Medically Unexplained Symptoms
News and updates from today’s conference held in partnership with the Tavistock and Portman NHS Foundation Trust and chaired by Chief Executive Paul Jenkins OBE.
The Lived Experience: it’s all in your head by Naomi Good Regional Development & Research Manager at NSUN Network for Mental Health. Naomi opened the conference giving the lived experience of what its like to experience Medically Unexplained Symptoms.
Naomi Good presentation
Improving support for people with Medically Unexplained Symptoms by Claire Murdoch National Mental Health Director at NHS England
Claire gave a national update on medically unexplained symptoms and opened discussing the difficulties of raising the profile of mental health, particularly within acute trusts. Claire said “the link between the physical and the mental is all our business”. “We all know this, the cost to the NHS is about £3.25billion per year – in poor responses to medically unexplained symptoms, and time spent in hospital, if we were to look at time off worth the economic costs are huge”. “This is distressing for people, we also know there are high degrees of treatability for those suffering.”
Claire discussed the development of the IAPT programme which is the key response to medically unexplained symptoms. Claire said “We are in NHS England committed to increasing the access to talking therapies in IAPT”. Task 1 is to get money invested in talking therapies, task 2 is to ensure best evidence and task 3 is to develop the model. We are current investing in doubling the number of employment advisors in IAPT with around 90 CCGs to take part in extensive testing of employment advisors in IAPT- gathering rigorous infomration for 2020/21.
We have a committment to drive the access and recovery target - the aim to be at a 50% recovery target by the end of this year and we will reach that. One of the big issues is building a competent workforce, its a huge endeavour to train more people in talking therapies, there is a high turnover rate. There is a massive workforce issue to treat the number of people we want to treat on an annual basis and increase it.
Two thirds of the expansion in IAPT is to be integrated IAPT services - integrated with physical health pathways for people with long term conditions or distressing and persistant medically unexplained symptoms. We are going to announce where the pilots will be any day now. In 2016/17 and 2017/18 early implementers are supported centrally, from 2018/19 CCGs are to commission integrated IAPT services. It is almost unthinkable that you would take money out of the acute trust and invest in mental health services - but you will save money and deliver better outcomes.
In terms of workforce there are currently around 6000WTE therapists in the current workforce, seeing on average 7 people a day. There is evidence of poor workforce wellbeing. There is a big question of how we build a sustainable workforce.
In conclusion, NHS Englands main focus is the notion of therapy for medically unexplained symptoms. There is a new way of thinking about the person and what they need and how therapy is a huge enabler to patient activation, triggering all sorts of points that I want you to love although I know many of you have reservations that IAPT could be the only answer. IAPT is a wonderful trogan horse into a different way of thinking of the physical and the mental. It is a time of big challenge and opportunity. The system knows we have to move towards a wellness based approch to healthcare, I would like to reclaim the term mental illness, we have sometimes done people a dis-service by normalising mental health for the people at the extremes - its a question I would like to leave with you. The big opportunity is to push forward on the wellness agenda, building resilience and looking at physical and mental and the links between the two. Claire also discussed digital developments and the role in the future of IAPT.
View Claire's presentation here
Session 3 focused on developing an effective integrated holistic medically unexplained symptoms service by Dr Julian Stern Director of Adult and Forensic Services & Consultant Psychiatrist in Psychotherapy, and Tim Kent Service Lead Primary Care, Consultant Psychotherapist and Social Worker at The Tavistock and Portman NHS Foundation Trust.
Julien discussed their dual focus offer to patients and staff. Julien said their retention of staff is excellent as they focus on wellbeing of staff. Julien said “looking after our staff is key”. Julien said that one of the strengths of their approach is to incorporate outcome monitoring measures that are compariable with the ones IAPT use and equally to do some health economic research. Our results have been excellent. Julien then discussed their outcome monitoring data which is available to delegates. The bottom line is about 75% of patients showed improvement in their mental health and about 55% recovered. In terms of money we have shown our service which costs about £1000 per patient, for every patient we save about £460 – so it still costs, but there is probably no service in the NHS that is entirely cost neutral. They have been told that if the service was a drug it would be approved on NICE guidelines based on the cost per QALY.
