10 priorities for integrating physical and mental health

The interaction between mental and physical health has important consequences at all levels of the health and social care system. The concept of integrated care in relation to mental and physical health therefore covers a wide territory.

This page, taken from our report Bringing together physical and mental health, provides a map of that territory by describing 10 areas where there is particular scope for improvement. For each area, from public health to acute hospital care, we describe the shortcomings of current approaches, the impact these problems have on patients and the system, and what a more integrated approach might look like. For more detail on these priorities, including references/evidence, please download the full report.

Incorporating mental health into public health programmes
1. Incorporating mental health into public health programmes
Promo
2. Promoting health among people with severe mental illnesses
Improving management of medically unexplained symptoms in primary care
3. Improving management of medically unexplained symptoms in primary care
Strengthening primary care for the physical health needs of people with severe mental illnesses
4. Strengthening primary care for the physical health needs of people with severe mental illnesses
Supporting the mental health of people with long-term conditions
5. Supporting the mental health of people with long-term conditions
Supporting the mental health and wellbeing of carers
6. Supporting the mental health and wellbeing of carers
Supporting mental health in acute hospitals
7. Supporting mental health in acute hospitals
Addressing physical health in mental health inpatient facilities
8. Addressing physical health in mental health inpatient facilities
Providing integrated support for perinatal mental health
9. Providing integrated support for perinatal mental health
Supporting the mental health needs of people in residential homes
10. Supporting the mental health needs of people in residential homes
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Priority 1: Incorporating mental health into public health programmes

Incorporating mental health into public health programmes

The problem

Poor mental health is a major risk factor implicated in the development of cardiovascular disease, diabetes, chronic lung diseases and a range of other conditions. It is also a major public health issue in its own right, accounting for 23 per cent of the burden of disease in the United Kingdom (UK). There is increasing evidence that at least part of this burden is preventable. Despite this, prevention of mental health problems and promotion of positive mental wellbeing often receives limited attention in health improvement work, and is not well integrated with action on other priority public health issues such as tobacco, alcohol or obesity. Mental health prevention and promotion activities account for less than 0.03 per cent of NHS spending on mental health, and the majority of joint strategic needs assessments (JSNAs) have little or no coverage of mental health and wellbeing.

Impact on people

Poor mental health is associated with higher rates of smoking, alcohol and drug abuse, lower educational outcomes, poorer employment prospects, lower resilience, decreased social participation and weaker social relationships – all of which leave people at increased risk of developing a range of physical health problems. For most people, mental health problems begin in childhood or adolescence. This can have lifelong effects, and is a major route through which health and social inequalities are transmitted across generations.

Impact on the health system

Poor mental health is associated with greater resource use within the health system and adds to the burden created by smoking, alcohol and other behavioural risk factors. The wider impact of mental health on public services and the economy is significant; the Organisation for Economic Co-operation and Development estimates that mental health problems cost the UK around 4.5 per cent of gross domestic product (GDP) – £80 billion – in 2015. Most of this is in the form of lost employment and reduced productivity. Within the NHS, the annual cost of staff absence and reduced productivity as a result of poor mental health is estimated to be more than £1 billion.

What would a more integrated approach look like?

A more integrated approach to population health would tackle the determinants of poor physical and mental health in a co-ordinated way, using ‘place-based’ approaches to combine resources from different sectors. Mental health and wellbeing would form a core part of joint strategic needs assessments (JSNAs), with health and wellbeing strategies giving particular priority to interventions capable of improving mental and physical health together. These might include: promotion of outdoor physical activity; prevention of hazardous alcohol use; and interventions that enhance social interaction, facilitate social cohesion and combat isolation.

Childhood health would be a particular priority, with a focus on intervening early to prevent the development of more significant problems later in life. This would include investment in evidence-based parenting interventions, nurse–family partnerships or Sure Start, and schools-based programmes to promote social and emotional learning. Targeted public mental health initiatives would be developed for population groups at greatest risk, such as black and minority ethnic groups. Strengthening the evidence base on public mental health would be a high priority.

Priority 2: Promoting health among people with severe mental illnesses

Promoting health among people with severe mental illnesses

The problem

People with severe mental illnesses such as bipolar disorder or psychosis are at particularly high risk of physical ill health as a result of medication side effects, lifestyle-related risk factors and socioeconomic determinants. For example, smoking rates among people with a mental health condition are three times higher than among the general UK population. Despite this, people with these kinds of conditions are less likely to receive health promotion interventions such as smoking cessation support, and most mental health professionals do not feel that reducing smoking is within their remit. People with severe mental illnesses are less likely to receive many other forms of preventive care, such as routine cancer screening.

Impact on people

Certain psychotropic medications are known to cause weight gain and obesity, leaving people at greater risk of developing diabetes or cardiovascular diseases, and contributing to low quality of life. The high prevalence of smoking, alcohol abuse and other lifestyle-related risk factors also contributes to this, and is one of the main factors responsible for the dramatic 15–20-year gap in life expectancy among people with severe mental illnesses. Contrary to some assumptions, people with severe mental illnesses who smoke are just as likely to want to quit as the general population, but are more likely to be heavily addicted and to anticipate difficulty quitting. Smoking cessation in this group is associated with improved mental health and reduced levels of medication, illustrating that quality of life as well as longevity is affected.

Impact on the health system

The significant costs to the health system and the wider economy caused by smoking, obesity, alcohol misuse and substance abuse are well established. What is less well known is that a substantial proportion of these costs occur among people with mental health problems. For example, the estimated economic cost of smoking among people with mental health problems was £2.34 billion in 2009/10, of which £719 million was spent on treating diseases caused by smoking. In the case of substance abuse, 85 per cent of people using alcohol services and 75 per cent of those using services for drug addiction also have a mental health problem.

What would a more integrated approach look like?

Local authorities would see people with mental health problems – and particularly those with severe mental illnesses – as a priority target group for public health interventions. This would include provision of tailored services to support healthy living – for example, bespoke smoking cessation services. Voluntary and community sector organisations would play an important role in supporting lifestyle changes, and families and carers would also be actively involved in this. Screening services would be accessible for all. There would be clear agreements over who holds clinical responsibility for the physical health side effects of psychotropic drugs. Closer working between health, local government and other sectors would help to address the social determinants of health for people with severe mental illnesses. All mental health professionals would receive substance misuse training, and there would be much closer working with addiction services. More fundamentally, cultural change within the mental health workforce would mean that all professionals see promoting physical health as being an important part of their role.

Priority 3: Improving management of medically unexplained symptoms in primary care

Improving management of medically unexplained symptoms in primary care

The problem

Medically unexplained symptoms are physical symptoms that lack an identifiable organic cause. They can include musculoskeletal pain, persistent headache, chronic tiredness, chest pain, heart palpitations and gastric symptoms. These symptoms are highly common and have a major impact both on the people experiencing them and on the health system. There is often no clear referral pathway for medically unexplained symptoms, and as a result patients are repeatedly investigated, which can cause significant harm and contribute to excess health care costs. Patients with medically unexplained symptoms are particularly common in primary care, yet most GPs receive no specific training in managing these symptoms and may lack confidence in exploring the psychological issues potentially involved. Identifying and managing medically unexplained symptoms can be highly challenging, not least because failing to identify a condition that has a straightforward medical cause can also have serious consequences.

Impact on people

Poor management of medically unexplained symptoms can have a profound effect on quality of life. People with such symptoms often experience high levels of psychological distress as well as co-morbid mental health problems, which can further exacerbate their medical symptoms. More than 40 per cent of outpatients with medically unexplained symptoms also have an anxiety or depressive disorder. Chronic pain can worsen depressive symptoms and is a risk factor for suicide in people who are depressed. Impact on the health system Patients with medically unexplained symptoms account for an estimated 15 to 30 per cent of all primary care consultations and GPs report that these can be among the most challenging consultations they provide. Medically unexplained symptoms also account for a significant proportion of outpatient appointments – in one study, accounting for more than 20 per cent of all outpatient activity among frequent attenders. In primary care, some of the biggest challenges are related to patients with a mixture of medically unexplained symptoms and poor adjustment to a long-term physical health condition, leading to disproportionate symptoms and medication use for the long-term condition. The annual health care costs of medically unexplained symptoms in England were estimated to be £3 billion in 2008/9, with total societal costs of around £18 billion.

What would a more integrated approach look like?

The needs of people with medically unexplained symptoms vary enormously, and evidence suggests that biopsychosocial management delivered within a stepped care framework can be an effective approach for some people. GPs have an important role to play in this, identifying people affected, exploring relevant psychosocial factors, and doing so in a way that acknowledges physical symptoms as real. Where symptoms are mild, sensitive handling and watchful waiting by the GP may be sufficient. People with moderate needs would receive appropriate psychological interventions and other support as necessary. Those with the most complex needs would be considered for referral to a dedicated service for medically unexplained symptoms with specialist mental health input using a collaborative care approach including joint case management with GPs. Where a referral for psychological intervention is made, GPs need to be able to discuss this with patients in a way that avoids implying that their symptoms are ‘all in the mind’.

Priority 4: Strengthening primary care for the physical health needs of people with severe mental illnesses

Strengthening primary care for the physical health needs of people with severe mental illnesses

The problem

Compared to the general population, people with severe mental illnesses are less likely to have their physical health needs identified or to receive appropriate treatment for these. Despite a policy commitment to reducing these inequalities, monitoring of physical health among people with severe mental illnesses remains inconsistent in both primary and secondary care. For example, only a minority are screened for cardiovascular disease, and other tests such as cholesterol checks and cervical smears are performed at lower rates than for the general population. Part of the problem historically has been a lack of clarity over whether responsibility for providing primary health care to this group of people lies principally with GPs, mental health teams, or both. There are skills gaps in general practice – for example, most practice nurses do not receive training in how to perform physical health checks for people with severe mental illnesses, and there is evidence of ‘diagnostic overshadowing’ in which physical symptoms can be overlooked as a result of an existing diagnosis. Barriers to accessing primary care for physical health may be further exacerbated by stigma and socioeconomic inequalities among people with severe mental illnesses.

Impact on people

Poor detection and treatment of physical ill health contributes to the threefold increase in mortality rates among people with schizophrenia. A review of the evidence found that people with severe mental illnesses receive a poorer standard of care for a range of conditions including diabetes and heart failure, and are less likely to receive medical treatments for arthritis. Primary care can play an important role in ensuring that people with mental illnesses receive equitable access to care across the system.

Impact on the health system

Poor detection and treatment of physical ill health in primary care contributes to people with severe mental illnesses being among the most frequent users of unplanned care, with high associated costs. A recent analysis found that in 2013/14, people with mental health problems had three times more accident and emergency (A&E) attendances and five times more unplanned inpatient admissions than a matched control group drawn from the general population. Eighty per cent of these admissions were for physical rather than mental health problems. While this cannot be attributed to shortcomings in primary care exclusively, effective primary care will be critical in addressing these inequalities.

What would a more integrated approach look like?

Responsibility for monitoring and managing the physical health of people with severe mental illnesses would be shared between primary care and specialist mental health services, based on clear local agreements. This would include comprehensive provision of annual physical health checks, with practice nurses receiving appropriate training to conduct such checks. General practices would systematically and proactively identify relevant individuals on their lists using disease registers and patient records. Practices would provide specific clinics for people with mental illnesses to review the services and treatments currently being received, undertake appropriate monitoring (eg, blood tests or electrocardiograms (ECGs)), provide health promotion information, and signpost people to appropriate services. All community mental health teams would have access to a physical health liaison service, providing easy access to advice and treatment from GPs and others, including for people not registered with a GP.

Priority 5: Supporting the mental health of people with long-term conditions

Supporting the mental health of people with long-term conditions

The problem

People with long-term physical health conditions are two to three times more likely to experience mental health problems, with depression and anxiety disorders being particularly common. Many experience psychological difficulties – for example, in relation to adjusting to their diagnosis, living with symptoms and with the impact on their social role and functioning, or managing side effects. Despite this, the detection of co-morbid mental health problems and the provision of support for the psychological aspects of physical illness are not of a consistently high standard; patients and practitioners alike tend to focus on physical symptoms during consultations.

