NHS

Improving Quality

Better outcomes,
better value:
integrating
physical and
mental health
into clinical
practice and
commissioning

Overview
Better outcomes, better value: integrating
physical and mental health into clinical
practice and commissioning
24 June 2014
This is a brief summary of the lessons and conclusions that emerged from the event and
reports key elements of the various presentations and workshops. We have used slides from
speaker presentations wherever possible so you can pick up key points without having to
read large amounts of text. Any statistics or facts presented have not been verified by NHS
IQ, where appropriate check the original authors slide deck for further information about the
sources cited.
This document is intended to be used by national bodies, commissioners and providers to
understand the need for integrated care for mind and body, with key recommendations for
these audiences to take action.
The programme for the day is available at http://tinyurl.com/nbm5ops
The speaker biographies are available at http://tinyurl.com/osvzt8w
The full slide set is available here: http://tinyurl.com/nqhhj5v
The event was intended to:
best practice in commissioning integrated physical and mental
Promote
health care
providers and commissioners to explore together the underlying
Allow
reasons for the slow progress towards such integration
commissioners to develop a greater understanding of the mental
Support
health needs of people with physical needs.
Health care professionals, commissioners, academics and patient groups attended the event.
Speakers included senior NHS England figures, including National Clinical Director for Mental
Health Dr Geraldine Strathdee, clinicians, academics, a patient and several commissioners.
This event was produced by NHS Improving Quality, in collaboration with NHS England and
supported by Primary Care Commissioning.

The morning session included addresses from: Dr Geraldine Strathdee, National Clinical Director
for Mental Health, NHS England; Michael Sharpe, Professor of Psychological Medicine at the
University of Oxford; and Bob Ricketts, Director of Commissioning Support Strategy & Market
Development, NHS England, combined with accounts from a patient, professionals and panel
discussions. In the afternoon, delegates heard from examples of commissioning best practice.
Delegates also met in smaller groups to consider commissioning scenarios and the barriers and
obstacles to integrated physical and mental health care.
Dr Strathdee appealed to attendees to support the recommendations and engage with other
commissioners and clinicians to achieve that integration.

Recommendations
Everyone
the myths and prejudices around condition treatment, and any preconceived
Dispel
ideas that physical and mental health are not related
Training and education for all care professionals on how to confidently, effectively and
sensitively screen patients holistically for physical and mental health symptoms, for early

detection and referral.

National bodies
Clearer national guidance about use of Commissioning for Quality and Innovation (CQUINs)
and
other measures to support and incentivise integration
a central repository for case studies of effective physical and mental health care
Develop
integration, to facilitate sharing of good practice and supporting evidence

Commissioners
and funding must reflect the system changes to enable effective
Commissioning
integration, by introducing incentives for integration/pooled budgets/requiring use of

recommended assessment tools

Needs Assessment chapters on mental and physical health/share experiences with provider
and commissioners

health input to physical healthcare service modelling and vice versa

Mental
with social services can address social factors that are affecting the persons
Integration
health and therefore should be included in planning health care.
Patients and the public should be given greater opportunities to support and redesign
services, to better understand the needs of the community involved in the Joint Strategic

Providers
patients commonly present with both mental and physical health conditions/
Where
specialist partnerships and integrated services/single integrated panels for decision

making/pooled budgets/multi-disciplinary teams in place to work across physical and

mental health boundaries
Patients with comorbidities should be provided with compassionate supervision,
a keyworker to step in at times of need

Better outcomes, better value: integrating

physical and mental health into clinical
practice and commissioning
Event report
One-third of
GP contacts are
about mental
health or mental
health is at least
a contributing
factor.

Dr Geraldine Strathdee, NHS Englands National Clinical Director for Mental Health,
questioned how we arrived at separate commissioning and delivery of services for the body
for the mind. Challenging delegates to think again about how we change that, she identified
training and commissioning as key areas of focus.
She pointed to some startling, bleak statistics that suggest we do not train our care staff as
well as other countries:
of people who commit suicide had recent contact with a primary
70%
care professional
than 1% of practice nurses are offered psychological and mental health
Less
training - in spite of the clear link between mental and physical health.
We do not commission integrated health care.
of people in intensive care need psychological support, yet such services are
75%
not including in intensive care unit (ICU) commissioning packages.
In mental health we still have a block contract.
The patient voice the human and long-term NHS costs of disjointed
commissioning
Following a stroke in 2009, Inger Wallis was discharged from hospital three weeks after
major brain surgery with a booklet and a phone number because she was able to make a
cup of tea.

Inger Wallis spoke powerfully and eloquently about her experiences following a brain
haemorrhagic stroke five years ago.
Inger received no initial psychological support to help her prepare for the dramatic impact her
stroke had on her personal and professional life. As the result of the physical changes Inger
experienced after her stroke, she was unable to continue with her fulfilling and successful
career in the Royal Academy of Arts. Not only did the family unit lose the main bread-winner,
but also a strong and independent wife and mother, resulting in her husband and daughters
all suffering poor health as a consequence. Eventually Inger was able to access the lifesaving psychological support she needed from the NHS and voluntary sector. She still relies
on this care to help her deal with the ongoing fear of another stroke, and the anxiety of
living in a world where her brain operates in a
different way to how it used to.
Asked what one thing the health system could
have done that would have helped, Inger replied
that recovery was done to her support should
have been given at the point when she needed
and was ready for it.

The integration of physical

and mental health is vital
and life-saving. Please be
trailblazers, she concluded.

Integration of physical and mental health: the science

Michael Sharpe. Professor of Psychological Medicine at the University of Oxford.

Historically, there was no division of physical and mental health care.

Over the last 100 years or so the parallel development of the greater understanding of
physical disease on the one hand and the development of a separate speciality of psychiatry
for illness where there was no identifiable bodily disease on the other led to a major split
between physical and mental health and its care.
In our modern NHS the separation of physical and mental health care remains and has been
exacerbated by separate trusts, treatments and training programmes.

The problems of this great divide in healthcare include:

a significant overlap of people with mental and physical conditions.
Comorbidity
68% of adults with mental disorders have a physical long-term condition and

29% of adults with physical conditions have mental disorders.

The focus on disease does not help those with symptoms not explained by disease.

The divide also has adverse implications for quality, outcomes and cost

Impedes the quality of care for patients and is extremely distressing for staff treating
patients
Leads to poorer outcomes in terms of patient-reported wellbeing and
Leads to a poor use of resources, including a higher length of stay and readmission driven
by mental health issues and poor use of medicines.
Professor Sharpes examples of the improvement that can be achieved by (re)integration of
physical and mental health care include:
assessment interface and discharge (RAID): A specialist multidisciplinary mental
Rapid
health service, working within all acute hospitals in Birmingham for people over 16 with

mental health or substance misuse needs.

A return on investment of 4 for every 1 spent has been reported with the greatest savings
among the frail and elderly.
Oxford University Hospitals NHS Trust, directly-employed consultant
Atpsychiatrists
work in an fully integrated way with medical and nursing staff to provide a

seamless patient experience.

in America provides a model of care that has proved very efficient and effective
TEAMcare
in treating people with three or more chronic illnesses: depression, heart disease and

diabetes. It involves the whole team treating the patient. The whole team includes
nurses, psychiatrists, primary care physicians and other medical providers and care is
delivered in the patients primary care clinic and by telephone. The model has achieved
average savings of 400 per patient in two years.

Sharpes own research into integrated care for depressed cancer patients found
Professor
that six months after the diagnosis of depression among patients who had integrated

care there was a 62% improvement compared to 17% for patients given usual care. The
findings also indicate that this integrated care is highly cost-effective in improving quality
of life.

For Professor Sharpe the largest challenges are:

and professional separation
Organizational
Unhelpful
attitudes
ignorance arising from inadequate education
Perverse incentives and
through
a focus on diseases and procedures rather than patient

outcomes.
He concluded that change to more integrated care could be achieved without centrally
directing NHS resources around but instead by an emphasis on payment based on patient
reported outcome measures (PROMs)

The commissioning and finance rationale

Bob Ricketts, Director of Commissioning Support Services Strategy and Market Development
at NHS England

There is a moral imperative for integration.

Commissioners are responsible for
parity of esteem, which is a key strategic
commitment.

There is a significant disparity in

outcomes for people with mental
health issues. For example, people
with schizophrenia are twice as likely
to die from chronic vascular disease
and three times more likely to die
from respiratory disease.

Life expectancy for men with mental health problems is 11 years less than the average.
People with diabetes who also have co-morbid mental health problems are at increased risk
of poorer health outcomes and premature mortality.

However, a lot can be done under the

current regulations.

Theory into practice - what good looks like.

