Health CommitteeWritten evidence from The Royal College of Psychiatrists (LTC 82)

This submission is from the Faculty of Liaison Psychiatry at the Royal College of Psychiatrists.

1. Introduction and Summary

1.1 The Royal College of Psychiatrists (RCPsych) is the leading medical authority on mental health in the United Kingdom and is the professional and educational organisation for doctors specialising in psychiatry.

1.2 Liaison psychiatry is the sub-specialty which provides psychiatric treatment to patients attending general hospitals, whether they attend out-patient clinics, accident and emergency departments or are admitted to in-patient wards. Therefore it deals with the interface between physical and psychological health.

There is now abundant evidence that medical and surgical patients have a high prevalence of psychiatric disorder which can be effectively treated with psychological or pharmacological methods.

1.3 Our evidence focuses on the interaction between mental health problems, such as depression and anxiety, and long-term physical health conditions, and the implications of this interaction for individuals, clinicians, healthcare providers and commissioners. This evidence will also be relevant to other issues under consideration by this Select Committee, including the location of care for people with long-term conditions (LTCs) and the integration of care across traditional healthcare boundaries.

1.4 The issues we consider include:

(1)What constitutes a long-term condition.

(2)The problem of multimorbidity.

(3)Where is the majority of healthcare for LTCs provided?

(4)What do patients with multimorbidity and complex healthcare needs want?

(5)Problems in the current system.

(6)What is needed to address the problems in the current system.

(7)Specific recommendations.

1.5 Our evidence will show that, among people with long-term conditions:

(1)Depression and/or anxiety are also commonly present.

(2)Depression and/or anxiety are associated with much worse physical and psychological outcomes.

(3)Such depression and anxiety is unlikely to be adequately treated.

(4)Integration of psychological and physical care improves both psychological and physical outcomes.

(5)Systems of care that integrate psychological and physical care, such as collaborative care, are effective, particularly when supported by expert psychiatric supervision, though such care is seldom available.

2. What Constitutes a “Long-term Condition”?

2.1 Long-term conditions are those conditions that are long-lasting and not curable, but are manageable with drugs and treatment. Such conditions include long-term physical health conditions (some of which are medically unexplained) and long-term psychiatric conditions. Depression and anxiety are treatable but chronic and recurrent disorders, resulting in considerable distress and disability. In the recent government report Long-term conditions compendium of information,1 depression constitutes the second most common LTC, affecting nearly five million individuals, according to Quality and Outcomes Framework disease registers. The WHO identifies depression as the leading cause of disability in high-income countries.2 Depression and anxiety must be considered when planning services for people with LTCs.

3. The Problem of Multimorbidity

3.1 The prevalence of long-term conditions is predicted to remain fairly stable over coming years, but the prevalence of multimorbidity, where people suffer from more than one LTC is likely to increase with the aging of the population.181 A significant proportion of this multimorbidity arises due to the co-occurrence (ie co-morbidity) of depression and/or anxiety with a long-term physical health condition. Around 10–20% of people with a long-term physical health condition also suffer from depression, which is about two to four times the prevalence seen in the general population. A similar percentage of people suffer from a range of other common mental disorders and symptoms, including anxiety, adjustment disorder and worry.

3.2 The importance of depression and anxiety when present in someone who also has a long-term physical health condition is that they are associated with much worse outcomes for the physical condition, including doubling of mortality and morbidity, worse health-related quality of life, greater healthcare utilisation and increased healthcare costs. Depression and anxiety probably exert such effects by complicating self-care,3 reducing adherence to medication, healthy diet, and exercise, and increasing maladaptive health behaviours, such as smoking, drinking and taking illegal drugs. It has been estimated that up to 18% of the NHS costs of managing LTCs is attributable to the presence of co-morbid depression and anxiety.4

4. Where is the Majority of Healthcare for Long-term Conditions Provided?

4.1 Specialist secondary care services mostly focus on single diseases or disorders affecting single bodily systems and (with few exceptions) are not equipped to manage the growing numbers of people with multimorbidity. Consequently the majority of care for people with long-term conditions, particularly those with multimorbidity, is managed within primary care, with support for the management of specific disease provided by secondary care.