Impact on people

Co-morbid mental health problems have a number of serious implications for people with long-term conditions, including poorer clinical outcomes and lower quality of life. For example, mortality rates after heart attack or heart bypass surgery are several times higher among people with co-morbid depression, while people with diabetes have an increased risk (by more than 40 per cent) of all-cause mortality over three years if they also have depression, after adjusting for other factors. These effects are mediated by a number of mechanisms, including reduced ability and motivation to manage health conditions, medication side effects and poorer health behaviours. Overall, co-morbid mental health problems have a greater effect on quality of life than physical co-morbidities.

Impact on the health system

By interacting with and exacerbating physical ill health, co-morbid mental health problems increase the costs of providing care to people with long-term conditions. For example, depression significantly increases the risk of unplanned hospitalisation for this group of people. Overall, between £8 billion and £13 billion of NHS spending in England is linked to co-morbid mental health problems among people with long-term conditions. Co-morbid mental health problems also have wider economic costs as a result of lower employment rates and productivity.

What would a more integrated approach look like?

People with long-term physical health conditions would receive support for the psychological aspects of their condition as a standard part of their care. This would include: routinely providing psychological education and support as part of cardiac and pulmonary rehabilitation and other self-management programmes; making full use of peer support groups (locally or online); and embedding clinical psychologists within multidisciplinary teams to allow skills transfer in both directions.

Active case-finding would be used to identify people at greatest risk, in line with guidelines from the National Institute for Health and Care Excellence. Integrated approaches involving close working between primary care and other professionals – for example, based on the collaborative care model in section 4 of the full report – would be available for people with co-morbid depression or anxiety.

The most complex patients with multiple conditions would not be referred to generic psychology services, but would be supported by professionals skilled in working at the interface between physical and mental health.

Priority 6: Supporting the mental health and wellbeing of carers

Supporting the mental health and wellbeing of carers

The problem

More than 6 million people in the UK provide informal care to someone with a health condition or disability. For many, doing so can have a significant impact on their own mental health and wellbeing. In comparison with the general population, people with substantial caring responsibilities have higher levels of stress and depression and lower levels of subjective wellbeing, as well as poorer physical health. In some situations – particularly in the context of palliative care – supporting the mental health and wellbeing of carers is an explicit part of a patient’s care plan. However, this is often not the case, and in general carers are provided with limited support. For example, two-thirds of carers responding to one survey reported that staff had not directed them to relevant sources of information or advice.

Impact on people

Survey data illustrates the toll that caring responsibilities can take on mental health and wellbeing. More than 9 out of 10 carers report that caring has a negative impact on their mental health, including stress and depression, while 75 per cent of carers said it was hard to maintain social relationships. This in turn can affect their ability to provide care and lead to the admission of the person they are caring for to hospital or residential care. Health impacts are often exacerbated by carers being unable to find time for medical check-ups or treatment.

Impact on the health system

The health and care system is highly dependent on informal care provided by family and friends. The value of this care is estimated to be around £119 billion per year – more than total spending on the NHS. Neglecting to look after the mental health and wellbeing of people making this significant contribution to the system risks adding to the burden of work conducted in the formal sector.

What would a more integrated approach look like?

The physical and mental health needs of carers and family members would be assessed as a routine part of the care provided to people with long-term health conditions, or people with a terminal condition. In particular, the need for support would be assessed during key transitional points in a carer’s journey, such as when a person first takes on caring responsibilities and during periods of significant change. People providing substantial levels of informal care would have their own written care plan, updated on an annual basis. An evaluation of the National Carers’ Strategy demonstrator sites programme suggested that it is possible to provide enhanced support to carers at a relatively modest cost and without creating a significant additional burden on health and care professionals. Further research is needed to identify the most effective ways of supporting carers and reducing psychological distress.

Priority 7: Supporting mental health in acute hospitals

Supporting mental health in acute hospitals

The problem

Mental health problems are highly prevalent in inpatient wards, outpatient clinics and emergency departments, and can profoundly affect outcomes of care for acute physical illnesses. However, they often go unidentified and unsupported. For example, two-thirds of NHS beds are occupied by older people, up to 60 per cent of whom have or will develop a mental health problem during their admission. Other conditions such as eating disorders can significantly complicate the management of hospitals patients. In recognition of this problem, there has been some growth in liaison mental health services in recent years, but there remains significant variation in approach across the country. Only 16 per cent of acute hospitals in England currently have access to a comprehensive liaison service. Acute hospital staff often lack the necessary training, knowledge and skills related to the recognition and management of common mental health problems affecting acute hospital care.

