A patient's experience is not fragmented, discontinuous and segregated so why is their treatment? Samantha Allen and Heather Hurford argue for integrated care
Even the most confirmed dualist would today admit the intimate connection between mind and body. Yet in healthcare we persist in treating mental and physical health in different systems.
This not only has a negative impact on the patient but also has serious consequences for the health service. Treating people in diagnostic silos creates inefficiency, redundancies and costs that only a more integrated approach can eliminate.
The commissioning and delivery of care must become more integrated, based on need, choice and experience. Developing a patient centred healthcare system has been on the national agenda for five years, but until we begin to take action and fuse mental health services into every aspect of care we will not be able to take this goal seriously.
A patient's experience is not fragmented, discontinuous and segregated but their care is all of these things. People may become depressed when they become ill and they may become ill when they become depressed and these are only the most obvious examples.
Indeed, despite all the well deserved attention focused on the importance of non-communicable chronic diseases such as diabetes and cancer, the non-communicable diseases with the biggest impact - disorders of stress, anxiety and depression - are invariably afterthoughts to commissioners. This is in spite of the programme of reform that the national service framework for mental health has provided.
In some areas, commissioning mental illness and mental health services is working well. In most areas it is presenting a real challenge. Why is it that mental health commissioners are often disconnected and in silos within their own organisations? Mental health commissioners should be providing subject matter expertise to ensure wise investments are being made to optimise outcomes and achieve best value.
Beyond the figures
In the UK, mental health problems affect approximately one in six people at any time. Nearly a third of GP consultations are related to mental health. These statistics represent the visible prevalence of mental health issues and impact on the NHS. However an integrated, person centred approach to care demands that we look beyond these figures.
Severe mental illness must be recognised as one of the most complex long-term conditions. There is strong evidence that people with schizophrenia or bipolar illness have significantly diminished health horizons.
On average their life expectancy is reduced by 10 years. They are twice as likely to die from coronary heart disease and have diabetes and are four times more likely to die from respiratory disease. They are likely to have a higher incidence of heart disease, stroke, hypertension and epilepsy and have a 50 per cent lower chance of survival from cancer.
Research shows there is a strong association between many physical health problems and depression and that depression is associated with poorer outcomes, lower levels of self-care and increased use of hospital beds.
In addition, there is strong evidence that a large proportion of secondary care resources are used by frequent attendees whose symptoms remain medically unexplained. Although they can be discharged from secondary care, many are often subsequently referred to another specialist and continue to attend.
There is growing evidence of high prevalence of psychiatric morbidity both in frequent attendees and in those presenting with medically unexplained symptoms in both primary and secondary care. Twenty-five per cent of patients with chest pain who come to accident and emergency departments have panic disorder and half of the patients seen in cardiology and neurology have medically unexplained symptoms.
The findings highlight the negative impacts of our disjointed and inefficient health system both at the individual level and more widely among providers and commissioners. Furthermore it demonstrates the urgency to redesign services which are fully integrated and completely meet the individual's needs.
A new system also needs to empower people to take responsibility for their own health. To date, integration and joint working has been taken forward by diagnostic category and/or age. In order to achieve this integration in care, both the NHS and social care will have to adopt integrated thinking about how it commissions that care. It would be a mistake to underestimate the barriers to doing so. Some of these barriers exist in the mental health community itself, with many valuing the special status it enjoys.
In part this is because mental health services do require a particular focus as they remain vulnerable to investment priorities and the decisions of commissioners. Particularly when services continue to be commissioned in diagnostic silos and against historic baselines, their effectiveness and efficiency remain difficult to measure. However, continuing to sequester mental health services ultimately undermines the provision of physical healthcare and disadvantages the provision of mental healthcare. Integrated care and integrated commissioning will work to the advantage of both systems and is essential in improving care for patients.
The vision for world class commissioning provides a platform for system reform which is not driven by diagnostic silo. The vision is "better health and well-being for all, better care for all and better value for all". This important policy makes no specific mention or focus on mental health commissioning. We should rejoice at the opportunity to transform our delivery system to one that is integrated around the individual, whatever type of care that person needs.
As we celebrate the NHS's 60th anniversary and await the outcome of the Lord Darzi's next stage review and a possible NHS constitution, let us hope person centred care is reflected in practice. Better health and well-being for all, better care for all and better value for all is all of our business - as patient, provider, commissioner and policy maker. To achieve this vision, integrated person centred care needs to be commissioned and delivered. This will challenge practice and policy at every level but it needs to be led by commissioners working with communities and providers at a local level.