Venetia Young 011110


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presentation Venetia Young at Prime Masterclass Croydon 01/11/2010

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Venetia Young 011110

  1. 1. Frequent attenders – a family systemic approach Dr Venetia Young GP, Bishopyards Surgery (now the Lakes Medical Practice) Penrith, Cumbria, England UK
  2. 2. Bishopyards, Penrith Small market town – population 20,000 5500 patients. 5 doctors (3 WTE), 2 nurses, pharmacist Consultations of more than 5 in Jan-March 2007 with GP in surgery 163 patients 1025 appointments. 3% of list 25% on antidepressants Top 50 33% on antidepressants Only one child High proportion middle aged women
  3. 3. Frequent attenders audit Top 5 – 3 major mental illness in contact with mental health services, one severe eating disorder, one social problem 10 with depression and anxiety. 2 with severe illness (both died) 7 with straightforward physical illness 26 multiple symptoms in which stress played a part.
  4. 4. Sheffield (UK) Study Waller and Hodgkin 2000 9 practices 1.3% patients generated 8.3% of consultations (20pa) 3.6% patients generated 17.6% of consultations (15pa) 42% on antidepressants 20pa cf 9% of population 22% of FA had no chronic disease 1/3 repeated behaviour the next year
  5. 5. How was this managed? Discussed with GPs 10 patients in referral process for PCMH team CMHT contacted re top 3 Eating disorder patient admitted Social problem family seen jointly at scheduled appointments as there were multiple medical problems Remaining frequent attenders noted and 15 worked with by VY alone: genogram, ICE elicited, stress cycle and hyperventilation explained, breathing exercises taught, HADS, depression treated where appropriate, 3 patients offered regular routine follow up.
  6. 6. continued Training – all staff on stress management and health related anxiety 2 GPs, pharmacist and HCA on Positive Mental Training- self-hypnosis CDs Regular meetings with HV Better focus with PCMH team Change in appointment system Cultural shift - Active management Less use of locums
  7. 7. One year on in Penrith 44 patients seeing GP 5 or more times, compared with 163 1 consulted 10 times compared with 11 Less than 1% of list, compared with 3% 18 male 31 female 18 not on Chronic Disease register 19 Hypertension, 4 Mental health, 2 DM, 2 cancer 8 under 20, 6 in 20-40, 5 in 41-50, 9 in 51-60, 8 in 61-70, 8 in 71-80. Saving 200 appointments over 3 months
  8. 8. Some cases Margaret 62 Divorced. Pain in head, neck, shoulders, knees and back. Dyspepsia. Migraine. Hypertension. Carer Genogram Reading self help leaflets Stress cycle explained Breathing and relaxation technique Solution focussed questioning Regular follow up: 5 appointments 120 minutes in all.
  9. 9. Case 2 Hilda 65 Type 2 DM on oral medication – poor control HbA1c 8.8 Barrett’s oesophagus Severe anxiety disorder CBT Work with her and daughter Medication – low dose escitalopram Breathing and relaxation Regular FU
  10. 10. Hilda 2010 DM well controlled for 2 years, HbA1c 6.6 reduction in medication Barrett’s oesophagus improving endoscopically, no dyspeptic symptoms Appointments every 8 weeks Anxiety gone: no panic attacks for 2 years, no worries about hypos, no anxieties about endoscopy Coping strategies: taking a step back from family dynamics, breathing, exercise
  11. 11. Patient comments Rachel 35 - pleased to have diagnosis of ME and not to have to pester the doctors any more Jo 68 - phoning doctors was a sign of not being well Mark 45 – phone number not near phone Liz – 32 finally referred for psychotherapy
  12. 12. What are the patients’ needs? Medically unexplained symptoms Distress – relationships, work, school, money, housing. Depression and antidepressants Anxiety disorders especially health related anxiety need recognition. Major mental illness Good quality self-help literature Appropriate referrals
  13. 13. Skill implications for whole team? Active management not reactive Good assessment Eliciting patients’ backgrounds Explaining stress and its effect on the body Explaining hyperventilation Managing affect in consultation and on phone Diagnosing sub-syndromal depression Therapeutic skills for watchful waiting Noticing the frequent attender Noticing the medication abuser Using self-help materials
  14. 14. More advanced skills BATHE SFBT CBT Hypnotherapy NLP EFT (Tapping) Human Givens approach- enhanced CBT Systemic (Family Therapy)
  15. 15. The Primary Care Team and the wider community Community resources: young mothers, middle aged women, lonely elderly Mental health organisations Social care organisations Third sector
  16. 16. Further updates Two practices have merged, with different frequent attender problems GP trainees and medical students given data to interpret PCMH meetings monthly in practice: school nurse, health visitor, community psychiatric social worker, primary care mental health worker. Plan to start a group for 45-60 yr old women who are beginning to attend frequently. MIND – charitable organisation – developed a sound recovery focus Menopause evening – 50 women plus nurses and doctors Training afternoon for 95 patients with COPD Systemic Training in all 11 practices in locality on genograms, breathing and stress cycle Training for all staff on personality disorders
  17. 17. ‘A pain in the neck?’ The use of a systemic lens helps the clinician to understand that if a community is not meeting the needs of groups of its people, then they will present in bigger numbers with multiple symptoms to their primary care organisation. The same applies to families failing to meet emotional needs of their members Clinicians will have frequent attenders if they can’t explain MUS
  18. 18. References Waller and Hodgkin: General Practice - demanding work 2002 Radcliffe Asen, Tomson, Tomson and Young: 10 minutes for the family, Routledge 2004 Larivara et al 1996 developing a family systems approach to rural healthcare: dealing with the heavy user problem. Families, Systems and Health 1996 14; 291-302 Kroenke and Mangelsdorf 1989 American Journal of Medicine 86 262-266 McDaniel et al 2004 Family Oriented Primary Care Springer Verlag