5. Improving the management of patients with both mental and physical health needs

What is it?

Developing a more integrated response to people with both mental and physical health problems, in particular supporting people with common mental health problems (such as, depression or anxiety) alongside a physical long-term condition.

Why is it important?

• Around 30 per cent of people attending general practice have a mental health component to their illness (Jenkins et al 2002).
• There is a strong association between mental and physical ill health. For example, depression has been associated with a four-fold increase in the risk of heart disease, even when other factors are controlled for (Osborn et al 2007).
• Co-morbid mental health problems have a significant impact on the costs related to the management of long-term conditions. For example, the total cost to the health service of each person with diabetes and co-morbid depression is 4.5 times greater than the cost for a person with diabetes alone (Egede et al 2002).
• Unidentified mental health problems are linked to patients with 'medically unexplained symptoms', who can place heavy demands on health services without their problem being resolved (Reidet al 2001).

What is the impact

• Improving the way we respond to co-morbid physical and mental health problems would have a high impact in terms of patient experience and clinical outcomes, since both of these are known to be poor relative to those for people with a single condition.
• There could also be a significant impact on costs, with evidence suggesting that addressing underlying mental health or psychological needs can reduce costs related to physical long-term conditions (Naylor and Bell 2010). For example, provision of psychological support for angina patients in Liverpool achieved a reduction in hospital costs of £1,337 per patient per year (Moore et al 2007).

How to do it

Some of the changes required – such as, expanding screening and monitoring – would be relatively simple for commissioners to implement. However, others would be more complex as they involve redesigning the interface between multiple providers. Specific actions might include:

• expanding screening for mental health needs among people with long-term conditions
• encouraging more systematic coding and recording of mental health needs
• implementing collaborative care models as recommended by NICE for people with depression and a long-term condition (NICE 2009). The model emphasises case management, systematic follow-up and close collaboration between primary and secondary care
• working with 'Improving Access to Psychological Therapy' (IAPT) services. The government's new mental health strategy gives these a key role in providing mental health support for people with a long-term condition, and many are already taking this on; for example, in Salford, IAPT services have developed a new care pathway for people with diabetes and co-morbid depression or anxiety commissioning new liaison psychiatry services in acute hospitals, care homes and elsewhere.
• commissioning new liaison psychiatry services in acute hospitals, care homes and elsewhere.

Useful resources

• The Joint Commissioning Panel for Mental Health, launched in March 2011, is developing a range of resources for GP commissioners to support effective commissioning of mental health services.
• A joint publication from The King's Fund and the Centre for Mental Health describes the opportunities to make savings and improve quality of care within mental health.
• A recent LSE publication evaluates the economic case for investment in 15 interventions to prevent mental illness and promote mental health.

For further information

• Download all ten priorities: Transforming our health care system
• You can also find all the references mentioned here in that version
• Listen to Candace Imison talk through the ten priorites in our audio slideshow