Physical and mental health have long been seen as separate entities, but in a new King’s Fund report it describes several case studies where services have joined up. How can commissioners heal the divide?
Physical and mental health have long been seen as separate entities, but in a new King’s Fund report it describes several case studies where services have joined up. How can commissioners heal the divide?
There has been hard-won progress on integrated care in recent years. Commissioners in many areas have played an instrumental role in developing services that bring together health and social care, or that bridge the gaps between hospital and out-of-hospital care. This is welcomed, and is a journey that is far from over. However, there is another fault line that has received less attention, and could undermine attempts to improve quality of care and control costs. This is the long-standing disconnection between care for physical and mental health.
The close relationship between physical and mental health has important implications for people and for health services. Consider the fact that people with long-term physical health conditions are two to three times more likely to experience mental health problems. Life expectancy among people with severe mental illnesses is 15 to 20 years below that of the general population, largely as a result of poor physical health. But while physical and mental health are intimately connected, the same cannot always be said of the services provided to meet these needs, or of the way these services are commissioned.
A few research findings highlight the clinical and financial case for closer integration:
- Mental health problems lead to significantly poorer outcomes among people with long-term conditions. For example, people with diabetes have a 40% higher risk of mortality over three years if they also have depression.1
- Between 12% and 18% of all NHS expenditure on long-term physical health conditions is linked to poor mental health and wellbeing.2
- People with mental health problems use significantly more unplanned hospital care for physical health needs than the general population, including 3.6 times the rate of potentially avoidable emergency admissions – a signal of weaknesses elsewhere in the system.3
- Poor management of medically unexplained symptoms adds to pressures in primary care; these symptoms account for between 15 and 30% of all GP consultations and costs the NHS around £3 billion each year.4
Limited support
More broadly, although progress has been made in some clinical areas, all too often the support provided for the psychological aspects of physical illness is limited. People involved in our research commonly reported that clinical encounters made them feel like “a heart patient rather than a whole person”.
There are however grounds for optimism – this is not a problem without a solution. There are already some inspiring examples of services that have made significant strides in bringing together physical and mental health. In our recent report, Bringing together physical and mental health: a new frontier for integrated care (see Resources) we describe several case studies of services that have embedded mental health or psychological support within routine health care, or that have improved the provision of physical health care for people with mental health problems.5
There has also been increasing recognition of the problem at the policy level. The report of the independent Mental Health Taskforce to the NHS in England (see Resources) made developing integrated approaches towards physical and mental health one of three main priorities for the next five years. However, plans to invest in areas such as liaison mental health in acute hospitals will not by themselves be sufficient to overcome the divide between physical and mental health. Change is needed across the system, including in primary care, public health and elsewhere.
Tackling the issue
Commissioners can play an indispensable role in helping to support this kind of change, and new approaches to commissioning may help with this. A commonly cited barrier is the separation of commissioning for physical and mental health, with separate budgets and different forms of payment. New contracting models and alternative payment systems may offer some routes for overcoming this problem. For example, prime provider contracts that give providers the incentive to build integrated care pathways across organisations could create a stimulus for closer collaboration between physical and mental health care providers (Case study 1).
Recent guidance from Monitor, the sector regulator for health services in England, encourages commissioners to develop new payment approaches for mental health services, including using capitated and year-of-care models. These approaches could be used to support integrated commissioning of physical and mental health services. For example, under capitated approaches, a group of providers can be paid to provide an integrated package of care for a defined population, including physical and mental health and potentially also social care and other relevant services.
Integration of physical and mental health should be particularly high on the agenda in areas involved in developing new models of care or place-based approaches. Commissioners can use the 10 areas identified in our report as a guide to where some of the most significant opportunities exist for quality improvement and cost control (see Table 1).
Commissioners can also play an important role by creating the right incentives to enable change – for example, using contractual tools to hold mental health providers to account for improving physical health outcomes, and vice versa.
What is needed now is for leadership and ownership of this agenda to move beyond the confines of a mental health strategy or mental health commissioning and become part of wider strategic thinking for the system as a whole. In recent years commissioners have been expected to work towards parity of esteem for mental health. This has often been taken to mean that mental health services should be as good as services for physical health. This remains an important goal, but there is a greater prize beyond it, in which mental health care is not only as good as but is delivered as part of an integrated approach to health.
Chris Naylor, senior fellow in health policy, The King’s Fund.
Resources
Bringing together physical and mental health: A new frontier for integrated care –
kingsfund.org.uk/publications/physical-and-mental-health
The five year forward view for mental health. A report from the independent Mental Health Taskforce to the NHS in England – england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf
References
1 Katon WJ, Rutter C, Simon G, Lin EHB, Ludman E, Ciechanowski P, Kinder L, Young B, Von Korff M. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care, vol 28, no 11, pp 2668–72; 2005.
2 Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A. Long-term conditions and mental health: the cost of co-morbidities 2012. London: The King’s Fund and Centre for Mental Health. kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf (accessed 6 April 2016)
3 Dorning H, Davies A, Blunt I. Focus on: People with mental ill health and hospital use. Exploring disparities in hospital use for physical healthcare. Research summary. London: The Health Foundation and Nuffield Trust; 2015.
4 Bermingham SL, Cohen A, Hague J, Parsonage M. The cost of somatisation among the working-age population in England for the year 2008–2009. Mental Health in Family Medicine, vol 7, no 2, pp 71–84; 2010.
5 Naylor C, Das P, Ross S, Honeyman M, Thompson J, Gilburt H. Bringing together physical and mental health: a new frontier for integrated care 2016. London. The King’s Fund. kingsfund.org.uk/publications/physical-and-mental-health (access 6 April 2016).