Impact on people

The failure to consistently support the mental health needs of people using acute hospital services has an important effect on both patient experience and care outcomes. For example, in approximately 50 per cent of cases, acute care staff fail to identify delirium in older inpatients, with significant negative consequences for the people affected. Patients with dementia are still prescribed antipsychotics on some inpatient wards, despite guidance indicating that this is often inappropriate. Under-treatment of other mental health problems such as depression leads to people spending longer in hospital than may otherwise have been necessary (see below).

Impact on the health system

Mental health problems have an important effect on costs in the acute sector. For example, general hospital inpatients with co-morbid depression have a longer length of hospital stay than patients who are not depressed. For older people, mental health problems have been indicated as a predictive factor for longer hospital stays and higher institutionalisation rates. Patients with dementia often experience delays in discharge, even when there is no substantive medical reason for delay. There is evidence linking untreated or under-treated mental health problems among general hospital inpatients to higher rates of re-attendance at A&E after discharge. Self-harm accounts for more than 150,000 A&E attendances per year in England and can require significant staff time to manage.

What would a more integrated approach look like?

An integrated approach would mean all acute hospital professionals having the necessary skills and confidence to manage mental health appropriately. Professionals working in emergency departments and inpatient wards would understand how to identify and respond to dementia, delirium, self-harm and acute psychosis. Outpatient teams would have the capability to help people make psychological adjustments to illness, or to manage medically unexplained symptoms. Liaison psychiatry or psychological medicine services would be instrumental in achieving these aims, performing an important educational function across the hospital. Liaison services would be age-inclusive, operate seven days a week, and would be available in every acute hospital, in line with current policy commitments. They would also offer outreach services to primary care.

Priority 8: Addressing physical health in mental health inpatient facilities

Addressing physical health in mental health inpatient facilities

The problem

Whereas liaison mental health services are becoming increasingly common in acute hospitals, it is rarer to find physical health liaison services in mental health inpatient facilities, despite significant levels of need and undiagnosed physical illness. People using these facilities are significantly less likely than the general population to be registered with a GP, and are more likely to present late with physical symptoms. Mental health professionals working in these settings may lack the confidence or skills required to identify medical conditions, and often there is a culture of giving low priority to physical health. Evidence suggests that at present, more than a third of patients fail to receive a physical examination within 24 hours of admission, in line with recommended practice.

Impact on people

Chronic health problems such as heart disease and chronic obstructive pulmonary disease (COPD), as well as acute conditions such as appendicitis and stroke, are under-recognised and sub-optimally treated among people with severe mental illnesses. Delays in accessing care as a result of late identification by staff working in inpatient units can lead to poorer treatment outcomes, contributing to the excess mortality rates reported in previous sections.

Impact on the health system

Reports from some mental health inpatient facilities indicate high rates of emergency transfers to general acute hospitals. More generally, there is clear evidence that for a wide range of common inpatient procedures, people with mental health problems are more likely to have an emergency rather than a planned admission, be admitted overnight, and stay longer in hospital, resulting in higher costs to the system. While this cannot be attributed solely to the quality of physical health care available in mental health facilities, it does indicate the potential for improvement through intervention in a variety of settings.

What would a more integrated approach look like?

Admission to a mental health inpatient facility would be seen as an opportunity to improve the person’s mental and physical health. All people admitted to a mental health inpatient facility would receive a full physical examination on admission or within 24 hours, with investigations carried out promptly and clearly documented. Mental health nurses would perform basic tests themselves, using standardised toolkits such as the Lester tool, and would consider this an important part of their role. Liaison physician roles would be widespread, advising mental health providers on patients’ physical health. Liaison roles would also exist for other professionals, such as clinical nurse specialists, practice nurses and health coaches. In secure or rehabilitation units with longer average length of stay, the more stable inpatient population would represent an opportunity to provide a comprehensive range of primary care services within the facility.

