Presentation by Dr Mark Griffiths, Consultant Lead Clinical Psychologist, Aintree University NHS Foundation Trust: Medically unexplained symptoms: An innovative approach for a primary care workforce on Wednesday 13 March 2019 at Haydock Park Racecourse.

1. Medically Unexplained Symptoms
Management:
Clinical Innovation, System Design &
Primary Care Workforce Implications
Dr Mark Griffiths
Consultant Clinical Psychologist
Lead Psychologist & Head of Psychology,
Clinical Health Psychology Services,
Aintree Hospital, Liverpool
mark.griffiths@aintree.nhs.uk

3. Medically unexplained/ Functional Symptoms (FS) are:
‘persistent bodily complaints for which adequate (medical) examination does not reveal
sufficient explanatory structural or other specified pathology’
(RC Psych, 2011)
Physical symptoms influenced by psychological factors present a significant burden on
services;
- accounting for half of all primary care consultations
- and a third of hospital outpatient presentations” (Bass, 2003)
MUS/ COMPLEX MEDICAL PROBLEMS
3

4. (UK) SECONDARY CARE – MUS PREVALENCE
(ROLFE & BURTON, 2013)
4
Cardiology- 53%
Gastroenterology- 58%
Neurology- 66%
Respiratory- 41%
Rheumatology- 45%
More generally, 25% of Hospital OPD attendances are likely to be
presenting with MUS

5. Impairment
Activity Limitation
Illness Behaviours
Environmental Restriction
Sickness in the society
Neurophysiological disorder
Health
Experienced
Biological
Psychological Sociological
THE BIOPSYCHOSOCIAL MODEL OF HEALTH
5

7. MUS
MODEL

8. REASONS FOR IDENTIFYING SUCH ‘COMPLEX PATIENTS’
 At risk of progress to polypharmacy including addiction to opiate analgesia and benzodiazepine
 At risk of longstanding poor quality of life and social functioning
 At risk of high dissatisfaction and increased anxiety in response to usual care
 Frequent contact with health care professionals but dissatisfied with outcome
 At risk of high referral rates for onward medical investigations and treatment without clinical
benefit
8

9. HEALTHCARE COST
9
RCPsych (2011):
• Annual NHS healthcare cost of MUS across the UK – exceeds £3.1 billion (more recent
research indicates the bill nearer £4 billion)
Patients presenting with MUS commonly having:
• Higher rates of onward medical referral and medical investigations
• More protracted patient journeys
• Less likely to be followed up within specialist care
• More likely to be referred back for GP management

10.  Whole system solutions needed
 Moving away from PH OR MH care pathways, to more integrated care models
 Biopsychosocial assessment considerations across all stages of patient journey
 Need for ‘Enhanced Care’ approach from when Stress/ Psychosocial factors can be identified
as having a likely detrimental impact on PPS presentations; and beyond (in the healthcare
journey)
10
COLLABORATIVE SOLUTIONS

11. 11

12. BEST PRACTICE EXAMPLES:
INTEGRATED MUS CARE
City & Hackney Primary Care Psychotherapy Consultation (Outreach) Service
 Balint group type Reflective Practice support for GPs and practice staff (to support enhanced
patient care)
 GP practice- based psychological treatment delivery
 ROI – costs savings of £463 per patient established
12

13. BEST PRACTICE EXAMPLES:
INTEGRATED MUS CARE
Aintree AED Medical Psychology LTC & MUS Service
 Clinical health psychology embedded into AED MDT & care pathway
 Facilitating routine biopsychosocial assessment
 Supporting internal triage for clinical health psychology review, treatment or clinical
management guidance
 Providing clinical management guidance to hospital staff and GPs
 Providing specialists psychological therapy pathway
 Established ROI of £7 for every £1 invested
13

14. Activity Change 12 months post 1st Psychol
contact
(N-224)
A&E Episodes A&
days
Ward admissions
following A&E
Days Admitted
- Down by 22%
- 291 A&E days avoided
- Down by 31%
- 167 admission events
avoided
- 917 bed days avoided
Activity Change 12 months post 1st Psychol
contact
(N-224)
Ambulance savings
(ambulance
journeys for A&E
Ax/ Tr)
- Down by 30%
- 52 ambulance journeys
avoided
OUTCOMES:
HOSPITAL ACTIVITY HEALTH
ECONOMIC ANALYSIS

15. AED MH (MUS) CQUIN PROJECT OUTCOMES (17/18)
0
2
4
6
8
10
12
14
16
Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18
MH ‘Mus cohort’ frequent attenders
AUH
15

16. LDS / PRIMARY CARE NETWORK CONSIDERATIONS
 Support for GPs
 Training & provision of clinical guidance materials
 Support for aiding GP Ax and clinical management of these complex presentations
 Support offer for IAPT (clinical supervision & training from clinical health psychology)
 Access to specialist clinical inputs (e.g. clinical health psychology & psychiatric liaison) to
assist in providing specialist Ax, clinical guidance & treatments
16

17. WORKFORCE GAPS (TO BE TACKLED)
 Clinical health psychology (to enhance Ax, clinical formulation, care planning and Treatment
offer in PC)
 Primary care psychiatric liaison
 IAPT PWP & HIT workforce skill set enhancement (to enable accessible psychological treatment
delivery in the face of complex & inter-related physical and mental health needs); supported by
CHP clinical supervision and support
17

18. WORKFORCE PITFALLS
 Limited clinical psychology workforce with the required expertise (i.e. clinical health
psychology/ clinical neuropsychology / pain clinical psychologists); to deliver on a ‘whole
system’ model in C&M currently
 IAPT (= community psychological therapies access):
 poorly set up to meet the needs of these complex patients
 generally sitting in the wrong pathways (i.e. MH) to best engage these patients in treatments
 Poor patient engagement in LTC patient population
 Locally/ regionally , very little clinical psychology within MHLT teams; further
increasing access difficulties to biopsychosocial care planning) 18

19. WORKFORCE GAP SOLUTIONS
 Increasing access to available Clinical Health Psychology/clinical neuropsychology/ pain
clinical psychology resources, through regional commissioning review
 Building CHP/ specialist CP resources (and PC liaison psychiatry resources) into Primary
Care network planning
 Clinical Associate Psychologist Proposal: workforce innovation to increase skilled workforce to
support enhanced MDT care (parity of esteem); bridging the current Gap between IAPT HIT
and CHP access (where this is available)
19

20. INTEGRATED CARE FINANCIAL IMPACT
Kings Fund:
“Every £1 spent on psychological care saves £6
[on physical interventions that often aren't necessary or
don't help]”
#kfintegratedcare
KF Integrated Care Summit, October 2016
20