Minutes of the Exeter Sessional Gps Group

Minutes of the Exeter Sessional GPs Group

at Darts Farm – 1 February 2011

The meeting was kindly sponsored by:

Fiona Jones Pfizer

Abby Tregelles Pfizer

Wioleta Wagstaff Pfizer

Attendance: 42 members

Welcome:

Hamish Duncan opened the meeting by thanking the reps for sponsoring. He reminded members to sign the attendance register.

The website is now up and running at http://www.devonsessionalgps.co.uk/ and all relevant information will be posted including meeting minutes. In the meantime Emma Green recently sent out an e mail with numerous attachments regarding upcoming meetings, a couple of initiatives to try to decrease the need for hospital admission and a locum opportunity. In future the plan is that all that information and more will be on the website.

Hamish welcomed Dr Mike Jefferys Consultant Physician, Dr Sean Lynch Consultant Psychiatrist as well as Dawn, Helga and Jess occupational therapists and also the co-ordinator for the Exeter Chronic Fatigue Syndrome service.

Chronic Fatigue Syndrome Service in Exeter

Dr Mike Jefferys

A multi-disciplinary team.

From 2005 has settled at about 150 patients per year – less the first year when first introduced, more the second once people became aware of it and there was a “backlog” of patients, then fairly steady. Was set up as there was a realisation that these patients needed specialist care but were not fitting well into any service previously available.

Initial assessment is 60-90 minutes.

Definition: fatigue:

·  New or had specific onset

·  Persistent

·  Unexplained

·  Causes significant reduction in activity level

·  Characterised by post exertional malaise or fatigue

Patients have often sought other avenues of management previously so they have expectations related to thyroid, mitochondrial metabolism etc. and these need to be discussed so that they do not continue with unrealistic ideas picked up from elsewhere.

Investigations usefully done before referral:

FBC, biochemistry, TFT, inflammatory markers, ferritin in young people, celiac screen, autoimmune profile if warranted. Best to put results in the letter as the clinic is held at an outpost in Whipton so not easy to access hospital computer.

Mimics:

·  Neurological e.g. multisystem atrophy, autonomic failure, myasthenia gravis, multiple sclerosis.

·  Endocrine e.g. Addisons, thyroid disease, pituitary tumours.

·  Sleep apnoea

·  Malignancy – especially renal cell cancers

·  Psychological e.g. depression, somatisation.

Role of the physician:

·  Medical filter

·  Affirm diagnosis

·  Help with symptom control including optimising management of co-existing pathology including diabetes, COPD.

Dawn

OT with physical and mental health background. Reminded us that the total therapist input is only marginally over one full time equivalent – all are part time for the chronic fatigue service.

Management in line with NICE guidelines:

·  CBT

·  Graded exercise

·  Effective rest

·  Grading and pacing

Given choice of group or individual guided self help – for mild only.

Patients learn effective rest and relaxation principles.

8 sessions run fortnightly – gap between sessions is important to allow practising skills.

Each session lasts 2 hours but there is a break in the middle.

Individual goal setting and a three month review after the course to continue further goal setting. Usually discharged at that stage.

Severe cases need initial home assessment – done by a consultant and Jess. Those with co-morbid mental health problems also seen at home. Joint working with re-ablement team and mental health team.

Web site is being developed on infopoint with protocol and how to refer.

A local support group due to start:

·  To start April 2011.

·  Initiated by group of patients with chronic fatigue syndrome.

·  Not NHS provision but providing help until established.

·  Network for carers, family and friends.

·  Emotional support.

·  Meet monthly at Jurys Inn.

·  Provide support and awareness of ME and raise profile of the condition.

·  Website is planned.

Helga

OT and yoga teacher

Works mainly around advising effective rest and relaxation.

·  First treatment of group programme.

·  Ongoing throughout programme.

·  Paradox explained – perspective change – get away from the boom then bust cycle where rest imposed by exhaustion to planned activity and rest.

·  Evidence based.

·  Mind – body connection.

·  Participants expected to practice – positive planning of rest periods.

Techniques:

·  Resting postures

·  Gentle movement series

·  Correct breathing

·  Deep relaxation

·  Sensory awareness / mindfulness

·  Visualisation

·  Positive memory bank

Home practice:

·  Place / length / time / frequency

·  No “BUTS”

·  Effective rest and relaxation to prevent boom / bust

·  Effective rest and relaxation to initiate change

·  Effective rest and relaxation to nourish oneself

·  Feel good factor deserved

We did a practice 5 minutes with Helga leading – sitting in resting position, concentrating on different parts of the body, listening for sounds and concentrating on breathing.

Jess

Chronic fatigue syndrome programme:

·  CBT approach meeting fortnightly for 2 hours.

·  Participants use time between sessions to gain confidence.

·  Self management strategies then to share experiences with group.

·  Seven sessions in group then one individual with OT and a three month review.

First half of group programme focuses on identifying existing habits and routines that help or hinder management of fatigue and provides practical tools.

·  Concepts – avoid boom and bust i.e. over activity and excessive rest cycle.

·  Involve mind activity as well as physical activity.

Tools:

·  Effective rest and relaxation.

·  Decrease demands – prioritise and delegate.

·  Set baseline and avoid boom and bust.

·  Improve supply of energy – diet, sleep, relaxation, pleasure.

·  Grading activity – setting the challenge according to time, distance and complexity.

·  Mix and match – physical and cognitive activity.

·  Use of activity diaries and 1:1 therapy session – look at work, self care and leisure.

·  Use visual analogies – e.g. pillars of rest supporting planned activity, jug of life – some things give and some things take from it, human battery.

Second half of group programme – cognitive component

·  Stress and assertiveness.

·  Explore response to stress and how to overcome it.

·  Assertiveness – encourage to identify own needs, say no where appropriate to avoid passive to aggressive swing.

·  Goal setting and stages of change – SMART goals, graded exercise, Kubler Ross change curve.

·  A change questionnaire is given out at the end of the programme.

Guided self-help

·  Time limited due to pressures on the service.

·  Self management material.

·  Sessions look at barriers to change and consolidate on principles explained in the manual.

·  Complex cases need onward referral.

Severe chronic fatigue syndrome

·  House or bed bound.

·  In depth functional assessment.

·  Cognitive difficulty, carer stress, isolation, usually do not have pre-existing care in place, falls, manual handling issues, tend to overdose on vitamins, avoid sensory stimulation, nutritional issues.

·  Provision of equipment and social services.

·  Explore illness perception and motivation to engage.

·  CBT.

·  Goals established and reviewed.

·  Monthly team meetings.

Dr Sean Lynch

Symptom clusters – fatigue, decreased energy, pain, muscular, sleep disturbance etc. overlapping with somatoform issues.

Risk of associated psychological distress increases with increase in somatic symptoms.

Diagnostic overlapping – e.g. chronic fatigue, fibromyalgia, irritable bowel.

In chronic fatigue syndrome:

·  Fatigue is principal complaint.

·  Fatigue of definite onset.

·  Fatigue of certain duration (generally over 6 months).

·  Fatigue is functionally disabling.

·  Fatigue is not relieved by rest.

·  Post exercise myalgia.

·  Cognitive changes.

·  Somatic complaints.

Outcome improved if shorter duration of symptoms.. CBT and graded exercise might improve the prognosis over time.

Psychological therapy modules:

·  CBT – many trials but models vary.

·  Other cognitive models not well studied.

·  Interpersonal therapy (IPT).

·  Psychodynamic therapy.

·  Neuro linguistic programming (NLP)?

Psychiatric co-morbidity very common – e.g. 25-50% or even more have depression.

Psychiatrist as diagnostic goal keeper.

Dilemma of case definition.

Patients need several sessions to be persuaded of a label different from what they want / think is their label – there is a problem of potential loss of engagement with the patient.

Housekeeping

Emma thanked the whole team for the talk.

Future ESGPG Meetings

Tuesday 1st March 2011 – Hazel Curtis – Community paediatrics and child development

Tuesday 5th April 2011 – Jane Whitehurst – Hospice update and symptom control

Tuesday 3rd May 2011 – Michael Gibbons – Pulmonary fibrosis and new COPD guidelines

Meeting time

Please note that the meetings are now scheduled to start at 7pm with the guest speaker planned to commence at 7.30pm.

Committee Contacts

Dr Hamish Duncan (chairman and LMC link)

Dr Diane Baker (appraisal support co-ordinator)

Dr Emma Green (educational co-ordinator)

Dr Katherine Wood (funding co-ordinator)

Dr Caroline Burton (treasurer)

Dr Kathryn Shore (minutes secretary)

Dr Clair Homeyard (social secretary)

Dr Francesca Vasquez (social secretary)

Megan James (LMC link)