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MUS, PPS services and IAPT integration into NHS primary care - what's happening across the UK?

trishrhymes

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I guess you could say that most initial referrals of patients to specialists are for MUS, in the sense that at the stage of referral, the GP isn't certain what is wrong with the patient and therefore wants to specialist to do further testing and/or use their expert knowledge to come to a diagnosis.

In most cases this probably leads to a clear diagnosis of a known condition, so the patient no longer has MUS.

The question is, are such referrals classed as MUS, because that's how they started, or only as MUS if the consultant can't diagnose it either.

As far as I'm concerned, MUS is simply a way of saying 'I don't know'. It's not a diagnosis, it's a lack of diagnosis.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Just to complicate matters:

In England, we are increasingly seeing the term "medically unexplained symptoms" deprecated in favour of the term "Persistent physical symptoms (PPS)".

In Scotland, "Persistent physical symptoms" is being used, on this site at least, where the term, "long-term conditions (LTCs)" is used in England.


http://www.nes.scot.nhs.uk/educatio...ogical-interventions-and-physical-health.aspx

NHS Education for Scotland
Quality Education for a Healthier Scotland


Psychological Interventions and Physical Health

NES Psychology directorate has been developing a programme of work aimed at addressing the training needs of the NHS Scotland workforce in relation to psychological interventions in physical health care...

(...)
https://www.ucl.ac.uk/pals/research...ople_with_Persistent_Physical_Health_Problems

The Matrix (2015) A Guide to Delivering Evidence-Based Psychological Therapies in Scotland; Persistent Physical Symptoms

The Psychological Therapies 'Matrix' is a guide to planning and delivering evidence-based Psychological Therapies within NHS Boards in Scotland. The Matrix is published by NES, in partnership with the Scottish Government. It provides a summary of the information on the current evidence base for various therapeutic approaches, guidance on well functioning psychological therapies services and advice on important governance issues. The sub-section relating to the psychological management of persistent physical symptoms was updated in 2015.

Persistent Physical Symptoms refers to health problems that last a year or longer, impact on a person’s life, and may require ongoing care and support. The definition does not relate to any one condition, care group or age category. Common examples include diabetes, heart disease, chronic pain, arthritis, inflammatory bowel disease, asthma and chronic obstructive pulmonary disease (COPD).

The evidence tables for persistent physical symptoms can be found and downloaded in the link below:

http://www.nes.scot.nhs.uk/media/3500010/matrix_-_persisent_physical_symptomstablesfinal_1.pdf

The document in the PDF:

Psychosocial Interventions for People with Persistent Physical Symptoms

Introduction


Persistent Physical Symptoms, refers to health problems that last a year or longer, impact on a
person’s life, and may require ongoing care and support. The definition does not relate to any one
condition, care group or age category. Common examples include diabetes, heart disease, chronic pain,
arthritis, inflammatory bowel disease, asthma and chronic obstructive pulmonary disease (COPD).
Around 2 million people in Scotland have at least one such condition, and one in four adults over
16 years reported some form of long term illness, health problem or disability, and one in five have
chronic pain. These conditions become more common with age. By the age of 65, nearly two-thirds
of people will have developed Persistent Physical Symptoms, however, more people under the age of
65 years in Scotland have multiple conditions.

(...)

Asthma
Cancer
Cardiovascular disease (CVD)
Chronic fatigue syndrome (CFS)
Chronic kidney disease
Chronic obstructive pulmonary disease (COPD)
Chronic pain
Diabetes Type 1 and Type 2
Irritable bowel syndrome (IBS)
Multiple sclerosis (MS)
Osteoarthritis
Rheumatoid arthritis
Obesity/Weight loss interventions


But in England, PPS is being used for:

"Medically unexplained symptoms"

under which is also included, in some cases:

Fibromyalgia
Irritable Bowel Syndrome
Chronic Fatigue Syndrome/ ME
Functional Neurological Symptoms (including Non-Epileptic Attacks)



The NHS Education for Scotland site has a separate page for MUS:

http://www.nes.scot.nhs.uk/educatio...chology/mus-long-term-conditions-toolkit.aspx

MUS - Long Term Conditions Toolkit

The term “medically unexplained symptoms” is used to describe a set of persistent physical symptoms (e.g. chest pain, dizziness, back pain) for which, after extensive investigation, there is no obvious underlying cause or diagnosis.

For those with persistent physical symptoms, the journey from symptom development to clear understanding and evidence-based treatment can be an arduous one. In an attempt to exclude more concerning underlying conditions, GPs often undertake a range of medical assessments and interventions. While necessary, these can cause patients to develop:
  • unwanted psychological and physical side effects, adding to distress and disability
  • beliefs about the nature and seriousness of their condition,
  • Additional pain, fatigue and other symptoms due to pharmacological interventions.
In the absence of a clear cause or diagnosis despite persisting symptoms, patients can become increasingly distressed, while fear of what may be generating symptoms often leads to avoidance of daily activities. Further investigations may also place the patient at risk of harm, for instance, due to infection from exploratory operations, and exceeding safe doses of radiation etc.
 
