“We have also seen significant improvements in crisis care including the roll-out of liaison psychiatry to over 90% of A&Es, of which half are 24/7. This may have contributed to a 6% fall in suicide rates”
Jeremy Hunt, 20 November 2017
If you arrive at A&E with urgent mental health needs or in crisis, the liaison psychiatry service is meant to help you.
Nearly all A&E departments had liaison services in 2016. In 2014 it was 89%, by 2016 it was 98%.
The types of services offered vary a lot, from big teams offering 24 hour care to much smaller ones running in working hours.
More than half of services are 24/7, and liaison teams are becoming better staffed overall. Only 12% offer at least what are called ‘Core 24’ standards of care, which requires 25 staff, including two consultants and 13 nurses. The target is for half of NHS hospitals to provide this kind of care by 2021.
Experts do say that liaison services can play a role in reducing suicides, so it’s possible that more liaison services may have contributed to the 6% drop in the suicide rate. But it’s a big ‘may’: there’s no direct evidence either way, suicide rates don’t tie neatly to individual years, and the rates tend to fluctuate from year to year anyway.
What is liaison psychiatry?
Liaison psychiatry is one form of crisis mental health care available.
The mental health charity Mind describes a crisis as when a person’s mental health is at ‘breaking point’, and they are experiencing symptoms such as suicidal feelings, self-harm, and extreme anxiety.
Liaison services provide mental health care to people with urgent needs arriving in A&E, and who need mental health treatment alongside physical treatment in hospitals.
There are different models of liaison psychiatry. The Royal College of Psychiatrists specifies how many members of staff a hospital needs for each model.
Core: Service during working or extended hours. 14 whole time equivalent (WTE) staff, including 2 consultants and 8 nurses.
Core 24: Service 24/7. 25 WTE staff, including 2 consultants and 13 nurses.
Enhanced 24: 24/7, with more specialist care, offering enhanced expertise in addictions and drug and alcohol use, and mental health problems in people with learning disabilities. 22-24 WTE staff, including 4 consultants and 10 nurses.
Comprehensive: 24/7, with inpatient and outpatient services to specialities at major centres. 69 staff, including 5 consultants and 29 nurses.
Another form of crisis mental health care is a ‘Crisis Resolution and Home Treatment’ team. These teams offer patients intensive treatment at home.
NHS England’s Five Year Forward View for Mental Health was produced in 2016, and includes two recommendations for mental health crisis care.
One says that community-based mental health crisis care should be available across England by 2020/21, and that crisis resolution and home treatment teams should be expanded.
The other says that by 2020/21 each acute hospital should have mental health liaison services in emergency departments and inpatient wards. At least half of these should meet at least core 24 service standards. The government accepted all the recommendations at the start of 2017.
Nearly all A&Es offer liaison services
Jeremy Hunt has used data from a 2016 survey of psychiatric liaison, run by academics from Plymouth University, in association with NHS England and Health Education England.
In 2014, 89% of A&Es in England had a psychiatric liaison service, compared to 98% in 2016. 95% of hospitals with A&E departments returned data in 2014 and 98% did in 2016.
Most of those services fall below the ‘core’ service model outlined above though, although an increasing number are meeting this standard. 14% of departments were at least the core standard in 2014, rising to 27% in 2016.
Where some kind of psychiatric liaison service was available, just over half of the services were available 24/7. That’s risen from 50% of them in 2015 to 55% in 2016. But only 12% met the criteria of ‘core 24’ or ‘enhanced 24’.
NHS England’s mental health strategy says that “the peak hours for mental health crisis presentations to A&E are between 11pm and 7am”.
The suicide rate fell between 2015 and 2016, but we don’t know much about the impact that liaison services have
The Royal College of Psychiatrists says that liaison services “can reduce the risk of self-harm and suicide”.
Self-harm is reported as the main reason for A&E referrals to the liaison service, according to a study by the Centre for Mental Health charity. Using a publication from the Royal College of Physicians, they say that half of all suicides have a history of self-harm, so mental health treatment for self-harm could help to prevent suicide.
But they also explain that: “little is known about the impact of liaison psychiatry services on the number of achieved suicides, mainly because suicide is a relatively rare event”.
The suicide rate in England fell from 10.1 per 100,000 people in 2015 to 9.5 in 2016—a fall of 6% and the lowest since 2010. The number of suicides registered in England fell from 4820 to 4575 in 2016.
The Office for National Statistics (ONS) points out that deaths by suicide in England and Wales can only be registered following an inquest, which can take months or even years. This means that not all of the deaths reported in these figures will necessarily have happened in 2016. Some may have happened in 2015 or even years earlier. Similarly there will be deaths in 2016 which may not yet have been registered, as an inquest wasn’t complete by the end of the year.
In Great Britain the rate fell from 10.6 to 10.1 per 100,000—a fall of 5%.
The government has pledged to invest in mental health
In January 2016, the Prime Minister at the time, David Cameron, promised nearly £250 million to place mental health services in every A&E, and over £400 million for crisis home resolution teams. This was followed by pledges to make intensive home treatment available across the country and mental health liaison in place in all A&Es by 2020.
NHS England has set up a dashboard monitoring progress towards the Five Year Forward View goals, including indicators for crisis care spending. However there is no data we’ve seen that’s available for these indicators yet.
The Samaritans’ helpline is available at all hours and can be contacted free on 116 123, or you can email firstname.lastname@example.org
Update 28 March 2018
When we originally wrote this piece the 2016 survey Jeremy Hunt referenced hadn’t been published. It’s inappropriate for Ministers to use figures that aren’t in the public domain, and figures like these should be published in full so that anyone can check where they’re from and how they’re calculated.
Since then NHS England and Health Education England have published the 2016 survey and we have updated the article.