NHS England is working with a range of partner organisations with a view to seeking to provide a clear steer to commissioners about the evidence base relating to clinical interventions and service developments which are likely to have the greatest impact on reducing mortality for people with a serious mental illness.
Much of the evidence set out in this section reflects work in progress and we intend to develop the evidence base further over the coming months. As a starting point, we held a workshop in January 2014 which was very well attended by stakeholders, patient groups and partner organisations. A range of recent service developments and SMI toolkits were presented and shared with delegates on the day. We will be publishing a follow-up report from the workshop, with information about the toolkits and evidence base, in the next release of these web resources during April 2014.
While the information provided in this section is aimed at patients with serious mental illness, we realise that inequalities exist among patients with more common mental health conditions including depression and personality disorder. Many of the interventions described can be applied to this patient population and are not necessarily specific to patients with a serious mental illness. However, we would encourage commissioners to address premature mortality in all patients with mental health conditions recognising that those with a serious mental illness may need more intensive action.
- 7.1 Extent of problem and degree of inequality
- 7.2 Health inequalities in relation to mental health services user
- 7.3 Suicide prevention
- 7.4 Developing smoking cessation programmes for people with a serious mental illness
- 7.5 Testing for physical illness in people with a serious mental illness
- 7.6 Improved treatment of people with serious mental illness (SMI)
- 7.7 Testing in prisons
- 7.8 Developing workforce skills around the physical well-being of people with mental health problems
- 7.9 Monitoring and surveillance
The SMI patient population makes up 5 percent of total population but accounts for 18 percent of total deaths (Shukla H and Watson S (2013) A Tale of two populations (Based on ONS Data) (personal communication, October 2013)).
There is an excess of over 40,000 deaths among SMI patients which could be reduced if SMI patients received the same healthcare interventions as the general population.
Data published by the Health and Social Care Information Centre (HSCIC) in February 2013 showed that mortality among mental health service users aged 19 and over in England was 4,008 per 100,000 (83,390 deaths in total) compared to the general population rate of 1,122 per 100,000. This mortality rate was 3.6 times the rate of the general population in 2010/11.
People in contact with specialist mental health services had a higher death rate for most causes of death, but in particular:
- Nearly four times the general population rate of deaths from diseases of the respiratory system (at 142.2 per 100,000 service users, compared with 37.3 per 100,000 in the general population);
- Just over four times the general population rate of deaths from diseases of the digestive system (at 126.1 per 100,000, compared with 28.5 per 100,000 in the general population);
- 2.5 times the general population rate of deaths from diseases of the circulatory system (at 254.0 per 100,000 compared with 101.1 per 100,000 in the general population).
Within these disease areas specific conditions that accounted for a high proportion of deaths among service users (under the age of 75) were:
- Diseases of the liver; at 7.6 percent of deaths (1,430 in total);
- Ischaemic heart diseases; at 9.9 percent of all deaths (1,880 in total).
By age, the relative difference in mortality rates was largest among people aged 30 to 39; at almost five times that of the general population – 300 per 100,000 service users (520 in total) compared to 63 per 100,000 in the general population.
Serious mental illness comprises of:
- bipolar disorder and
- Schizoaffective disorder
Patients with schizophrenia will on average die 14.6 years earlier, bipolar 10.1 and patients with schizoaffective disorder die 8 years earlier than the general population.
The causes for the premature mortality and higher rates of death among patients with SMI are primarily due to a higher burden of cardiovascular disease, cancer and liver disease. The risk factors for these conditions are not being managed as well as they are in the general population. As a result, patients with SMI have the same life expectancy as the general population had in the 1950s.
Prevention and early intervention
Issue: There has been considerable success over recent years in reducing suicide risk for mental health services inpatients and in prisons but less progress has been made in reducing suicide rates in the community.
Commitment: NHS England has a role, through its Local Area Teams, in supporting the establishment of local suicide prevention partnerships. These partnerships will maintain oversight of local delivery of the suicide prevention strategy, monitor local incidents and responses and the relationship with local media.
Issue: Smoking is a proven risk factor for cancer, respiratory disease and circulatory disease which are all major causes for premature mortality among patients with a serious mental illness. Smoking rates amongst patients with a serious mental illness are significantly higher than for the average population and smoking is considered to be a major contributory factor to premature mortality in people with a serious mental illness.
Suggested action: Target smoking cessation programmes at people with a serious mental illness. Increase access to and outcomes from smoking cessation programmes for people living with mental health problems in line with Royal College of Physicians and Royal College of Psychiatrists (2013) recommendations. Increase the number of mental health residential units becoming completely smoke free, in line with NICE (2013) recommendations.
Early diagnosis of comorbidities
Issue: It is vital that the physical health of people living with a serious mental illness is checked and it is important that appropriate follow through is provided where physical illness is diagnosed.
Commitment: NHS England will work with partners to explore whether there are models of service provision (including screening) which have proved successful in delivering engagement of people with a serious mental illness, and models of testing for physical illness in community and/or acute mental health services.
Issue: A number of health risks are associated with the prescribing of anti-psychotic drugs.
Commitment: Over the medium term, NHS England will explore learning from best practice examples about how to consistently implement safe prescribing and monitoring practice in primary and mental health specialist care settings, with a view to seeking to:
- reduce harm from prescribing errors and the lack of essential monitoring associated with lithium;
- promote improved awareness and act to reduce the risks of obesity associated with the prescription of anti-psychotics; and promote testing for CVD risk in people on certain anti-psychotics.
Issue: People who are detained in institutions are at higher risk of mental illness than the average population.
Commitment: NHS England will explore the feasibility of delivering health checks for people in prisons, including the feasibility of including testing for mental illness over the medium term.
Issue: Mental health professionals have an important role to play in supporting and improving the physical well-being of people with mental health problems.
Commitment: NHS England, working with Health Education England, will increase the training and support available for mental health professionals in recognising, responding to and improving the physical well-being of with mental health problems.
Issue: In order for effective service delivery and development to take place, relevant data and intelligence need to be captured and communicated.
Commitment: NHS England, working with Public Health England, is establishing a Mental Health Intelligence Network. This will routinely capture data and intelligence on the physical well-being of people living with mental health problems.