Improving the psychological care of medical patients
Anthony Harrison provides an update on work to improve the psychological care of medical patients
In 1994, the Royal College of Physicians and Royal College of Psychiatrists collaborated to produce a report entitled 'The Psychological Care of Medical Patients'. This looked at the psychological and mental health needs of people admitted to general hospitals suffering from physical health problems. Since the publication of the original report, there have been a number of key developments in both the treatment of mental health problems associated with physical illness, alongside the changes in public health policy and mental health service developments. Given these developments, both colleges agreed to review and revise the report.
There is a high rate of psychological and psychiatric morbidity among general hospital patients. It is estimated that about 25 per cent of medical patients have a mood disorder, 10 per cent have delirium and as many as 25 per cent have dementia. Over 16 per cent of people admitted to general wards also have a significant alcohol problem.
A number of studies have demonstrated that the majority of general nurses have difficulty in meeting the needs of patients with mental health problems. Alongside this has been the recognition that general hospitals, particularly accident and emergency departments, are often used as gateways into specialist mental health services for those people with existing mental health problems.
A working group was convened in February 2002 consisting of clinical specialists from across medicine, psychiatry and rehabilitation, along with a service user and two nursing representatives - me, representing the RCN, and Steve Lennox, head of clinical development at Epsom & St Helier NHS Trust. The working party met on six separate occasions, in order to discuss and develop the work on each chapter of the report. The majority of the work was undertaken outside the group meetings.
The report is aimed largely at medical staff practising across the range of hospital specialties, but the particular focus has been on medical settings. Having said that, much of the guidance within the report is of a generic nature and can be readily adapted for use in any setting. For example, there are chapters on communication and psychological assessment, psychological responses to illness, and alcohol and drug misuse. Of particular interest is the section on planning and developing liaison services within the general hospital - a subject that generates numerous questions from those with an interest in the area, as well as problems for PCTs in deciding how to commission services and develop service specifications relating to mental health in the general hospital setting.
It was disappointing that there was not greater nursing representation within the working group - with so many doctors, it was difficult to get the nursing voice heard at times! I am also conscious that many of the clinical problems, and aspects of care outlined, deserved more robust descriptions of the nursing contribution, particularly in the sections concerning the management of self-harm and addressing the needs of older adults with mental health problems. Many nurses reading the final report will, I am sure, experience feelings of exasperation at the cursory way in which the nursing contribution to the psychological care of general hospital patients is addressed. In part, this is a reflection of the fact that the target audience is medical staff, but I suspect it is also connected with the fact that at times there seemed a genuine sense of uncertainty within the working group as to what the focus of the report should be and how much detail it should contain. While starting out by saying that the aim was not to write a textbook on the subject, in many ways this is what the end result became.
Anthony Harrison is Consultant Nurse (Liaison Psychiatry) and Visiting Fellow, University of the West of England