Download file - Northern England Strategic Clinical Networks

Meeting:
Functional Neurological Conditions Special Interest Group
Date:
7 October 2014
Time:
3pm – 5pm
Venue:
Waterfront 4, Newburn Riverside, Newcastle
AGENDA
1.
INTRODUCTION
Lead
Time
(mins)
2.
1.1
Welcome and Apologies
PG
1.2
Declarations of Interest
PG
1.3
Minutes of the previous meeting – 8 April 2014 Enc 1
PG
AGENDA ITEMS
2.1
Broad principles of approach
2.2
Progress update:
•
Education plans (including videos) Enc 2
•
Online training for all
•
In depth for specialists
Patient information leaflet
•
3.
4.
10
PG
PG /
VD /
MW
5
30
2.3
Multidisciplinary model / South Tees Pathway
PG /
JP
20
2.4
Resilience training for children and young people / PHE
perspective
PG /
DG
20
2.5
Next steps
PG /
All
15
STANDING ITEMS
3.1
Any Other Business
• Functional paper attached for information Enc 3
3.2
Next Meeting
MEETING CLOSE
Enc 1
Functional Neurological Conditions Meeting
8th April 2014
Attendance List
NAME
TITLE
ORGANISATION
Paul Goldsmith
SCN Clinical Lead / Consultant
NUTH
Neurologist
Katy Collinson
Clinical Neuropsychologist
NUTH NHS
Emma Robinson
Trainee Clinical Psychologist
NUTH NHS
Philippa Bolton
Psychiatrist
TEWV
Christine Cook
Nurse – Mental Health
TEWV
Miriam Lomas
Clinical Psychologist
TEWV
Jason Price
Consultant Clinical Neuropsychologist
South Tees
Suzanne Thompson
Clinical Networks Manager
NHS England, Clinical Networks
Claire Braid
Network Delivery Lead
Clinical Networks
Anne Richardson
Network Delivery Facilitator/ PPI
Clinical Networks
Elspeth Desert
Consultant Clinical Psychologist
Cumbria
Margaret Whittaker
CBT Therapist/ IAPT Lead
NTW
Jane Roberts
Mental Health SCN Clinical Lead / GP
SCN NHS
Paula Dimarco
Physio Team Leader – Newcastle RVI
RVI NUTH
Matthew Rowett
Consultant – Liaison Psychologist
TEWV NHS NUTH
Martin Harvey
Clinical Psychologist
NTW
Vishaal Goel
Consultant Psychiatrist
NTW
Adam Cassidy
Consultant Neurologist
CHSFT
Name of Group / Meeting:
Date:
Time:
Venue:
1.
Functional Neurological Conditions Meeting
8th April 2014
13.00 – 15.00
Evolve Business Centre
Minutes
INTRODUCTION
1.1 Welcome & Introduction
Paul Goldsmith welcomed everyone to the meeting and
introductions were made.
1.2 Previous Minutes
N/A
1.3 Action Points from Previous Minutes
N/A
2.
Locality Perspectives
PG introduced the subject and representatives from each locality
gave their perspectives on current services, issues, innovations
and vision.
PG – Functional neurological symptoms/ persistent physical
symptoms are cross-cutting to many conditions.
Neurologists are seeing an increase in numbers of patients with
functional symptoms.
Cumbria (Elspeth Desert)
Looking at persistent physical symptoms (PPS) across a range of
conditions and currently has 6 neuropsychologists working into
many patient pathways. Focusing on health psychology and
neuropsychology posts that have a general view.
Service has received an increase in referrals for patients with
chronic pain, which is often combined with other conditions.
Focusing on a generic PPS model to provide consistency of
information and reduction in investigations.
Using the London Commissioning Programme model as a basis
for this service, aiming to train a GP in every practice, plus
another individual, in identifying PPS and implementing early
CBT. Using Nottingham health profile tool.
Trying to maintain a locality focus to services.
Model works by having a single point of access for a definitive
opinion, patient is then managed by the specialist team.
Enclosure
Currently having discussions with commissioners regarding the
chronic pain service (run by North Cumbria University Hospitals),
and using the principles of the London Commissioning
Programme for PPS. The service is hoping to roll out this model
across Cumbria. Information and care will be shared via EMIS
web system. There is a plan written up with potential cost savings
(linked with chronic pain).
Cumbria is using a pyramid model of ‘Matched Care’, where
patients can go directly to any stage of the service, depending on
need. This is not the same as the ‘stepped care’ model used in
IAPT, which requires patients to move through each level of
service in turn. IAPT model is not helpful in long term conditions
as is inflexible and too prescriptive.
The service has run a pilot in South Cumbria for patients with
CFS/ME: positive outcomes in terms of wellbeing and patients
managing their symptoms. Approximately 90 patients involved in
this pilot.
Level 2 practitioners receive regular supervision from
psychologists.
Currently delivering CBT training with a wide range of allied
health professionals around identifying psychological distress and
basic skills in dealing with this. Cumbria has delivered education
to AHPs around the panic cycle and symptoms. Approximately
50 physiotherapists attended an introductory CBT day.
There is no liaison psychiatry in the service, only as part of the
crisis team and not part of the PPS group.
Newcastle/Sunderland (Katy Collinson)
Health psychology was approached for help with patient group
approximately 6 years ago.
Work focused around non-epileptic attack disorder-found that
improvement occurred quickly in this patient group following
intervention.
Trauma is usually found to be at the root of the issue, but this
may not have been previously disclosed to health professionals.
Chronic stress can cause the onset of non-epileptic attacks.
2 year pilot study completed in Newcastle showed a reduction in
A+E admissions and a reduction in investigations for the patients
involved.
Difficult to identify one specific service in terms of cost saving, as
the impact would affect a wide range of services, including
primary care, ambulance services and emergency care.
Education and training needs to be delivered to staff at different
levels, including ambulance staff and A+E.
Issues around lack of clinician confidence with working with this
patient group, mainly due to lack of experience.
Newcastle previously had a liaison psychiatry service for patients
with PPS-no longer running.
Neuropsychology for non-epileptic attack disorder is provided to
Sunderland only at present.
Some patients are referred for private neuropsychology due to
lack of NHS service.
Psychology clinics are based at RVI.
Margaret Whittaker commented there was possibly around £12k
per year allocated to IAPT for patients with PPS.
Margaret has been working with Dr Vincent Deary – funding
obtained for research into PPS.
IAPT had been tailored to the PPS service previously in
Sunderland.
