Close-up care of those with complex conditions – connecting with the community

Patients who consult often and widely, and with ‘medically unexplained’ symptoms, can pose a particular clinical challenge. Keith Cooper reports from a service which tries to understand their motivations and help them

This is an edited version of an article first published by the BMA and was written by Keith Cooper.

Pauline Linton – not her real name – a 53-year-old mother of three and a civil servant, was at work when matters came to a head. She shouted at colleagues, stormed out of a team meeting and burst into tears in front of her boss.

She went home and visited her GP. “They said, ‘I don’t know what to do’,” she says. “‘You’re on all the medications I can give you. I’m not sure what I can do right now.’”

‘Black and dark’

This was two years ago. Ms Linton had seen her GP a lot, previously, for her fibromyalgia, diabetes, irritable bowel syndrome, osteoarthritis, problems with her thyroid gland, insomnia, and sleep apnoea. She’d had anxiety and depression, on and off, since her 20s, taken months off work and faced disciplinary action.

”I was struggling with friends and family. I was keeping myself to myself. Things were just really black and dark,” she recalls. Her GP mentioned a pilot service run by Chris Schofield, a consultant liaison psychiatrist at Nottinghamshire Healthcare NHS Foundation Trust.

Community focus

This new service, primary care psychological medicine, offers liaison psychiatry through GP practices instead of hospital clinics, as is the NHS convention. “You get a much closer connection in the community,” says Dr Schofield. “You get closer to real [life].”

It’s for people, such as Ms Linton, who have chronic physical health problems, some of whose symptoms are ‘medically unexplained’. It’s a poor phrase, Dr Schofield admits. “’I have no idea’ is not what I call a diagnosis.’

Many patients see multiple doctors and take numerous medications. The pilot service has helped hundreds so far, those cases too complex for Improving Access to Psychological Therapies, the standard NHS talking-therapy service.

Two years on from her initial referral, Ms Linton says she better understands how her physical and mental health connect. She feels more in control of her medication. Her job is no longer in jeopardy.

”I’ve realised the fibro can be a sign that I’m about to take a dip,” she says. “It’s a beginning sign before the mood drop, so I can slow down a bit. Instead of going on a bike downhill uncontrolled, I’ve got brakes.”

Budget buster

However, two years on, despite independently verified evidence of its benefits, the service’s future is not yet certain. It has been rolled out across south Nottinghamshire for further testing and all six clinical commissioning groups (CCGs) are ‘supportive’ following the ‘successful pilot’ in Rushcliffe, they say; they’re helping to draft a ‘business case’ for its continuation.

Its time-limited funding is, however, due to run dry next December as the NHS in Nottinghamshire seeks £78.2m of savings across its 2019/20 allotted budget. Rising demand, as in many other parts of the country, is busting its budget.

All this as managers are occupied with major ‘structural’ changes in Nottinghamshire.

Its six CCGs are merging into one, matching the footprint of its integrated care system, which brings together NHS and local authority care managers. In addition, three integrated care providers are being set up. All will have some say on services – what stays, what goes.

It’s not an easy environment in which novel, relatively unknown services can survive, however much good they do.