Abstract
Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care. 1
Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. 2 While such investment is also crucial, we believe that there is great unrealised opportunity for integration in developing new approaches to mental health within primary care.
Mental health problems are very common in the community; 90%of adults with mental health problems are supported largely or exclusively by primary care. 2 Mental health problems often co-exist with physical health problems; the King’s Fund highlighted that 12–18%of NHS expenditure on long-term conditions is linked to anxiety, depression or other mental health problems. 3 Furthermore, as the UK population ages, we will see an increase in the number of people with co-existing physical and mental health problems. Alongside diagnosable mental health problems, sub-threshold symptoms are common in primary care and often co-exist with high levels of complexity and challenging social circumstances, such as unemployment and poor housing. 1 Medically unexplained symptoms and substance abuse disorders are also highly prevalent in primary care.
Unfortunately, these kinds of problems are often poorly managed through current arrangements. Clear referral pathways exist for people suffering severe mental illnesses and, in England, the Improving Access to Psychological Therapies (IAPT) programme has recently improved availability of psychological therapies for non-complex cases of mild to moderate depression or anxiety. However, for more complex presentations, current arrangements are often poor in terms of clinical and cost-effectiveness. In addition, monitoring of physical health among people with severe mental illnesses remains inconsistent.
General practice is currently under extreme pressure in England and elsewhere;4,5 part of this pressure relates to complex cases with superimposed mental health, physical health and social challenges, associated with frequent service use and attendance in general practice. This is compounded by significant pressures in specialist mental health services, 6 which in some cases lead to raised eligibility thresholds and more complex patients being managed in primary care. GPs have expressed concern over the level of risk they carry in the absence of specialist support. 4 Furthermore, despite the introduction of the IAPT programme, there remains considerable variation in availability of psychological therapies for adults with common mental health problems, which meet only 15% of current need. 2 Overall, part of the high stress and dissatisfaction levels experienced by GPs relates to managing these patients effectively.
We believe that a new approach towards mental health in primary care could alleviate some of this pressure. There is no simple solution that can be implemented everywhere, but we can learn from examples of real-life innovations. In the UK, there is a ‘Primary Care Psychotherapy Consultation Service’ in City and Hackney, London, where a multidisciplinary team of mental health professionals help GPs manage complex patients (e.g. medically unexplained symptoms, co-morbidity, personality disorders). This service includes direct one-to-one consultations with patients, joint consultations with GPs and a significant emphasis on training and skills transfer. Outcomes include increased confidence among GPs, significant improvements in mental health and functioning, and reduced service use in primary care and A&E. 7 New approaches are also being developed in ‘vanguard sites’ as part of the NHS ‘Five Year Forward View’; for example, the integration of mental health support within enhanced primary care models.
Internationally, the Mental Health Integration programme delivered by Intermountain Healthcare in the USA provides an example of what can be achieved by re-engineering the relationship between mental health and primary care. 8 A key lesson from this programme is that consistent messaging is needed from senior leaders in the health system, which normalises mental health as part of routine care in general practice. 1 More widely, it is increasingly being recognised in the USA that mental health needs to be a core part of the patient-centred medical home (PCMH) model, as captured by a joint statement of professional bodies asserting that ‘PCMH would be incomplete without behavioural health care fully incorporated into its fabric’. 9
Research trials in the UK, USA and elsewhere have demonstrated the clinical and cost-effectiveness of collaborative care models for supporting people with co-existing mental and physical health conditions in primary care, involving a case manager working closely with GPs and a mental health specialist.10,11 NICE now recommends this approach for treatment of moderate to severe depression alongside a chronic physical health condition. However, outside of research trials, the approach has not yet been widely adopted.
The GP Forward View emphasises the importance of developing new models of general practice, with GPs acting as leaders of larger multidisciplinary teams. 12 As part of this, primary care should seize its crucial role in delivering closer integration of physical and mental healthcare. General practice has traditionally been seen as the jewel in the crown of the NHS but it is coming under growing pressure that is multi-factorial. 5 Securing the future of general practice will require innovative thinking; in particular, we need an integrated approach to managing complex patients with overlapping mental health, physical health and social issues effectively within primary care.