Durham/Darlington (Philippa Bolton/ Miriam Lomas)
Service provided by TEWV (secondary care mental health trust
providing a service to an acute trust)
Service consists of psychology/psychiatry/AHPs/support workers
work closely with pain clinic.
Patients with functional neurological symptoms make up the
largest single referral group; this can include patients with
functional movement disorder/voice disorder.
Patients present with a wide range of symptoms, which include
co-morbid mental health conditions.
Ongoing issues with medical staff wishing to continue with
investigations.
Need to have psychologically focused pain clinics.
IAPT cover primary care; psychology service is commissioned to
cover secondary care.
Some geographical issues; patients North of Spennymoor tend to
be referred to Newcastle Services, South tend to go to South
Tees.
6 months of data is available from this service.
TEES (Matt Rowett)
Liaison Psychiatry Service
Service provided by TEWV, walks into acute hospital, seeing
patients with complex needs.
Not commissioned to provide a service for functional patients
specifically, but sees these patients by default due to their
complex presentation.
Referrer usually suspects functional condition, refers to liaison
psychiatry who explain about functional disorders, provide
assessment and formulation.
Part of this work is around ‘re-framing’ functional conditions and
helping patients + colleagues understand.
Tries to keep people out of secondary mental health services as
this can exacerbate the issue.
Currently providing more of a liaison role than true psychiatry.
There can be lots of overlap between psychiatry and psychology,
although service provided will differ depending on the skills of the
psychiatrist.
Physiotherapy (Paula Dimarco – Newcastle)
Implemented a change in approach to therapy by encouraging
patients that they are able to move how their body is intended and
offering reassurance.
No current links with psychology for inpatients at Newcastle.
Sometimes refer to the Regional Disability Team at Walkergate
Park, but some reluctance to accept referral (no psychology input
to team at present).
Inpatient psychology is siloed and there is no routine input.
3.
Terminology
Discussion around appropriate terminology; the group agreed that
the term ‘unexplained’ in ‘medically unexplained symptoms’
remains unhelpful.
Some members favour psychiatric terminology as this helps to
group patients into primary and secondary care.
Elspeth Desert (ED) commented that her team had discussed this
with patients, who felt that although their symptoms were better
managed; the symptoms remained, so they could identify with the
term ‘persistent symptoms’.
The group agreed that the terminology needed to be meaningful
to both patients and professionals, and agreed to use ‘persistent
symptoms’ or ‘functional symptoms’.
4.
Terms of Reference
The group agreed that the symptoms within the scope of this work
covered a broad range of conditions, which were linked by
treatment.
There was a concern that specific pathways could exclude
patients.
The group agreed that the terms of reference be broadened to
reflect the wide-ranging impact of persistent symptoms.
5.
CAMHS
The group discussed how input could be provided at the early
stages of emotional dysregulation in children, and the roles of
schools should be involved in supporting children’s wellbeing.
This would influence resilience and primary prevention in children.
Need to consider how this work links with Maternity and Child
Health SCN, development of CAMHS group within this network
and possibly of a functional group within this.
Need to think about how to improve identification of children with
emotional dysregulation in schools to increase understanding.
There are increasing numbers of children seen by paediatric
services who are presenting with functional symptoms.
? Some work around this being done at South London and
Maudsley NHS Foundation Trust.
6.
Communication Methods
The group agreed that having a central online resource to share
information would be useful.
Discussion around whether this could be linked to SCN website
when developed.
The group is happy to communicate via email in the interim.
Arrange next face to face meeting later in the year (possibly 6
months).
7.
Objectives for the group
• Develop standardised information, education and training
on persistent/functional symptoms for a broad range of
professionals
• Develop consistent information for patients to improve
understanding of their conditions.
• Deliver training across primary and secondary care around
identification and basic management of
persistent/functional symptoms.
• Identify potential cost savings of improving services.
• Reduce the culture of over-investigation through education
and training.
• Look at design of services across primary and secondary
care, including referral routes (e.g. GPs being able to refer
directly to psychology)
• Training to encompass both adults and children.
• Consider holding an education event (possibly linking with
Health Education North East).
8.
Next Steps
• ED to request assistant to link with CB regarding collecting
and collating all existing information leaflets / training and
education materials across the network patch.
• CB and ST to discuss possibility of online resource for
sharing of information and communication.
• CB to amend terms of reference and circulate for
comments.
• All to send existing outcome measurement tools to CB to
collate.
• CB to remain in contact with group members regarding
development of standardised education / training /
information materials.
Date of next meeting
Next meeting to be arranged for October 2014
MEETING CLOSE
ED
ED / ST
CB
All
CB
Enc 2
Persistent Symptoms
If you would like this leaflet in another language or
format, e.g. Braille, large print or audio, please call:
01228 603890, email:
[email protected] or write
to: Membership and Communications Department,
Voreda House, Portland Place, Penrith, CA11 7QQ
What if I have more questions?
For more information about persistent or functional
symptoms visit:
NHS Choices www.nhs.uk/conditions/medically-unexplainedsymptoms/Pages/Somatisation.aspx
Neurosymptoms http://www.neurosymptoms.org/
What are Persistent Symptoms?
In this leaflet we are discussing persistent symptoms, these are
frequent and distressing symptoms for which no clear physical
cause or explanation has been found. There are other labels that
have been given for persistent symptoms including, for example
medically unexplained symptoms (MUS) and functional symptoms
(FS). However patients and health care professionals feel these
are not helpful and thus, we will be referring to such symptoms as
‘persistent symptoms’.
The symptoms affect every person differently- some will see their
GP regularly with relatively minor symptoms, but distressing
problems, while others may become disabled or bed bound by
them.
Acknowledgments
Acknowledgments for parts of the content of this leaflet to;
• NHS Choices
•
Neurosymptoms.org
There
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is a huge variety of symptoms, for example:
Fatigue- tiredness, exhaustion or lack of energy
Pain
Headaches
Sleep problems
Memory and concentration problems
Dizziness
Nausea
Skin rash
Digestive problems
Heart palpitations
In some people these symptoms can be grouped into disorders or
syndromes such as chronic fatigue syndrome (CFS), fibromyalgia
or irritable bowel syndrome (IBS). For example, numbness,
nausea, loose bowels, constipation and abdominal pain are all
symptoms of irritable bowel syndrome.
People with persistent symptoms are often afraid that people
will not believe their symptoms are real and will think that
their symptoms are ‘all in the head’. It is important to
emphasise that symptoms are REAL and not imagined, and
can have a big impact on your life.
