and Partnership NHS Foundation Trust

The Yorkshire Centre for Psychological Medicine

The Yorkshire Centre for Psychological Medicine Content

Introduction 5

Purpose 7

Treatment Approaches 9

Environment 11

Quality and Effectiveness 13

Finance and Value 15

Who to refer to YCPM 19

Patient Vignettes 21 Patient feedback ‘I would never have got going without you. I Patient Testimonial 23 have appreciated the kindness and cheerfulness of you all, even when I was at my most How to refer to YCPM 25 miserable, you always had something positive to remind me of.’ How to find us 27

The Yorkshire Centre for The Yorkshire Centre for 02 Psychological Medicine Psychological Medicine 03 Introduction

The Yorkshire Centre for Psychological Medicine (YCPM) of expertise within the team. Further details of this can be delivers biopsychosocial care for people with complex found in later sections of this brochure, along with information medically unexplained symptoms and physical/psychological regarding value for money, illustrated by real case examples. comorbidities. More details regarding the range of treatment approaches The YCPM is an eight bed specialist in-patient unit which was available, the environment, and quality and effectiveness, originally established on Ward 40 of Leeds General Infirmary are also provided in this brochure, but requests for further in 1980. information can be directed to:

This is a unique service which has a history over many years Clinical Team Manager of delivering services within Leeds and , but Yorkshire Centre for Psychological Medicine which is now able to offer access to patients from across the Wing north of and beyond. Leeds General Infirmary Great George Street The YCPM is part of the wider Liaison Psychiatry service in Leeds LS1 3EX Leeds. This is the sub-speciality concerned with clinical service, Telephone: 0113 39 27140 teaching and research in the general hospital setting. It aims to provide healthcare professionals in general hospitals, Research activity within the service is facilitated by close primary care and secondary care with defined access to a links with the Institute of Health Sciences at the University specialist multidisciplinary team, for the care of patients of Leeds. Patient feedback presenting with psychological as well as physical problems. “All I can say is a very big thank you to all of The YCPM is part of Leeds and York Partnership NHS you. Everyone has been so supportive and I The YCPM aims to help people with complex difficulties Foundation Trust. Everything we do accords with NHS leave here looking forward”. make significant improvements with regard to their health values and our stated Trust purpose of improving health and and quality of life. Clinical outcomes, even in a range of improving lives. very chronic and complex cases, are often very good, and patient feedback positive. This is possible due to the nature of the YCPM Unit and its function within the general hospital setting, but also due to the depth of experience and breadth

The Yorkshire Centre for The Yorkshire Centre for 04 Psychological Medicine Psychological Medicine 05 Purpose

The YCPM team specialises in helping n Dietetics people with the following types of n Pharmacy problems: n Administration

n Chronic and/or complex and/or severe medically The unit benefits from staff with dual (general/physical in unexplained symptoms and somatisation addition to mental health) training, and others trained in (psychologically-based physical symptoms and cognitive behavioural and psychodynamic psychotherapeutic syndromes). approaches.

n Severe physical and psychological/psychiatric The Unit also has direct access to the comorbidity: following personnel: A) in people who are already general hospital in-patients but who have psychological needs at a n Cognitive behavioural therapists level that cannot be effectively met on a general n Psychosexual therapists medical or surgical unit. n Outpatient chronic fatigue/ME team Or n Hospital mental health team B) in people in other services or the community who could benefit from focussed multidisciplinary The unit provides a biopsychosocial approach to assessing and treatment provided in an in-patient setting. treating the full range of patients’ problems. The expertise of Patient feedback the team has been developed over many years and the YCPM n Patients with severe CFS/ME. “My care has been excellent and it has given me exists within the broader liaison psychiatry service provided (We provide the in-patient component of the Leeds and hope for much more of a normal life”. by Leeds and York Partnership NHS Foundation Trust. This is West Yorkshire CFS/ME Service). the most comprehensive liaison psychiatry service in the UK.

The YCPM is staffed by a multidisciplinary Patients may have difficulties attending outpatient team, with the following elements: appointments or may have failed to make improvements n Liaison psychiatry with this level of care. An in-patient stay at YCPM allows for n Nursing comprehensive assessment followed by carefully planned n Occupational therapy and implemented treatment approaches. As a result, other n Physiotherapy services from across Yorkshire and beyond refer cases to the n Social Work unit.