Practical examples of integration.
Diabetes and mental health
Depression is at last being considered as a factor in the care of people with diabetes,
described by Professor Jonathan Valabhji as the cardinal multifunctional disorder.
Professor Valabhji, National Clinical Director for Obesity and Diabetes at NHS England,
cautioned however that the association between schizophrenia and type II diabetes is still
poorly understood.
The geographical separation between acute and mental health trusts, he suggested, means
that it is difficult to incorporate whole care in ward rounds.
He pointed to practical solutions such as that in North West London where colleagues are
working across health and social care. They are developing new forms of care coordination
and planning for two key groups, including people with diabetes.
Multidisciplinary teams have proven one of the most successful features of this pilot,
enhancing communication and collaboration among professionals.
Some 11 clinical commissioning groups (CCGs) are also piloting the development of service
specifications with National Institute for Health and Care Excellence (NICE). These would set
quality standards for CCGs to use that bring mental health aspects into physical care.
Dr Steven Reid, Clinical Director for Psychological Medicine at Central North West London
presented the work of the mental health strand of the London Strategic Clinical Network. The
network has already influenced integration in the physical care of people affected by cancer
and stroke. By drawing together clinical expertise it now aims to break down silos between
physical and mental health care in long term conditions.
The initial focus of the group was on diabetes with the aim of transferring the learning to
other long term conditions.

Examples of work in London on integrating

diabetes care and mental health came from
Dr Anne Doherty and Dr Carol Gayle from
Kings College hospital who presented the
award winning 3DFD project.
Depression is common in diabetes and
associated with worse health outcomes.
In inner cities in particular, patients
have multiple social problems which
they prioritise over their self-care. Their
management involves multiple separate
referrals to independent parallel services
where effective communication is more
difficult.
The underlying principle of the project is
that by helping patients with their social and
psychological problems, they will be more
confident in attending to their diabetes.

3DFD has effectively addressed

inequalities in access to
psychological and social health
care and sustained improvements
in Hba1c.

10

There are also considerable savings.

This has been recognised nationally as the first example of a community liaison service
and the innovations have been incorporated into new services around the country both
diabetes specific services, and also wider integrated care services.
This has brought bringing liaison psychiatry into the community.

11

Cardiovascular disease and mental health

Dr Golnar Aref spoke about the significant link between cardiovascular disease and mental
health and what we can do to improve care and support for those who have both.
Between 10% and 20% of people with cardiovascular disease have depression as well approximately three times the rate found in the general population.
Dr Aref outlined the prospects for Jeremy, a service user at the recovery centre formerly
known as a psychiatric day hospital - who had suffered a heart attack a year earlier.

12

Dr Aref introduced a simple practical assessment for use with patients in primary and acute
care. A nurse or GP asks the patients:

During the last month have you been feeling down, depressed or hopeless?
the last month have you often been bothered by having little interest or pleasure
During
in doing things?
If patients with a chronic physical illness answer yes to either question, the following three
questions should be asked:
the last month, have you often been bothered by:
During
Feelings
of worthlessness?

Poor concentration?

Thoughts of death?

If the answer is yes, then the patient has a more comprehensive three-minute biopsychosocial assessment.
Conventional psychological and antidepressant treatments are effective at improving
depression and anxiety in people with cardiovascular disease.
She recommends a stepped-care model, with treatments related to the level of depression.
When people with physical symptoms receive psychological therapy, the average
improvement in physical symptoms is so great that the resulting savings on NHS physical
care outweigh the cost of the psychological therapy. A stepped-care model provides a
framework in which to organise the provision of services, and supports patients and
practitioners in identifying and accessing the most effective interventions.
Jeremy was assessed by primary care services, seen by a psychiatric team, referred for
psychology, started on Sertraline (an anti-depressant) and resumed work after eight months.

13

Chronic obstructive pulmonary disease (COPD) and mental health

Dr Vincent Mak, physician in integrated respiratory care at Imperial College Healthcare NHS
Trust, spoke about his work with COPD patients in the context of value, as defined by the
outcomes achieved for the expenditure.
The five year mortality rate for respiratory disease is much higher in people with mental
illness and at least a quarter of deaths in people with mental illnesses are due to respiratory
disease.
It is thought COPD in people with mental illness is undiagnosed not least because
spirometry is offered less often to people with mental illness.
There are very strong links between smoking and mental illness. More than 42% of tobacco
is smoked by people with mental illness and these people are also the very heavy smokers.
There are obvious cost savings in smoking cessation programmes.
Studies show that many people with
mental illness do want to stop smoking.
However, smoking cessation is very
rarely offered to mental health patients
because of the perception of behaviour
change. Healthcare professionals need
to believe (from evidence) that it is
their role and responsibility to refer to
quit smoking services and to do quit
smoking work themselves.
This requires leadership and incentives.
All above speakers are included in
the following photograph. Dr Mak
(standing), Professor Valabhji, Dr Aref,
Dr Reid, Dr Gayle and Dr Doherty.