Whilst there is currently no ‘medical cure’ there are things
that can be done to help you manage symptoms. Even if the
symptoms persist, we know from both the research and our
services that people can still be helped to lead a more full and
active life and learn how to manage their symptoms.
Who is more likely to experience Persistent
Symptoms?
Persistent symptoms are common, accounting for as many as
one in five GP consultations in the United Kingdom. Persistent
symptoms are reported to be more common among women
and younger people (symptoms often start before the age of
30). However, it's worth bearing in mind that women are on
average more likely to visit their GP, and that some older
people don't like to bother their GP.
How are Persistent Symptoms
diagnosed?
A diagnosis or ‘name’ can be given for certain patterns of
persistent symptoms into disorders or syndromes as
mentioned previously e.g. irritable bowel syndrome,
fibromyalgia, chronic fatigue syndrome.
For symptoms that are not diagnosed as a particular disorder
or syndrome, it is common to use the general term, ‘persistent
symptoms’, or ‘functional symptoms’- the latter is typically
used when the symptoms are due to a problem in the way the
body is functioning, even though the structure of the body is
normal.
Adapting to and understanding the diagnosis is the first step to
recovery.
What tests should I have for my symptoms?
Persistent symptoms can be frustrating for the patient as they
are often associated with repetitive investigations and tests
with inconclusive results. You may want investigations or tests
for your symptoms such as a blood test or a scan, your doctor
can tell you what investigations are suitable for the symptoms
you have. However, having unnecessary investigations can
also be unhelpful, they may be painful, carry risk of harm and
lead to disappointment, as many come back ‘normal’ but you
still feel unwell.
What causes Persistent Symptoms?
There is a lack of present understanding about the cause of
persistent symptoms and this can be very difficult for patients to
adapt to. However, we do know that most illnesses have a number
of causes that are often linked in complicated ways and this is
probably true for persistent symptoms. This complexity means
doctors prefer not to talk of causes in the everyday sense. Instead,
they use the more accurate term ‘factors’ and they divide factors
up into three types:
1. Factors that make someone more likely to get the
illness. An example might be their sex, as more women
than men develop persistent symptoms. Doctors call this
a predisposition
2. Factors that bring on the illness in the first place. An
example might be an infection. Doctors call this a
trigger
3. Factors that stop people recovering from the illness.
Sleep disturbance might be an example. Doctors call this
a maintaining factor
What is a factor for one person may not be a factor for somebody
else. For instance, sleep disturbance may be a maintaining factor
in one person and not in another person.
As you can begin to see, persistent symptoms is very individual in
terms of what symptoms you have, what factors relate to you etc.
This is why we need to treat everyone as an individual and begin to
understand what having persistent symptoms means to you and
your family – not something a test is going to tell us!
Although there are not any scientifically proved causes, there are
various theories (well-informed scientific ideas that have yet to be
proved or disproved) and persistent symptoms is a current
research interest.
Examples of some of these theories
Biopsychosocial model of illness
This theory states that persistent symptoms are due to a complex
interaction between different factors:
physical/biological (e.g. illness, injury, physical symptoms),
psychological (e.g. trauma, preferred coping styles)
social factors (e.g. lifestyle, relationships).
Chronic Stress
Chronic Stress may predispose you to all kinds of illness it is
another factor. In turn, having persistent symptoms in itself will
add to your stress which creates a vicious cycle that maintains
symptoms.
Sleep disturbance
Many people with persistent symptoms have problems sleeping.
They may find it hard to fall asleep or stay asleep, and they can
wake up un-refreshed. Poor sleep may hinder improvement in
persistent symptoms.
Families
Being prone to symptoms can sometimes run in families, although
the reason why is unclear.
Injury/illness or infection
Increased vulnerability to persistent symptoms following an injury,
illness or infection.
What treatments are there for Persistent
Symptoms?
Although there is no current ‘cure’ for persistent symptoms,
several treatments and therapies, for which the trials are
promising, are available which may help alleviate symptoms or
help people to cope better with their symptoms.
There is no recommended treatment for persistent symptoms.
However, at the current time cognitive behavioural therapy (CBT)
and graded exercise therapy (GET) have the strongest evidence as
effective treatments for persistent symptoms.
CBT and GET
GET is about gradually increasing your physical activity or level of
exercise to help you do more and feel better. This involves
working with a physiotherapist or occupational therapist to design
a basic activity routine that suits your particular symptoms.
Together you plan to gradually increase the amount of physical
activity you do. Patients sometimes say “But I feel too exhausted
to exercise”, but with very small steps they begin to increase their
stamina again.
CBT is a type of ‘talking therapy’ that aims to help you manage
your symptoms by enabling you to understand links between your
symptoms, worries, feelings and behaviour. This involves working
with a CBT therapist or psychologist to identify unhelpful or
distressing thoughts about yourself and your health, which may
make symptoms worse. These unhelpful, but often
understandable thoughts are then tackled and ways to change the
way you think and behave are developed, which can improve
symptoms.
Some people are reluctant to take up psychological therapy
because they fear being thought of as ‘mad’ or that their
symptoms are ‘all in the mind’. This is not the case and the fact
that psychological treatments works does not always mean that
the illness is psychological. Research has shown that
psychological therapy can help people learn to cope or manage
with all kinds of illnesses, such as cancer, diabetes and heart
disease. Psychological therapy such as CBT can be a very
positive experience. It’s a chance to talk things through, and
explore your own thoughts and feelings about things that matter
to you and set achievable goals that you decide on to make
progress.
Self-help
There are self-help guide books available that you might choose
to read.
Complementary and alternative therapies
Some people take complementary or alternative therapies that
are not available from the NHS and some say they benefit from
them. Yoga and aromatherapy are two examples. However, we
cannot recommend these therapies, because there is no
scientific evidence that they are effective, however patients can
seek these themselves if they wish to see if they find them
helpful.
Medication
One of the things your doctor may have suggested is medication
to try and help your symptoms. Medication rarely fixes symptom
all by itself but it can be useful in dampening down symptoms,
improving pain, low mood and fatigue and reducing worry.
People get better from persistent symptoms without medication
and no one should feel forced in to taking medication, but in
some cases it can be helpful.
Is it true that Persistent Symptoms can lead
to other illnesses?
What can healthcare professionals do to
help?
