Clinical Outcomes of a Primary Care Liaison Psychiatry Service for Patients with Complex Persistent Physical Symptoms.

Background: Patients with Persistent Physical Symptoms (PPS) may have chronic physical disorders such as diabetes, COPD, Crohn’s, MS and/or ongoing medically unexplained symptoms, and in either case there can be both physical and [psychiatric aetiologies combined. Such co-morbidity tends to be chronic and hard to manage in any healthcare setting and therefore frequent attendance in healthcare settings is present for these patients. We rolled out a primary care based integrated multidisciplinary liaison psychiatry team to 3 CCG areas in Nottinghamshire in October 2019 to see this patient group and have taken patient reported outcome measures from baseline up to 15 months later as part of normal service evaluation.


Background
Patients with Persistent Physical Symptoms (PPS) may have chronic physical disorders such as diabetes, COPD, Crohn's, MS, or ongoing medically unexplained symptoms, and in either case there can be both physical and psychiatric aetiologies combined.Such co-morbidity tends to be chronic and hard to manage in any healthcare setting.The awareness of complex physical & psychiatric comorbidity is increasing (1), and increasingly coming into focus in publications and guidelines (2) (3) (4) (5).
Patients and clinicians often feel that there is not much that can be done to help.It is known that single interventions help some but not all patients (6).What is required is a multidisciplinary team that can tailor interventions to the individual much more exibly (7), but currently no one service in the NHS is designed to manage such patients in the community.There are liaison psychiatry services in the UK and elsewhere that offer ward-based and outpatient-based services for some of this patient group, but even that is rare.Even where there is a local service, if the patient is unable to get to the hospital outpatients department, then this tertiary level service is not available to them.Interventions that can be delivered in primary care are available, but it remains unusual to nd a primary care-based service developed as part of routine service organisation rather than for research purposes (6).
The aim of this paper is to describe an initial evaluation of a new multi-disciplinary integrated service based in primary care, aimed at helping with the management of complex problems characterised by PPS.

Sta ng
The Primary Care Psychological Medicine (PCPM) service was set up 4 years ago as part of the Multi-Care provider Vanguard programme from NHS England (8) that was running in Rushcliffe, Nottinghamshire.This was a fast-track programme to set up innovative services and evaluate them.PCPM is an integrated liaison psychiatry multi-disciplinary service for people with complex PPS based in the community.
In October 2019, the PCPM service increased to cover 3 CCG areas (population approx.340K).The team consists of 1 consultant liaison psychiatrist, 5 Mental Health Liaison Nurses, 1 Physiotherapist, 1 Occupational Therapist, 1 Care Support worker and 3 admin staff.

The target population
The service offers an holistic, integrated multi-disciplinary service to improve the management of patients identi ed by the primary care clinician falling within the following: Complex PPS -whether medically explained, medically unexplained or both.
Multiple referrals to secondary services Distress and functional impairment Polypharmacy More recently we have found that our input to this patient group has been key during the COVID-19 pandemic.A large proportion of our patients are clinically at the extremely high-risk group for COVID-19 due to multiple physical diagnoses.

Assessment and intervention
Whilst there is no easy search term for practice IT systems to identify this patient group (7), we have found that GPs and practice staff can quickly identify them accurately and mostly refer appropriately.
After referral, patients are assessed by one of the MDT team, the professional discipline that does this depends on initial needs of the patient.Most commonly this is one by a doctor of one of the nurses.This assessment is done either in the patient's home or in a local GP practice.We use a biopsychosocial approach, and an individual formulation is developed, and provisional diagnosis is made.
Each plan is tailored to the person's individual needs.The patient's care is co-ordinated by the most appropriate member of the multidisciplinary team and different professional disciplines see the person at varying levels of intensity as the treatment strategy is developed.
We have a consultant liaison psychiatrist, Clinical Nurse Specialists and Physiotherapist and Occupational Therapist as part of the core team as well as a care support worker.Together this brings a truly multidisciplinary team with a wide variety of investigations, functions, and treatment capabilities.We adopt a full biopsychosocial approach to the individual patient's care plan.
Treatment could be any of the following.

