Chris Naylor discusses our report, Bringing together physical and mental health, and gives his personal reflections on integrating physical and mental health care services.
This presentation was recorded at our conference Joining up physical and mental health care on 8 March 2016.
What I am going to do is just give a few personal reflections, standing back from our work in this area, and a few messages that strike me. And the first of those reflections is about this term triple integration. So triple integration is a term that Simon Stevens has used to describe what is needed in the NHS, and the health system generally, to bring about the kind of changes seen in the five year forward view, so integration of health and social care, integration of hospital and out of hospital care, and integration of physical and mental healthcare. Now it is our contention that the third of those components is so far thinking about it at the policy level, is less well developed, and it has been less of a focus for activity at the local level when we look at what is going on in integrated care initiatives.
Now there are pockets of innovation, there are some really good things going on, but what we don’t have is a concerted joined up strategic way of tackling this challenge of integrating physical and mental health. My second stand back reflection is on the theme of this idea of parity of esteem. Now when people from beyond the mental health world talk about parity of esteem, the first question is often ‘What on earth is parity of esteem?’ and it is a reasonable question. In general terms I suppose what we mean by it is that mental health services should be as good as physical health services in terms of the quality of care they offer and the access to services. And that is a really, really important agenda, and it is something that we still have some distance left to travel on. But what we argue in this report is that we need to go beyond that. We need to move from as good as to as part of. So mental health fully embedded within an integrated approach to health, so that actually in the future it doesn’t make sense to be talking about physical and health and mental health, we just talk about health.
It is a very wide territory talking about integrating mental and physical healthcare. There is at least four related issues that it is important to mention. The first is co-morbidity, so all of the people out there who have a physical health problem of some kind, plus a mental health problem. This slide goes back to some work we did a few years ago with the Centre for Mental Health which tried to estimate the scale of the overlap. So the blue circle is the fifteen million people in England who are believed to have a long term physical health condition, the green circle is the ten million adults with a mental health problem in England, and the yellow area in the middle is the four and a half million people who have both of those things. So it is a lot of people affected, but actually it doesn’t stop at that, because we are not just talking about people who have a diagnosable mental health problem, there is also the issue of the wider psychological aspects of health and of illness generally, and the limited support that we tend to give for those wider psychological aspects of health.
There is the issue that we have heard about already today of the persistent inequalities in life expectancy, the fact that we see this fifteen to 20 year gap in the case of people with severe mental illnesses, and finally there is the issue of medically unexplained symptoms which really exemplify this interrelationship between mental and physical health, and which tend to be poorly managed, not just in the NHS but actually in health systems across the world, really struggle to manage these kinds of conditions well, even though they are very, very prevalent.
So if we take these issues together, the impact that they have is really, really quite profound. So there is an impact in terms of increased cost of providing services, they perpetuate the inequalities in health outcomes, and they mean that care for a whole range of conditions is less effective than it could be. Just taking the financial impact first, if we focus on the first and the last of these bullet points, the co‑morbidity and the issue and the medically unexplained symptoms issue, the NHS as a conservative estimate spends at least £11 billion each year dealing with costs that arise in relation to those two issues. So it is a lot of money at play, and I would argue that if you care about cost control in the system, then you need to be thinking about this issue of how the mental and the physical interrelate and how one drives up costs in the other.
I mentioned that it is a wide territory that we are covering within this conference and this report. One of the things we wanted to do with the report was map out that territory a little bit by describing ten areas where we think the opportunities for integrating physical and mental health are particularly important. And I am not going to read through all of these ten, but just to say they span the system. So starting with something that we haven’t talked about that much today, prevention and public health, there is a need to incorporate a mental health and wellbeing perspective much more within existing public health programmes. Then moving through general practice and long term conditions management, that includes something that we touched upon in this room in the last session, which is the need to support the mental health and wellbeing of carers, people caring for people with a physical or mental long term condition.
In terms of hospital care, I think there is a lot of unfinished business. We have talked a lot about liaison psychiatry today, and the sort of progress that has been made in terms of psychological medicine services in various parts of the country, but there is still I think all would agree a lot more to do on that front, and there is also the flip side that Myra Stern and colleagues were talking about in the last session, namely how do we address physical health problems within mental health inpatient institutions.
And finally there is roles for professionals working in community services and in social care in this as well. So if we think about the role that community midwives or health visitors can play in providing an integrated support for perinatal mental health issues. So there is change needed at lots of different levels. The good news I think is that when we look out into the system, if we look across the NHS, at each of those levels there are examples of good practice already, there are things going on in each of these areas. I am not going to describe the case studies that we looked at in the report, but I wanted to pick out a few common themes from some of the integrated service models we have looked at.
Firstly clearly there is no single approach to integration. We are talking about some very different things here. But one of the things that is common to some of the most promising models of integration is that as well as providing an additional service they also redefine core business by pushing the boundaries of existing services and challenging notions about who is responsible for what. In part they do that often by delivering an educational function as well as a clinical one. So for example by creating new opportunities for physical and mental health professionals to work alongside each other and therefore the skills transfer to happen between the two groups. Lots of the interesting service models are looking at in some way bridging the gaps between primary and secondary care, either by creating new ways of accessing specialist support within primary care or by increasing the capability and confidence of general practitioners and other primary care team members working in this space themselves.
There is interesting things going on in terms of redesigning the workforce, so thinking about new roles like liaison physicians, there is a kind of flip side of liaison psychiatrists. And the last thing I would highlight is that one thing that several of these examples we looked at have done really well is reduce stigma, reduce the stigma attached to accessing mental health support by embedding it in normal day to day care processes. So the main point that I want to make about these examples is simply just that there are lots of good case studies out there that we can learn from, but what I don’t want to leave you with is the impression that integrating mental and physical healthcare is all about sophisticated service redesign and tricky things like that, because to some extent it is also about getting the basics right, and this again is a point that I think has been alluded to by some of the previous speakers.
We did a lot of work for this research talking to service users, talking to carers, trying to understand from their perspective what integrated care for mental and physical health would look like. And often it came down to things like good communication, the kinds of language that a professional can use can have the effect we heard from many service users of shutting down the conversation, so people feeling like they were being given a signal wittingly or unwittingly that this is a time to talk about your physical health and not your mental health or vice versa. A simple example, compare starting a diabetic consultation with the question ‘How are your HbA1c levels looking today?’ versus starting with ‘How are you, how are you managing at the moment?’ People also talked a lot about feeling guilty and feeling judged as a result of the kind of language that people use, not necessarily intentionally. But we heard from people who had been undergoing treatment from cancer and had been suffering from mental health issues related to that, who said actually ‘I was made to feel guilty for experiencing depression. I felt like I was letting the side down by not being a fighter’.
So there are all these kind of things that go on that relate to careful use of language. There is also an attitudinal thing about willingness to take a whole person perspective. I was really conscious of the comments this morning, I forget who made them, but the way that actually lots of clinical professionals are taught a lot about communication skills and want to take a whole person perspective, but it is about the environment that we are working in that makes that difficult to do in practice. But what we often heard from the service users in our focus groups was this kind of story about going for an appointment about your respiratory disease, and feeling very much that for the purpose of that appointment you are the disease. And then going for a different appointment about the anxiety condition that you have been experiencing related to that respiratory disease, and for the purpose of that consultation you are the anxiety disorder, and rarely do the two meet.
A really important point that some of the people who contributed to this research made though, is that it is not about turning everyone into experts in everything. We still need specialism, there is still a value in that. But we perhaps do need to have an openness to consider a person’s need beyond the boundaries of the clinicians’ own specialisms.
So one of the conclusions that we took from this work with service users and carers was about the importance of thinking about professional education. I am not going to say too much about this, because it is the subject of the panel discussion after this presentation. But we recommended that all health and social care professionals need a foundation of basic common competencies in both mental and physical health. I think it is really encouraging that several of the royal colleges and other educational bodies are already doing work exploring adding new components to professional educational curricular to try and achieve exactly that. I think it is also worth just making this last observation on the slide which is that it is not all about reinventing the wheel. Some of these skills are out there in the clinical workforce already, and to some extent it is about kind of harnessing what we already have. Elizabeth England writing about general practice has made that point, saying that actually lots of the skills and the knowledge that general practitioners need to be working in this area is already there, and it is a case of reviving, refreshing, re-invigorating.
I want to say a few quick words about recent policy developments. I think the mental health taskforce report is really encouraging. It is really welcomed that it has placed such an emphasis on the need to develop integrated approaches towards physical and mental health. It is also welcomed that there is targeted investment in certain service models like liaison psychiatry, perinatal mental health care, and expanding access to psychological therapies for people with long term physical health conditions. But I don’t think the job is done yet, for several reasons, partly because there are specific things where I think we still need more thought and more progress, thinking for example about thinking more about mental health in primary care, collaborative care models, supporting people with medically unexplained symptoms in primary care, the role of liaison services beyond A&E settings, as well as some of these ideas around trying to get the basics right. So I think there is areas we need further thinking on.
And finally the main reason I would be hesitant to align work in this area completely with the mental health strategy, is about the question of ownership. I think it takes two to integrate. If we are going to make progress, to return to my original comment, if we are going to make progress on this area it can’t be through a mental health strategy, it needs to be something more overarching than that.
The last thing we talk about in the report is about how some of the kind of practical measures that we can look to to try and make progress faster, partly it is about leadership. So developing clinical leaders who have the skills and the passion to build relationships and work across organisational boundaries. The recommendation about identifying board level champions for physical health in mental health trusts and vice versa was picked out by several people this morning. In terms of overcoming some of the barriers in relation to finance and commissioning, one of the messages that we took from lots of the case studies we looked at was involve your commissioners early. The commissioners have played very different roles in the different sites that we looked at, but that message stood out.
And there is value in looking at some of the new payment systems and new contracting mechanisms that can help enable some of this. So perhaps including mental and physical health within the scope of capitated budgets, using contractual innovations like prime provider models as a way of overcoming some of the traditional divisions between mental health commissioning and physical health commissioning. So there are some things at that level that can help. Outcomes measurement is a perennial issue that has been a struggle for a long time, particularly in mental health. But as we heard from several of the speakers earlier, we do need to figure out how to do that and make more progress on that if we are going to demonstrate the value that these integrated services can offer.
Finally I think there is lots and lots of opportunities for digital technologies to support work in this area, including by making progress on this thorny issue of IT systems which don’t speak to each other and don’t allow physical and mental health professionals to share data in a way that would be in everyone’s interests.
So I wanted to wrap up with a few conclusions. A general point I wanted to make is that I am very conscious that you don’t change things by publishing a report in and of itself. At The King’s Fund we also do work with local systems trying to support people in implementing thinking along these lines. So one thing I would be interested in hearing from all of you is any ideas on how we as an organisation can support you in your local areas in making progress in this kind of space, and what you would find valuable from us going forwards. Overall I think there is a compelling case for seeking to support mental and physical health in a more integrated way. As I have mentioned there are lots of promising examples of local integration, but we need to find ways to scale up still. And the new models of care that are being introduced in Vanguard sites and elsewhere, the emerging place based approaches that are being developed across the country, both of those offer two ways of trying to scale up some of this work, and I think it is important for all of us to try and do what we can to make sure that this agenda is on the radar of people involved in those kinds of programmes.
We need I think more thinking about professional education, hopefully that will happen in five minutes time. And finally and most importantly I think we need leadership from across the system on this. This is about improving physical health as much as it is about improving mental health. It is about thinking intelligently about outcomes, the outcomes that we get, and the way we use resources across the NHS and beyond.
Thank you very much.