Priority 9: Providing integrated support for perinatal mental health

Providing integrated support for perinatal mental health

The problem

Mental health problems affect one in five women during the perinatal period. Problems encountered include depression, anxiety disorders, postpartum psychosis and post-traumatic stress disorder. Despite the numbers of people affected, half of all acute trusts in the UK have no perinatal mental health services, and three-quarters of maternity services do not have access to a specialist mental health midwife. Midwives and health visitors receive variable and often limited training in identifying women who have, or are at risk of developing, perinatal mental health problems. Where perinatal mental health services are available, these are usually part of generic adult mental health services and are not always fully integrated with other maternity services. Access to services is particularly poor for minority ethnic groups – black Caribbean women are less likely to receive treatment for perinatal depression than their white British counterparts.

Impact on people

There is considerable evidence that untreated mental health problems are associated with increased risk of obstetric complications and can adversely affect both the parent–child relationship and the child’s social and emotional development. There may be lasting effects on maternal self-esteem, as well as on partner and family relationships. Almost a quarter of maternal deaths occurring between six weeks and one year after pregnancy are due to psychiatric causes. Women may delay seeking help due to stigmatisation and fears that their baby might be taken from them.

Impact on the health system

Perinatal depression, anxiety and psychosis carry a total long-term cost to society of about £8.1 billion for each one-year cohort of births in the UK, of which £1.2 billion falls on the NHS and social services. In comparison, estimates suggest it would cost around £280 million a year to bring perinatal mental health care pathways across the UK up to the standards recommended in national guidance.

What would a more integrated approach look like?

In an integrated service, perinatal mental health care would be delivered by specialist perinatal mental health staff embedded within local maternity services, providing training to colleagues and working closely with obstetricians, midwives, health visitors and GPs. All professionals involved in pregnancy and the postnatal period would have a role to play in ensuring that women’s mental health and wellbeing are supported throughout the perinatal process. This would include important roles for midwives and health visitors in screening and providing basic support and advice. Wherever possible, perinatal mental health problems would be identified early, during pregnancy. Specialist health visitors would be given advanced training in perinatal mental health to enable them to deliver brief psychological interventions, manage cases jointly with supervision from a psychiatrist, and provide training to other health visitors to improve awareness of mental health conditions and the different care pathways available. The voluntary sector would play an important role – for example, in providing peer support groups – and all professionals involved in maternity care would be able to signpost to these local resources.

Priority 10: Supporting the mental health needs of people in residential homes

Supporting the mental health needs of people in residential homes

The problem

Mental health problems are not a normal or inevitable part of the ageing process – the majority of older people enjoy good mental health and make valuable contributions to society. Nonetheless, depression, dementia and other conditions are common in residential homes. Two-thirds of people living in care homes have dementia and are usually at a more advanced stage of the illness. Many homes are not equipped to provide the one-to-one, person-centred care that people with dementia need, and access to support from external specialist services is variable. Depression occurs in 40 per cent of people in care homes and often goes undetected, with many carers seeing depression as a normal phenomenon among older people. Very few care homes cater explicitly for residents’ mental health needs other than dementia, and the extent of mental health training provided to care home staff is often limited.

Impact on people

Mental health problems significantly affect the physical, psychological and social wellbeing of people in care homes. Confusion related to dementia or delirium can be highly distressing for residents and their families. Depression among care home residents with dementia has been associated with poor nutrition and excess mortality rates. Depression is also a risk factor for suicide in care homes. Although depression can seriously affect the quality of life of older people, many do not receive adequate treatment, with symptoms frequently being misunderstood as an inevitable part of ageing.

Impact on the health system

Poorly managed mental health problems in residential homes are associated with challenging behavioural problems, non-compliance with treatment, and increased nursing staff time. Depression and other mental health problems in older age can reduce motivation to manage physical health, adding to health system costs – for example, in the form of emergency transfers from care homes to acute hospitals.

What would a more integrated approach look like?

Staff working in care homes would have sufficient training to be able to detect and manage dementia, delirium, depression and other conditions, with support and supervision from specialists as required. They would understand how to promote the mental wellbeing of residents – for example, by encouraging social connection, physical activity and continued learning. GPs working with older people in care homes would be able to identify those in need of mental health support, and provide relevant education and advice to care home staff. Specialist mental health in-reach services would be available and accessible in all residential settings – for example, to help staff manage residents who need intensive support or who exhibit challenging behaviours.

Further reading