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Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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I guess you could say that most initial referrals of patients to specialists are for MUS, in the sense that at the stage of referral, the GP isn't certain what is wrong with the patient and therefore wants to specialist to do further testing and/or use their expert knowledge to come to a diagnosis.

In most cases this probably leads to a clear diagnosis of a known condition, so the patient no longer has MUS.

The question is, are such referrals classed as MUS, because that's how they started, or only as MUS if the consultant can't diagnose it either.

As far as I'm concerned, MUS is simply a way of saying 'I don't know'. It's not a diagnosis, it's a lack of diagnosis.

It's widely cited that up to 50% of referrals to specialists are found not to have an identifiable medical cause for their symptom(s).

In secondary care, 50% of outpatients fulfil criteria for MUS with a wide range of disorders

The following shows the % at 12 months


• Gynaecology (66%)
• Neurology (62%)
• Gastroenterology (58%)
• Cardiology (53%)
• Rheumatology (45%)
• General Medicine (40.5%)


Source: Guidance for health professionals on medically unexplained symptoms (MUS)
(2011). Royal College of General Practitioners and Royal College of Psychiatrists​
 

trishrhymes

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In the absence of a clear cause or diagnosis despite persisting symptoms, patients can become increasingly distressed, while fear of what may be generating symptoms often leads to avoidance of daily activities. Further investigations may also place the patient at risk of harm, for instance, due to infection from exploratory operations, and exceeding safe doses of radiation etc.
This is truly bizarre. Can they really mean that there is a danger of patients with MUS being subjected to operations and radiotherapy?
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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This is truly bizarre. Can they really mean that there is a danger of patients with MUS being subjected to operations and radiotherapy?
What they mean is not carrying out "unnecessary" investigations or interventions that expose patients to the risks inherent to all patients undergoing operations, X-rays etc.
 
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trishrhymes

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Exactly. MUS is a tautology.

Whereas a PPS diagnosis is explicitly admitting the medical system is failing.
Unless you take PPS literally to mean anyone with persistent physical symptoms, including those of well diagnosed and understood causation like asthma, diabetes, arthritis etc.

It seems that some groups offering IAPT include these, widening the scope for them to take over more scarce NHS funding with their message to GPs that they can magically reduce patients demands on GP services with their patronising positive thinking 'therapies' administered by people with no understanding of the underlying illness.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Unless you take PPS literally to mean anyone with persistent physical symptoms, including those of well diagnosed and understood causation like asthma, diabetes, arthritis etc.

It seems that some groups offering IAPT include these, widening the scope for them to take over more scarce NHS funding with their message to GPs that they can magically reduce patients demands on GP services with their patronising positive thinking 'therapies' administered by people with no understanding of the underlying illness.

Extending existing services and developing new services for integrated IAPT specifically for long-term conditions was part of the Implementing the Five Year Forward View for Mental Health plan.

22 "Early implementer" sites were launched in 2016:

https://www.england.nhs.uk/mentalhealth/adults/iapt/mus/

Long Term Conditions and Medically Unexplained Symptoms

Two thirds of people with a long term physical health condition also have a co-morbid mental health problem, mostly anxiety and depression. In addition, up to 70% of people with Medically Unexplained Symptoms also have depression and/or anxiety disorders. These common mental health disorders are detectable and treatable

"As set out in Implementing the Five Year Forward View for Mental Health the expansion of Improving Access to Psychological Therapies (IAPT) services will focus on people with long term conditions or medically unexplained symptoms. New psychological therapy provision will see physical and mental health care provision co-located. Therapy will be integrated into existing medical pathways and services – either primary care, or secondary care services (eg diabetes, cardiac, respiratory).

A consensus statement has been developed by national clinical leaders setting out the key characteristics of integrated IAPT services. NHS England is working to support new services.

Resources

These are the 22 "Early implementer" sites with summaries:

https://www.england.nhs.uk/mentalhealth/adults/iapt/mus/sites/

Integrated IAPT early implementers

------------------------


Now additional funding is being made available to bidders for a range of projects (submission deadline 18 January 2017), which included a call for bids for additional funding for Improving access to psychological therapies (Integrated IAPT):

https://www.england.nhs.uk/stps/tf-call-to-bid/

(...)

