title: The choking woman.
abstract: BACKGROUND
  There is a small, but significant cohort of patients that receives inappropriate care, in the wrong setting, and that utilises a disproportionate amount of healthcare resources. People with multiple co-morbidities and often-undetected mental illness fare better with integrated care and case management approaches.
  
  
  METHODS
  In North West London, we have been working in the 'Integrated Care Programme' for four years to try to improve the care this cohort receives.
  
  
  OBJECTIVE
  Can psychiatric intervention with case management improve outcomes for this cohort?
  
  
  METHODS
  We describe the case of a 64-year-old woman who presented at an Emergency Department (ED) with functional dysphagia 25 times in the space of eight weeks. During that time, she was referred to numerous specialists, and had multiple invasive investigations even though her symptoms were not suggestive of organic pathology, and were in fact suggestive of anxiety.
  
  
  RESULTS
  Her pre- and peri-psychiatric intervention healthcare costs were, on average, £3330/month. These reduced to an average of £276/month after three months of psychiatric intervention.
  
  
  CONCLUSIONS
  We reflect on the possible reasons why the story unfolded in the way it did and suggest generalised implications for clinicians caring for this cohort and for service delivery in future.
authors.affiliation: Consultant Liaison Psychiatrist, West London Mental Health Trust, London, UK; Co-chair, South Fulham Multidisciplinary Group, London, UK.
authors.forename: Amrit
authors.initials: A
authors.lastname: Sachar
authors.affiliation: Foundation Year 1 Doctor, Colchester Hospital University Hospital NHS Foundation Trust, UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Stimson
keywords: fragmented care; healthcare utilisation; integrated care; mental health; somatisation