Bringing together physical and mental health

A new frontier for integrated care
Until now, most efforts to promote integrated care have focused on bridging the gaps between health and social care or between primary and secondary care. But the NHS five year forward view has highlighted a third dimension – bringing together physical and mental health.

This report makes a compelling case for this ‘new frontier’ for integration. It gives service users’ perspectives on what integrated care would look like and highlights 10 areas that offer some of the biggest opportunities for improving quality and controlling costs.

Bringing together physical and mental health

Print copy: £15 | Buy

No. of pages: 120

ISBN: 978 1 909029 60 6

Key findings

Efforts to develop integrated care should focus more on the integration of physical and mental health, addressing in particular four major challenges:

  • high rates of mental health conditions among people with long-term physical health problems
  • poor management of ‘medically unexplained symptoms’, which lack an identifiable organic cause
  • reduced life expectancy among people with the most severe forms of mental illness, largely attributable to poor physical health
  • limited support for the wider psychological aspects of physical health and illness.

Failure to address these issues increases the cost of providing services – the first two alone cost the NHS in England more than £11 billion a year – and affects outcomes for patients. There is much that can be achieved within existing structures to bring together mental and physical care at the clinical level. But this needs to be supported by wider changes such as development and evaluation of new service models, changes to professional education and increased use of new payment systems and contracting models.

Policy implications

  • NHS England should support and encourage vanguard sites and other areas to develop integrated approaches towards physical and mental health as part of efforts to build new models of care.
  • All health and care professionals have a part to play in taking a ‘whole person’ approach towards physical and mental health. Integrated service models can support this by creating opportunities for skills transfer between professionals.
  • Royal colleges and other bodies should continue working together to redesign curriculums so that all health professionals have a common foundation in mental as well as physical health.
  • Local authorities should assess how mental health and wellbeing interacts with other public health priorities and include this in joint strategic needs assessments.
  • Commissioners should take advantage of new payment systems and contracting approaches to overcome some of the current barriers to integration.
  • Mental health trusts should consider having a board-level champion for physical health, and vice versa in acute trusts.

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#545883 Kim Lyons
Psychological therapist/RMN

Fantastic report. Something that North East London Trust have been constantly improving on. We even have intergrated electronic mental health/clinical health notes, much safer for clients

#545885 Dr David Marjot
Retired Consultant Psychiatrist

I started work in a large 'unreformed' mental hospital in 1958. We worked hard at bringing about the discharge of patients and establishment of community care. We were greatly helped by full employment, social security and 'council housing'. It became clear that community care was not cheap and required a large investment in staff and other facilities. There were a number of patients who could be better cared for in a residential facility. The net result was of inadequate clinical facilities including 'beds' attached to general hospitals and poor community facilities. Indeed the general hospital units were the old Observation Wards attached to the workhouse reinvented. As they did not discharge patients rapidly or transfer them to the Asylum after 28 days the general hospital units became psychiatric slums. Much if not most of the resources freed by the closure of the asylums went into general NHS expenditure.What I call the cynical rape of the assets of psychiatry or CRAP for short. As psychiatric services are now so inadequate it means that much/most expenditure is wasted. I am and distressed that we have come to this. Sadly as retired a long time ago not in a very good position to help. Having immediate family suffering or having suffered from 'psychiatric' conditions I have personal experience as well although as being better off and knowledgeable we have managed to get by. Any problems were not of the quality of the services but quantity.

#545888 Pearl Baker
CARER Independent Mental Health Advocate and Advisor

I totally agree with the comments of Dr David Marjot, and probably in a similar position, however although the Report is good, and describes it as the 'third way' it is important to remember CARERS are often supporting and Caring outside of the system due to inadequate resources allocated to those responsible for implementing a service that could prevent all the difficulties we find ourselves in today.

I would suggest there should be a 'fourth' way! if Carers were respected for what they do, and the knowledge they have acquired while providing often the ONLY SUPPORT and CARE to their relatives, we could eliminate STRESS, and ANXIETY that all Carers experience, while at the same time improve the lives of those we CARE for.

The 'forth' way? Multidisciplinary assessment of both the Carer and the Patient 'INTERESTING' identify their Health and Social Care Needs.

Ask any CARER why they are stressed and anxious, and suffer from anxiety. It is because we can never contact anyone in emergency, often providing Health and Social Care without any support, NOT acknowledged for what they do, no respite. and finally we ALL worry about what will happen to these vulnerable son's daughter's and friends when we die.

The above is probably me, but having experienced this 'feeling' for thirty years, we find other ways of 'coping'.

Carers are NOT given sufficient help or support for what they do. It is has become a 'battle' of the 'Titans' A war that lasted 10 years, which we don't have.

#545891 GeraldDavies
Retired Aviator

It has taken the NHS some 70 years to realise that the brain controls everything including mental health, addiction etc. Finally recognising that one cannot separate Health and Care they have come to a belated and logical conclusion that the program in one's brain controls all the functions of the body, including mental health.