Those with persistent symptoms often have other illnesses- but we
don’t know that people get them because they’ve got persistent
symptoms; as on the law of averages we all can get other health
problems. These can be either/both physical or mental illnesses.
Your doctor will be working very hard in partnership with you, to
help you to effectively understand and manage your symptoms and
increase your quality of life. This will involve:
• Taking a detailed history from you to understand your
symptoms
• Ruling out possible serious causes of your symptoms
• Listening to your concerns
• Fully exploring your symptoms
• Setting goals with you and creating personal health plans
• Referring or signposting you to specialists such as
psychologists and physiotherapists for further treatment
• Sharing decisions about further investigations and
treatments with you
What’s the connection between physical and mental
health?
Just as poor physical health can lead to unhappiness and
psychological problems, the opposite is also true. Conditions such
as chronic pain and IBS are known to be triggered or made worse
by psychological problems such as stress, anxiety or depression.
This can lead to a vicious circle – for example, the emotional upset
from being in constant physical pain can lead to depression, the
depression then worsens the pain and may trigger other symptoms.
People with persistent symptoms often become understandably
anxious or depressed. Treating these problems can often make
symptoms easier to handle and even improve persistent symptoms.
How soon will I get better?
Most people with persistent symptoms improve over time with
treatment, but we can’t predict how long this will take. Some
symptoms rectify themselves quickly, while others can last longer,
in these cases it can be helpful to make scheduled appointments
with your GP. Even if you experience symptoms for a long time,
there is much that can be done to help you live a better life by
coping with and managing the symptoms more effectively.
What can I do for myself?
Try to remember that you have a REAL medical condition. You are
not imagining your symptoms, and it is not your fault that you have
these symptoms. Remain positive and give yourself time to get
better!
To help manage your symptoms try to lead a healthy lifestyle. For
example by:
• Reducing stress in your life
• Finding time to relax
• Healthy eating
• Avoiding excessive drinking and smoking
• Having a regular sleep routine to stick to
• Taking regular exercise – However don’t overdo it, gradually
increase the amount of activity/exercise you do
Enc 3
Strategic Clinical Networks
Functional / Persistent Physical Symptoms
Paper prepared by
Claire Braid
Northern England Strategic Clinical Networks
Dr Paul Goldsmith
Consultant Neurologist / Neurological
Conditions Network Clinical Lead
Purpose
This paper provides an overview of current
issues relating to patients with functional /
persistent physical symptoms
Version
V0.3
Status
Draft
Date
1st October 2014
Revision History
Version
Revision date
Summary of changes
V0.2
31 Aug 2014
Diagrams added and amendments made to text by PG
V0.3
1st October
2014
Additional link added
V0.1
FNC/PPS Draft v0.2
CB/PG August 2014
1
Functional / Persistent Physical Symptoms
Executive Summary
FS/PPS cut across multiple specialities and are one of the biggest secondary care
health costs. They are also a very common problem in primary care.
Care and outcomes are currently very poor. The key reasons behind this relate to
silo practises, lack of knowledge of health professionals and poor communication to
patients.
Therefore the route to radical improvement is reorganisation of existing services and
education of practitioners rather than 'new money'.
Dr Brigid Joughin, Newcastle West CCG MH lead: "It
is the biggest problem I see in primary care…our
key objective is to address this…training in
functional conditions should be mandatory for GPs".
FNC/PPS Draft v0.2
CB/PG August 2014
2
Measurables
1. IAPT Services to accept functional referrals from Apr 15
2. >25% of psychologists, physiotherapists, Psychological Wellbeing
Practitioners (PWPs) have received basic online training by Apr 15
3. >80% of psychologists, physiotherapists, PWPs have received basic online
training by Dec 15
4. >25% of rheumatologists, gynaecologists, pain physicians, orthopaedic
surgeons, cardiologists have received basic online training by Dec 15
5. >80% of rheumatologists, gynaecologists, pain physicians, orthopaedic
surgeons, cardiologists have received basic online training by Apr16
6. >80% of patients with a functional condition have the diagnosis communicated
to them by the diagnosing clinician
7. >50% of patients with greater than 2 secondary care interactions for functional
problems have a named GP with specialist expertise in FS/PPS
8. at least one PWP, one psychologist and one physiotherapist from IAPT and
community services per GP ‘federation’ has completed x day course in
functional skills by June 15
9. clinics with concentration of functional patients with psychologist or PWP,
clinician and physiotherapist being held in the same clinic area at the same
time, per GP federation at least once per fortnight by June 15
10. at least one PWP or psychologist or physiotherapist from IAPT or community
services co-locates a clinic once per month with a weekly movement
disorders clinic, epilepsy clinic, gynaecology clinic etc
11. regional functional lead (Cumbria, Newcastle, Sunderland, Durham,
Middlesbrough) nominated to coordinate services, CPD and peer support,
including monthly review meetings where the ‘spokes’ return to the ‘hub’
FNC/PPS Draft v0.2
CB/PG August 2014
3
Outcomes / ROI
£ spent on functional conditions decreased by x% by 2016 through:
•
•
•
•
decreased repeat referrals
decrease in GP attendances
fewer investigations
decreased welfare spend
Levers
•
existing contracts which already require and expect functional conditions
provision
•
termination of contracts for providers not engaging with
•
new methods of working
•
existing silo methods, lack of diagnosis and treatment regarded as not best
practice and therefore at risk of medico-legal consequences
FNC/PPS Draft v0.2
CB/PG August 2014
4
FNC/PPS Draft v0.2
CB/PG August 2014
5
Introduction and Background
In April 2013, twelve Strategic Clinical Networks (SCNs) were introduced to the new
NHS structures for England.
Working within the Mental Health, Dementia and
Neurological Conditions Network, each area has been tasked with improving
services.
During the first year of operation, there has been time invested in
reviewing evidence and speaking to local stakeholders about areas of health and
social care which warrant large scale change. Functional conditions were identified
as a key area that has a major impact on neurology services, and these patients
have a poor experience of services.
Functional symptoms are generally regarded as the most frequent, time consuming,
costly and debilitating problems seen by neurologists. There are a wide variety of
manifestations. Common neurology presentations are blackouts, paralysis and
abnormal movements. These symptoms are due to, and can be maintained by, a
complex combination of physical, psychological and social influences on brain
function.
