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The Nottingham Tool Kit: how the UK is selling ME patients down the river with £200 million for MUS

Countrygirl

Senior Member
Messages
5,429
Location
UK
Here's some heart-sink nonsense.

A friend has just introduced me to this web site.The Nottingham Toolkit: bad news for people with ME. Here is the driving force behind the implementation of MUS, with CFS quoted as an example. Nurses are to be given four months training to cure us of our 'mental' health condition. Just look at the cost of it! Think of the research that could have funded!



http://impact.ref.ac.uk/casestudies2/refservice.svc/GetCaseStudyPDF/28021

Institution: University of Nottingham Unit of Assessment: UoA4 - Psychology, Psychiatry and Neuroscience

Title of case study: The development of psychological treatment pathways and better identification of Medically Unexplained Symptoms (MUS) in primary care

1. Summary of the impact Work on better management and identification of Medically Unexplained Symptoms (MUS) has led to the introduction of new treatments in primary care in England through the Improving Access to Psychological Treatment (IAPT) programme as well as having an impact on service planning and commissioning.

These approaches have also been implemented into the routine training and practice of General Practitioners (GPs) in parts of Europe. A clinical and economic evaluation of a psychosocial approach to chronic fatigue syndrome using general nurses and development of a cognitive behaviour therapy approach has changed general practice and enhanced the patient experience for those with MUS.


Effectiveness of reattribution training In order to provide a framework for GPs to tackle these issues through the use of a structured approach to increase confidence, a psychosocial approach called reattribution was adapted for a broader group of patients with MUS. Reattribution refers to an intensive structured consultation delivered by a GP, which aims to provide a psychological explanation to patients with somatised mental disorder.

To explore the potential advantages of reattribution within a clinical setting, a randomised controlled trial (‘Training family practitioners in reattribution to manage patients with Medically Unexplained Symptoms: MUST- see section 3 for details) was conducted2 .

The trial compared reattribution with treatment as usual in 16 GP practices with 74 GPs and 141 MUS patients to explore feasibility. A six hour training package was developed and adapted for use by GPs to deliver reattribution to patients with MUS.

Morriss and colleagues developed training materials and practice-based delivery of such training by mental health facilitators to improve both the recognition and management of such patients.

Findings showed that such practice-based training improved doctor-patient communication and highlighted a number of attitudinal, practical and organisational issues that needed to be addressed e.g. that patients needed GPs to demonstrate to them that they would take any new symptoms seriously in terms of physical disease rather than assume them to be psychologically created.

Challenges in the implementation of reattribution in a clinical setting were explored through qualitative methods and results showed that barriers included the complexity of patients' problems and patients' judgements about how to manage their presentation of this complexity. Many patients reported not trusting doctors with discussion of emotional aspects of their problems and therefore chose not to present them.

Therefore it was concluded that simply improving GP explanation of unexplained symptoms is insufficient to reduce patients' concerns. Rather, GPs need to help patients to make sense of the complex nature of their presenting problems, communicate that attention to psychosocial factors will not preclude vigilance to physical disease and ensure a quality of doctor-patient relationship in which patients can perceive psychosocial enquiry as appropriate3 .

In light of this, more recent research funded by the Medical Research Council showed that with training and ongoing supervision, psychological treatment for some MUS patients with specific syndromes such as Chronic Fatigue Syndrome could be delivered by adult specialty general nurses who had received four months’ training, including supervised practice, in each of the supportive listening and rehabilitation interventions4 .

This streamlined the process and reduced barriers to delivery such as patients not disclosing psychological problems to GPs. Better identification of patients with MUS Previous research highlighted the need for a streamlined process of identification of MUS within general practice. Therefore,

Morriss and colleagues conducted Department of Health (Care Services Improvement Partnership, CSIP) funded research investigating streamlined diagnosis of MUS by developing methods for estimating the number of patients suffering with MUS using electronic patient records held by practices5 . With additional support of CSIP, Morriss developed a search tool ‘The Nottingham Tool’.

This searches a GP Practice Database, to identify a cohort of patients that fulfil the criteria for MUS. This cohort provides an overview to the commissioners, or the practice, about the number of people likely to have a MUS.