#545893 Mrs E Wenn

With respect to Priority 3- Improving management of medically unexplained symptoms in primary care- this represents outrageous and shameful discrimination against women. According to NHS figures 30% of women and 10% of men who attend primary care with physical symptoms will have them attributed to ‘MUS’ i.e. that it must be a somatising problem since it lacks an identifiable organic cause. Their physical symptoms couldn’t possibly be due to adverse drug reactions, currently unknown medical conditions, failure to diagnose correctly or diagnostic overshadowing or testing error now could they? So 3 times as many women as men, an extra 20% of the female population compared with men attending primary care, will be given this spurious ‘mental health’ diagnosis….. and not just for fatigue anymore but a wide range of physical symptoms – headache, dyspepsia, chest pain, bowel problems….the list goes on and on. (These figures are based on NHS figures of 20% of attendees having so-called MUS, with 4 times as many women as men reportedly having MUS and the fact that the ratio of women:men attending primary care is about 1.46:1). At the moment GPs may use their own initiative to do investigations and request appropriate referrals to secondary care but if this move goes ahead then they will be urged, even more then they are already, not to investigate further and not to refer to secondary care, instead casting their patients into a mental health waste-basket with the only help available to them being psychotherapy or graded exercise therapy. This can only be regarded as a discriminatory move to save the NHS £3billion a year (and the wider economy £18 billion) at the expense of women’s physical health under the guise of providing better mental health care. For too long women have put up with this discrimination - women out there should prepare themselves to sue the NHS whenever their GP delays their diagnosis by attributing their symptoms to stress, anxiety or depression – money talks.

#545894 Alex Franklin
Ontario Medical Associatioon

As Late BBC philosopher Prof Joad used to say ; "It all depends what you mean by...." Using simple English the idea is to make the recipient as healthy and happy as possible using Public and Private services. A GP with DPH could do the job.

#546134 Dr Dorothy Frizelle
Consultant Clinical Health Psychologist
Mid Yorks Hospitals NHS Trust

Faculty for Clinical Health Psychology of the Division of Clinical Psychology have been lobbying for integrated physical and mental health care for years. At last there is a quality document which brings the arguements together and which can be used to make the case for wider MDT care vs. over-reliance on medical models and services.

#547638 heather middleton

the lack of mental health services and poor quality of them when they are available will not necessarily be improved by integration but it may make it easier for carers to be involved.
As the mother of a son who committed suicide I can only look on now and hope this will help,unfortunately my experience with regards to mental health provision and support in the community leaves me fearful.

#547660 Dr Neil Watson
Clinical Psychologist

Bringing together physical and mental health services presents itself with significant potential benefits for physical health services and mental health services - but also significant risks for mental health services within this relationship.

There is, and has been for sometime, benefits for patients with long term conditions (e.g. diabetes, cardiopulmonary disorders, chronic pain) in understanding and treating their mental health, with potential benefits to their wellbeing and the efficiency of services (e.g. reduced unplanned admissions). Similarly there are benefits to those with mental health problems who have long been known to have poorer physical health care and subsequent outcomes.

However, the relationship comes with significant risks, often specifically for mental health. Risks to mortality often are perceived to outweigh those of morbidity; it can be easier to justify cuts to mental health services in favour of those supporting physical health care on safety grounds at the costs of parity of esteem. From experience these risks are not insignificant and increased collaboration whilst providing significant benefits needs to be considered in the light of ensuring that mental health does not become neglected to support the physical healthcare of patients and the public.

#548243 Polly
Health activist

“There is a common tendency in medicine when faced with medically unexplained symptoms to assume that they are psychogenic in origin. This is a high-risk approach that can have disastrous consequences.”
This is a quote from Prof R Grahame, from a paper about EDS. He goes on to discuss that the symptoms of EDS/JHS were – and sometimes still are - considered to be a form of ‘illness behaviour’ He concludes by saying “To dismiss disparate symptoms as ‘illness behaviour’ is, in my view, wrong and does much disservice both to our patients and to our reputation as a profession.”

In the light of what happened to the late Dr Lisa Steen, I have to hope that the medical profession will take a long, hard look at how easy it is for patients to be inappropriately labelled as having ‘medically unexplained symptoms’ and take appropriate measure to prevent this from happening to anyone else. My area of interest is rare conditions and it is stunning to know that, according to the 2016 RDUK report, the main barriers to diagnosis are that patients are not being believed and/or are told that their symptoms are ‘psychological’. This is not OK.

Meanwhile, whilst I agree with Mrs Wenn that patients need to take action if their GPs label or diagnose them inaccurately, this can be very difficult. Doctors have been known to wriggle off the hook by saying that these diagnoses are ‘only an opinion’ and that all patients are entitled to a second opinion (see the NHS Choices information on ‘MUS/functional’ diagnoses). And far too often I hear reports back from patients who challenge these labels only to be told that they are resistant to mental health diagnoses because they are prejudiced against people with mental health conditions. This is also not OK.

Ultimately it doesn’t surprise me that people who are diagnosed as having ‘functional disorders’ cost our health service so much. It would be interesting to know how much of this cost is due to patients having to go to their GPs (often after consultations with neurologists) in an attempt to find out what ‘functional’ means. The only answer to this question that has ever made sense to me is that a ‘functional’ diagnosis ‘is a form of lazy psychological profiling.’ We deserve better.

#548317 Clive Spindley
my own business
my own business

integartion of care, mental and physical, NHS and non NHS will not 'appen unless it is backed up by the integartion of data supported by a data model designed at the national level

#548320 Graham Morgan
Evolve:A Social Impact Company

At Evolve we are pioneering an innovative, preventative intervention, Project HERO (Health Engagement Real Outcomes).
Delivered by inspiring Evolve Health Mentors HERO simultaneously provides physical health, emotional wellbeing and school progress gains.

Independent studies give testimony to the positive outcomes the HERO programme delivers. Our challenge is support with national roll out.


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