Improving access to psychological therapies (Integrated IAPT)


( which is PDF: https://www.england.nhs.uk/wp-content/uploads/2016/12/mental-health-call-to-bid.pdf )

From call for bid document:

 
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trishrhymes

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Extending existing services and developing new services for integrated IAPT specifically for long-term conditions was part of the Implementing the Five Year Forward View for Mental Health plan.

22 "Early implementer" sites were launched in 2016:
Thanks for the reminder, I'm glad you're collating all this information in one thread. Sorry my comment was a bit behind the times, I haven't had the energy to read it all, so I was probably stating the bleedin' obvious. It's all too depressing.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Not sure whether I've posted this report on the "MUS Whole System Approach" project (it's worth skimming if you are up to it):


NHS Commissioning Support for London

Medically Unexplained Symptoms (MUS) Project implementation report
March 2011

http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/MUS-Project-Implementation-Report.pdf

(...)

3 Introduction and background
3.1 Background of the project – model of care

MUS is not a discrete syndrome or presentation but a shorthand for people seeking help with mainly physical symptoms that may be exacerbated/maintained by stress and that the GP cannot explain. They vary in severity and in severe cases psychiatric diagnoses may be appropriate.

In 2008/09, the "MUS Whole System Approach" document, referred to as the Model of Care and developed by a pan-London clinical reference group for Medically Unexplained Symptoms (MUS), demonstrated a requirement for early identification of MUS patients and early intervention at the beginning of the MUS patient journey.

In November 2009, the mental health team at Commissioning Support for London (CSL) were requested to use their experience in project implementation to pilot the MUS whole systems approach in a small number of GP practices to test the assertion that identification and management of MUS would result in savings to practice based commissioning budgets. Working with the assumption that MUS patients are over-investigated and that a significant number of these investigations are initiated within primary care it was agreed that the pilot should be undertaken in primary care. It was also expected that starting at this very early stage in the pathway would, over time, impact on the flow of patients through to secondary care for investigation. Due to time constraints, implementation within pilot sites was scheduled to run for six months and produce a snapshot of MUS activity and cost in GP practices.

The "MUS Whole System Approach" provides examples of a range of approaches from across the whole system including those used by a variety of services to manage MUS. Stakeholders contributed to the "MUS Whole Systems Approach" document including patient representative, clinicians from a range of service providers (including primary and secondary care) and commissioners.

Appendix A contains practical tips and a poster developed to support implementation.

------------

Earlier documents:

Medically Unexplained Symptoms (MUS) A whole systems approach
NHS Commissioning Support for London
July 2009 – December 2010


Medically Unexplained Symptoms (MUS): A Whole Systems Approach in Plymouth

In partnership with:
Plymouth Hospitals NHS Trust, Sentinel Healthcare Southwest CIC, Southwest Development Centre, September 2009
 
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Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Thanks for the reminder, I'm glad you're collating all this information in one thread. Sorry my comment was a bit behind the times, I haven't had the energy to read it all, so I was probably stating the bleedin' obvious. It's all too depressing.
You're welcome, Trish, and yes, it makes for depressing reading.

What I may do next week is add a list of documents at the end of the initial post in this thread with a link for the source and a link to the post, for ease of reference.
 

user9876

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I guess you could say that most initial referrals of patients to specialists are for MUS, in the sense that at the stage of referral, the GP isn't certain what is wrong with the patient and therefore wants to specialist to do further testing and/or use their expert knowledge to come to a diagnosis.

In most cases this probably leads to a clear diagnosis of a known condition, so the patient no longer has MUS.

The question is, are such referrals classed as MUS, because that's how they started, or only as MUS if the consultant can't diagnose it either.

As far as I'm concerned, MUS is simply a way of saying 'I don't know'. It's not a diagnosis, it's a lack of diagnosis.
It can be very hard to get a GP to give a diagnosis unless what is wrong has a big flashing red light with a certified bit of paper saying what it is. Many GPs seem to have a default assumption that patients are time wasters and just tell them its a virus go away. If they keep coming back it must be psychosomatic. So I can see why GPs think so may of their patients have MUS - its not that things are undiagnosable but its that they don't diagnose.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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https://www.gov.uk/government/stati...port-on-the-use-of-iapt-services-2015-to-2016

Psychological Therapies, Annual report on the use of IAPT services 2015/16

Ref: ISBN 978-1-78386-841-4 http://content.digital.nhs.uk/pubs/psycther1516

PDF: http://www.content.digital.nhs.uk/catalogue/PUB22110/psych-ther-ann-rep-2015-16.pdf

The fourth annual report from the Improving Access to Psychological Therapies data set provides national- and CCG-level information about psychological therapies services in England.

------------------------

http://content.digital.nhs.uk/catalogue/PUB23186

Improving Access to Psychological Therapies Report, October 2016 Final, November 2016 Primary + Quarter 2 2016/17


Publication date: January 24, 2017

Summary
This statistical release makes available the most recent Improving Access to Psychological Therapies (IAPT) monthly and quarterly data, including activity, waiting times, and outcomes such as recovery.
 