The tool is designed to generate a list for GPs of patients with possible MUS. The GP can then refine the list to exclude or include patients known to have the condition. Morriss noted that whilst identifying the individual patient is important, it is also important for commissioners of services to have a better understanding of the numbers of people who are likely to have a MU symptom. It is important so that appropriate services can be planned and commissioned6 .

As a result of such work on both the organisation of care and the development of The Nottingham Tool to help GPs estimate the care needs of patients in their practice, the National Health Service (NHS) in England extended the provision of specialist psychological care as part of the IAPT programme for such patients.

Therefore, in summary, taken as a whole, Morriss’s body of research about MUS has shown how GPs can be taught to deliver better doctor-patient communication, organise care for such patients, estimate the numbers needing care, better identify patients and develop strategies to engage patients in psychological treatment at a time when the NHS in England will be spending nearly £200 million over a 3 year period on such treatment.

Introduction of a national streamlined pathway for psychological treatment (IAPT) In April 2008, the Government announced that they would invest approximately £33 million in 2008/09, a further £70 million in 2009/10 and an additional £70 million in 2010/11 (totalling £173 million) to introduce IAPT treatment for MUS and long-term conditionsa . This document was prepared in collaboration with the Care Services Improvement Partnership (CSIP) and the NHS commissioning team for MUS/long-term conditions (LTC).

Later, in October 2008, the Positive Practice Guide published by IAPTb outined changes in clinical practice proposed by Morriss and colleagues, discussing barriers to treatment, identification, the impact of psychological problems and gaps in GP training. Morriss is a key member of the MUS/LTC special interest group for IAPT who also aim to improve access to psychological therapies for the whole community by removing barriers to treatment and increased understanding of patient needs, thus translating the work directly to local communitiesc . Work conducted by Morriss through this group has had impact on patients by raising awareness of MUS as a long-term debilitating condition and a disabilityd .

This formed a major part of the need for increased government funding to address the issue. Based upon more recent work by Morriss6 , the government have decided to introduce nurse-delivered and CBT psychological interventions for MUS in primary care. This has resulted in a major training programme to be developed to expand the psychological therapist workforce in order to respond more effectively to the needs to patients with MUS/LTC and co-morbid anxiety and depressionc . In 2009, Morriss’s work on reattribution training (cited in research from 2007)1,2 informed the Royal College of Psychiatrists Practical Management Guide for Patients with Physical and Psychological Problems in Primary Caree as well as the practical guidance document for GPs to help manage MUS by encouraging reattribution and reducing GP anxieties about tackling psychological problems with the patientf .

More recently, in 2012, a NHS Emotional Wellbeing and Physical Health Care Case for Change described Morriss’s findings on symptom reattribution as a successful technique as part of a wider package of care for people with MUSg thus further improving the patient experience.

Looking forward, and as evidence of government acknowledgment of its importance, in 2010 the government decided to increase the funding of IAPT services to £400 million over the next 4 years to fund the expansion of work into further areas including medically unexplained symptomsh .

Increased recognition of MUS in general practice through The Nottingham Tool For further impact on GPs and patients, Morriss’s work has increased recognition of MUS cases in primary care through the development of The Nottingham Tool. This tool has helped estimate the need for psychosocial treatment through better identification of patients with MUS within the general practice community. In 2009, NHS Commissioning Support for London recommended

The Nottingham Tool for general practitioners to increase recognition of MUS within the local community by scanning medical records to generate a list of patients with MUSk . The Tool has its impact primarily on commissioners, raising awareness of numbers of individuals within local communities with MUS so that funding can be distributed appropriately. The Tool has been praised by practitioners, including the chair of Sainsbury Centre for Mental Health and IAPT MUS/LTC special interest group.


Finally, Morriss’s continued work on this topic continues to be cited as important in informing the thinking of health-care decisions, in particular in the domain of mental health. Publications are on-going with new advances being made in 2012 (e.g. Morriss: Role of mental health professionals in the management of functional somatic symptoms in primary care).

The chair of Sainsbury Centre for Mental Health commented on these on-going contributions. ‘I have no doubt that your work has advanced national and international knowledge and practice, and continues to do so; I am currently a CCG Governing Body Member, leading on mental health - but I am still asked regularly for advice on this subject, part of my reply usually references your work’l . 5. Sources to corroborate the impact a. Improving Access to Psychological Therapies, Commissioning Toolkit.
 
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Messages
2,158
What a truly appalling waste of money. It looks unstoppable.

'Reattribution refers to an intensive structured consultation delivered by a GP, which aims to provide a psychological explanation to patients with somatised mental disorder'

I wonder whether anyone has told them that somatised mental disorders don't exist except in the imagination of a few psychiatrists and psychologists.

:cry::cry::cry::cry::bang-head:
 
Messages
13,774
In light of this, more recent research funded by the Medical Research Council showed that with training and ongoing supervision, psychological treatment for some MUS patients with specific syndromes such as Chronic Fatigue Syndrome could be delivered by adult specialty general nurses who had received four months’ training, including supervised practice, in each of the supportive listening and rehabilitation interventions4 . This streamlined the process and reduced barriers to delivery such as patients not disclosing psychological problems to GPs. Better identification of patients with MUS Previous research highlighted the need for a streamlined process of identification of MUS within general practice.

LOL - the reference for that is FINE. They took the no benefit over control result, and interpreted that as the exciting new that both the PR intervention and the control intervention would be worth delivering?!

Some of these REF2014 sumbmissions seem a lot like fraud to me. Anyone know if there's anything that can be done about this?
 
Messages
1,478
im surprised it takes 4 months of training....surely it doesn't take that long to train the nurses to tick a box on a form to say, I've retrained their brain and released them back to the community? After all there is no need to prove whether the treatment works ...so this makes it just an attendance record keeping exercise? In fact why not save more money and just do it online. That way the GP could just give a preprinted card to the patient to say attend this retraining course by following this web address...job done!

The last page of the the training could say " congratulations you have completed the course and are now cured. Your medical records have been updated automatically, there is no need to revisit your GP. If you feel the need for further retraining please log in again for a refresher course".
 
Messages
2,158
LOL - the reference for that is FINE. They took the no benefit over control result, and interpreted that as the exciting new that both the PR intervention and the control intervention would be worth delivering?!

Yes, I noticed that they justify using the two methods tested in the FINE trial by quoting that trial as if it showed these treatments worked! Actually what it showed was that their 'control' group with 'supportive listening' was no better or worse than their active treatment group with combined GET/CBT. In other words it was a null trial. Now they seem to be using it to say both these are treatments that work!

Huh????

I think this is a new low in so called science. You set up a trial with a control group, and when the trial shows no difference between active treatment and control, you declare it as showing both control and active treatment are successful.

It gets worse and worse. This isn't science. All the other papers quoted are by Morriss and his minions, and all seem to be qualitative stuff designed to prove what they already believe.

How on earth do they get away with this. A whole edifice of IAPT costing millions built on nonsense. And all designed to 'help' GP's to explain to patients with stuff they can't diagnose that this means it's all in our pretty little heads.

:bang-head::bang-head::bang-head::bang-head::bang-head:
 

PhoenixDown

Senior Member
Messages
456
Location
UK
Impact on cost effectiveness of care and international uptake
Although it is hard to give a precise estimate of cost savings at this early phase, previous estimates
made independently (Bermingham et al., 2010) suggest that if IAPT were to deliver
psychological treatments based on approaches in the MUS and LTC Positive Practice Guide (based on
Morriss’s work), savings of at least £75 million per year may be made (9% of GP estimated expenditure of £837 million per year).
So it's about saving money, once again ME patients are sold down the river.

A clinical and economic evaluation of a psychosocial approach to chronic fatigue syndrome using general nurses and development of a cognitive behaviour therapy approach has changed general practice and enhanced the patient experience for those with MUS.
Enhanced, my ass! I've been made permanently worse thanks to the BPS approach. Conflating ME with MUS/somatizing is dangerous for patients.
 

Countrygirl

Senior Member
Messages
5,429
Location
UK
Huh????

I think this is a new low in so called science. You set up a trial with a control group, and when the trial shows no difference between active treatment and control, you declare it as showing both control and active treatment are successful.