At one end of the spectrum neurologists will see several cases per year of patients
receiving 24 hour full supportive social care and using electric wheelchairs. A far
greater number of patients have a variety of milder symptoms, representing up to a
third of neurology outpatient clinics (1). The most well recognised presentation is the
patient with functional seizures, also known as non-epileptic attack disorder or
pseudo seizures. Such patients are frequent A & E attenders and a significant
number of patients intubated for status epilepticus are actually having functional
seizures. FS/PPS can also be present in people with other physical or mental health
problems, for example, the same person can experience both epileptic and nonepileptic seizures, which can be very challenging for clinicians from a management
perspective.
Functional symptoms extend beyond the neurology clinic. Common examples are
chronic pain states (including pelvic pain), irritable bowel syndrome, fibromyalgia,
and chronic fatigue syndrome (2).
FNC/PPS Draft v0.2
CB/PG August 2014
6
550 Consecutive new patients to South London hospital over two years
“current somatic complaints reported by patients, for which
conventional biomedical explanation could not be found on routine
examination or investigations, rated 3 months after the initial
appointment”
Gynaecology
66%
Neurology
62%
Gastroenterology
58%
Cardiology
53%
Rheumatology
45%
Chest
41%
Dental
37%
Mean
52%
Courtesy of Vincent Deary
The extent of the problem has been increasingly recognised nationally with various
reports on “medically unexplained symptoms” (1, 2, 3, 4). Key opinion leaders in the
field stress that this term is inappropriate as labelling symptoms as unexplained can
compound a situation, with functional or persistent physical symptoms (FS/PPS)
preferred (2,3). Functional has the advantage of facilitating explanation to the
patient, but one can get tied up in semantic knots. Nevertheless it tends to be the
preferred term from neurologists. The alternative term of persistent physical
FNC/PPS Draft v0.2
CB/PG August 2014
7
symptoms is very helpful particularly in recognition of the overlap and spread of
presentation into areas not primarily covered by neurology, such as various pain or
fatigue syndromes presenting to rheumatology, gastroenterology, orthopaedics,
neurosurgery, respiratory and cardiology.
The Healthcare Improvement Scotland paper (1) provides data on the size, extent
and cost of FS /PPS. Data from the Scottish Neurological Symptoms Study in 2003,
identified that people typically develop functional neurological symptoms in their
twenties and thirties, at working age. This study found that 27% of patients with FS /
PPS were not working for health reasons, incurring high social costs (including
disability benefits) as well as increased attendance at of healthcare services. These
costs were estimated at approximately:
•
￡1.3 million per year for outpatients,
•
￡6.01 million for inpatients (including 13,887 bed days), and
•
￡4.01 million for primary care.
An extract from the Healthcare Improvement Scotland paper (1, p10) highlights other
key findings from data collection in Scotland:
•
‘Non-epileptic attacks account for 1 in 7 referrals to a first fit clinic, and up to
50% of patients brought to hospital with suspected ‘status epilepticus’.
Patients often mistakenly end up with treatment for epilepsy including ITU
admission for ‘status epilepticus’’.
It can therefore be seen how addressing management of functional conditions can
help major impact on the SCN epilepsy program.
•
‘Functional weakness is at least as common as multiple sclerosis. Moreover,
follow-up study showed that 12 years after diagnosis, one third of patients
were medically retired and levels of disability were comparable to a group of
patients with multiple sclerosis of similar duration.’
‘Patients with functional neurological symptoms have high rates of other physical and
psychological symptoms especially pain, fatigue, poor memory and concentration,
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gastrointestinal symptoms, anxiety, panic and depression. Indeed, functional
symptoms are not confined to neurology but are a significant problem in many other
specialties (for example, irritable bowel syndrome and chest pain with normal
coronary arteries). Not surprisingly, many of these patients are referred to multiple
specialties. Patients may have chronic fluctuating symptoms or be unable to improve
with optimal management. But even then, greater understanding can improve health
related quality of life.’ [quote taken from Health improvement Scotland paper]
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Northern England FS/PPS project scope
The Northern England SCN is addressing FS/PPS because of a clear request from
stakeholder events. We debated whether focus should be restricted to pure
neurological presentations, but considered this non optimal as:
1. Patients often present with multiple symptoms and to multiple disciplines,
indeed this being a characteristic feature.
2. It is felt that management practice has evolved more in neurology than other
areas and that addressing things across the board will increase the likelihood
of success through addressing problems early and systematically with
consistent message.
Currently FS/PPS patients encounter a wide variety of healthcare professionals.
There is extensive silo practice. Where there is lack of knowledge unhelpful
messages are communicated to patients and extensive investigations, repeated
referrals and prescriptions with side effects given. For the more skilled practitioner
they may feel lack of support from colleagues in other areas, particularly with the
most difficult cases.
There are examples of good practice, principally in Edinburgh (1) and in London.
This area has also been identified as one of the key evolutions for the national IAPT
programme (2). In February 2012, Healthcare Improvement Scotland (1) published
a paper on a stepped care model for functional conditions. This paper focussed on
functional neurological symptoms.
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Example Case:
A patient twists and gets a twinge in their lower back. They have been
told that they have a ‘crumbling spine’ based on an x-ray report done
previously and when they move and feel pain think that this could be
indicative of major harm being done. Subconsciously the legs are moved
less and heightened awareness results in the perception of altered
sensation in the legs. Referral to orthopaedics and an MRI scan shows
left L5 nerve root entrapment. Although of a similar level seen in
individuals with no symptoms, surgery is undertaken but symptoms get
worse and now, as a result of increasing immobility, the knees start to hurt
and a rheumatology referral is made. ‘Hypermobility syndrome’ is
diagnosed; the patient becomes increasingly housebound and applies for
sickness benefits. A pain syndrome evolves and referral to the Pain Clinic
leads to increasing prescription of opiates. These are initially helpful but
higher and higher doses are required and then Gabapentin is added in.
The patient gains more and more weight and becomes more sedated and
more immobile. The patient is given a wheelchair and is referred for
various injections to try and help with the pain. A gastroenterology referral
ensues because of constipation and abdominal pains. Eventually a
colectomy is undertaken for severe constipation. Referral is also made to
neurology for query epilepsy because of periods of loss of consciousness.
The neurologist identifies these as sleep attacks consequent upon the
high doses of sedating medication, plus sleep apnoea from obesity.
Examination of the nervous system is limited by pain, but no “hardware”
deficit is detected.
A working group with stakeholders from a wide variety of healthcare professionals
(HCPs) including neurology, physiotherapy, occupational therapy, psychology,
psychiatry, commissioning and primary care have come together to transform the
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management of patients with FS /PPS. What has been very striking is how, despite
this being regarded as a very difficult problem to deal with, there was unanimous
agreement from all areas as to what needed to happen and what best practice would
look like. This provides great encouragement that transformation can be achieved.
