The development of psychological treatment pathways and better identification of Medically Unexplained Symptoms (MUS) in primary care
Submitting InstitutionUniversity of Nottingham
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
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.
Barriers to identification and treatment of MUS
Medically unexplained physical symptoms such as abdominal pain, headache,
back pain and
fatigue are common, accounting for as many as one in five new
consultations in primary care.
Professor Richard Morriss (Professor of Psychiatry and Community Mental
Health at Nottingham
from 2006-present) first published work on MUS conducting qualitative
interviews and recording
consultations between GPs and patients with MUS in 2007. Findings showed
presenting with MUS in primary care were often poorly managed leading to
Interviews showed that GPs found MUS patients challenging to work with and
had no specific
training about their management. In particular, co-morbid psychological
problems in patients with
MUS are common and counterproductive to medical symptoms. Previous
research had suggested
that GPs held a negative attitude to MUS patients with psychological
symptoms, whereas Morriss's
work showed that many GPs were simply under-confident regarding their
abilities to tackle the
complex psychological issues raised by patients with MUS1.
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
delivered by a GP, which aims to provide a psychological explanation to
patients with somatised
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
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,
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
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
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
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
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.
References to the research
1. Salmon P, Peters S, Rogers A, Gask L, Clifford R, Iredale W, Dowrick
CF, Morriss R.
(2007).Why do general practitioners decline training to improve management
Unexplained Symptoms. Journal of General Internal Medicine; 22;
565-571. DOI: 10.1007/s11606-
006-0094-z. IF: 3.278; Citations: 41.
2. Morriss R, Dowrick C, Peters S, et al. (2007). Cluster
randomised controlled trial of training
practices in reattribution for medically unexplained symptoms. British
Journal of Psychiatry; 191:
536-542. DOI:10.1192/bjp.bp.107.040683. IF: 6.619; Citations: 50.
3. Peters S, Rogers A, Salmon P, Gask L, Dowrick C, Towey M, Clifford R,
Morriss R. (2008).
What do patients choose to tell their doctors? Qualitative analysis of
potential barriers to
reattributing medically unexplained symptoms. Journal of General
Internal Medicine, 24: 443-449.
DOI: 10.1007/s11606-008-0872-x. IF: 3.278; Citations: 54.
4. Wearden AJ, Dowrick C, Chew-Graham C, Bentall RP, Morriss R, Peters S,
et al. (the FINE Trial
Writing group on behalf of the FINE Trial group). (2010). Nurse-led
home-based self-help treatment
for patients in primary care with chronic fatigue syndrome: A randomised
controlled trial - the FINE
Trial. British Medical Journal; 340:c1777. DOI: 10.1136/bmj.c1777.
IF: 17.215; Citations: 21.
5. Morriss R, Lindson N, Coupland C, et al. (2012). Estimating
the prevalence of medically
unexplained symptoms from primary care records. Public Health.
126: 846-54. DOI:
10.1016/j.puhe.2012.05.008. IF: 1.350; Citations: 0
6. Morriss R, Kai J, Atha C, et al. (2012). Persistent frequent
attenders in primary care: costs,
reasons for attendance, organisation of care and potential for cognitive
intervention. BMC Fam Pract. 13:39. DOI: 10.1186/1471-2296-13-39.
IF: 1.61; Citations: 3.
Medical Research Council: Exploratory randomised controlled trial of
training general practitioners
to manage patients with persistent medically unexplained symptoms (trial
number and details
PI- R Morriss
Care Services Improvement Partnership funding to develop The Nottingham
tool. "Developing a
tool to enable primary care clinicians to identify early people with
symptoms". PI- R Morriss, T Avery. Awarded January 2007 for 24
Details of the impact
The key beneficiaries for Morriss's body of work are GPs, other
clinicians (such as psychologists
and practice nurses) and patients with MUS through the following
- Successful attainment of government funding for IAPT for MUS
- Changes to general practice training
- Reattribution training taken up by clinicians and researchers
internationally based upon
- Better identification of patients through the development of The
Nottingham Tool, an aid to
identification of MUS within the clinical and patient community
Introduction of a national streamlined pathway for psychological
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
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
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
treatments based on approaches in the MUS and LTC Positive Practice Guideb
Morriss's work), savings of at least £75 million per year may be made (9%
of GP estimated
expenditure of £837 million per year). Morriss's work has also been
instrumental in finding and
translating the message that many patients could be better managed
clinically and more cost-
effectively in primary care. As such, work on clinical communication and
organisation of care for
patients with MUS is now part of standard GP and psychiatry training in
England through the Royal
College of General Practitionersi and internationally in
Denmark, Germany, Netherlands and Spain.
The Denmark group has taken up reattribution methods using Morriss's
framework through the
development of `TERM'. There is also evidence of uptake in the USj.
Increased recognition of MUS in general practice through The
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
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.
`Your work in producing the Nottingham Tool, to allow practices to
estimate prevalence of MUS
was of great value to the programme, and informed much of the national
thinking on this very
important topic' l.
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
Sources to corroborate the impact
a. Improving Access to Psychological Therapies, Commissioning Toolkit.
Health and Care Services Improvement Partnership April 2008, p1 for
b. Medically Unexplained Symptoms a positive practice guide. NHS IAPT.
to Psychological Therapies October 2008.
c. Commissioning IAPT for the whole community. NHS IAPT. Improving Access
Psychological Therapies. November 2008.
d. Equality Impact Assessment (EqIA). NHS IAPT. Improving Access to
Therapies. October 2008.
e. The management of patients with physical and psychological problems in
primary care: a
practical guide. Report of a joint working group of the Royal College of
Practitioners and the Royal College of Psychiatrists January 2009 CR152.
f. Guidance for health professionals on medically unexplained symptoms.
Making sense of
symptoms, managing professional uncertainty and building on patient's
RCPsych, Trailblazers and National Mental Health Development Unit.
g. Emotional Wellbeing and Physical Health Care Case for Change.
Medically unexplained or
`physiologically explainable' symptoms? NHS September 2012.
h. Talking therapies: A four-year plan of action. A supporting document
to `No health without
mental health: A cross-government mental health outcome strategy for
people of all ages'.
Department of Health. December 2010.
i. Psychological therapies in psychiatry and primary care. Royal College
Practitioners and Royal College of Psychiatrists CR151. June 2008.
Primary Care Toolkit: Practical Resources for the Integrated Behavioral
Larry C. James, William T. O'Donohue, Springer 2008.
k. Nottingham Tool (screenshots- http://www.iapt.nhs.uk/ltcmus/medically-unexplained-symptoms/the-nottingham-tool/)
and Morriss R (2009). Unpublished. Medically Unexplained
Symptoms Commissioning Tool: Workshop. Nottinghamshire Healthcare
l. Chair of Sainsbury Centre for Mental Health (SCMH) e-mail supporting
involvement in IAPT for MUS/LTCs.