It gets worse and worse. This isn't science. All the other papers quoted are by Morriss and his minions, and all seem to be qualitative stuff designed to prove what they already believe.

How on earth do they get away with this. A whole edifice of IAPT costing millions built on nonsense. And all designed to 'help' GP's to explain to patients with stuff they can't diagnose that this means it's all in our pretty little heads.

:bang-head::bang-head::bang-head::bang-head::bang-head:

Worse than that. The author has contacted my GP (I find that most strange) and instructed my doctor to send me to a fatigue clinic and arrange for me to have CBT/GET. Before the phone call my GP was supportive and 'believed' ME was a genuine physical illness although she knew little about it; however, after the call of four months ago, her whole attitude has changed and she is hostile and is proposing to take various actions that will make me much more ill. I have tried to reason with the doctor but she is adamant that ME now belongs in the mental health department. She dismissed the work of people like Fluge, Davies etc as irrelevant and not worth a candle.

How many other surgeries are being contacted in this way?
 

Mohawk1995

Senior Member
Messages
287
So this may surprise a few on PR.....This is the plans for one the greatest wastes of money in the history of medicine! The disease is not psychological at its core and not even psychologically predisposed in any way. It hits people from all walks of life, ages, nationalities, sexes, levels of education and levels of income. No official data, but I might even suggest that those who develop ME actually have less mental health issues prior to illness than does the general public.

The whole MUS thing is rather ridiculous. Note to NHS: Cant't explain it? Then work harder on physiological ways to do just that! Don't sit back on your arses and pat yourself on the back. Get out there and really work hard!

The arrogance to suggest that just because something cannot be explained medically, that it then must be primarily psychological is plain idiocy!

As some have suggested, the money would be better spent on practical ways to address these patients needs. Might even be better to just calculate the number of people impacted by "MUS" and hand the cash straight to them. Oh but wait, they would loose their ability to control people's lives and think more highly of themselves for "doing" so!

At least if you going to discuss psychological issues, do it from a standpoint of trying to honestly help people cope with these devastating and confusing diseases!

Maybe Robin Hood needs to return to Nottingham ;)
 

A.B.

Senior Member
Messages
3,780
They could actually use that money to advance research and build real knowledge and effective treatments. Or at least help people that actually need mental health treatments.

It's going to be a trainwreck, and no amount of advertising and spin will change that.
 
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user9876

Senior Member
Messages
4,556
LOL - the reference for that is FINE. They took the no benefit over control result, and interpreted that as the exciting new that both the PR intervention and the control intervention would be worth delivering?!

Some of these REF2014 sumbmissions seem a lot like fraud to me. Anyone know if there's anything that can be done about this?

I think in others Oxford and QMUL were pushing the PACE output as significant. I do wonder about these as they are essentially pushing stories of 'successful' research to gain further research funding and reputation. Perhaps that is why QMUL would spend so much money suppressing PACE results.

I wonder if the university of Nottingham can be held legally liable (in the new commercial NHS world) for the failures of their training courses and tools when they fail to work.
 
Messages
13,774
I think in others Oxford and QMUL were pushing the PACE output as significant. I do wonder about these as they are essentially pushing stories of 'successful' research to gain further research funding and reputation. Perhaps that is why QMUL would spend so much money suppressing PACE results.

I wonder if the university of Nottingham can be held legally liable (in the new commercial NHS world) for the failures of their training courses and tools when they fail to work.

I think that REF2014 played an important role in determining future funding for research, so a lot of money could have been at stake. I did try to see how much the REF2014 analysis of submissions worked, but didn't get very far. Surely there are authority figures who'd be concerned by the spin found in their submissions, but I don't know who they are or how to contact them.

The REF2014 contact details don't look that promising: http://www.ref.ac.uk/contact/

There was some body that looks at the misuse of public funds... maybe they'd be interested?
 

Countrygirl

Senior Member
Messages
5,429
Location
UK
Thank you for posting this @Countrygirl . It's horrific.

(I wonder if this thread should have something along the lines of '£200 million for pychological treatment for MUS'? I only knew to read as I had seen mention of Nottingham Tool Kit mentioned on twitter. Ignor if I don't know what I'm talking about - brain fog bad)

Done! @moosie