Health CommitteeWritten evidence from Centre for Mental Health (LTC 17)

About us

Centre for Mental Health is an independent national charity working to improve the life chances of people facing or living with mental ill health. We act as a bridge between the worlds of research, policy and service provision and we promote high-quality evidence and analysis. We encourage innovation and advocate for change in policy and practice through focused research, development and training. Our evidence to the Committee is derived from our research and analysis work. We have responded to the Committee’s questions on which we have relevant knowledge.

Evidence

The scope for varying the current mix of service responsibilities so that more people are treated outside hospital and the consequences of such service re-design for costs and effectiveness

The readiness of local NHS and social care services to treat patients with long-term conditions (including multiple conditions) within the community

The practical assistance offered to commissioners to support the design of services which promote community-based care and provide for the integration of health and social care in the management of long-term conditions

The ability of NHS and social care providers to treat multi-morbidities and the patient as a person rather than focusing on individual conditions

At least one-third of people with a long-term physical illness in England also have a mental health condition, most commonly depression or anxiety.1 People with a severe or enduring mental illness, meanwhile, typically have very poor physical health. In neither case is the NHS currently well placed to offer “whole person” care to people living with a combination of mental and physical ill health. The barriers to integrated care include:

Different payment systems: The development of Payment by Results in mental health care has been slow and there is not yet a national tariff in place. Differences in the way mental and physical healthcare are paid for have hampered the development of integrated support.

Diagnostic overshadowing: People with a long-term physical illness rarely have their mental health needs recognised. Likewise, people with a severe mental illness seldom receive adequate support for their physical health despite having very high rates of smoking, obesity and alcohol dependency.

Poor outcome measures: the NHS, public health and adult social care outcome frameworks contain few measures relating to multi-morbidity. Data collection tends to focus on single conditions and episodes of care, obscuring the needs of people with multiple conditions.

Current examples of effective integration of services across health, social care and other services which treat and manage long-term conditions

Community mental health services have for a long time featured high levels of integration between health and social care. Social workers are embedded in community mental health services, including teams with specialist functions such as crisis resolution, early intervention and assertive outreach. A growing minority of mental health services also integrate support with housing, employment, welfare and debt advice.

There is increasing evidence of the economic benefits of integration: the Individual Placement and Support approach can help more than half of people using mental health services into paid work, compared with a national employment rate of about one in ten, yet it costs no more than traditional vocational services.2 One of its key components is the integration of health and care, employment support and benefits advice.

The implications of an ageing population for the prevalence and type of long term conditions, together with evidence about the extent to which existing services will have the capacity to meet future demand

The interaction between mental health conditions and long-term physical health conditions

Mental and physical health are inextricable. People with a mental health condition are more likely also to have a significant physical illness and to experience poorer outcomes.

Depression is at least twice as common among people with a range of long-term conditions including stroke, COPD, cardiac disease and diabetes. Cardiovascular patients with depression have higher mortality rates: including a 3.5 times higher death rate following a heart attack. People with diabetes also have higher mortality rates and a greater risk of complications if they also have depression.3

The cost to the NHS of mental ill health among people with a long-term physical condition is an estimated £10 billion.4 This additional cost can result from poorer self-care, higher rates of hospitalisation and outpatient service use, and greater use of medications. Improving mental health support for this group could significantly cut the extra costs and generate large savings to the overall health economy of an area (including to social care). Measures that would help to reduce the cost and improve quality of care include:

Liaison psychiatry services in general hospitals: these offer immediate access to mental health support throughout the hospital. They provide specialist treatment as well as advice and training to other hospital staff. The biggest cost savings can be achieved through reduced admissions and lengths of stay among older patients, particularly those with dementia. A well-managed liaison psychiatry service could cut the costs of a “typical” hospital by £5 million a year.5

Improving access to psychological therapies: the IAPT programme is beginning a pilot programme to extend psychological therapy access to people with long-term conditions and those with medically unexplained symptoms.

Collaborative care: there is growing evidence that integrated health support for people with co-morbid physical and mental health conditions is cost-effective.6 This is achieved through appointing a “care manager” who coordinates all the services an individual requires and offers advice and support for self-management.

For people with a severe mental illness, better physical health support is vital to close the 15–20 year life expectancy gap. This should include tailored smoking cessation services, medication management and practical support with diet and exercise. Emerging evidence from the United States suggests that multi-disciplinary teams working to support the physical and mental health (as well as social care, housing and financial needs) of people with a severe mental illness are cost-effective.7

The extent to which patients are being offered personalised services (including evidence of their contribution to better outcomes)

Mental health services are increasingly moving away from their traditional focus on symptom management to a new focus on helping people to achieve personal recovery. Taking a recovery approach means focusing on what people need to achieve the best possible life with or without the symptoms of mental illness. Clinical care remains important but it is in support of other goals in life (eg relating to work, family and friends) and it is the individual service user who determines their own priorities.

Key features of recovery-oriented mental health services include increased use of Peer Support Workers—people whose experience of mental illness enables them to offer hope and knowledge to others—and the development of Recovery Colleges, which provide education opportunities and are delivered by service users, carers and professionals together.8 The use of personal budgets can also support a recovery focused service. A pilot in Northamptonshire offering personal budgets to mental health service users found that about two-thirds of the money was spent on “traditional” mental health care while the remaining one-third was spent on a range of alternatives including personal assistants, exercise, education and IT equipment.9

Evidence about the outcomes that recovery-focused services can achieve is still emerging. Longer term evaluations of Recovery Colleges and Peer Support Workers are yet to be attempted. Nonetheless, we do know that supporting people with mental health conditions into paid employment generates significant improvements in physical and mental health, including evidence of reduced hospital admissions over time.10

9 May 2013