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Current Service Provision across the Northern SCN Geography
Examples of current practice:
•
many non-neurology clinicians do not make a positive diagnosis of functional
conditions but instead say what the patient does not have; patient seeks
multiple opinions
•
many neurologists make a positive diagnosis, but do not communicate it to
the patient
•
local IAPT services often reject referrals of functional patients as they have
not heard of the concept or regard it as too complex
•
some local neuropsychiatry services do not accept functional patients
•
NIHR multi-centre study on functional epilepsy management had to exclude
Newcastle as a collaborating centre because of lack of adequate liaison
psychiatry
•
excellent pathfinder psychology work in Cumbria, although lack of neurology
integration
•
emerging pockets of excellence in South Tees, Sunderland and Durham
Cumbria
•
Developing a general PPS model across a broad range of conditions, using
the London Commissioning Programme (5,6) model as a baseline
•
Focusing on health psychology and neuropsychology to provide a general
view.
•
Currently rolling out training across primary care and a range of allied health
professionals in identification and basic management of patients with PPS.
•
Developing a model based on the principles of the London Commissioning
Programme for the chronic pain service in North Cumbria.
•
Currently using a pyramid model of ‘matched care’, rather than ‘stepped care’.
•
Established education programme around the panic cycle and symptom
management.
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Cumbria Partnership FT currently provide a Cumbria-wide training programme to
enhance the Cognitive Behaviour Therapy (CBT) skills of HCPs, enabling them to
support patients with long-term physical health conditions and a level one to three
complexity of psychological need (e.g. mild to moderate anxiety or depression). The
programme is based on a training course developed in Newcastle by Mannix, Baker,
Moorey and Sage (Mannix et al. 2006) (13) which is designed to upskill HCPs, by
enabling them to become ‘CBT First Aiders’:
Trainees
•
The training programme is delivered to a wide range of HCPs including, but
not limited to, GPs, Consultants, Specialist Nurses, Physiotherapists,
Occupational Therapists and Speech and Language Therapists.
•
Twenty trainees are enrolled on each course.
Structure of delivery
1. One day CBT taster course- To introduce trainees to the basics of CBT and
allow them to decide if the training course would be useful.
2. Six day training course- Involves 3x two day sessions over six months,
interspersed with five group supervision sessions.
•
Training days involve:
 Education on different topics through PowerPoint presentation,
teaching and hand outs
 Stop-start demonstrations in which there is time for questions,
clarifications and group feedback
 Interactive skills practice in triads using vignettes to role play
 Setting homework at the end of each training day, which is reviewed at
the following training day e.g. reading, presentations
•
Supervision is led by an experienced cognitive therapist or clinical
psychologist and involves the provision of support and skills-building, through
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case discussion and reflective practice. Supervision groups are small usually
being made up of three to four trainees.
Training style
•
The aim is to create a shared experiential learning environment, in which all
trainees contribute to each other’s learning experience. This is achieved
through:
 A mixture of teaching, discussion, skills practice and feedback
 Active engagement of trainees e.g. asking questions
 Presentation and discussion of cases at training days and in
supervision by trainees
Measuring outcomes
•
Evaluation forms are completed at the end of each training day to gain some
feedback on the course.
•
A recorded interview assessment takes place on the final training day. This
consists of a 20 minute taped role play of a case formulation with an actor
‘patient’. The trainer marks this using the Cognitive Therapy First Aid Rating
Scale (CFARS; Mannix et al. 2006). All trainees are sent an audio-file of their
role play along with constructive comments following the end of the training.
Funding
•
This course is allied to a three year project, funded by Macmillan Cancer
Support for the North of England Cancer Network, Marie Curie Cancer Care.
•
The training is offered to staff by the Cumbria Partnership NHS Foundation
Trust free of charge and is open to those from Health, Social Care and third
sector organisations affiliated to these.
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Practical applications for the PPS education plan
Results show that this training style is an effective and simple method of educating
and upskilling HCPs. For example Mannix et al. (2006) found this method of delivery
led to increased competency in staff skills and confidence in applying these to their
clinical practice. Therefore, elements of this programme’s structure and delivery
(such as group supervision, shared experiential learning and role play assessment)
may be used within the proposed education plan for PPS.
Newcastle / Sunderland
•
Pilot study using inpatient psychology resource around non-epileptic attack
disorder showed a reduction in A&E attendances and investigations
•
No current service for PPS for Newcastle locality.
•
Sunderland-based PPS group run in primary care for people with pain and
fatigue symptoms. Classes are 5 weeks in duration and are run from a local
supermarket with logic being to de-stigmatise.
County Durham / Darlington
•
Psychology provision to this patient group is provided by the ‘liaison MUPS’
[medically unexplained physical symptoms] service (psychology / psychiatry /
allied health professionals and support workers).
•
Patients with functional neurological symptoms make up largest single referral
group to this service.
•
This service is for secondary care; IAPT services cover primary care.
•
Darlington was a pathfinder site for long term conditions / ‘medically
unexplained symptoms’ service based within IAPT. Based around training for
primary care staff (including practice nurses / specialist nurses), delivered
jointly with Teesside University.
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Teesside
•
Liaison psychiatry service provided into secondary care
•
Not specifically commissioned for FS/PPS patients but this service sees many
of these due to their complex needs.
•
Integrated working between an enthusiastic psychiatrist and neurologist
•
Main service delivery is around assessment and re-framing functional
conditions for patients and staff members, education and improving
understanding.
•
Attempts to prevent people being admitted to secondary care mental health
services.
FS/PPS in children, early intervention and primary prevention
FS/PPS occur from childhood through to late life (2) and for many patients, risk
factors and vulnerabilities to later development of FS/PPS can be traced back to
early childhood and problems with emotional resilience, emotional dysregulation and
unhelpful patterns of interpreting bodily symptoms. The most effective way of
decreasing the frequency and severity of functional conditions in both childhood and
adulthood would be by promoting mental and emotional resilience for all, pre-natally
onwards.
