What kind of Communication do General Practitioners expect from an Accident & Emergency Mental Health LiaisonTeam?

Mary-Anne Cotton, David Ellis, Angela Robinson

Introduction

With an increasing emphasis on psychiatric care in the community, it is increasingly important for general practitioners (GPs) to receive information promptly and of good quality. In Liaison Psychiatry, patients seen in Accident & Emergency Departments are usually discharged back to their GP rather than being admitted to a psychiatric unit. The GP is therefore integral in formulating an appropriate management plan in the community. However, there is little consensus regarding the way the assessment conducted in Accident & Emergency should be relayed to the GP. Thus far, there have been no studies which consider the written communication from Liaison Psychiatric teams to GPs. Most of the literature focuses on discharge letters sent following a hospital admission, and, in this respect, it has been shown that GPs like to receive information promptly,1,2 and ideally, on the same day by fax.3 GPs also prefer interim discharge letters to be on one side of paper,4,5 with structured information about diagnosis, management, risk factors and the roles of those involved in future management.6

Participants, methods and results

The Islington Mental Health Liaison Team provides an acute psychiatric assessment service for patients seen in the Accident & Emergency Department and the general medical and surgical wards of the Whittington Hospital in North London. The Accident & Emergency Department sees approximately 70,000 patients per year. Patients seen by the Mental Health Liaison Team are either referred following triage, or after they have been seen by an Accident & Emergency Senior House Officer.

The aim of this study was to discover how Islington GPs would like information relayed to them regarding patients of theirs who had been seen by the Mental Health Liaison Team. Currently, the team sends letters 2-3 sides long via the hospital post system. It was also thought to be of interest to ascertain how long letters normally take to arrive. We were also interested to know whether GPs would prefer the Mental Health Liaison Team to prescribe initially if a change of psychotropic medication was indicated.

One hundred and fourteen Islington GPs were sent a dated letter, a one-sided questionnaire, and copies of four types of assessment letters. The first two were one-page proformas: one was developed by a similar Mental Health Liaison Team at University College Hospital, London, and the other is used by the Islington Crisis Resolution Team. The latter differs from the University College Hospital proforma in having fewer headings with a separate section for risk assessment. The third form of assessment was the Mental Health Liaison Team's 'front sheet', which is also one-sided and mainly involves circling options rather than free text entry. This was originally devised for data collection. Finally, an anonymised example of the letter currently sent by the team was enclosed. GPs were asked to return the questionnaire within a month. The questionnaire included space for comments on the existing service.

Fifty-nine GPs responded (52%), which is comparable with other postal surveys.3 95% requested same day feedback of the assessment: 90% asked for a faxed summary to be sent, 29% requested information by telephone, and 10% supported e-mail. 53% thought the one-page University College Hospital proforma as being most suitable for same day feedback, 32% supported the one-page Crisis Resolution Team's proforma, 25% supported a full letter, and 10% supported the front sheet. 92% indicated that they would prefer a full letter at a later date. Only 7% of GPs received the letter on the next day. 83% of GPs indicated that they would prefer that the Mental Health Liaison Team to prescribe initially if a change of psychotropic medication was indicated.

Of the comments made, four GPs felt that the current letter was too long and one side would be adequate. Others suggested that a full letter should only be sent at a later date if appropriate. GPs highlighted the need for clarity regarding diagnosis, treatment and management. Some GPs commented that the need for same-day contact depended on whether the GP was required to do something quickly. Others thought that same-day contact was essential as they might be confronted by the patient the following day with recommendations suggested by the team. GPs thought that patients should be asked by the team to arrange an appointment with them if they were implicated in any treatment changes.The response from the questionnaire suggested that most GPs would prefer that the liaison team prescribe initially for one to two weeks, although they asked to be informed at the earliest opportunity of any medication change.

Discussion

This survey suggests that the current practice of communication between a Mental Health Liaison Team and GPs does not match their expectations. Relying on the hospital postal system is clearly unsatisfactory, as 50% of letters take more than three days to arrive. Ideally, GPs would prefer same day contact, and the preferred method of relaying this information was fax or phone. E-mail was another option favoured by some GPs, but there are security issues related to e-mail and few GPs are likely to be equipped with this facility. In the future, with the implementation of the proposed NHS Net, this may become a more appropriate and secure form of communication.

The responses of Islington GPs were similar to other studies exploring the format of the summary sent, with the majority requesting one-page, clearly structured proformas as the immediate form of relaying information. It has been shown that such purpose-designed summaries can include more information which GPs want.7 However, if such proformas are used exclusively, this may run the risk of reducing the accuracy of the information, particularly if they are handwritten.8 Although this might be avoided if fuller assessment letters were sent at a later date, this would add to the workload of the team. A solution may be for senior staff in Liaison Psychiatry to more closely supervise the quality of communication with GPs.

 

References

1. Smith S. A new Discharge Summary. Psychiatric Bulletin 1992; 16: 607-608
2. Penny TM. Delayed communication between hospital and GPs - where does the problem lie. British Medical Journal 1988; 297: 28-29
3. Carey SJ, Hall DJ. Immediate psychiatric discharge letters by fax. Scottish Medical Journal 1999; 44: 079-080
4. Clements D. An improved interim discharge letter: A successful outcome from audit. Journal of the Royal College of Physicians of London 1992; 26: 169-171
5. Blakey A. Communication between GPs and psychiatrists: the long and short of it. Psychiatric Bulletin 1997; 21: 622-624
6. Essex B. The psychiatric discharge summary: A tool for management and audit. British Journal of General Practice 1991; 41: 332-334
7. Walker SA, Boeblhoff GA, Eagles JM. Early discharge summaries. Psychiatric Bulletin 1998; 22: 148-149.
8. Isles C, Campbell J, et al. Communicating with General Practitioners - An audit of the formal discharge summary in a District General Hospital. Health Bulletin 1998; 56: 484-487.

Authors

* Dr Mary-Anne Cotton
Senior House Officer
Mental Health Liaison Team
Waterlow Unit
Camden & Islington Community Health Services NHS Trust
Highgate Hill
London N19 5NX

Dr David Ellis
Consultant Psychiatrist and Honorary Senior Lecturer
Mental Health Liaison Team
Waterlow Unit
Camden & Islington Community Health Services NHS Trust
Highgate Hill
London N19 5NX

Angela Robinson
Administrator
Mental Health Liaison Team
Waterlow Unit
Camden & Islington Community Health Services NHS Trust
Highgate Hill
London N19 5NX

* For correspondence

 

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