By Preety Das
Bringing together physical and mental health - A new frontier for integrated care
By Preety Das
For my first rotation on the Imperial GP Specialty Training scheme, I was excited by the opportunity to apply for an Innovative Training Post (ITP). ITPs in this scheme comprise a split post between general practice and a dynamic range of portfolio options. With a keen interest in public health and research, I was fortunate to be selected by my first choice post at the King’s Fund. Originally set up by Dr. Martin Block (Imperial VTS Programme Director), this post provides a unique platform for trainees to understand the wider picture and engage with healthcare policy. I decided to fully immerse myself in a range of projects over the six months that followed, to include: qualitative and quantitative research, departmental presentations, blog writing and event chairing. Launched recently at the Fund, I summarise below key findings from our report, entitled, ‘Bringing together physical and mental health: A new frontier for integrated care’ (http://goo.gl/ZmULcS). The report was accompanied by an editorial in The Lancet Psychiatry, highlighting its recommendations for transforming aspiration into practice (http://goo.gl/WOINq8).
Integrated care initiatives in England and elsewhere have paid insufficient attention to the relationship between physical and mental health. Our report draws on a review of published research evidence, qualitative interviews and focus groups with service users and carers, and case studies of ten services in England. We conclude by arguing that overcoming the longstanding barriers to integration of mental and physical health should be a central component of efforts to develop new models of care that bring together resources from across local health systems.
The case for seeking to support physical and mental health in a more integrated way is compelling, and is based on four related challenges: 1) high rates of mental health conditions among people with long-term physical health problems 2) poor management of ‘medically unexplained symptoms’, which lack an identifiable organic cause 3) reduced life expectancy among people with the most severe forms of mental illness, largely attributable to poor physical health 4) limited support for the wider psychological aspects of physical health and illness. Collectively, these issues increase the cost of providing services, perpetuate inequalities in health outcomes, and mean that care is less effective than it could be. The first two issues alone cost the NHS in England more than £11 billion annually.
Examples of innovative service models described in the report demonstrate that there are opportunities to redesign care in ways that could improve outcomes and may also be highly cost effective. These include various forms of enhanced support in primary care, integrated community or neighbourhood teams, comprehensive liaison mental health services, physical health liaison within mental health services, and integrated perinatal mental health care.
All health and care professionals have a part to play in delivering closer integration. Our research with service users and carers highlights the importance of professionals being willing and able to take a ‘whole person’ perspective, and having the necessary skills to do so. Integrated service models can support this by facilitating skills transfer and shifting notions of who is responsible for what. Equally, a great deal of improvement is possible within existing service structures. New approaches to training and development are needed to create a workforce able to support integration of mental and physical health. This has significant implications for professional education; all educational curricula need to have a sufficient common foundation in both physical and mental health.
My involvement in this project provided a unique opportunity to relate everyday clinical practice to the range of barriers that have prevented wider adoption of integrated approaches. These include: separate budgets and payment systems for physical and mental health; the challenge of measuring outcomes and demonstrating value; and cultural barriers between organisations or groups of professionals. The report describes several enabling factors and practical lessons, including the value of having a board-level champion for physical health in mental health trusts, and vice versa. New payment systems and contracting approaches offer commissioners various options for overcoming some of the financial barriers.
In recent years there has been a welcome focus in national policy on achieving ‘parity of esteem’ for mental health. Colloquially, this phrase has often been interpreted to mean that mental health services should be ‘as good as’ services for physical health. We argue that there is a greater prize beyond this, in which mental health care is not only ‘as good as’ but is delivered ‘as part of ’ an integrated approach to health.