Title: Liaison Psychiatry: Measurement And Evaluation of Service Types, Referral patterns and Outcomes LP-MAESTRO
Funder: Department of Health and Social Care

Abstract: In Workstream 1 (service mapping and characterization) we will use data from detailed case studies in selected services and from a prospective audit of referrals, to characterize the configurations and referral patterns of services. We will generate a taxonomy of services and we will then sample services to identify typical and critical cases eg ED cover only; acute ward in-reach only; mixed provision including specialist clinics; no liaison service. In Workstream 2 (Econometric modeling and evaluating cost effectiveness) we will link data from: ResearchOne a research database containing patient data from primary care settings using SystmOne; Hospital Episode Statistics (HES); a database provided by the Health and Social Care Information Centre (HSCIC) containing patient data relating to A&E, inpatient and outpatient episodes; local mental health clinical databases, such as Paris, Amigos. Following appropriate approvals we will link data from these databases to construct longitudinal records that correspond to patient care pathways from a particular hospital identified by liaison service configuration (WS1). From this record we will identify characteristics for the index admission and 12 months prior that are closely associated with liaison psychiatry referral. Data mining techniques will enable discovery of associations that may not otherwise be obvious. We will identify two groups of non-referred patients with matching characteristics, one from admissions to the same hospital at the same time as the index cases, and one from different hospitals chosen because they do not have equivalent liaison psychiatry services to which the patient could be referred. This will allow us to take account of referral indication bias in the analysis. For referred and comparison patients, primary and secondary care health-related outcomes will be established for 12 months after index hospital episode. We will combine health care utilisation within pathways of care with cost figures from national databases. We will compare the cost of each pathway of care and the impact of a broad set of health-related outcomes, for preliminary estimates of the cost-effectiveness of liaison services. We will investigate the relation between health care utilisation, health care costs and the pathways of care using applied health econometric methods. We will consider a range of dependent variables, and determine if there is an association between cost and pathway of care controlling for major confounders. The vector of factors will include the configuration of liaison services, including no formal liaison service, from WS1. We will carry out an exploratory incremental cost-effectiveness analysis from a whole system perspective, and compare cost and effectiveness of the “referred” group over the control group both within hospitals and between hospitals with different or no liaison service. In Workstream 3: (developing a commissioning framework and guidelines for evaluating service performance against remit) we will undertake a review of existing commissioning frameworks for liaison services and also examine existing and developing outcomes frameworks including that being developed by RCPsych. We will undertake a concept mapping exercise and use the findings to integrate with our findings to build a web-based resource for commissioners. Using results from the econometric model we will identify those variables that are the main determinants of costs so that the web-based tool that can be populated with local data that determine the parameters for cost-effectiveness estimates. We will undertake PPI work in focus group discussions and an online survey to identify the key non-quantifiable values that should inform service commissioning and provision.

Lay abstract: Liaison psychiatry involves the provision of mental health services in non-psychiatric settings, in this case in general hospitals. Liaison services have been around since at least WW2 and exist because there are higher rates of most mental health problems in general hospitals than there are in the general population. The two main questions asked of them are: do they improve outcomes for the people referred to them and if so can they do so in a cost-effective way? It has even been claimed, in relation to the second question, that they actually save the NHS money because they lead to reduction in inappropriate use of expensive general hospital stays and treatment for people who are best helped in other ways. The challenge in answering these questions is that liaison services vary greatly in how they are set up (configured) in the sort of referrals they see, and in how they deliver care. Some see only emergencies (acute mental disorders or presentations in the Emergency Department) others see only referrals from wards, others run specialist clinics and a few have specialist liaison or even shared-care wards. Liaison psychiatry for the elderly does not cover the same ground as that for working age adults. So asking whether liaison services are cost effective isn’t like asking whether a cardiac surgery service is cost-effective but more like (on a smaller scale!) asking if general practice is. We want to do three pieces of work to tackle this problem. First, we will use data from a national liaison psychiatry accreditation scheme run by the Royal College of Psychiatrists, and from a telephone survey, to identify services that we will then characterize according to how they are configured and the types of referral they see. This work stream will use case study methods to describe service configuration and an observational study to describe referrals. Second, we will link data from routine NHS sources in hospital and primary care, to identify and describe patients referred to liaison psychiatry services and two similar (matched) groups of people who haven’t been referred. We will use routine data to find out how these people do over the next 12 months – what health problems they have, what services they use and how much their healthcare costs. By comparing outcomes and costs for referred and non-referred people, and looking at how they vary according to the effects of different liaison service configurations, we will be able to estimate the cost-effectiveness of particular sorts of liaison service for particular sorts of problem. Finally, we will use our results to develop a web-based tool to help commissioners who have to decide what liaison psychiatry services, if any, they want to commission. This will involve a framework to assist in describing the desired service and the referrals it will see, and the expected costs and outcomes. It will allow consideration of local features of the NHS that might make results different from those developed elsewhere in the country. It will recommend data collection so that services can be evaluated in the longer-term to ensure they are within remit and meeting expected outputs. Not all values that should inform commissioning and provision of services can be easily quantified, and we will undertake group discussions and an online survey with service users to identify their views on types of service and on criteria that should be used in commissioning decisions, that might be otherwise missed by our approach using NHS data and economic analysis.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH