Dr Rebecca Jacob. CLAHRC Fellow 2012

Rebecca Jacob_1Rebecca Jacob is a consultant general adult psychiatrist, a joint undergraduate tutor of the Cambridge medical student rotation and Chair of the Cambridge Consultant Psychiatrist Advisory Forum.  Her research interests include medico-legal aspects of psychiatry, an area in which she has published and lectured.  She has obtained an MPhil in Medical Law in 2009 and is on the East of England Section 12 Approval Panel.  She lectures on the regional Section 12 and Approved Clinician courses.Rebecca has a special interest and Royal College of Psychiatrists accreditation in the field of Liaison Psychiatry and her CLAHRC Fellowship project relates to designing and evaluating a pathway of care for Medically Unexplained Symptoms, a clinical area which is still underdeveloped and of significant interest to service users, clinicians and commissioners alike.

Project title: Identifying Medically Unexplained Symptoms among Frequent Attenders to the Emergency Department: Research to inform Service Design 

Rebecca’s chosen project continued the work begun by Mai Luen in the previous CLAHRC cohort.

In February 2013, Rebecca and Mai Luen Wong made a joint poster and had it accepted at RCPsych Annual Liaison Psychiatry Conference.

Abstract: A service design approach to frequent attendance in the emergency department

Drs Mai Luen Wong, Rebecca Jacob and Cecily Morrison, NIHR CLAHRC for Cambridgeshire & Peterborough, Cambridgeshire & Peterborough NHS Foundation Trust, Cambridge University Hospitals NHS Foundation Trust, Cambridge Engineering Design Centre

The aims

Frequent attenders (FAs) to emergency departments (ED) draws interest from multiple stakeholders with attempts to reduce attendance because of beliefs that use is inappropriate.  Design methods help deconstruct this heterogeneous group to avoid the trap of an “elastic user” service that serves no one.
A working group set-up to tackle the issue of unmet mental health (MH) needs contributing to ED FAs prompted this two-stage project to inform service design.


Project 1 was a service evaluation project that anonymised and analysed extracted data from the Addenbrookes ED electronic registration system from January 1st 2003 to December 31st 2010.  Specialist clinical knowledge, local data and design concepts were applied to develop MH personas.

Project 2 involved a case note review of 100 consecutive FAs in a 12-month period with the MH personas in mind.


97% of attendances were by moderate FAs (MFA) who attend <20 times/year with more urgent and severe complaints, often requiring admission.  Only 3% of attendances were by extreme FAs (EFA) who attend >20 times/year with less urgent and severe complaints. Two MFA and one EFA MH related personas were developed and included the MFA persona with medically unexplained symptoms (MUS).

Project 2 confirmed the MFA-MUS persona (p<0.001) with 45% of MFAs with an established MUS diagnosis, attending more than 1 specialist clinic.  91% of this group continued to have multiple invasive procedures. Only 4% had specific input for their MUS.


The most common stereotyped image of a FA is the EFA but local data supports the MFA as the most likely group causing the greatest impact on our ED. The high MFA-MUS link suggests the ED may be an important entry point for MUS patients. Designing a service with the above in mind is likely to give the greatest returns to investment.


In May 2013, Rebecca and colleagues’ submission “Identifying Medically Unexplained Symptoms amongst Frequent Attenders Presenting to the Emergency Department to inform service design:” was accepted as a poster at the 1st Annual Scientific Meeting of The European Association of Psychosomatic Medicine on July 5th in Cambridge.


Dr Rebecca Jacob*, Consultant Psychiatrist and CLAHRC Fellow, Cambridge and Peterborough NHS Foundation Trust,

Dr Catherine Hayhurst, Consultant in Emergency Medicine, Cambridge University Hospitals NHS Foundation Trust,

Dr Peter Watson, Senior Statistician, MRC Cognition and Brain Sciences Unit, University of Cambridge

Dr Cecily Morrison, Research Associate, Engineering Design Centre, Engineering Department, University of Cambridge



Frequent attendance (FA) to emergency departments (ED) has drawn interest from healthcare providers, researchers and policy makers. Studies show FA’s include those with medically unexplained symptoms (MUS), defined as physical symptoms, which are not/ inadequately explained by somatic disease, posing a high cost to health care services.  This project characterises the needs of FA’s, with emphasis on patients with MUS.


Using IT methods to flag FA’s, a case note review of 100 consecutive patients attending 5 or more times/year was conducted. The review included: demographic details, diagnoses, frequency, reasons for attendances, specialist outpatient appointments, invasive tests, service provision and at least one mention of a clinical impression of MUS.  


Forty-five % (45/100) had a clinical diagnosis of MUS. Whilst a proportion of MUS patients were under secondary mental health services only 2 patients actually received specialist support for MUS. Mean age of patients with MUS was 36.8 years and 87% (39/45) were less than 65 years; MUS was associated significantly with younger age (p<0.001) but not with gender (p>0.05). Frequency of attendances was not significantly different for those with/out MUS, however MUS was largely represented by ‘Moderate Frequent Attenders’ (p<0.001), attending ED >5 and < 20 /year.


ED is a useful hub for identifying and signposting FA’s with MUS to specialist psychiatric services. The majority of FA’s with MUS were of working age and of ‘Moderate Frequent Attenders’ category. Designing a care pathway for this group will most likely encompass the target population.