The co-occurrence of mental and physical health problems is very common among patients, often leading to poorer health outcomes and increased healthcare costs. People can face lengthy waits before being referred on to the relevant service.
Birmingham and Solihull Mental Health NHS Foundation Trust developed the Rapid Assessment, Interface and Discharge model for liaison psychiatry services in December 2009 as a pilot in City Hospital in Birmingham, with an investment of £0.8 million. The Rapid Assessment, Interface and Discharge team, comprising nurses, psychiatrists, psychologists and physicians assistants, will promptly assess anyone 24/7 attending A&E or who is a hospital inpatient, who might have mental health problems.
The Rapid Assessment, Interface and Discharge network, which is supported by WMAHSN, was established to strengthen links between Rapid Assessment, Interface and Discharge services to facilitate collaborative working on research and innovation projects, facilitate adoption of Rapid Assessment, Interface and Discharge and improve and expand the overall service provided across the NHS.
- Following the success of te eservice in City Hospital, there is now a Rapid Assessment, Interface and Discharge service established in every acute hospital in Birmingham
- 27 organisations nationwide have now taken up Rapid Assessment, Interface and Discharge
- In its 2014 document Achieving Better Access to Mental Health Services by 2020, the Department of Health highlighted strong evidence that the Rapid Assessment, Interface and Discharge model can deliver clinically and cost-effective care to patients with a range of mental health problems
- A paper published in The Psychiatric Bulletin (2013) uses data from admissions to all 600 beds in City Hospital between December 2008 and July 2010. The paper showed that the main direct effect of the Rapid Assessment, Interface and Discharge model was on time to readmission:
- The rate of readmission in the Rapid Assessment, Interface and Discharge group was four for every 100 patients, while in the pre-Rapid Assessment, Interface and Discharge group it was 15 for every 100
- Including the Rapid Assessment, Interface and Discharge-influence group, the total reduction in readmissions is estimated to be 1,800 over 12 months. This equates to a saving of 8,100 bed-days per year
- The model is estimated to save between 43 and 64 beds per day, which is equivalent to two-three wards
- Most of the savings were accrued by geriatric wards
- The study estimates the potential savings to be £4-6 million per hospital by reducing both admissions and length of stay
- There is also a strong indirect effect resulting from the broader influence on those not referred to the service, in the form of reduced lengths of stay: the Rapid Assessment, Interface and Discharge-influence group demonstrated an average length of stay 3.2 days shorter than that of the pre-Rapid Assessment, Interface and Discharge group. This corresponds to a total saving of 13,935 bed-days per year
- The service won a prestigious HSJ Award for innovation in mental health in 2010
- Rapid Assessment, Interface and Discharge was highlighted in 2011 in an NHS Confederation Mental Health Network briefing paper which documented the benefits of liaison psychiatry
- An independent economic evaluation of the original Rapid Assessment, Interface and Discharge service was produced by the London School of Economics and Centre for Mental Health in 2011
- Rapid Assessment, Interface and Discharge was cited in a 2012 HSJ article, “Liaison psychiatry can bridge the gap”
- An economic evaluation of the Rapid Assessment, Interface and Discharge roll-out across Birmingham was produced in 2013 by the Midlands and Lancashire Commissioning Support Unit
- Further liaison psychiatry service guidance which discusses the range of potential models was produced for the South West Strategic Clinical Network for Mental Health, Dementia and Neurological Conditions in 2014
- A review was commissioned from the University of Birmingham’s Health Services Management Centre, with six West Midlands implementation sites involved (2015)
- Dementia and self-harm e-learning, tailored for acute trust staff, has been delivered to more than 60 staff in each module across two acute trusts
- A national Rapid Assessment, Interface and Discharge Network has been established to support organisations and individuals who are using or planning to use Psychiatric Liaison models. To date two meetings have been held, the second of which had Geraldine Strathdee, National Director for Mental Health, as a key speaker. The network’s first event attracted delegates from across the region, along with people from across England and the wider UK. 61 people from 24 organisations attended the first event, and 64 people from 31 organisations registered for the second event. In total, representatives from 41 different organisations registered to attend, with 17 new organisations coming to the second event. This has created a mechanism for sharing best practice for liaison services nationally. In addition, the network’s long term funding has been secured by BSMHFT in partnership with East London NHS Foundation Trust
- The national Rapid Assessment, Interface and Discharge Network is supported by a website and newsletters
- Two academic organisations, two acute trusts, two mental health trusts and three industry bodies were involved in project delivery
- An independent innovation audit by GE Finnamore in October 2016 found that:
- Up to 5:1 financial return to commissioners and acute hospital trusts
- Financial benefit in police time diverted to escorting A&E patients (two officers for up to 20 hours =£500)
- Proven cost-saving and quality improvement in pathways and education through provision of memory clinics in acute hospital
- Support for Section 136 patients provided much quicker due to proactive approach to find such patients in the hospital system
- Prevention of each Section 136 - £3K
- Parallel physical and mental health assessment
- Focus on frequent attenders (200-250) as identified by A&E, police and community trust
- Improved awareness of mental health issues in frontline service delivery functions
- Improved delivery of compassionate care.
- Intentional scouting across the hospital for Section 136 patients to provide more appropriate care in the trust 'safe haven' in the Oleaster facility close to the Queen Elizabeth Hospital, making hospital transfers more straightforward
- The West Midlands was the first area to include a paramedic as part of the Street Triage team, which has brought significant benefits to the operational delivery of the service
- Inter-agency collaboration and support has delivered significant benefit for the patient in providing timely physical and mental assessment and care, often in the patient’s home
- Repeat users of this service have been identified and other service interventions put in place to support those requiring frequent intervention, saving time and money
- Section 136 cases are being avoided by dealing with patients early in their mental health episode.
- Establishment of a psychiatric decision unit (PDU) to assess patients away from A&E, which has been effective in reducing A&E lengths of stay and ensuring patients receive care in the most appropriate setting
- By integrating with other services such as the Street Triage team (which refers directly to the PDU rather than to A&E), support for reducing A&E attendance has been significantly improved
- Senior clinical leaders shared approach and experience nationally
- While having a specialist Rapid Assessment, Interface and Discharge team has meant A&E staff no longer provide psychiatric elements of care, a proactive approach to education has meant that mental health issues are more widely understood and while some patients require to be seen by Rapid Assessment, Interface and Discharge teams, others are benefitting from receiving care from mainstream physical health teams trained in Rapid Assessment, Interface and Discharge principles, thereby improving the overall mental health service provision
- Development of mental health training interventions, including the 4D classroom based course and the WMAHSN-funded online training modules in self-harm and delirium
- The service now has sufficient prominence in the main acute hospitals in Birmingham to influence and drive changes in physical and mental health service delivery
- West Midlands Rapid Assessment, Interface and Discharge team and senior clinical leaders spent time sharing experiences, approach, models, dashboards and data, resulting in development by the National Collaborative Centre for the benefit of the wider NHS.
Click to read the Health Services Management Centre's policy paper, Mental health matters: improving mental health services in acute settings and understanding how innovation spreads, to help collate and share learning from the rollout of Rapid Assessment, Interface and Discharge in the West Midlands.
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