5. Problems in the Current System

5.1 Current health services are not well organised to support an integrated response to patients with complex healthcare needs due to multimorbidity, because care is organised around single conditions.5 This has always been a problem in secondary care specialist services, though introduction of health policies and service targets that mostly focus on single disorders (National Service Frameworks, NICE guidance, Quality and Outcomes Framework targets) mean that primary care in now similarly affected. There is limited service organisation around multimorbidity and when multiple conditions co-exist, they are dealt with “in series” rather than “in parallel”,6 with the result than treatment of some conditions is prioritised over that of others, and some conditions never receive adequate attention. Professionals recognise the tensions between focusing on disease-orientated targets and providing care that focuses on the individual needs of the patients, and that they are exacerbated in people with co-morbidity.

5.2 The institutional and professional separation of mental and physical healthcare means that care becomes particularly fragmented when physical and psychological health problems co-exist.7 Depression and anxiety among people with long-term physical health conditions are often not detected, and even when they are detected often remain under-treated, due to:

(i)the prioritisation of the associated long-term physical health condition,

(ii)a reluctance to diagnose stigmatising conditions such as depression and anxiety, and

(iii)a lack of time to assess, diagnose and negotiate treatments for depression and anxiety.8 ^, 9

5.3 Support/supervision available from secondary care to manage such patients is very limited. For patients this failure to treat depression and anxiety leads to persistence of unpleasant psychological symptoms and their continued adverse impact on physical health. Inefficient and poorly co-ordinated care further adds to the illness burden on patients, with repeated visits to multiple professionals. For primary healthcare professionals, depression and anxiety complicate both assessments and management decision-making; they also place a strain on limited resources, such as short appointment times. Such care is often split between professionals, for example between practice nurses and psychological therapists, so inter-professional communication becomes more important but also more complicated and therefore likely to fail.10 Under such circumstances, the quality of patient care is poor and patients’ confidence in and satisfaction with their healthcare can suffer as a consequence.

6. What do Patients with Multimorbidity and Complex Healthcare needs want?

6.1 In a survey of public opinion, patients with LTCs said that they want to be supported to engage in their care and to contribute to the decisions made about it. They also want a proactive and seamless service, in which the NHS acts as a team and they are treated as a whole person.11 This is very consistent with the preferences stated by individuals with multiple long-term conditions,12 who stressed convenience of access, continuity of care, clear communication, care that is individualised around their own unique requirements and to have their opinions heard. Considerable value is placed on care being integrated around the needs of individual patients, rather than fragmented due to a focus on a single disease.

7. What is needed to Address the Problems in the Current System?

7.1 Some of the problems around the detection and management of depression and anxiety in people with long-term physical health complaints relate to the inadequate training of professionals in primary and secondary care. In medical and nursing schools the emphasis on psychiatric training is placed on diagnosing and managing hospital patients with psychosis, despite the fact that very few trained doctors/nurses are ever required to treat such severe disorders. Training around detection and management of depression and anxiety in people with long-term physical health problems is virtually non-existent, despite the fact that all doctors will encounter these problems. Training in mental healthcare among qualified professionals usually does not extend to the complexities of diagnosis and management of people with long-term physical health conditions (even among psychiatrists).

7.2 In additional to training, there are broader and more deeply ingrained problems around the management of patients with multiple problems. When faced with a patient with complex needs, commonly a professional will formulate a problem list, with objectives ranked and addressed from those perceived to be the most important downwards. In current circumstances, in which resources, not least time, are limited, this frequently means that not all problems are given adequate priority. Mental health problems are usually seen as having minor importance, and consequently are not dealt with at all.

