Patient services - Medically unexplained symptoms

New scheme reduces the burden on the NHS and GPs. By Dr Rhiannon England, Brian Rock and Russel Ayling.

Dr England: proposed a mental health service for high-demand patients without identifiable organic disease (Photograph: JH Lancy)
Dr England: proposed a mental health service for high-demand patients without identifiable organic disease (Photograph: JH Lancy)

Much has been written about people with medically unexplained symptoms (MUS) in terms of the cost to the NHS of frequent GP consultations, multiple investigations and referrals, but little attempt has been made to provide services for them.

In this time of austerity, providing more appropriate and cost-effective therapy for this group is increasingly important.

A few years ago, mental health providers in City and Hackney, east London were asked for proposals for service developments. Local GPs Dr Rhiannon England and Dr Clare Highton proposed a new service aimed at people, particularly MUS patients, who are not engaged with mental health services.

Complex patients
GPs vary in their ability to consider the problems presented by more complex patients in this group. However, their increasing commissioning role is forcing them to look at A&E attendances, outpatient referrals, follow ups and prescribing costs - a list in which patients with no identifiable organic disease feature prominently.

The City & Hackney Primary Care Psychotherapy Consultation Service (PCPCS) was commissioned from the Tavistock and Portman NHS Foundation Trust and launched in October 2009. The team is multi-disciplinary (psychology, psychiatry, nursing and social work) and clinicians are highly skilled in a range of therapeutic approaches.

The PCPCS has very flexible referral criteria. It is based in local surgeries, is for GP referral only and, as well as seeing patients, it can advise GPs about patient management.

Clinical co-ordinator
Each group of practices has a named clinical co-ordinator who liaises with the PCPCS team. GPs can discuss referrals with the co-ordinator to establish what will be most helpful to them and their patient.

From receiving one referral in its first month, uptake has risen to around 50 referrals per month. Contractually the PCPCS expected to working in around half of City and Hackney practices. In fact around 90 per of practices make referrals.

Every referral prompts a discussion on how the PCPCS can be involved most effectively. Should it support the GP, assess the patient or work with GP and patient together or involve additional services or be a combination of these steps?

GPs largely determine the balance and nature of PCPCS involvement depending on patient demographics, list sizes, in-house expertise and other available services and support networks. Some draw more heavily on PCPCS consultative approaches. Others refer to the PCPCS patients for assessment and therapeutic interventions.

The service provides up to 16 sessions per referral, but this varies according to the patient's needs and the referring GP. Clinicians also signpost patients to other services. PCPCS clinicians provide therapeutic case management where this will help to deliver more integrated care and enable the patients to make better use of appropriate statutory/voluntary services or community resources.

There are two key principles. One is the GP's central role in the lives of patients and their families in promoting emotional/physical wellbeing and continuity of care. The other is ensuring that experienced clinicians are available from the start of the referral pathway.

The aim is to reduce both economic and emotional cost. An important component of evaluating the PCPCS service will be to consider how the use of NHS resources changes for these patients.

The emotional cost of MUS patients on GPs is equally important. The PCPCS approach specifically addresses the sense of helplessness that complex patients can instil in those who try to help them. We hope to build on the PCPCS's successful start to provide a MUS service in City and Hackney that will link up primary and secondary care in providing holistic and appropriate treatments.

Primary Care Psychotherapy Consultation Service at Work

Hackney GP Dr Rhiannon England asked clinical psychologist Russel Ayling to have a joint consultation with her patient 'Julia' who has a mild, genetic motor disorder.


Dr England was concerned that Julia's physical functions were disproportionately affected by the disorder and suspected that a psychological component was likely.


Julia resisted this idea, demanding further neurophysiological interventions, but agreed to the joint consultation.


During this, Julia was able to relate enough of her adolescence and early adulthood to enable Mr Ayling to formulate a dynamic of abandonment and rejection.


Julia had tried to repair this in her career but had received inconsistent feedback, so she strove harder to prove herself at work. This led to efforts beyond her body's limits, and an eventual breakdown.


The two clinicians discussed the possibility of a chronic fatigue-type condition. They also considered that Julia's relationships with healthcare professionals might be a proxy for the lack of close family support while growing up - and whether formally recognising her 'disability' would serve to encourage her uptake of neurophysiological services.


However, Dr England was pleased to have gained more insight into Julia's requests for care. The joint consultation had also been helpful in engaging the patient in some explorative psychotherapeutic work that she previously rejected.

  • Dr England is a GP in east London; Russel Ayling is a clinical psychologist at Barts and the London NHS Trust; Brian Rock is a consultant clinical psychologist and service lead for the City & Hackney PCPCS service (email for more information)

Reflect on this article and add notes to your CPD Organiser on MIMS Learning

CPD IMPACT: Earn more credits

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Consider how much of a strain high demand patients without organic disease are placing on your practice.
  • Hold a meeting with the GPs, receptionists, nurses and other staff to discuss what can be done to ease the pressure. Approach community-based services to explore initiatives.
  • Draw up an action plan for the practice team and set a time limit for implementation. Audit what has been achieved after six/12 months.

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