Manage and review psychotropic medication.
A mixed model of psychological interventions including distress tolerance and EMDR, grounding and CBT approaches as well as.
Identifying and reducing barriers to social participation and providing broader education and understanding regarding symptom management.
We also provide training, supervision and support for GPs and other primary care professionals to help manage patients.

Outcome measures and analysis
Patient-reported outcome measures (PROMs) are collected at our initial assessment as a baseline, and then at every 3 months -at the appointment closest to each 3 month point in time.Patients are with the service for an average of 44 weeks (10 months).
In the period 1st Oct 2019 to 29th Jan 2021 the service received 322 referrals and made an initial contact with 201 patients.The data analysed is for all patients where there were at least 2 data points on the PROMs over a 15 month period (patients signposted elsewhere after an initial assessment are not included).
The data was analysed using the R software (14) to generate descriptives (means and 95% con dence intervals) and to evaluate change over time using (R) we tted a simple linear model using the lmod function and the table of values later were outputted from the summary function of this lmod (summary(lmod)).The con dence intervals were calculated using the predict function.

Ethics
Because the data presented here were collected routinely for service evaluation, and no new methodolgy was applied Research Ethics Committee approval was not required.

Results
In the analysis cohort there are 100 patients in the PHQ-9 & PHQ-15 groups, 98 in the GAD-7 group and 97 in the EQ-5D-5L group.The average age of the cohort was 47.9 years (range 19-83) and 74% were female.
At baseline the mean scores and con dence intervals (CIs) for the sample were: The p values above are for the simple linear models for each of the individual aspects.
In all domains modelling change over time on the data using simple linear models shows clinically and statistically signi cant improvements as reported on the PROMS completed by the patients (see gures 1 & 2).An indication of rate of improvement is shown by the change in each PROMs value for each month since referral to the service.(see Figure 1)

Main ndings
Our baseline data shows how complex the symptoms in this patient group is.The physical severity is too high (98th centile for PHQ-15, for age matched population) for routine mental health services to clinically manage and the psychiatric severity is too high (severe depression and severe anxiety) for physical health services to clinically manage.As has been shown in reports from the Kings Fund and Centre for Mental Health (15,16,17,18,19) the lack of a clinical service that can effectively meet the needs of these patients means that they use a disproportionate amount of healthcare resource this not surprising as their symptoms have not improved which is why they return.
Our integrated multidisciplinary liaison psychiatry model based in primary care delivers signi cant clinical results for patients.These are statistically signi cant and clinically relevant improvements in depressive symptoms (PHQ-9), anxiety symptoms (GAD-7) and physical symptoms (PHQ-15), see gure 1.The improvements in the EQ-5D-5L shows that in a whole health measure there are signi cant improvements over all and speci cally in the anxiety/depression and usual activity domains; the mobility improvement is very close to signi cance whilst the others show a trend towards improvement, see gure 2.
Our data show that with our new service's integrated muliti-disciplinary model of treatment there are signi cant improvements in patients report of symptoms.This is encouraging because often the patient group is thought by some clinicians to not improve and with the multiple symptoms they have they visit healthcare professionals regularly trying to get help.It is is even more remarkable when one considers that these improvements are occuring during the COVID-19 pandemic and restrictions, where most people are feeling more anxious and low in mood.
This data shows that our integrated multidisciplinary model helps patients symptoms improve.We have shown elsewhere (20) that there are process and cost saving, but this is only because patients symptoms improve and therefore do not need further input.This shows that wrapping the right clinical care around the patient is right for the patient, right for clinicians and right for the wider health service.
Integrated nancing of these integrated clincial services should be looked at by commissioners and those that decide on which clincial services are funded as many funding models are not across health sectors, let along across mental, physical, social, primary and secondary care, like ours is.

Comparison with existing
Whilst there is much published on the burdens of medically unexplianed symptoms and comorbid physical and mental health conditions, there is a relative scarcity on sevice models for this patient group and clinical outcomes for this group.There are reports by places such as the Centre for Mental Health and Kings Fund (15,16,17,18,19) on new services or models but these do not include outcome data nor are they peer reviewed.EQ-5D-5L domain changes seen individually.

Figure 1 Patient
Figure 1