As the NHS strains to deliver productivity improvements to the value of £20 billion by 2014, Chris Naylor argues that paying greater attention to the mental health and psychological components of physical illness could provide an important part of the answer.
The interaction between physical and mental health has been attracting increasing attention across the political spectrum. Last year, the government’s mental health strategy, ‘No health without mental health‘, recognised the importance of the issue. And more recently, Andy Burnham chose integration of mental and physical health care as the subject of his first major speech since returning to the health portfolio.
People with physical health problems, particularly long-term conditions such as diabetes or heart disease, are several times more likely to experience mental health problems than the general population. But health and social care services in England are not currently organised in a way which supports an integrated response to the dual mental and physical health care needs that people often present with. The institutional and professional separation of mental and physical health care leads to fragmented approaches in which opportunities to improve quality and efficiency are missed.
For several years the overriding priority of health systems across the developed world has been to build more effective ways of supporting people with long-term conditions. The challenging financial environment now makes this more pressing than ever. In England, these conditions account for approximately 70 per cent of total NHS expenditure. The ‘Nicholson challenge’ – productivity improvements worth £20 billion by 2014 – is unlikely to be met without redesigning services for this critical group. In this context, the effect of mental health problems in exacerbating these conditions becomes impossible to ignore.
Around 30 per cent of people with a long-term condition also have a mental health problem, such as depression, anxiety or dementia. The effect of these co-existing (in medical parlance, ‘co-morbid’) problems on service costs is striking. New research published by the King’s Fund and the Centre for Mental Health shows that by interacting with and exacerbating physical health problems, mental health problems raise per patient medical costs by between 45 and 75 per cent. These are the costs associated with care for physical illness, and exclude any additional mental health treatment costs. The effect is seen across a wide range of very different conditions, including diabetes, heart disease, arthritis and respiratory conditions.
These excess costs imply that between 12 and 18 per cent of all expenditure on long-term conditions is linked to poor mental health – between £8 and £13 billion across the NHS in England. Again, it is important to stress that these are the indirect costs of poor mental health exacerbating physical illness, rather than any direct mental health treatment costs, which are additional to this.
While the effect on costs is important, co-morbid mental health problems also have a measurable impact on what matters most to people using health services; their prognosis and outcomes. Mental health problems can complicate people’s physical health conditions significantly, resulting in them spending more time in hospital, experiencing poorer clinical outcomes and lower quality of life, and requiring more intensive support from services. For example, studies have shown that children with diabetes are more likely to suffer retinal damage if they also have depression, and that depression increases mortality rates after a heart attack by an astonishing 3.5 times.
Why does poor mental health have such a marked effect on physical health? There are a number of factors involved, but one of the most significant is that mental health problems can significantly reduce people’s ability and motivation to manage their condition, and are associated with poorer adherence to treatment plans and increased rates of unhealthy behaviours such as smoking. There is also a growing evidence base suggesting that poor mental health; for example, chronic stress, can have a direct impact on the cardiovascular, nervous and immune systems, leading to increased susceptibility to a range of diseases.
The impact of poor mental health on service costs and patient outcomes is made stronger still by harsh socio-economic conditions. For people with multiple long-term conditions living in socially deprived areas, co-morbid mental health problems are the exception rather than the rule, affecting over 50 per cent of patients. Supporting the mental health needs of people with long-term conditions should therefore be a particularly important concern in less affluent areas.
It should be stressed that this problem, and the human and financial costs that arise from it, are not unavoidable. There is growing evidence that supporting the psychological and mental health needs of people with long-term conditions more effectively can lead to improvements in both mental and physical health, and can also reduce the excess costs associated with co-morbidity. Existing health care provision often fails to realise these opportunities. A separation of mental and physical health is hard-wired into institutional arrangements, payment systems and professional training curricula. As a result, mental health problems commonly go undetected among people with long-term conditions, and where problems are detected the support provided is often not effectively linked or co-ordinated with care provided for physical problems.
The evidence reviewed in our paper suggests that there are a number of ways we could support the mental health needs of people with long-term conditions more effectively, including through closer working between primary care and mental health professionals, integrating psychological interventions into disease management programmes used to support people with long-term conditions, and investing in psychiatric liaison teams which detect and treat mental health problems among hospital patients.
The scale of the impact of co-morbid mental health problems on service costs and clinical outcomes suggests that developing services that respond more effectively to these combined needs should be a priority in the NHS and elsewhere. The government’s mental health strategy includes positive reassurances about the importance placed on this agenda. The challenge however lies in implementation and in holding the system to account for delivering the more integrated services needed.
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Note: This article gives the views of the author, and not the position of the British Politics and Policy blog, nor of the London School of Economics.
Chris Naylor joined The King’s Fund in 2007 and conducts research and policy analysis on a range of topics. He leads the Fund’s research on mental health, and also works on other policy issues including clinical commissioning, health system reform, and the development of integrated care.