Achieving equitable outcomes between mental and physical health: how can we make change happen?

At a recent event on Transforming mental health in London, held at The King’s Fund, Geraldine Strathdee, NHS England’s National Clinical Director for Mental Health, identified achieving parity of esteem between physical and mental health services as a national priority. She was of course referring to the NHS Mandate that there should be measurable progress towards achieving this parity by 2015. However, a recent survey of practitioners, providers and commissioners conducted on behalf of the Health Service Journal (HSJ) concluded that, while attitudes within the NHS are in keeping with parity, practice is ‘not even close’. What needs to happen to change this?

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. 

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Comments

#40990 Syril Derage
Primary Care Plus Practitoner
West London Mental Health NHS Trust

I undertook a post in 2003 as Development Dul Diagnosis Practitioner at South London ST Georges MH NHS Trust. I subsequently attended a residential course coordinated and chaired by Professor Andre Tylee--Project: "TRAILBLAZERS". This wa saim to look beyound Dual Diagnosis and to also consider physical health of service user with dual diagnosis in primary care setting.
Hence the modality of care that you are suggesting has been thought before but due to financial limitation and lack of integrated startegies this was not possible to follow through.
I feel tha currently I am back in a clinical setting that can initiate the above startegy but this has to be agreed between commissioners and include latter modality in there operational policies.
I was an active member who implement the Good Practice Guide In Dual Diagnosis 2002 as a DNP IN DD at Kingston CDAT where the latter was initaited. Should you need my help and expertise in latter startegy I will be too happy to offer my assistance.

#40994 Kate Woodhouse
Freelance

On the one hand, all health workers need to understand psychological aspects, as both cause and effect of physical disease. On the other hand, mental health workers need to understand physical illness as cause and effect of psychological distress. But how do we join these two hands which are not in reality separate?

#40995 Vijay Bhatia
Higher specialist trainee in psychiatry
KMPT

There is ample evidence that mental health is highly associated with physical health issues not only by its nature but as side effects of the medications used to manage mental health problems.
This blog is asking an important question that how can we achieve parity. My experience would suggest following changes.
1. The mental health practitioners should be able to access the medical notes from the general hospital, general practitioners and visa versa. Many of my clients who have mental health problems also have a number of physical health problems. Many times these clients have been on certain medications that can interact with medications for treating mental health issues, these has been stopped, dose changed and some clients been admitted to general hospital without the mental health professionals being aware of these. By nature and severity of the mental health problems these clients are not able to give all the information. I suggest that mental health practitioner if I have access to the blood test reports, up to date physical conditions and their visits to GP, hospital, X ray imaging reports I should be able to make a better judgement and understanding of the physical health monitoring. Similarly the primary care and general hospital practitioners should be able to access the mental health notes.
2. The mental health practitioners and general practitioners have to work in close collaboration. One responsible person takes the responsibility for monitoring the health issues. At present the mental health practitioners do not feel competent enough to monitor all the medical issues faced by the mental health patients and the general practitioners do not feel the responsibility or competency to monitor all the side effects, physical problems of the mental health problems.
I had personal experience where my elderly clients were admitted to the general hospital and we were not aware of their admission and we even sent letters for out patient appointment on the days they were inpatient either as an emergency or routine. Some clients or their carer were astonished to know that we as mental health professionals are unaware of our own clients.
Sometimes I feel frustrated that I do not have all the medical information I need to manage the mental health issues of my clients. Many times we spend long hours calling the general practitioners to get hold of the medical summaries, updated medication lists, allergies and it is very hard in late hours and emergency when we need this information.
3. I have experience that general medical staff at the general hospital do not take very seriously the mental health issues. The moment they find out that client has a history of mental health they tend to undermine the medical issues.
I wonder if other practitioners feel the same.

#41002 george coxon
various inc MHNA national chair, MH specialist advisor Nursing in Practice
MHNA - mental health nurse association

I am just back from presenting at a European conference in Istanbul where together with an MHNA colleague we also led a workshop with a group of MHNs from across Europe on this very issue - amongst the valuable and transferable ideas we shared was the recognition that 2 of the greatest challenges in addressing these issues are.... 1) the life expectancy gap theme for people with MH problems who live up to (and in some cases beyond) 20 yrs less when living with a long term MH problem - mainly due to the treatment consequences not least the increased risk of metabolic syndrome risk and associated CV diseases and ... 2) the challenge of 'reaching the hard to reach' of those receiving long term MH treatment are people who often tend to disengage from support and the disconnect between primary, secondary and specialist MH services loses some of the most vulnerable people in our society. I am an advocate of a more seamless, multi skilled, proactive type of 'virtual ward' style of MH assertive care including annual MOTs for people on long term MH treatments, access to better profile medications and even planned admissions for the so called 'frequent flyer' patients prone to chaotic life styles- high levels of self neglect and early mortality risk. I may be perhaps forgiven for recommending that this approach be a MH nurse led service model !! we are well placed to build a robust business case with commissioners and ensure impact and positive outcomes that are cost and clinically effective - I would be interested in further exchanges on these ideas and this theme - thank you for the excellent blog Helen

#41006 Sheila Hardy
Education Fellow
University College London Partners

Nurses deliver most of the care in the NHS and it is vital that they receive the right education and support. Additionally more than 90% of mental health problems are dealt with in primary care. We are currently developing a train the trainers education package where mental health nurses educate the practice nurses in their area about mental health and wellbeing. This brings primary and secondary care clinicians together and provides ongoing communication. It is anticipated that we will also do the reverse in that practice nurses will train mental health nurses about physical health.

#41014 Jacquie White
Senior Lecturer
Faculty of Health and Social Care, University of Hull

Mental health nurses are positive about delivering both physical health and medicines management interventions as part of their role but complain of a system that does not support them and has only just started to recognise how important skills, knowledge and a system to support this is. There are many examples of good practice across the UK where mental health nurses are delivering health checks in secondary care using the serious mental illness Health Improvement Profile [HIP] or an adapted HIP to support their confidence and competence. This works well in adult acute and rehabilitation inpatient areas where it is integrated into the patient record system and care pathway and is commissioned as part of a CQUIN target. In community mental health teams, radical redesign of services has been taking place including the abandonment of assertive outreach teams in many areas and organisation of teams around payment by results and care clustering. The result seems to be less time to deliver interventions to people who are not in crisis, people only remaining on case loads for the shortest possible time with less opportunity for screening and (importantly) interventions. I believe this, along with stigma (diagnostic overshadowing and a society that continues to see the person with serious mental illness as someone who has less value) and NHS information systems that fail to communicate across the primary-secondary care interface is why people with serious mental illness are continuing to die of cardiovascular disease. If you die of an atheroma aged 40 while under the care of a community mental health team, unless the family pushes for answers there is not even an investigation to learn lessons as this is considered a death by 'natural causes'. If you die of suicide, this would be investigated in an attempt to learn lessons. I think the solution is that mental health services and commissioners need to start to seriously consider if what they provide has a positive impact on all health outcomes, an investment in primary care mental health services (placing community mental health teams and staff into primary health care centres works well as it supports integrated working) and a further attempts to address the legacy of developing IT and services in silos.

#41018 Sarah Pierpoint

As someone with a degenerative physical health condition and a co-existing mental health disorder I waould like to throw in my pennyworth.
Firstly, as long as the NHS continues to see these conditions in the paradigm of the medical model nothing will move. It is a reductionist approach that creates an artificial separation of mind and body and all traing , all policy and all funding supports this paradigm. Look at Payment By Results, look at Clustering in Mental Health.

As far as mantal health practitioners having automatic access to othe medical records I cant think of anythng worse. In the field of Mental Health there appears to be zero unserstanding of confidentiality with an ingrained idea that if someone has a mental health condition then suddenly their rights not to share infomation disappear. No they don't - there are actually very few legal grounds to legitimately share information without consent and they are clearly defined. And in mental health regularly breached. Until the culture changes then why would they be trusted with this information - the opportunity to futher breach condidentiality is then extended.

Health professionals are not the experts in my conditions- I am. Health professionals are a resource , a support to help me make informed decisions. Including poor decisions. I will share on a need to know basis but can think of few occasions why I would. Ditto with Social Care. They need to know how to support my own defined needs not my extensive - and irrelevant - medical history.

So currently you have a system with different paradigms, a medical model versus a social model of disability, a complete lack of knowledge of confidentiality in action and a belief that every one is an expert except for the individual concerned. And you only need one incident from the patient's point of view for all trust to be eradicated.

So can't see why there would be change. I have been active in my own care needs from the get go and have ensured that I opt out of sharing and have challenged the multiple breaches in confidentiality. But being active and defining your own needs is unheard of in healthcare and in mental health while there are multiple processes and forms etc etc it is still done from the paternalistic'we know best' position

#42412 Martin
Consultant
Solar Blue Partnership

As an off and on user of mental health services both private and NHS for over 30 years. I agree a basic starting point is to understand the interaction between mind and body. I for one led a very strange and unnecessarily exotic life until I established those connections.
But in my experience the NHS is technologically incapable of maintaining joined up records.
That is the big Ask, But which government is fit to the purpose of managing cost effectively such a gargantuan task. Could we ask Google, Amazon and Facebook to help in lieu of their limited tax contribution. Damn I am back in politics which is the bete noire of this debate.

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