Given the significant burden of functional conditions in children, return on investment
would be seen within a relatively short time frame, although the big impact would be
in the long-term. Every national and international review we have read comes to
similar conclusions, although approaching their root cause analysis from different
starting points (e.g. social mobility, life chances, education attainment, forensic
issues, substance misuse etc) (7,8,9,10). Pertinent reviews are:
•
Marriott, G; Asher, J and Butler, Z (2014) Born in South Lakeland –
developing emotionally resilient children. (8)
•
Care and Wellbeing Overview and Scrutiny Committee Working Group
(2012) Policy A – Give every child the best start in life. Northumberland
County Council. (9)
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•
Care and Wellbeing and Family and Children’s Services Overview and
Scrutiny Committee Working Group (2013) Policy B – Maximise capabilities
and have control. Northumberland County Council. (10)
All groups want the same thing, but progress in moving beyond pilots to a systematic
and comprehensive change in approach appears slow or non-existent.
There are a number of programmes that are currently being implemented in various
schools around the country, which aim to improve the mental and emotional
resilience in children. Locally, the areas that are developing, running or have piloted
resilience training are:
•
County Durham
An initial programme targeted at adults had been running for 4 years on
mindfulness based stress reduction (delivered by ‘Living Mindfully’). This
programme was piloted with young carers last year, and there is a plan to roll
out the ‘.b’ mindfulness programme in schools for all children aged11+.
Durham County Council is working in conjunction with Newcastle University
for evaluation of the programme. The Council is also aiming to broaden the
‘Relax Kids’ programme. This strategy is supported by the local Health and
Wellbeing Board.
•
South Tyneside
Participated in the UK Resilience Programme in 2007-8 (for one year and
one age group only), along with two other sites nationally. The report (11)
indicated some short-term improvement immediately after the programme
was delivered, and recommended longer-term implementation.
•
North Tyneside
Marden School – all staff are trained in the ‘.b’ programme. No outcome data
has been obtained.
•
Cumbria
As part of a recent review into Child and Adolescent Mental Health Services
(CAMHS) (6), the ‘HeadStart’ programme was identified as a service aimed at
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improving resilience among 10-14 year olds. This is a national initiative,
supported by the Big Lottery Fund, and Cumbria is one of 12 sites nationally
to bid for £500k to run an initial pilot between July 2014 and December 2015.
Around half of these sites will go on to receive a further £10 million to fund the
roll out of this project between 2016 and 2020. This programme is aimed at
equipping children to be able to cope with the stresses and pressures of
modern life.
Positive mental health and mental resilience training is most advanced and promoted
in leading private schools, e.g. nationally, the ‘.b’ programme is being delivered at
the Hampton School, through ‘Mindfulness in Schools’, a not-for-profit organisation
who offer training for teachers in the delivery of mindfulness within the school
curriculum.
Outcome measurement is currently through anecdotal evidence, and there is no
specific measure of effectiveness linked with the programme.
Some children (& their families) need much more intense support. Health visitors,
teachers and other professionals typically know who they are, but the links are often
not made. Systematic identification is happening in some places, e.g. NHS Greater
Glasgow and Clyde, in partnership with the University of Glasgow developed and
implemented a ‘Strengths and Difficulties’ questionnaire, which is a brief behavioural
screening questionnaire for 3-16 year olds. This tool facilitates the identification of
children who have, or are likely to have, psychological problems. This would help to
facilitate early referral and intervention for these children. This questionnaire can be
accessed at www.sdqinfo.org.
What is apparent looking at the natural history of many children and adults, is that
the ideal approach would be to give every child from the prenatal stage, through
preschool, primary and secondary schools, through their parents and embedded into
the curriculum, the mental well-being skills that those private education receive.
Many of the tools and techniques are likely to be already established. We reflect on
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the fact that whilst this is already an aspiration of most councils, related activity
already happens (e.g. PHSE), so the challenge is similar to the adult FS/PPS
situation, how to use existing resource differently and at scale.
We recommend that a separate steering group is established, tasked with
implementing at scale using existing tools and ‘teaching the teachers’ through elearning for cost effectiveness and ongoing review to enhance, optimise and audit
methods and implementation.
The body would ideally include representatives from the Mental Health, Dementia
and Neurological Conditions Maternity and Child Health SCN, Health Education
North East, LA7, LA5, Cumbria and link with any existing work streams within Public
Health England.
Existing training mechanisms for resilience and FS/PPS
There is a range of training mechanisms and resources available both locally and
nationally, around different aspects of identifying, managing and preventing FS/PPS.
These are:
•
Newcastle and Teesside Universities for training in FS/PPS for IAPT
practitioners;
•
Specific model in Cumbria targeting primary care and allied health
professionals, in the identification and basic management of FS/PPS;
•
Children and Young People’s (CYP) IAPT programme, delivering training via
Tees, Esk and Wear Valley NHS Foundation Trust (TEWV);
•
‘MindEd’ online training module on FS/PPS in children and young people;
•
Mindfulness in Schools (national mindfulness training provider);
•
Living Mindfully (County Durham-based service for adults and children).
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Other services and resources include:
•
Pathways 2 Wellbeing (Hertfordshire-based company providing services to
people with ‘medically unexplained symptoms’).
•
www.neurosymptoms.org – self-help website for people experiencing
FS/PPS.
•
Service specific to non-epileptic attack disorder based in Sheffield.
•
Service based in Edinburgh for functional neurological conditions (exemplar
service).
Local Plans
As highlighted previously, a working group with stakeholders from a wide variety of
healthcare professionals including physiotherapy, occupational therapy, psychology,
psychiatry, commissioning and primary care have come together to transform the
management of people with FS/PPS across the Northern SCN area. Following the
first meeting of this group, despite this being regarded as a very difficult problem to
deal with, there was unanimous agreement from all areas as to what needed to
happen and what best practice would look like. This indicates the level of motivation
and enthusiasm to achieve that transformation. The key principles of the
transformation are listed below.
Key principles for service-level development
1. A matched care, pyramid of need model should be adopted with patients
receiving input with intensity and complexity according to needs, with most
people requiring low intensity input and the minority requiring highly complex
intervention.
2. CBT-based approaches involving co-production models are the mainstay of
therapy, together with in most cases graded exercise therapy.
This could be delivered by a wide range of disciplines and will reflect existing local
skills. Delivery could be through IAPT, other psychology, psychiatry, specialist
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nurses or doctors. The exact person delivering the therapy would partially depend
on patient co-morbidities and also cost effectiveness of service offering.
The first key step in management is making a positive diagnosis and making a
positive plan. Historically doctors have told patients what they don’t have and
unwittingly led to the “one more test, one more opinion” spiral (2,12).
