On World Mental Health Day, NHS England's National Clinical Director for Mental Health, Dr Geraldine Strathdee, explores the barriers to accessing physical healthcare for people with mental ill health and how we can overcome them.
This week new QualityWatch analysis will explore what differences in hospital use can tell us about the quality of physical health care for people with mental ill health.
The main cause of premature mortality in those with mental ill health is untreated physical illness
It may come as a surprise to many to learn that the main cause of premature mortality in those with mental ill health is unassessed and untreated physical illness. Deaths from causes related to mental ill health, such as suicide, account for under one third of the total.
The facts, which have been known for over a decade, are that people with serious mental ill health die on average 10 to 17 years earlier. For people with psychoses, the under-75 mortality rate is more than three times higher than in the general population.
Forty-six per cent of people in England with a mental illness also have a chronic physical illness, compared to 30% in the general population, and all of the main chronic physical conditions occur at higher rates for those with severe mental illnesses. The conditions that most commonly lead to premature death include respiratory disease and diseases of the digestive system, which are four times higher in mental health service users compared to the general population. Deaths from circulatory diseases are two and a half times higher.
Tackling the stigma
So why, since such excellent progress has been made in the past decade in reducing premature mortality in England, is the situation so different for those with mental ill health compared to their peers? The answers lie in a number of factors, and we need to find ways to tackle this iniquitous health inequality.
First is the issue of stigma, which has prevented people coming forward to seek help early. This is now rapidly changing with public education. The attitude that ‘only the weak and poor’ develop mental ill health has been robustly disabused by the Time to Change programme, as well as courageous speaking out by high-profile, high-achieving parliamentarians, celebrities and sports personalities, and men and women from all walks of life.
This movement to help the public understand the nature of mental ill health, the effectiveness of the treatments once accessed, and the terrible human and economic costs of lack of treatment, has now been recognised.
The impact of illness
Secondly, there is the impact that these illnesses, especially untreated, have on a person’s ability to access help and care. It can be a Herculean task for a person with an active disabling illness, feeling confused, drowsy, anxious and unwell, to travel to get blood tests and attend outpatient clinics in unfamiliar settings.
It can be a Herculean task for a person with an active disabling illness to attend outpatient clinics
Anti-psychotic medications can compound the problems if they are not prescribed and monitored well by a GP or prescribing psychiatrist, and if the patient and their support network are not provided with essential education, lifestyle coaching, robust monitoring and other holistic, NICE-recommended bio-psychosocial care resources.
Until our healthcare system, and those that lead prevention planning and ‘physical’ healthcare, recognise the compelling need for outreach to bring care to people who can’t themselves easily access it, we will continue to see these major inequalities in access and outcomes.
Outreach by third sector and healthcare professionals, whether by phone, text, online, or even face-to-face home support, is of proven effectiveness and not as expensive as the current pattern of neglect, followed by high cost hospital episodes.
Understanding and integrated care
Thirdly, there is the lack of integrated mind and body care in our healthcare system, and the levels of knowledge and attitudes within primary, acute and mental health services around providing physical care for these patients. This is now the major barrier to address.
There are those with the attitude that ‘it’s all about their lifestyle - they need to stop smoking, drinking, taking drugs, and get active, eat better’. As healthcare professionals, we can understand that patients find ways to decrease pain and distress, and the means they choose may lead, unfortunately, to more problems.
The duration of unrecognised and untreated severe mental illness can run into several years. I would argue that it is the major distress caused by untreated or inadequately treated illness that can lead to people finding a way to ‘anaethetise’ their distress.
The search for solutions
Within primary care, people with mental ill health account for one third of consultations each day. However, less than a third of GPs and less than 1% of the practice nurses who would usually carry out routine annual checks are supported with postgraduate training in mental health.
The basic digital systems that have been implemented to support hard-pressed clinicians to treat other conditions, such as diabetes, have not been there for mental health checks. However, the Bradford template, if adopted at pace and scale across England and accompanied by primary care educational support, can deliver fast progress. The same digital support and education is now being rolled out across all specialist mental health inpatient services through NHS England’s Commissioning for Quality and Innovation (CQUIN) scheme, and improvements are now rapid.
Much-needed evidence
The forthcoming QualityWatch report will provide timely evidence of the need to improve overall care for people with mental ill health, showing striking disparities in the amount of emergency care they use compared to the general population.
I hope these findings will focus the minds of policy makers, commissioners and providers on finding a way to rapidly reverse the poor pattern of spending on dealing with adverse impacts of the lack of physical health care for those with mental ill health. Ultimately, they must commission and provide prevention programmes and service models that are proven to provide excellent clinical care at an affordable cost.
The QualityWatch report People with mental ill health and hospital use will be published on Wednesday 14 October.