7.3 Systems of care, such as collaborative care, which integrate psychological and physical care, have been shown to be cost-effective in primary and secondary care settings. In such care, depression and anxiety are treated at the same time as the long-term physical health condition, by the same healthcare professionals, using synergistic treatments that are coordinated. Such care is most effective when supported by supervision from experts in physical and psychological health, for example by a liaison psychiatrist. However, integrated care such as that delivered by collaborative care is seldom available. Most of the evidence supporting its use comes from the US; it remains unclear whether it is effective in NHS primary care setting and how it is best implemented, indicating that further research is required.

8. Conclusions

8.1 The natural home for management of people with multimorbidity, particularly with combined physical and psychological problems, is primary care, with specialist support easily available from secondary care.

8.2 Depression and anxiety are common in people with long-term physical health conditions, predict worse medical outcomes and increased costs.

8.3 Depression and anxiety are usually under-detected and under-treated in people with long-term physical health conditions due to:

(i)a lack of knowledge and skills to detect depression and anxiety, then to negotiate, initiate and monitor evidence-based treatment.

(ii)limited resources to manage people with complex healthcare needs arising from combined physical and psychological problems.

(iii)systemic barriers that prevent easy access to supervision and support from specialists with expertise in managing people with complex physical and psychological healthcare needs.

8.4 Systems of healthcare that integrate physical and psychological care are available, but their effectiveness in the UK is unclear, as is the best means to implement them.

9. Specific Recommendations

9.1 Informed and supported self-care should remain the basis of care for many people with LTCs.

9.2 Appropriately resourced general practice should remain the main location for managing the majority of care for people with LTCs, including patients with depression, anxiety and long-term physical health conditions. Primary healthcare professionals skilled in the detection and management of depression and anxiety would provide integrated healthcare for long-term physical and psychological problems. For patients with the most complex needs, specific professionals could work across practices, to coordinate care, maintain continuity, promote inter-professional communication and to ensure healthcare needs are met. This professional role might look something like that of Community Matrons, though with enhanced training in the management of depression and anxiety, which was not previously considered a significant part of the professional role. Access to high-quality liaison psychiatry support in primary care, either via out-reach from secondary care or the development of primary care liaison psychiatry services, would assist with the supervision of care of the complex patients. Other specialist secondary care services should be available as required and available within the primary care setting wherever possible.

9.3 Training of generalist healthcare practitioners in primary care should include an increased focus on the causes, effects and treatments of depression and anxiety in people with long-term physical health conditions. This training should start in medical and nursing schools and should extend to qualified healthcare practitioners, with appropriate expertise being a required outcome of professional training.

9.4 Systems of healthcare are required which direct delivery of treatment, maintain continuity of care, and which integrate care across the boundaries of professional expertise, healthcare settings and service providers. Such models of care are available, some are even known to be cost-effective and are part of current healthcare policy, such as collaborative care (in which a particular healthcare professional takes responsibility for coordinating and integrating care), stepped care (where care is escalated to meet patient needs), and shared care (in which care for patients with specific combinations of health problems is shared between professionals).

9.5 Lack of information on the effectiveness of these approaches within the UK National Health Service and guidance on how to implement these complex systems of care, for example when to change care in stepped care, and which professionals deliver collaborative care, mean that delivery of such care is patchy and incomplete. Much of the evidence supporting the use of these complex healthcare systems has been developed in the US and does not necessarily transfer to the UK NHS. More research is required to identify the models of care most appropriate for use in the NHS, and to produce evidence to support the successful implementation of such models of care.

9.6 IT systems should be developed that facilitate both information sharing and communication across boundaries, between providers of health and social care.

9 May 2013

Contributors:

Chris Dickens
Professor of Psychological Medicine
University of Exeter

Michael Sharpe
Professor of Psychological Medicine
University of Oxford

Peter Aitken
Chair-elect of the Liaison Faculty of the Royal College of Psychiatrists