Patients will relapse and display concerning behaviours and it is important that the
therapist has ready access to support. Too often the patient will collapse or describe
concerning features in the community and the inexperienced therapist sends the
patient back in to secondary care.
Key principles of Network-wide education plan
A major programme of education for all healthcare professionals will be required.
This needs to be sustainable, reflecting turnover of staff and evolution of therapeutic
practices. Some will only require, or pragmatically only be able to receive, a brief
video-based training module, whereas others will need comprehensive practicebased courses.
1. A lead psychologist (or psychiatrist) is nominated for each area to lead and
coordinate the service, dissemination of best practice and education.
2. Complex cases are seen by more experienced therapists, such as the above
leads, in clinics located in the same corridor and at the same time as
specialist clinics (neurology or other), for example at the same time as an
epilepsy clinic to facilitate knowledge exchange and support between
neurology and psychology. Where liaison psychiatry clinics exist these should
be co-locate.
3. Each GP practice or group of practices (“federation”) should have a therapist
(equivalent to Level 2 IAPT) operating from their practice with this therapist
trained in management of FS/PPS. This would logically be an existing IAPT
PWP / psychologist spending part of their week in a different location. One
GP from each practice will be the nominated FS/PPS lead. Patients identified
with FS/PPS will be highlighted / encouraged to book with a single GP and a
management model following the London GP pilot followed in terms of
consultation, frequency and management strategy [this primary care pilot
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service for FS/PPS in London showed a decrease in secondary care costs of
30%, GP contacts by 33% and investigations by 25% (4)]. Frequent A & E
attenders should also be flagged by electronic means.
Training
There is an opportunity to build on existing expertise and training mechanisms (as
identified above) within the Network area. There could be potential within this project
to utilise existing, or develop new, modules using the proposed structure below:
tiered
1. Eight day course
2. Two day course
3. Half day course
4. One hour lecture
5. Online training module.
The aim is for this training to be available to a broad range of staff from all
disciplines, including (but not restricted to):
Selected IAPT therapists
GP leads
Other GPs
Allied health professional staff
Nursing staff, including practice, district and specialist nurses.
All staff across all medical specialties, including pain therapy
All medical students
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HENE will: to insert
Primary Prevention
A key implementation is a systematic incorporation into the school curriculum of
good mental health techniques including mental resilience, emotional dysregulation
management and this should be seen as enhancing the positive, rather than just
avoiding the negative. It is recommended that a curriculum review subcommittee is
involved in the roll out and monitoring, with a plan to enhance on a yearly basis. .
We propose that mental well-being / resilience training is integrated into standard
antenatal, health visitor and school teaching and rolled out across the entire region
and from nursery school right through to aged 18, sitting within the PSHE curriculum.
Early Intervention
Early functional symptoms and at risk thought patterns and behaviours are typically
seen in childhood. We propose that identification of such children is undertaken
through assessments as part of their core systematic teaching, but also with direct
referral from school nurse or from GP practice as a result of frequent GP
attendances. Network-wide implementation of the ‘Strengths and Difficulties
Questionnaire’ could facilitate this. We propose that these children (and their
parents) receive a similar input as the adult functional patients, but tailored to their
situation and delivered as part of CAMHS, linked with children and young people’s
IAPT training programme. The latter should also involve a hub and spoke model
with practitioners embedded into each group of GP practices / federation.
In many situations children will respond best to peers and there are some excellent
examples locally of teen-led mental health projects that could be incorporated into
schools systematically.
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Financials
Extensive cost savings are anticipated. Most of the service reconfiguration involves
moving existing pieces around but it is recognised that a key cost will be around
education. Potential areas in which funding could be diverted are those where
commissioners already have a budget for “medically unexplained symptoms” such
as some neuro-psychiatry services where currently FS/PPS services are not actually
being delivered.
We would also consider removal of payment for secondary care referrals where the
patient had been identified as FS/PPS unless the referral was from the GP specialist.
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References for Functional Overview Paper
1. Healthcare Improvement Scotland (2012) Stepped care for functional
neurological symptoms.
2. Improving Access to Psychological Therapies (IAPT) (2014) Medically
Unexplained Symptoms / Functional Syndromes Positive Practice Guide.
Department of Health.
3. Stone, J; Carson, A and Sharpe M (2005) Functional Symptoms in Neurology:
Diagnosis and Management. Advances in Clinical Neuroscience and
Rehabilitation. 4(6) 8-11.
4. Parsonage, M; Hard, E and Rock, B (2014) Managing patients with complex
needs. Centre for Mental Health.
5. NHS Commissioning Support for London (2010) Medically Unexplained
Symptoms (MUS) A whole systems approach.
6. NHS Commissioning Support for London (2011) Medically Unexplained
Symptoms (MUS) Project implementation report.
7. Department for Education (2014) Mental health and behaviour in schools:
Departmental advice for school staff.
8. Marriott, G; Asher, J and Butler, Z (2014) Born in South Lakeland – developing
emotionally resilient children.
9. Care and Wellbeing Overview and Scrutiny Committee Working Group (2012)
Policy A – Give every child the best start in life. Northumberland County
Council.
10. Care and Wellbeing and Family and Children’s Services Overview and
Scrutiny Committee Working Group (2013) Policy B – Maximise capabilities
and have control. Northumberland County Council.
11. Challen, A; Noden, P; West, A and Machin, S (2010) UK Resilience
Programme Evaluation: Final Report. Department for Education.
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12. Stone, J (2009) The Bare Essentials – Functional symptoms in neurology.
Journal of Neurology, Neurosurgery and Psychiatry. 9 179-189.
13. Mannix, K.A., Blackburn, I.M., Garland, A., Gracie, J., Moorey, S., Reid, B.,
Standart, S., & Scott, J. (2006). Effectiveness in brief training in cognitive
behaviour therapy techniques for palliative care practitioners. Palliative
Medicine, 20 (6), 579-584.
Extra material from Dr Jon Stone:
www.neurosymptoms.org
https://itunes.apple.com/gb/podcast/diagnosing-treatingfunctional/id426391174?i=232353463&mt=2
http://www.aan.com/rss/index.cfm?event=feed.items&channel=1 - See the Nov 12, 29 and 26
episodes and skip to the functional section.
https://www.aan.com/rss/search/home/episodedetail/?item=2819 [1Aug14; navigate to the
Contemporary Clinical Issues section]
Training Module for GPs working with Children and Young People:
https://www.minded.org.uk/course/view.php?id=51
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