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Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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It can be very hard to get a GP to give a diagnosis unless what is wrong has a big flashing red light with a certified bit of paper saying what it is. Many GPs seem to have a default assumption that patients are time wasters and just tell them its a virus go away. If they keep coming back it must be psychosomatic. So I can see why GPs think so may of their patients have MUS - its not that things are undiagnosable but its that they don't diagnose.
I wonder how many GP appointments (and repeat visits) are for iatrogenic symptoms due to adverse reactions to commonly prescribed drugs, for example, antihypertensives, long-term low dose aspirin, proton pump inhibitors, statins etc or due to interactions between drugs where patients are on several drugs.

Not all GPs will readily accept that a new and difficult to live with symptom might be due to prescription medications.
 
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slysaint

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Not all GPs will readily accept that a new and difficult to live with symptom might be due to prescription medications
No, they rarely accept the possibility that it is anything to do with their treatment. Apart from asking the patient "is there anything that you are allergic to" (which incidentally should be flagged up on the patients notes) there is very little cross referencing, if any. IE the patients medical history summary.
But even then this would only work if the information was complete and accurate, which, in my experience, is often not the case.
 
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Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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No, they rarely accept the possibility that it is anything to do with their treatment. Apart from asking the patient "is there anything that you are allergic too" (which incidentally should be flagged up on the patients notes) there is very little cross referencing, if any. IE the patients medical history summary.
But even then this would only work if the information was complete and accurate, which, in my experience, is often not the case.
Yes, medical history summaries may not be accurate and these are accessible to secondary care.

Three or four years ago, I was given a rapid referral to the local acute eye clinic to confirm a suspected acute posterior vitreous detachment and rule out retinal detachment. I was given a referral note to take with me plus a print out of "significant medical history". I was puzzled to see this listed a referral to a diabetes clinic. I had no history of diabetes, pre-diabetes, suspected diabetes or referral to a diabetes clinic. I had however, been referred some years earlier for acute thyroiditis to the endocrinologist's outpatients clinic whose department also ran the diabetes clinic.

So if you ever have sight of a medical history summary it would be worth checking what has been included under "significant medical history" and requesting that any inaccuracies are amended.
 

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https://digital.nhs.uk/summary-care-records

Summary Care Records (SCR)
The SCR is an electronic record of important patient information, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care.

Health and care staff can access SCR through the Spine web portal

Patients can ask to view or add information to their SCR by visiting their GP practice. For more patient information see your health records - NHS Choices.

These pages are under construction. If you can't find what you are looking for try the Summary Care Record archive pages..

Access to SCR information means that care in other settings is safer, reducing the risk of prescribing errors. It also helps avoid delays to urgent care.

At a minimum, the SCR holds important information about;
  • current medication
  • allergies and details of any previous bad reactions to medicines
  • the name, address, date of birth and NHS number of the patient
The patient can also choose to include additional information in the SCR, such as details of long-term conditions, significant medical history, or specific communications needs.

How do I use SCR?
SCR for patients
If you are registered with a GP practice in England your SCR is created automatically, unless you have opted out. 98% of practices are now using the system. You can talk to your practice about including additional information to do with long term conditions, care preferences or specific communications needs.

Discover more patient information on SCR at your health records - NHS Choices.

The SCR is created automatically through clinical systems in GP practices and uploaded to the Spine. It will then be updated automatically. Additional information can be added, with express patient consent, by the GP. The information can be included automatically by changing the patient's consent status.

Read more on including additional information in the SCR.

Creating SCRs and including additional information
The SCR is created automatically through clinical systems in GP practices and uploaded to the Spine. It will then be updated automatically. Additional information can be added, with express patient consent, by the GP. The information can be included automatically by changing the patient's consent status.

Viewing SCRs
The SCR can be viewed by health and care staff, and viewing is now being rolled out to community pharmacies. SCRs can be viewed through clinical systems or through the SCRa web viewer, from a machine logged in to the secure NHSnetwork, using a smartcard with the appropriate Role Based Access Control codes set.

Guidance on viewing the SCR

Summary Care Record in community pharmacies

Security and the SCR
Data within the SCR is protected by secure technology. Users must have a smartcard with the correct codes set. Each use is recorded. A patient can ask to see the record of who has looked at their SCR, from the viewing organisation. This is called a 'Subject Access Request'.

Patient data is protected by strict information governance rules and procedures. Each organisation using the SCR has at least one privacy officer who is responsible for monitoring access and can generate audits and reports.

A patient can also opt out of having an SCR by returning a completed opt-out form to their GP practice.
 
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Keela Too

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