have more to do. In greater detail. With more patients. With more complicated kit and interventions. We've more nurses in management (so statistics show we still have fair numbers of nurses) but invariably in acute hospitals I visit we've substantially less on wards than wards need and patients deserve.

Much badness.

Nurse Anne very reasonably asks why patients with primary psychiatric problems are admitted onto an acute medical ward. Sadly, she's also given the answer in the sentence questioning, "Why the hell are the medical consultants getting this dumped on them?" Because it does seem that the medics are simply being dumped on. It's really impossible to defend this.

Nurse Anne also has the workings of a solution. "We have no RMN's on staff so basically we are up shit's creek." Indeed. We've got RMNs working in the acute Trust in my corner, who've made a big difference. The nurses and I've persuaded the acute Trust and PCT, through what we've delivered on, that RMNs and Psychiatrist time can improve quality, reduce length of stay and save squillions.

Liaison Psychiatry done well works brilliantly, with patients, acute staff and mental health staff all feeling happy (and having shorter admissions and saving cash, incidentally). Liaison Psychiatry done badly is ghastly. Utterly ghastly. I've no answers for Nurse Anne, no explanations, but inwardly cringe at the shabby service it seems my mental health colleagues provide in her corner. Ouch.

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