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Psychological Therapies
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Summary
This paper considers cutting edge research which shows that psychodynamic interventions for
people with Personality Disorder (PD) and Medically Unexplained Symptoms (MUS) have the
potential to save millions of pounds for the NHS. It focuses on two separate ongoing projects - the
Devon Personality Disorder Service Pilot and the Birmingham Medically Unexplained Symptoms
Project.
Key Points
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The Devon Personality Disorder Service Pilot has used psychodynamic interventions to treat
people with severe and complex PD. Patients have been provided with a care pathway
which costs a maximum of £76,200 per patient per year and has led to significantly
improved health outcomes and patients living successfully in the community. If these
patients had not been in the pilot, they would have been in locked specialist PD units
costing £200,000 per person per year. Therefore the pilot shows that well over £100,000
can be saved per patient with severe and complex PD per year.
The Royal College of Psychiatrists and the Royal College of GPs have recently formed a
working group looking into building on the Devon PD Service research nationally.
The Devon PD Service Project also has significant implications for treatment of people with
MUS. The service assessed the top 55 people reporting at the Devon and Exeter Hospital
with MUS and found 47 of them having Attachment Disorder and PD. A pilot is required to
look at effect of psychodynamic treatment and a care pathway on people with MUS.
The Birmingham Medically Unexplained Symptoms Project is a whole system redesign of
primary care, acute care and specialist mental health care for people with MUS. People
with MUS are offered psychodynamic interpersonal therapy and, to a much lesser extent,
cognitive behavioural therapy. Evaluation of phase 1 of the project has shown improved
patient symptoms and reduced secondary healthcare costs by an average of £841 per
patient per year.
The MUS project is shortly to be expanded to a larger population.
1) The Devon Personality Disorder Service Project
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Personality Disorder is prevalent in 10 – 13% of the general population. It accounts for 29%
of GP attendances, 36 – 67% of psychiatric inpatients and 30% of community mental health
caseloads (National Institute for Mental Health in England 2003). Most people with PD do
not present with complex or severe symptoms but a significant minority have psychotic
symptoms, mood disorder, eating disorders, substance misuse and child protection risks.
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PD arises from attachment and parenting problems. People with PD find relationships with
other people stressful and relationships typically worsen their symptoms.
Unless therapeutically managed, contact with services actually worsens symptoms for
people with PD – and adds considerable costs.
Availability of local PD services is patchy and usually absent.
The Devon Personality Disorder Service recently undertook a 3 year pilot, beginning in
2011, using an intensive psychodynamic treatment programme to help people with severe
and complex Personality Disorder.
Patients in the pilot have a local PD service and therapeutic care pathway funded by money
saved from out of area placements they would otherwise have had. This allows for £1.1
million to be invested in the local PD service and care pathway each year.
The PD Service commissions beds from local supported housing providers for its patients
and provides:
 a psychodynamic day programme for 6 months. This helps 16 patients per
year
 a psychodynamic outpatient therapy programme for 2 ½ years. This helps
28 patients
 other evidence-based therapies – family, mentalisation-based, dialecticalbehaviour, cognitive analytic
 training, consultation and supervision to Mental Health professionals across
the Devon Partnership NHS Trust (in which the PD Service pilot was based).
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In mental health, high risk complex patients – including with severe and complex PD – are
placed in locked specialist PD units – typically costing around £200,000 per year. With no
care pathway, placements can last for years. Patients in the pilot would be in these units
were they not in the pilot.
The costs of each patient in the trial vary according to the needs of each patient but an
average figure for the maximum cost of each patient in the first year of the trial is £76,200.
In practice, however, many patients cost less than this sum in the first year of the trial.
Patients in the trial have cost on average well over £100,000 less than if they had not been
in the trial.
All patients have also cost less year on year as the trial has continued.
In the past 3 years, the PD Service has brought 19 patients in locked placements back to the
community in Devon. It has also diverted 17 patients from placements in locked units.
Attempts were made to repatriate a further 15 patients who were not yet ready to return.
The below chart provides a visual idea of the cost of not providing a psychodynamic
treatment programme / care pathway like the project delivered. Each number stands for a
different patient the PD service is not working with yet or failed to engage with. The bars
represent the costs of each individual patient’s placement budgets. The chart is ranked in
order of the most expensive patient (number 1) down to the cheapest patient (number 22).
All these patients remain in placement, have discharged themselves from services, or –
tragically - have committed suicide.
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£900,000.00
£800,000.00
£700,000.00
£600,000.00
£500,000.00
£400,000.00
£300,000.00
£200,000.00
£100,000.00
£0.00
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2021 22
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By contrast, a second chart – below - shows what a difference psychodynamic interventions
make to the costs associated with patients with PD. This chart looks at patients who were in
the pilot and shows how much patients cost before and after psychodynamic intervention.
Each number corresponds with one of the patients involved in the pilot – patient 1, patient
2, and so on. The blue bars identify costs before psychodynamic interventions. The orange
bars identify costs after psychodynamic interventions. Please note that patients 20 to 24 did
not have out of area placements before the pilot but were offered local alternatives. Unlike
the PD patients mentioned above who were not in the pilot, patients in the pilot are now
living successfully in the community and engaged in therapeutic work.
£800,000.00
£700,000.00
Total Cost before
PD intervention
£600,000.00
£500,000.00
£400,000.00
Total Cost after PD
intervention
£300,000.00
£200,000.00
£100,000.00
£0.00
1
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3
5
7
9 11 13 15 17 19 21 23
The pilot has been followed with considerable interest by the Royal College of Psychiatrists
and by the Royal College of GPs. These 2 Royal Colleges have recently formed a working
group looking into building on the Devon PD Service research nationally.
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Personality Disorder Service implications for people with Medically Unexplained Symptoms
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The Devon PD Service has also uncovered significant implications for treatment of people
with medically unexplained symptoms (MUS). The service assessed the top 55 people
reporting with MUS at the Devon and Exeter Hospital and found 47 of them have
Attachment Disorder and PD. These 55 people are the most frequent users of the Devon
and Exeter Hospital – presenting primarily with physical health problems – and the
estimated lifetime cost of these 55 patients to the NHS is £6.2 million.
The Devon PD Service is looking into doing another pilot – with the above 47 people with
MUS assessed as having Attachment Disorder and PD. Such a pilot is required to look at
effect of psychodynamic treatment and a care pathway on people with MUS. The British
Psychoanalytic Council is following this with great interest – the implications of such a pilot,
if successful, could be enormous both in terms of improved health outcomes for people
with MUS and in terms of savings for the NHS.
The Birmingham Medically Unexplained Symptoms (MUS) Project
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Medically unexplained symptoms (MUS) are common health problems which can cause
significant distress and disability.
They account for 11% of the NHS budget (Bermingham, S.L., Cohen, A., Hague, J., Parsonage,
M. (2010). The cost of somatisation among the working-age population in England for the
year 2008 – 2009. Mental health in family medicine 7: 71 – 84)
People with MUS can be stressful for healthcare staff and are neglected in medical education.
The Department of Health has called on NHS commissioners to develop services for patients
with MUS.
People with severe MUS have physical health problems rooted in psychological problems and
are typically the most frequent attenders of hospitals - presenting repeatedly with physical
problems – as with the above example of the 55 most frequent attenders of the Royal Devon
and Exeter Hospital. Symptoms typically worsen the more care someone with severe MUS
receives.
The Birmingham Medically Unexplained Symptoms Project is a partnership between
Birmingham & Solihull Mental Health Foundation Trust, Karis Medical Centre (a GP practice),
Sandwell & City Hospital Trust, and NHS Birmingham South Central Clinical Commissioning
Group.
The Project is a whole system redesign of primary care, acute care and specialist mental
health care for people with MUS. Birmingham’s Specialist Psychotherapies Service and Rapid,
Assessment, Interface and Discharge (RAID) Liaison Psychiatry Service provide medical
training, advice to doctors and psychological therapies.
Evaluation of the first phase of the MUS Project has shown that:
 GPs and acute care doctors have felt supported by the Project
 Patients have reported improved symptoms and positive experiences of care
 Secondary healthcare costs have been significantly reduced - by an average
of £841 per patient per year.
Regional funding has now been secured to expand Birmingham’s MUS project to a larger
population.
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