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NHS England’s National Clinical Director for Mental Health, who is among the speakers at the Health+Care Commissioning Show, examines the need for integrated care:
Integration is now one of the most commonly used words today in healthcare.
The Five Year Forward View sets out the principles of integration: the integration of physical and mental health, integration of primary and specialist care, and integration of health and social care.
There are many interpretations, and in this blog I want to set out some of the thinking about implementation from the perspective of a mental health clinician.
People come with integrated minds and bodies. To achieve clinical care integration would mean that in our interactions with patients, we use an integrated clinical approach.
This would mean that, at registration with a service, in assessments, in annual checks, in treatment programmes and in care pathways, in patients care records and care plans, we address both physical and mental ill-health.
Healthcare staff would be trained in physical and mental health awareness as a minimum, teams would have integrated physical and mental health experts in varying degrees, depending on the needs of the patient groups, and NICE/SCIE guidelines, national audits, and research would routinely include both physical and mental health components.
Our payment and incentivisation systems would be based on delivery of the outcomes that integrated care demonstrably achieved, and the strange British dislocation of mind and body would end!
Around the world, and in England, the good news is that integrated clinical care solutions are being developed and evaluated. A few examples are:
At registration with the GP in New Zealand, and designed by GPs, patients complete, either on paper or using iPads in the waiting room, a simple 10 item, self-completion questionnaire to provide information on their lifestyle, mood, psychological and behavioural health context.
The eChat is described as ‘an acceptable and feasible means of systemic assessment of patients for behaviours and mood states and is easily integrated into the primary care electronic health record’. There is, of course, a distinction between basic history taking in medicine, and screening for illness, and more work needs to be done on the latter, but the eChat assists the former.
For patients living with long-term ‘physical’ conditions, mental illness is a common and disabling occurrence, particularly depression and anxiety.
If the mental illness is left untreated, it is harder for the person to gain control of their treatment and engage with a rehabilitation care plan. It’s harder to find the motivation and energy to shop and cook for a healthy lifestyle, attend for monitoring and appointments.
In these situations, people relapse more, need more crisis care, get admitted more often, have more severe illnesses. The clinical and economic impacts are well described in authoritative summaries of the research.
Equally illogical is that the separation of physical and mental health care has meant that patients with more severe mental illnesses die up to 20 years prematurely from unassessed and untreated cardiac and lung diseases, diabetes, cancer and other treatable conditions.
And the avoidable costs to the system are large. Co-morbid mental health problems are associated with a 45 to 75 percent increase in service costs per patient (after controlling for severity of physical illness)/ between 12 percent and 18 percent of all expenditure on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term conditions.
There are encouraging signs of change, and a few innovations are described below.
In June, patients, clinical and commissioning experts in stroke, diabetes, respiratory conditions, and cancer came together to summarise the evidence and the value for commissioners of an integrated approach.
The London strategic clinical network has produced a guide to integrated diabetes care. Integrated diabetes expert posts have been established in Kings in London.
In Oxford, patients with cancer have had improved outcomes due to an integrated care pathway where, in addition to their cancer, their anxiety and depression are also treated. Professor Michael Sharpe, says: “The systematic model of care for psychiatric comorbidity in cancer integrates mental and physical care and also links primary and specialist care. The cost per QALY is about £9,000 with potential cost savings. It could be potentially applied to psychiatric comorbidity any chronic medical illness”.
The LIFT psychology services in Swindon provide integrated physical and behavioural care for people on the bariatric surgery waiting lists, enabling 70 percent to avoid unnecessary operations and change their pattern of thinking and lifestyle permanently. Patients are treated in groups in a large health centre, offering economies of scale as well as peer support.
For mothers and babies it is vital that perinatal care is integrated. Our NHS England published case study, has attracted great interest from around the world.
The Multispecialty community providers are now leading the way with new and highly efficient integrated care teams, care plans, health and social care and prevention programmes. Stockport has integrated thinking in every aspect of care from public health to care for people with delirium and dementia.
This is an exciting and radical time in healthcare in England and the dumping of the Descartian false premise that mind and body exist separately looks to be finally on its way to the grave…