The psychology behind medically unexplained symptoms

In Nottingham, we have been piloting a primary care psychology medicine (PCPM) service – a joint project between Principia, a multi-speciality community vanguard, and Nottinghamshire Healthcare, the local mental health and community provider. This is a prime example of integrated care, bringing together specialist professionals with GPs and other community providers, to promote the equal importance of mental health with physical health, and to provide the emotional and psychological support to people living with long-term conditions.

Every day our health services see patients with physical symptoms that lack an identifiable organic cause. We refer to these as medically unexplained symptoms and the evidence suggests that they make up between 15-30% of all GP appointments and about one in five hospital outpatient appointments among frequent attenders – all of which adds up to  a yearly cost of £3 billion.

Looking at other studies, we can see a close relationship between physical and mental health. About 30% of the population has a long-term condition, and about a third of those have a mental health problem. We’re talking about 4.6m people.

Who of us can honestly admit that they have not experienced moments of stress? It might be triggered by that tight deadline at work or it might be fuelled by a difficult relationship at home.

Our bodies can respond to these stresses in the form of musculoskeletal pain, persistent headache, chronic tiredness, chest pain, heart palpitations and gastric symptoms, among others.

Our primary care psychology medicine (PCPM) service has seen and assessed people with medically unexplained symptoms, as well as those with complex medically explained conditions that have a clear psychological link. We are also supporting patients that are being referred frequently to hospital specialists. We also review patients’ medication.

Together we arrive at a care plan with personal goals to help patients look after their health and wellbeing. We support them to better manage their conditions, pain or symptoms and improve their socialisation and quality of life.

We also run community clinics for patients living with anxiety and depression. Part of the service delivers ongoing training for practice nurses about the benefits of these services and the criteria for referral to the clinic.

Are we making a difference? Yes, I am sure we are. We have had very positive feedback from patients on their experiences after being seen and supported by these new services. They felt listened to and understood and found the reflective nature of assessment very helpful. One of the interesting discoveries was finding that men were more likely to attend a clinic appointment in the community than in a hospital psychiatric setting.

GPs seem delighted. One GP reports that the PCPM clinic has saved them two hours a month. Another GP said: “PCPM provides a wonderful service to the practice and patients. The service offers a very prompt response time and the feedback from patients has been fantastic.”

Clinically, we have also rated outcomes based on a before and after scale. Again, this shows early, but promising results.

In terms of managing demand, we have seen a fall in GP attendances and a drop in prescribing costs as we review medication. We estimate a yearly saving of about £6,000 per patient – and the potential for greater savings of up to £3.5m based on reduced occupied bed days.

It’s important now that we continue to evaluate the impact of the service over a longer period time and we will be independently assessed by the Centre for Mental Health over the next 12-18 months.

I believe this will support the spread of these community services across Greater Nottinghamshire as we grow as an integrated care system – and I hope others will explore the potential and adopt similar ways of working.

10 Aug 2018