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The participants vote

At the end of the morning session, 68 participants were asked for their opinion
on key issues related to the days presentations. Here are the results.
Integration of physical and psychological
care could best be improved by:
32%

1. Greater patient participant in care

2. Creation of multidisciplinary
delivery teams

25%

3. Training and education of staff

5. Development of specialist
mental health teams
integrated into medical
services

19%

16%

4. Joint commissioning of outcomes

What is the biggest barrier to integrated

commissioning for physical and mental health?

7%

51%
1. Political will

24%

2. Better patient experience

3. Organisational silo working/

separate trusts

31%

4. Local public opposition

What has integrated commissioning

already delivered?
1. Improved patient outcomes

2. Lack of expertise in integrating

5. Organisational cultures

13%
4%

4%
21%
16%

3. Increased value for money

19%

21%

0%
2

74%

4. Better joint working of

partner organisations

What would help you in achieving integrated

commissioning for physical and mental health?

5. More creative forms of

care delivery

1. Trust mergers/different
management arrangements

24% 25%

2. Freed up procurement to
pool budgets

25%
21%

3. A new national policy mandate

What return on investment do you expect

from integrated commissioning?
74%
1. Financial savings

4. A national task force to

support the change process

6%

5. Champions to lead
clinical changes

2. More creative care packages

3. Fewer complaints / better
patient experience
4. Active and positive patient
engagement
5. Better patient outcomes

10%
10%

7%

4%

4%

7%

4%

4%

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Integrated physical and mental care: commissioning best practice

Liverpool CCG and Coventry and Warwickshire Partnership Trust explained how they have
each moved towards commissioning integrated physical and mental health care.
Local pressures forced Liverpool CCG to develop a new approach.

The CCG and partners amalgamated budgets created a joined-up system of mental health
care and primary care.
CQUINS are already being used locally in mental health, including a new way of collaborative
working with primary care. This involves establishing primary mental health liaison workers
to champion proactive engagement with GPs across Liverpool.
The work was presented by Dr Nadim Fazlani and Tony Woods.
Veronica Ford presented the work of the integrated practice unit (IPU) in Coventry for HIV
patients. IPUs provide the full cycle of care for a condition, including patient education,
engagement and follow-up. This requires a dedicated team who devote a significant
proportion of their time to the medical condition and are co-located in dedicated facilities.
The treatment of HIV is particularly suited to this approach.
The IPU in Coventry delivers parallel healthy lifestyle and improved access to psychological
therapies (IAPT) depression and anxiety clinics within the service. It supports selfmanagement, ensures patients do not need to be referred onto other services and has
achieved a reduction in waiting time to access other health services, as well as providing
shared equipment and administration support.

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Towards a joint long term payment strategy: enabling an integrated approach

for mental health services
Katie Brennan, Pricing Development Lead,
Monitor shared Monitors thinking on the
design of a long term payment strategy.

However pricing is just one element to

improving outcomes. This also requires
leadership, right care and core enablers such
as information systems and workforce skills.
Monitors proposed vision for payment
reform includes regulatory levers that
extend beyond price. These measures could
improve the quality of data that underpins
the payment system, develop a credible
regulatory stance and introduce different
payment approaches for different types of
care needs.
Monitor is also considering what can be
done in the 2015/16 national tariff against
the background of a challenging financial
context.
In the subsequent question and answer
session, speakers were asked to consider
how to keep politicians and leaders engaged.
Clinical commissioning and populationbased commissioning were seen as critical
to this, with patients at the heart of the
commissioning decisions.

17

Scenario sessions
In workshops participants worked on commissioning scenarios, considering barriers and
enablers around integrating physical and mental health care.