Tim Kent continued the presentation by showing a powerful film that a service user wanted to make to show doctors about why people might look ok but they are not ok. Tim discussed issues around GP mental health training, understanding pressure in general practice and primary care practice. Tim also talked about the importance of supporting receptionists particularly with reference to the news this week.
Pre-event Abstract: Developing an effective integrated holistic MUS service
In this presentation Julian Stern and Tim Kent present the Tavistock primary care model, pioneered in the London Borough of Hackney, and recently commissioned in Camden, and the subject of much interest throughout the UK .
The service provides experienced and qualified psychologists, psychotherapists and medical staff, to GP practices throughout the 2 boroughs, offering a range of psychotherapeutic modalities to patients, many of whom suffer from MUS and /or LTC’s (Long Term conditions) as well as other comorbidities.
In addition the services offer consultations to and with GPs and the other members of the primary care staff team.
Independent health economics research has shown the cost-effectiveness of the model, and the Hackney service has won a number of national awards.
The model of work is influenced by psychodynamic and systemic thinking, and the practitioners offer a wide range of therapeutic interventions. Close attention is paid to key relationships with partners in the local health economy - GPs and their staff, local IAPT services, secondary care services and Third Sector organizations as well as attending to the requests and anxieties of commissioners.
This presentation will focus on aspects of the work of the service -clinical work with patients, interactions with other Health Care Professionals , and the wider system.
Guidance for commissioners of medically unexplained symptoms services by Professor Carolyn Chew-Graham and Dr Simon Heyland Co-Chairs Joint Commissioning Panel for Mental Health MUS Expert Reference Group
Pre-event abstract: Commissioning guidance for Medically Unexplained Symptoms (MUS)
The Joint Commissioning Panel for Mental Health (JCPMH) is co-chaired by the Royal College of Psychiatrists and the Royal College of General Practitioners. It is a collaboration between seventeen leading organisations, aiming to guide commissioners to improve mental health and wellbeing, using a ‘values based’ commissioning model.
This presentation will provide an overview of MUS, problems with definitions and an outline of the impact of MUS on the patient, the clinician, the health service and society.
We will discuss the principles which should underpin good MUS services and present our ten key messages for commissioners. We will discuss service models which demonstrate good practice.
Professor Carolyn Chew-Graham and Dr Simon Heyland presentation
Medically Unexplained Symptoms: Evaluating the Stepped Care Model and Learning from the National Pathfinders by Professor Rona Moss-Morris Institute of Psychiatry, Psychology and Neuroscience and IAPT Lead (Medically Unexplained Symptoms) at NHS England, and Dr Abrar Hussain Consultant Liaison Psychiatrist Berkshire Healthcare NHS Foundation Trust.
There is a huge area of unmet need for patients with MUS in the community. In 2012, the national IAPT pathfinder programme allowed Berkshire to develop a stepped care model with general practitioners, IAPT clinicians, health psychology and liaison psychiatry. The service provided training and supervision to GPs and IAPT in addition to delivering psychological and pharmacological treatment.
Over the years, the service/pathway has evolved and is currently commissioned by the respective CCGs in East and West Berkshire. The current pathway includes collaboration between IAPT, community liaison psychiatry and the hospital based psychological medicine service.
One of the highlights of the current pathway is the effective collaboration between psychiatry and psychology which allows patients to access a biopsychosocial approach with case management and effective interagency liaison.
The joint liaison psychiatry clinics with hospital specialties (currently neurology and respiratory medicine) ensure patients with medically unexplained symptoms can access psychological treatment with ease. Being co-located reduces stigma and normalises the use of psychological approaches in the treatment of physical symptoms thereby reducing iatrogenic harm.
Future events of interest:
Working with Staff in Conflict held by Tavistock Consulting
Tuesday 22 November
Hallam Conference Centre, London
21 October 2016