Nisi sana mens, non sanum corpus – there’s no health without mental health
In the time I have spent working in the area of mental health few things have impressed themselves more forcibly on me than the impact of the artificial divide between physical and mental health. Institutionally the NHS has neglected the physical health needs of people with long term mental health issues and the mental health needs of people with long term physical health conditions. It has done so at enormous cost both to the individuals involved and the public purse.
In February 2012 the Centre for Mental Health and the Kings Fund published an important report Long term Conditions and Mental Health: The Cost of Co-Morbidities which set out the scale of the issue. They estimated that co-morbid mental health problems, interacting with and exacerbating physical illness, raise health care expenditure by 45% for each person. In total these extra costs account for between 12 and 18% of all NHS expenditure on long term conditions or, in cash terms, between £8 and 13 billion each year. At the same time, there is evidence that the provision of psychological interventions for this group of patients and better liaison between mental health specialists and their colleagues in acute and primary care can play a major role in reducing those extra costs.
For an NHS struggling with unprecedented financial pressures this has got to be a crucial focus for investigation and intervention and yet, so far, it only seems to be playing a marginal role in debates about integrated care and the transformation of services.
I have been very pleased that my new organisation, the Tavistock and Portman NHS Foundation Trust, has been playing an important role in developing a service model which addresses this issue. Working with local GPs in City & Hackney we have been delivering a Primary Care Psychotherapy Consultation Service which supports them in the management of patients with complex mental health and others needs which result in frequent health service use. This including patients with medically unexplained symptoms, personality disorders or other chronic mental health issues which are not currently being managed by secondary services. The service supports GPs either through case discussions and training or through brief psychological interventions.
Today we are publishing an evaluation of the service carried out by the Centre for Mental Health. This shows that the service is both achieving good outcomes for patients (75% show improvements in mental health, well-being and functioning and 55% met clinical thresholds for “recovery”) and having a significant impact in reducing the utilisation of primary and secondary care. The service saves £463 per patient in the 22 months following the start of treatment. This is against a typical cost of treatment of £1,348 per patient and in my view there would be a strong case to believe that greater savings would accrue over a longer term period in cases where the services succeeds in addressing underlying long term mental health issues.
This is not a one size fits all response to the challenge of integrating physical and mental health and there are plenty of other opportunities for mental health services to work creatively with their physical health partners to address individuals’ need in a holistic way which helps them and makes better use of health service resources. Primary care is a good place to start because many GPs already clearly understand the interrelationship of physical and mental health issues. This kind of thinking however should also be high up on the agenda of acute providers and has a good claim on resources available through the Better Care Fund.
There are many good practical and financial reasons for supporting this kind of approach. It does also raise a more fundamental need to challenge a medical paradigm which focuses on every greater specialisation and on physical health as an exclusively biological phenomenon without considering wider psychosocial factors which might impact on a patient’s life. Furthermore it highlights the current inadequacies of clinical training which mean, for instance, that is still possible for a medical trainee who does not end up as psychiatrist spending as little as 5 weeks of the undergraduate training on mental health.
As a layman it makes total intuitive sense that my physical health and wellbeing are intimately tied up with my mental state. It’s time the NHS really acknowledged that there can be no health without mental health.
The evaluation of the City and Hackney Primary Care Psychotherapy service can be found at: