Consultation-Liaison Psychiatry (CLP), also known as liaison psychiatry is a subspecialty of adult psychiatry and refers to clinical services which deliver care at the intersection of mental and physical health care. CLP provides specialist medical expertise of the management of conditions which occur in areas overlapping mental and physical healthcare. Internationally, this specialty is known variously as liaison psychiatry, psychological medicine, and general hospital psychiatry, (1). It is delivered in general or acute hospital settings. A key component of the work of CLP teams is to the Emergency Departments (ED) of their hospitals. The service provided to people who present following self-harm in Ireland is guided by the National Guidelines of the National Clinical Programme for people presenting to EDs following self-harm (NCP-SH), which in addition to providing mental health nursing staffing for EDs, also has guidelines on evidence-based practise such as full biopsychosocial assessments for all people who present, the co-production of an emergency care plan and communication with and bridging to next care (2). Some services provide outpatient services, which accept referrals from medical and surgical clinics in secondary care. Where a hospital has supra-regional or national programmes which require dedicated psychiatry resources for optimal patient care, such as organ transplantation programmes, neurological services or haematology-oncology hubs, there are often additional CLP resources to support the associated additional complex specialist mental health need associated with these.

Although CLP is a relatively new specialty, there has been much development in the past decade of service-based research which has aimed to quantify the activity and best practise of CLP services and to define needs and future development. The seminal publication in 2011 of the economic evaluation of the Rapid Assessment and Interface Discharge (RAID) service in Birmingham was pivotal in drawing the attention of funders of healthcare services in the UK to the potential of CLP services to effect cost savings. This study reported that every £1 invested in CLP services would effect a saving of £4 for that hospital (3, 4). Since this initial publication there have been further publications replicating RAID in examining the impact of CLP on the economics of the hospitals in which they are based (5–7). The effectiveness of CLP services has been supported by a systematic review conducted by Wood et al. and a narrative review conducted by the Netherlands Psychiatric Association conducted as part of the development of their guidelines (8, 9).

In England, near-annual surveys have examined the CLP services provided at all acute hospitals with EDs (10). These are in the context of commissioning guides which examined the key factors which influence the success of CLP services, set standards for good services, and described and named differing levels of service provision (11). There are also specific government targets for growth in the specialty in England [5 year forward View in Mental Health].

In Ireland, the document a vision for change provided clear guidance on staffing levels for all mental health services (12). Although this document was published 15 years ago and refreshed in 2020, there has not been any assessment of the degree to which CLP services are resourced to the minimum levels of this standard.

In this study we aimed to examine the nature of CLP services in Ireland and to define the key components of the psychiatry service provision at acute hospitals in Ireland to inform future work.

Data were collected from 100% (n = 29) of clinical sites where there is an emergency department: nine Model 4 hospitals, 18 Model 3 hospitals and 2 tertiary paediatric hospitals. Each service was benchmarked against the levels of service provision as set out in A Vision for Change. Of the 9 Model 4 hospitals, 5 (56%) are located in Dublin along with both paediatric hospitals. The remaining Model 4 hospitals are based in the other urban centres (Cork, Limerick, Galway and Waterford). Of the 18 Model 3 hospitals, 17 (94%) are located outside the capital, Dublin.

This study found that Irish CLP services are not resourced to the level recommended by the 2006 policy document A Vision for Change. When a benchmarking exercise was used to compare staffing levels per 500 beds with the standard, no services were adequately resourced.

The Model 4 or tertiary hospitals were significantly bigger and busier than the Model 3 hospitals, and their work is more of the complex mix of CLP rather than the predominance of emergency psychiatry at the smaller sites. All services are severely under-resourced by any defined standards. Model 4 hospitals had levels of medical and psychological provision which were on the surface at the levels set out by A Vision for Change. More specialised services require higher levels of medical input due to the level of complexity of the patient group. They do not have the levels of nursing staff required to safely provide 9–5 level staffing, much less any extended hours offering. Notwithstanding these deficits, 33% of services provided some form of extended hours services, although none provided a 24 h service.

When benchmarked against the international standards of the NHS England-NICE standards in England and Wales, no adult services meet the level of resourcing for CORE services, much less CORE-24, as no services ran 24/7 (13). Like in Norway, the availability of CLP services outside of working hours is severely limited in this study (18). However, consistent with many services in England, several Model 4 hospitals had elements of Comprehensive services (i.e., highly specialised input for discrete clinical areas, e.g., neuropsychiatry, psycho-oncology, transplant psychiatry), combined with “sub-Core” provision across the service more generally. Existing services have developed organically at certain major national centres by individual funding by these tertiary/national services at these hospitals. These were similar to “Cluster 3” services identified in the UK by Walker et al. (10). Unlike services in hospitals on continental Europe there is little history of psychosomatic medicine services. Compared with a European survey of CLP services published 20 years ago, the Irish Model 4 hospitals are equivalent to Cluster II and III and the Model 3 to Cluster I, and found a mix of traditional medical model and multidisciplinary services (19). This study, however was an opt-in model and likely included those services who were most interested in research and service development. A more recent Italian study of 5 hospitals of various sizes concluded that the better resources and more active a hospital service, the more likely patients were to be referred, and that the existence of strong services overcame systemic barriers to patients receiving needed mental health care, consistent with finding of Chen et al. from an Australian study (20, 21). Lobo et al. in a survey of Spanish CLP services reported higher proportions of services with psychology provision and less specialist nursing provision. Neither this Spanish study, nor a similar Norwegian described the degree of ED input (18, 22).

The existing levels of nursing resourcing owe much to the NCP-SH which has set the standard for the staffing of mental health services at EDs at 1 CNS/200 presentations per annum, and without which the mean CNS staffing levels would certainly be much lower especially in the Model 3 hospitals (2, 23). This, along with the effective delivery of the Perinatal Model of Care, emphasise the importance of funding accompanying staffing requirements to ensure services are adequately resourced (16).

Among Model 3 hospitals, there were higher staffing levels for nursing staff compared with Model 4 hospitals (39% meeting the standard of 5 CNS/500 beds, compared with none in the Model 4 hospitals), but this is counterbalanced by the lack of medical staff. The five hospitals with consultant staffing (any WTE) met the minimum standard of A Vision for Change. While it may be difficult to justify a fulltime CLP consultant for a hospital with 200 beds, this indicates a need for some degree of on-site medical leadership and there may be potential to combine a 0.5 WTE CLP consultant role with other roles in psychiatry or to provide part-time working options.

For the paediatric hospitals, there were no staffing levels specified in A Vision for Change and UK-based documents did not specify what resourcing of paediatric hospitals should be. However, as the assessment and treatment of children and adolescents is arguably a lengthier process in the main, there is an argument for higher levels of staffing per presentation in these settings (24).

Resourcing levels in Ireland compare poorly to English levels of staffing and service delivery. With all services being sub-core, the resources are not in place to provide high quality 24/7 care. In the UK, 21% met at least Core standards, and 10.1% were at least Core24 (10). Activity levels are higher than those reported by services in UK and Australia although the levels of resourcing are poor (25, 26). There is an identified need to ensure services are resourced to the minimum levels established by national and international standards.

Data and information systems are a significant barrier to the development of services. The provision of these is idiosyncratic and there is no national standard. Where hospitals have data and information systems in place it allows for a more granular examination of the work of the CLP service (27, 28). Universal information systems would allow comparisons to be made to similar work conducted internationally, and to establish whether the work of Irish CLP differs from other countries, and where it needs to be improved (25, 29, 30). The data available suggests very high levels of clinical activity, compared to other areas of mental health services.

The most significant limitation was the absence of any systematic consistent activity data across the sites, as a result this study was dependent on self-report data, rather than independent observation. However, this is not dissimilar from other published work in the area of CLP service-based research (10). At the smaller sites where self-harm data represents a significant proportion of the workload, this is captured by the NCP-SH data. It is difficult for clinical teams with little administrative support, often struggling to meet the clinical demands for their services, to prioritise data collection ahead of delivering clinical care.

The full (100%) response rate gives a clear view of the national provision of services, similar to the work of Walker et al. in the UK (10). It is a very strong response compared with the 62% response rate in the Spanish study and the 41% response rate in a similar Norwegian study (18, 22).

The findings of this study will be used as a basis of a Model of Care for Irish CLP services, a model that will be developed in keeping with the recommendations of the 2020 policy document Sharing the Vision (31). It is expected that this will result in the implementation of minimum safe resourcing levels and allocation of information systems and administration to facilitate future development of Irish CLP services.

Further work will incorporate the patient voice into both the design as well as capturing the qualitative experience of patients who come into clinical contact with liaison psychiatry services. There is a clear need for robust data to be routinely collected in order to identify the areas where there is greatest need as well as simply quantifying activity. This is a challenge internationally (32). Such data would allow for the activity-based commissioning of services and would lead the way toward ensuring that services are adequately resourced for the needs of their patients. Once there is data available it will be possible to establish outcome measurements such as the FROM-LP and to use this to enhance the quality of services delivered (33).

This study found that despite the strong and evolving data on the economic benefits of a well-functioning CLP service the development of CLP services in Ireland is lagging behind the development of policy. Despite this, services provide high volume of care, and a high proportion are adhering to best practise guidelines such as regarding parallel assessment. In Ireland, CLP services are grossly under-resourced, and report high levels of clinical activity. There is an urgent need for robust data collection and for investment to bring these services to a sustainable level of resourcing for the activity undertaken. This paper has demonstrated the need for a systematic approach to developing and evaluating services, with twin key areas: adequate staffing and information systems to capture data on service need and activity.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

AD, MC, EK, EC, EB, EG, and SM conceived of the research. WL provided external advice. RP, KM, and AD carried out the survey. AD carried out the statistical analysis and wrote the first draught. All authors contributed to the manuscript and approved the final version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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