14 October 2015
Felicity Dormon - Health Foundation - image

Felicity Dormon

Senior Policy Fellow
Health Foundation

People with mental health problems are more likely to have poorer physical health than those without. Premature mortality is higher among people with both severe and common mental health problems – almost three and a half times higher among people with serious mental illness – and this difference is primarily due to issues with physical health.

In this context, the findings of today’s QualityWatch research into hospital use for people with mental health problems are predictably stark. It shows that people with mental health problems use more emergency care and have a greater rate of potentially preventable hospital admissions for conditions which could have been successfully managed in primary care.   

An inspiring conversation

The reasons for poorer physical health among those of us with mental health problems are complex. Health behaviours, mental health medications and access to and quality of health care all play a role.

Alan and his team took a multidisciplinary approach: as well as focusing on prescribing they involved physiotherapists, dieticians and exercise therapists.

So what can be done? I was recently inspired by a conversation with Alan Cohen, who has led work to improve physical health in West London’s secure mental health services. As a liaison physician, Alan leads a team that supports mental health patients and staff with physical health care. Their work has reduced cardiovascular risk among service users classified as high risk from 7% to 2%. This is compared to a rate of 1.7% among the general population, and 4% among people with severe mental health problems living at home.

Alan and his team took a multidisciplinary approach: as well as focusing on prescribing they involved physiotherapists, dieticians and exercise therapists. When progress was difficult, the team took training in motivational interviewing, which really helped support people in making changes. 

In terms of integrating care, they have built physical health into standard care coordination – ensuring information is available for meetings, and being on hand to discuss how best to make sure people’s physical health improves.

Some aspects of secure inpatient care make physical health care easier than the community: people stay in the service for a long time, and are available for appointments and check-ups. But this is also a cohort of people who you might expect to have the worst physical health: on high levels of medication, limited opportunities to exercise, relatively isolated from family and friends.

Parity in physical health

So if people in West London’s Broadmoor site, who have severe and enduring mental illness, can have the same cardiovascular health as the general population, surely this is an attainable goal for everyone with a mental health problem?

Three things are needed to tackle the issue:

  • Excellent physical healthcare for people with mental health problems, and support for behaviour change – for instance, stopping smoking or taking more exercise.
  • A holistic approach to treating people’s mental and physical health – with tailored interventions depending on each individual’s co-morbidities, as helpful.
  • Understanding of the best ways to organise and deliver services to achieve the above.

Government has recognised the problem and taken some steps towards solving it.: smoke free mental health units are being encouraged, and a smoking ban is in prisons is being phased in from January.  In 2014, a payment for health checks in mental health inpatient settings was introduced. This followed the previous removal of health check payments for people with severe mental health problems in general practice. Whether or not payments for health checks are part of the solution, they are certainly not the whole thing.  

Opportunities for change

The shifting landscape in health and care offers an opportunity to rethink what the physical aspects of integrated care for people with mental health problems are. How will ‘vanguards’ and devolved areas rise to the challenge?

In West London, the liaison physician model has worked well for people in secure services – but it is harder to envisage this running in parallel with general practice for the majority of people using mental health services, who already have GPs. Instead, GPs could co-locate with community mental health teams (perhaps as a service provided by a federated system), and people in the teams’ care could see their GP as part of normal mental health care. This would also allow co-located GPs to specialise in physical health management of people with mental health problems, and easily get involved in the mental health multidisciplinary team.

GPs could co-locate with community mental health teams, and people in the teams’ care could see their GP as part of normal mental health care

Another model, given that around 20% of the population have a mental health problem and these patients constitute a disproportionate volume of GPs’ workload, would be to have GPs in every practice with responsibility for people on the list who have mental health problems. This would allow them to build their skills and focus on integrated care for this cohort.

Psychological therapies could also be a part of the solution. Pilots have shown their positive impact in the NHS when tailored to particular long-term conditions, improving mental health and physical health simultaneously. Personal budgets – traditionally underutilised in mental health – could support physical activity and reduce isolation. So, too, could the voluntary sector, through social prescriptions or other innovative methods of broadening the scope of healthcare.  

There are examples of exciting and innovative practice around, including in the plans for vanguards. But they are not widespread – perhaps because of money, perhaps because of priority, perhaps because of our collective lack of aspiration for people with mental health problems.

The challenge now for national policy makers and local leaders is to find the will and resource to make change happen at a pace, before another generation of people with mental health problems die years earlier than they should.


AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE Thanks so much for your emphasis on opportunities and solutions. There is one further aspect I would propose and thats the opportunity for early intervention to address the cardiovascular and metabolic risks that accelerate within weeks of the diagnosis of psychosis and its treatment. This was an aspect dear to the late Professor Helen Lester, another inspirational GP like Alan Cohen dedicated to the art of the possible (see Professor Lester's extraordinary James McKenzie Lecture to the RCGP only months before her death https://www.youtube.com/watch?v=tqyACm5OQOM ). In the last few years it has been my privilege to work with Helen and Sydney psychiatrist, Jackie Curtis and her colleagues on initiatives to address these early antecedents of future physical illness - see 1. Lester Positive Cardiometabolic Resource http://www.rcpsych.ac.uk/quality/nationalclinicalaudits/schizophrenia/nationalschizophreniaaudit/nasresources.aspx 2. Healthy Active Lives international consensus https://www.nice.org.uk/guidance/cg178/resources/healthy-active-lives-heal-consensus-statement-international-physical-health-in-youth-working-group-191766493 By attending to these potentially modifiable risks early Jackie Curtis's team in Sydney are now demonstrating remarkable results http://www.ncbi.nlm.nih.gov/pubmed/25721464 Moreover these benefits are being translated into english service developments in Worcestershire - the SHAPE programme - a case study for NHSIQ http://www.nhsiq.nhs.uk/media/2582868/shape-case-study.pdf In summary I think these new service developments challenge us to think of integrated approaches that don't just wait till CVD risks become established and far more difficult to reverse. This is not rocket science - these are exactly the approaches that have driven preventive approaches to CVD in the general population. CVD and diabetes need not be inevitable consequences for people experiencing severe mental illness.
David Shiers (not verified)
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