The Yorkshire Centre for The Yorkshire Centre for 06 Psychological Medicine Psychological Medicine 07 Treatment Approaches

Patients referred to the YCPM will be contacted to discuss Individual sessions with key members of the multidisciplinary the aims of the admission and to answer any questions team - focus on particular areas of the psychological care regarding treatment approaches, length of stay, housekeeping plan - working with ambivalence / motivation / symptom arrangements, etc. A key individual will keep contact with the management and symptom reattribution, etc. patient about the proposed admission date. The first meeting may be an assessment in hospital or at home, or a visit to the Cognitive behavioural and psychodynamic psychotherapy unit. This usefully facilitates meeting key individuals from the approaches. team and an appreciation of the location of the unit in the general hospital. Family members and carers are offered support and can be included in discussions around clinical care, with agreement On admission, and in the first week, the various members and consent from the patient concerned. of the MDT will meet the patient and carry out specific assessments. These are then shared with the patient at the Social (for example) weekly MDT meeting. The care planning process is designed Specific social needs are assessed in relation to the patient’s to encompass physical, psychological and social health needs. Care plans are designed by the team in collaboration home and community situation. The unit is essentially a social with the patient. space and patients are encouraged to talk to and engage with each other in the experience of being in hospital. To this Physical (for example) end there are various groups and activities which enable the Physical monitoring - liaison with and input from medical/ social environment to work therapeutically. surgical teams within the general hospital. Any required physical treatments to improve health. Groups The unit provides a group treatment programme with Programmes to improve physical functioning - Occupational psychotherapeutic, educational, and activity based groups Therapist and Physiotherapist interventions. Patient feedback Risk management Graded activity programmes - particularly in relation to Formal risk assessments are carried out regularly with “Thank you for seeing me as a ‘whole’ person fatigue. Pharmacological treatments. all patients. Risk management plans are reviewed at all and not as a list of problems to be separated off MDT meetings and inform planned interventions, including Psychological (for example) as either mental or physical. This is something observation procedures and individual and group therapies. ‘Living with pain’, ‘Living with anxiety’ and ‘Living with illness’ that I have really appreciated, as it is so rare to are all packages of care available to each patient delivered happen in other health settings.” on an individual basis. Patients may also then be referred on to the particular groups focussing on this work.

Programmes to deal with particular fears and anxieties (graded exposure)

The Yorkshire Centre for The Yorkshire Centre for 08 Psychological Medicine Psychological Medicine 09 Environment

The unit is in the centre of Leeds with excellent rail, road and The YCPM is based at Leeds General Infirmary. Although this public transport links and parking facilities. This facilitates is a general hospital setting, the environment is specifically admission and visiting but also means the unit is ideally designed to provide a therapeutic environment for patients placed to help patients re-engage in normal activities in the with mixed physical and psychological/psychiatric difficulties. wider community as and when appropriate. The unit provides a comfortable environment with communal The eight bedrooms all have: areas where patients have the opportunity to socialise with peers but also have their own individual bedrooms. Patients n An electric profiling bed have the use of two lounges which provide televisions, DVDs, n Vanity suite music and other group and therapeutic activities. n Wardrobe n Bedside table The conservatory and balcony areas enable patients to spend n blind time with their fellow patients and with their visitors in a n Armchair relaxing environment. n Privacy/observation window n Extra wide 2 way opening doors n Assistance call facilities

In addition the Unit provides Patient feedback n One assisted bathroom “...deeply grateful for your knowledge and n One independent bathroom expertise that has put me on the long road to n recovery from CFS. Also for the manner in which One level access shower room it has been done…..without exception the staff (each with assistance call facility) have been kind, encouraging and supportive…’ n Laundry Room n Patient telephone

The Yorkshire Centre for The Yorkshire Centre for 10 Psychological Medicine Psychological Medicine 11 Quality & Effectiveness

The YCPM delivers its therapies and treatment packages about their experiences of the Unit. This is within the standards and levels of quality assurance set achieved through several means: by Leeds Partnerships NHS Foundation Trust. Quality and effectiveness are addressed in an organised way within • The Forum (discussion meeting involving patients the Clinical Governance structure of the organisation, and and staff) which takes place once a week. This provides the Specialist Services Directorate, within which the Liaison the opportunity for patients and staff to identify any Psychiatry Service and YCPM are managed. problems with the ward environment and identify solutions. The Liaison Psychiatry Service, including YCPM, has its • Individual patient feedback sessions with key staff own multidisciplinary Clinical Governance Council. This is • Every patient is asked to complete a feedback accountable to the Specialist Services Directorate Clinical questionnaire at the point of discharge. Importantly, this Governance Group chaired by the Associate Medical Director all takes place in the setting of a philosophy which and reporting to the Trust Clinical Governance Committee. invites and encourages discussion and feedback throughout the admission. Clinical Governance within this structure is Clinical outcome measurement is achieved organised under the following headings: in three main ways:

n Risk Management • Routine use of CORE—OM outcome measurement tool n Clinical Guidelines at the point of admission and again at discharge. Patient feedback n Audit • Use of condition specific and therapeutic modality “Thank you so much for all your hard work, n specific measures as required in each case. patience and determination over the past few Research and Development • Clinical Global Impression Scoring at the point of months and for all your advice in helping me n Patient and Carer Experience and discharge. kick start my recovery” Views n Access to Services n Information Information / figures regarding outcomes and effectiveness are available in the YCPM Annual Reports, which are being n CPD/Staff Development produced from 2009/10 onwards. n Public Health Issues n Service Development The YCPM service is registered with and has been inspected by the Care Quality Commission (in 2011) and declared to be The YCPM is committed to collecting and compliant with all essential standards of quality and safety. acting upon patient and carer feedback

The Yorkshire Centre for The Yorkshire Centre for 12 Psychological Medicine Psychological Medicine 13 Finance and Value

For details regarding cost per bed day referrers / commissioners Department with severe pain within hours or days of transfer should contact the Clinical Team Manager (see contact details home. All attempts locally, including by the liaison psychiatry on page 25). in-reach team, had proved to be unsuccessful in attempting to improve his condition. The basic cost of the bed days of It should be noted that the cost per bed day is inclusive the medical ward over the five month period concerned were of all treatment interventions. This includes all necessary approx. £61,000 (this does not include any cost attached investigations, all medication, all psychotherapeutic work, to the multiple contacts required with neurology, ENT, pain all physical treatment interventions, and all catering needs management and liaison psychiatry teams). Transfer to (including NG tube feeding, etc). The only additional cost that a national pain management centre was considered but may, on rare occasions, be applied would be with regard to assessment by the team from that centre led to the conclusion increased levels of observation if requiring additional staff. that this gentleman would need a very flexible / bespoke package of care to address his physical and psychosocial issues The YCPM service represents good value for money. Many together, which could not be provided using a standardised patients referred will previously have required a great deal of pain management approach. Transfer to the YCPM followed, input over a prolonged period of time, including both multiple leading to a multidisciplinary biopsychosocial assessment physical investigations and long periods of treatment. It may and care plan. Treatment involved physical and occupational be helpful to consider the potential impact of an admission rehabilitation alongside psychological work in relation to to the YCPM upon immediate and medium / long-term costs. underlying issues and relationship dynamics which were the Two cases are described below by way of examples which basis of his physical symptoms. This took place over a period of Patient feedback may help to illustrate some issues regarding finance and value six weeks, at the end of which full recovery had been achieved “Staff were polite, courteous and available for money. and the patient was able to walk prolonged distances and to at all times. Nothing was too much trouble”. function normally. The inclusive costs associated with this six 1. A young man was referred to the Unit from North East week admission were £19,698. This case clearly illustrates England who had been suffering with medically unexplained the immediate financial benefit of the admission, without weakness and pain in his lower limbs and head since a which the medical admission would have continued. Perhaps routine ear operation. The severity of his symptoms and just as importantly the resolution of all symptomatology has the perceived need for continuing investigation and input profound implications for avoiding the very significant costs by a range of medical and surgical specialties meant that which are attached to cases such as this in the longer term. he was an in-patient in a general medical ward for a five month period post-operatively. All attempts to discharge him home failed, as he returned to the hospital through the A&E

The Yorkshire Centre for The Yorkshire Centre for 14 Psychological Medicine Psychological Medicine 15 Finance and Value continued

2. A married mother in her early 40s was referred from inability to function within the family or to work outside of the South of England with a history of four years medically the home she had remained pain free since discharge, was unexplained perineal pain. The presentation was extremely enjoying life, and had returned to work full time. severe, with regard to the impact upon the life of the patient and her family. She was presenting on a daily basis at either It is very difficult to assess the cost of her care prior to admission, the GP’s surgery or the A&E Department asking for more although daily attendances at the GP practice, frequent and medication to help with her excruciating pain and demanding numerous unnecessary physical investigations and assessment a nerve block. Her local Acute Hospital Trust was taking legal and treatment through the local A&E Department obviously advice to be able to refuse to provide care, due to the amount carry a very high financial cost. Although the admission was of time that was being taken up by the constant calls and several months in duration the impact of this patient’s recovery attendances. The GP was also finding it difficult to help, and with regard to the avoidance of future healthcare costs, which the patient was taking a wide range of analgesic medication otherwise would certainly have been required, is very clear. which was not helping. The working diagnosis by the local teams, including liaison psychiatry, was Somatoform Pain Disorder. She was admitted to the YCPM and within a few days, in the context of a more intensive multidisciplinary assessment approach than had previously been possible, it became clear to the team that the diagnosis was actually one of an atypical psychotic depression presenting with delusional beliefs Patient feedback regarding her pain, the causes of it, and treatments for it. This “My care on the unit has been first class and was a difficult case which involved the patient being detained if I have had a problem it has been dealt with on Section 3 of the Mental Health Act for several months whilst straight away”. treated for the aforementioned condition. Antipsychotic and antidepressant medication (the latter involving combination therapy) were required alongside psychological interventions. After a relatively prolonged admission of around six months this patient had fully recovered and was, for the first time for almost five years, entirely pain free. She was discharged home to be followed up by the local psychiatry team and when an enquiry was made by the YCPM team some ten months later the news was that despite her previous level of distress and

The Yorkshire Centre for The Yorkshire Centre for 16 Psychological Medicine Psychological Medicine 17 Who to refer to YCPM

The YCPM team specialises in helping people with the following types of problems:

n Chronic and/or complex and/or severe medically unexplained symptoms and somatisation (psychologically-based physical symptoms and syndromes).

n Severe physical and psychological/psychiatric comorbidity: A) in people who are already general hospital in- patients but who have psychological need at a level that cannot be effectively met on a general medical or surgical unit. Or B) in people in other services or the community who could benefit from focussed MDT treatment provided in an in-patient setting.

n Patients with severe CFS/ME. Patient feedback (We provide the in-patient component of the Leeds and “I have been very happy with my care on the unit and have felt my needs were met”. West Yorkshire CFS/ME Service).

The nature of some of the patients we help is illustrated in three brief vignettes on page 21.

Enquiries and referrals are taken from any health care professional in either primary or secondary care settings.

The Yorkshire Centre for The Yorkshire Centre for 18 Psychological Medicine Psychological Medicine 19 Patient Vignettes

Previous patient brief vignettes

Patient A was a 22 year old man who had Insulin • Consistent education about her condition (1:1 and Dependent Diabetes since 4 years of age. groups). • Graded activity and pacing using detailed activity • He had ‘manipulated’ his glycaemic level from a scheduling. very young age to escape bullying and difficult • Intensive psychological therapy including cognitive circumstances by ensuring frequent and prolonged behavioural therapy with symptom reattribution, and admissions to hospital. addressing complex family problems systemically. • Very high sugar levels over years suppressed his growth hormone secretion so that he was of diminutive size Patient C was a 60 year old woman on a surgical ward and lacking secondary sexual characteristics. post-mastectomy. • Also led to secondary medical complications of diabetes; seriously impaired eyesight, chronic renal • Presenting with severe depression and paranoid failure, neuropathy and poor peripheral circulation. ideation. • Depression and anxiety (mainly social phobia). • Refusing to eat and drink. The underlying behaviour causing his major problems had • Frightened, frail and generally physically unwell leading not been addressed by the diabetes teams previously. He to transfer to the YCPM. required admission to YCPM to: A structured plan was developed to support her in beginning • Effectively treat his psychological problems through to eat and drink. This was alongside the administration of medication, individually tailored psychotherapeutic antipsychotic medication under the Mental Health Act. work and involvement in the group treatment Regular surgical review, and investigations including head programme. CT and bone scans, were carried out. Raised serum calcium Patient feedback was dealt with promptly with input from the endocrinologists • Monitor and treat his range of physical problems with which contributed to the good outcome. Support was also “The team has saved my life for the regular input from renal, endocrine and ophthalmology provided to her husband and family members. second time, and I am determind to stay teams which would not be possible at the level required well and enjoy the rest of my life.” on a different Mental Health Unit.