Scenario 1 considered the case of a 40 year old African woman with type 2 diabetes and
a history of breast cancer. The lady has chronic neuropathic pain and anxiety attacks when
she leaves her home. She is a single mother to three children, one of whom has a learning
disability and sensory problems. Her diabetes is totally out of control as she does not take
insulin or test blood glucose.
The group concluded that her care should be coordinated under a Care Programme Approach.
This involves a needs assessment with links made to physical and mental health care
professionals and social services. The partnership working between the hospitals diabetes
and mental health teams stimulated more creative thinking and ideas which resulted in
changes to the patients care that took account of her mental health condition.
The woman took part in cognitive behaviour therapy (CBT) in her home, her diabetes regime
was simplified, her medications optimised. She was also given social support with her
finances to help her attend her rheumatology and physiotherapy appointments.
Challenges identified:
of knowledge amongst physical health specialists about the impact of mental health
Lack
issues and vice versa
area where a patient may not be eligible for the Care Programme Approach when
Grey
neither their physical condition nor their mental health condition alone is deemed severe
enough
Specialists are often working in parallel rather than collaboratively.

Key learning points:

Education and training: Up-skilling nurses within mental health teams around diabetes
and the importance of glucose testing so they can challenge the patient about compliance.
Similarly, physical health teams should have the skills and appropriate vocabulary to uncover
any mental health issues and the ability to discuss it sensitively with the patient.
Screening: Physical and mental health professionals should have the confidence and skills
to assess both disease areas during initial screening.
Specialist partnership and collaborative working: In this scenario having the
diabetologist present at the psychologist appointment allowed immediate decisions to be
made on the physical care regime. Integration with social services can address social factors
that are affecting the persons health and therefore should be included in planning
health care.

18

Scenario 2 considered the case of a pregnant diabetic 32 year old with a history of bulimia,
who collects but does not take her medicines all the time. She grew up in another country,
and was raised by a younger brother as her parents were absent most of the time.
The group agreed that if GPs, pharmacy and other family services had worked together
there could be a central point of care. This would link into other services - making it less
complicated for the patient who would be working with fewer providers.
Structured medicine reviews and monitoring between GPs and pharmacy would ensure that
collected medications are being used.
Changes that should be made to deliver improved outcomes and experience include:
Training provided to all levels of medical staff to identify mental health issues
Sharing
of care plan with all those involved in her care with a patient centred approach
Identification
when required.of the key relationships within that care plan as a base for her to contact
Three key points arising from the discussion that were shared in order to support the
recommendations were:
detection in primary care this would help identify other issues
Early
Basic
mental health training of all antenatal staff
Integrated
care within the acute sector so complex conditions can be identified.

Scenario 3 considered the case of a 49 year old man named Brian who was transferred
from Kings College Hospital to a Neuropsychiatry Unit. Brian experienced alcohol withdrawal
seizures and prolonged status (seizures).
An MRI had identified a marked generalised volume loss and diffuse cerebral white matter
signal change. He had aspiration pneumonia, alcohol-related brain damage and other
physical symptoms. His mini mental state examination on admission was 6 and on
discharge 19.
Brian displayed aggressive behaviour with added complications such as self-neglect, aphasia
and memory impairment.
He had no capacity to consent to treatment or admission. He was therefore sectioned and
detained for six weeks.
His discharge was delayed by months. The young physically disabled (YPD) team were
initially involved in a placement search. However, once Brian was detained under s.3, YPD
immediately discharged him.
Adult mental health services took 3 months to accept Brian into the service. Requests for
organisations to assume responsibility for his care had previously been passed between
various health and social care panels.

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Challenges and barriers

clear working relationship between the different services, particularly where there is
No
perceived to be no link i.e. stroke/brain injury/substance misuse and alcohol
criteria for acceptance into different areas of mental health/brain injury
Conflicting
services (e.g. brain injury, stroke, mental health) creating gaps that patients fall through
specialties have different panels for decision making and funding purposes
Different
making obtaining treatment often extremely difficult and time intensive. Current

systems and selection criteria create blocks in patient movement across service
boundaries delaying the start of care and actions to meet ongoing care needs
Significant geographical variations in provision

Recommended actions
review of guidelines and criteria:
Thorough
Single integrated panels for decision making

Pooled budgets
Integrated multidisciplinary teams
Skill base across services to avoid silo working and referrals

to the other

selection criteria for specialty areas to bridge the gaps

Review
the myths and prejudices around condition treatment, i.e. alcohol dependent
Dispel
patients are often declined mental health support as one is seen as not necessarily related
with comorbidities should be provided with compassionate supervision,
Patients
a keyworker to step in at times of need
Commissioning and funding must reflect the system changes to enable effective
integration

Geraldine Strathdee
closed the event by asking
everyone to remember
that a persons physical
and mental health are
inextricably linked. She
pointed out that the
evidence shows that when a
patient is treated as a whole
person, with psychological
and physical needs, the best
outcomes are achieved.

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Primary Care Commissioning 2014