The poor health outcomes of people with co-existing mental and physical conditions represent one of the greatest inequalities in health. Mental illness is involved in one in three avoidable deaths every year, while people with severe mental illness die on average 20 years earlier than the rest of the population – a situation described as lethal discrimination by Rethink. Significantly higher incidences of diabetes and hypertension, along with poor outcomes from coronary heart disease and respiratory disease in people with mental health problems, all contribute to these figures. Furthermore, a report by the Royal College of Physicians found that those tasked with their care often lack the basic skills to manage general physical health and good integrated care remains the exception rather than the rule.
The link between poor physical health, mental illness and mortality is not new and was made as far back as 1991 in a Canadian study by Newman and Bland. Despite numerous recommendations since then on how to tackle the issue, implementation has been poor or limited. Take, for example, the recommendation that routine physical health checks should be undertaken to monitor cardiovascular risk in people with schizophrenia. This formed part of the original NICE guidelines for schizophrenia in 2006 but, due to lack of implementation, is reiterated again in the recommendations of the Schizophrenia Commission in 2012. Given the strength of evidence presented by expert groups the question remains, why is implementation so slow?
The answer may lie in the wider policy arena, where the focus has been less on individual solutions and more on the infrastructure that underpins inequality. Issues such as underinvestment in mental health and a lack of integration with physical health services have received particular attention – both issues that the HSJ survey respondents focus on. These calls have not gone unheard, as evidenced by the prioritisation of mental health in our forthcoming survey of health and wellbeing boards, and government proposals to support commissioning for parity, but will this deliver realisable change by March 2015? Wide scale reconfiguration is unrealistic in that time, and in the current economic climate, a rebalancing of funds between acute and mental health provision is highly unlikely.
Perhaps this is missing the point. Opening the Mental and Physical Health: one agenda conference, Norman Lamb clarified that ‘this is not about organisational change but a model of care shaped around the needs of patients’, and there are many examples of how this can be and is being achieved.
Implementation of best practice would be a good place to start. For example, effective monitoring and management of medication and attention to diagnostic overshadowing could help practitioners to improve the identification and management of physical health problems. The adoption of smoke-free policies by mental health services can have a measurable impact on both the physical and mental health of patients with no deleterious effects on patient management. Finally, projects such as the IMPARTS study demonstrate how building collaboration between acute and mental health trusts in order to share expertise, skills and information can facilitate more integrated models of care.
What is clear from a growing number of examples is that leadership at a local level can bring about substantial progress in improving the health of people with co-existing conditions, often with little or no requirement for additional resources. While the calls for adequate funding of mental health and new models of commissioning should not be abandoned, they can no longer be allowed to dominate the agenda.
Professionals and providers need to take responsibility for what they can individually do and become accountable for action. This challenge represents a unique opportunity to start reversing the historical disparity in outcomes between mental and physical health services. Unless we act now, it is likely we will be faced with this shameful failure in care for patients once again in 2015.