Patient B was a 32-year old woman who was moving from service to service requesting frequent physical investigations for her range of medically unexplained symptoms. These included: fatigue, somatoform pain and reduced mobility. She was moved from one GP to another and was presenting to general hospital services through multiple attendances at A&E. She was transferred from a neurology ward to the YCPM, where she received a package of care tailored to her needs including:

The Yorkshire Centre for The Yorkshire Centre for 20 Psychological Medicine Psychological Medicine 21 Patient Testimonial

‘I had been ill for 6 1/2 years when I arrived at (YCPM) and was bed bound, unable to tolerate any light or noise, unable to talk or listen to more than a few words from others or have them in the room. I was also unable to feed myself, my hair hadn’t been washed or brushed for 18 months and I couldn’t even be physically washed by others or have my pyjamas changed. Despite completing a music degree in the past I was now unable to carry out any mental tasks. I hadn’t been left alone in the house for over 2 years due to my emotional state of complete fear, anxiety, frustration and anger.

Overall I was in a state of utter desperation and just wanted to get better.... but didn’t know how to…….

My Life Now – Since being discharged from the service I have got back in touch with friends and family and completed training in occupational therapy. I am now happily married and working as an Occupational Therapist four days a week Family feedback covering two jobs, one in palliative care and one in CFS/ “We will always be eternally grateful to the ME. I continue to use the strategies taught by the service team for giving us our daughter back; without and cannot recommend their professionalism and approach them the outcome could have been so different. highly enough. Be prepared to trust them, and never give up.”

The whole process was a joint effort between me, the team, and family/friends. Although it was difficult, I am so glad that I persevered to get my life back. I will be eternally grateful to the YCPM and its commitment to helping people.’

The Yorkshire Centre for The Yorkshire Centre for 22 Psychological Medicine Psychological Medicine 23 How to refer to YCPM

Enquiries All enquiries should be directed to the Clinical Team Manager, or any member of the senior YCPM team. Please contact the team on 0113 39 27140. Informal visits to the unit can be arranged by prior notice.

Referrals Referrals are accepted by letter and should be addressed to:

Clinical Team Manager Yorkshire Centre for Psychological Medicine Brotherton Wing Leeds General Infirmary Great George Street Leeds LS1 3EX

Telephone: 0113 39 27140

Patient feedback Pre-admission Assessments “I can’t thank you all enough and will never Patients and their families/carers are encouraged to visit forget each and every one of you for your care the unit prior to admission to discuss and plan their dedication and a job well done”. care and treatment. This will be coordinated by a member of the multidisciplinary team in discussion with the patient.

The Yorkshire Centre for The Yorkshire Centre for 24 Psychological Medicine Psychological Medicine 25 How to find us

Contact Details Clinical Team Manager Yorkshire Centre for Psychological Medicine Brotherton Wing Leeds General Infirmary Great George Street Leeds. LS1 3EX

Telephone: 0113 39 27140 Website: www.leedsandyorkpft.nhs.uk (click “Our services” and then “Yorkshire Centre for Psychological Medicine”)

To find the YCPM enter Leeds General Infirmary at the Street entrance, which is directly opposite Millennium Square. YCPM is situated on the ground floor immediately to your left.

Map: For a useful map go to ‘Google Maps’ and search for our postocde (LS1 3EX)

Patient feedback “I found the unit warm and welcoming and staff made me feel comfortable at a stressful time”.

All flower photographs in this brochure have been provided by the YCPM Horticulture Group

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