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.
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