Evidence
Alert

Better evaluation of physical health services for people with severe mental illness is needed

Approaches to improve the integration of physical health services for people with severe mental illness are generally poorly described, and most evaluations are small in scale and poorly reported. Better descriptions and evaluations are needed to help identify and replicate best practice in the UK.

About 1% of the UK population have severe mental illness, such as schizophrenia, bipolar disorder or severe depression. They are often poorly served by the NHS in terms of their physical health, often due to fragmentation of services. This review set out to describe recent approaches, such as shared information systems, co-location of services or care-coordinators, to improve the integration of physical and mental health services for this underserved population.

While the evidence quality was poor, some tentative findings emerged, including: ensuring care co-ordinators hold suitable authority; protecting time for training; simplifying the sharing of information between health professionals; greater clarity in multidisciplinary teams about who is responsible for physical health, and using shared protocols and joint action plans.

Why was this study needed?

About 1 in 100 people will experience a severe mental illness, such as schizophrenia, bipolar disorder or severe depression. People with severe mental illness have lower life expectancy and poorer physical health than people without mental illness. Many are underserved by the health system. For example, in 2014 only 33% of people with schizophrenia were adequately monitored for diabetes and cardiovascular disease.

One reason for the shortcomings of physical health care for people with severe mental illness is that mental health services have traditionally been separate from physical health services. In response to this, there has been an increasing emphasis on developing models of care that improve integration between physical and mental health services.

The objective of the review was to summarise recent evidence in the integration of physical and mental health care for people with severe mental illness.

What did this study do?

This NIHR-funded rapid review summarised 45 recent publications describing 36 widely varying service models of integrated care for people with severe mental illness within healthcare settings (as opposed to social care or other non-health settings). Studies were published from 2013 to 2015.

Most service models incorporated two or more of the factors identified by the Mental Health Foundation as facilitators of integrated care. For example, shared information systems, shared protocols, co-location of services and multi-disciplinary teams. Most programmes were in the UK, North America or Australia.

The review was designed to describe interventions, not test their effectiveness. Therefore, methodological quality was not assessed and many study designs and reports featured in the review. These included systematic and non-systematic literature reviews, primary studies, book chapters, conference abstracts, dissertations, policy and guidance documents, feasibility studies, descriptive reports and programme specifications. Eighteen studies were “descriptive” and 27 studies “evaluative”.

What did it find?

Description of programmes and models of care was poor, and few were evaluated. Therefore it is unlikely to be possible to replicate existing approaches elsewhere.

The authors described the following findings based on their reading of the evidence.

  • Care co-ordinators may be more effective when given authority to influence other care professionals and over care-integration processes as a whole. Care co-ordinators can empower users by advocating for them in certain settings.
  • All health professionals involved in collaborative care need to undergo training. Time should be protected for this.
  • The most promising means of simplifying collaboration between individuals and services, such as integrated information systems and electronic records, have not been implemented because of technical, legal and organisational barriers.
  • In multidisciplinary teams, each individual team member should have clear responsibilities.
  • Shared protocols, joint action plans and decision support tools help clarify responsibilities and support record keeping and communication across boundaries.

What does current guidance say on this issue?

The Joint Commissioning Panel for Mental Health 2012 recommends that people should be managed mainly by the primary health care team working collaboratively with other specialist and secondary services as required.

The Mental Health Foundation in 2013 identified nine factors as facilitators of integrated care. They were: 1) information sharing systems; 2) shared protocols; 3) joint funding and commissioning; 4) co-location of services; 5) multidisciplinary teams; 6) liaison services (e.g. provision of shared expertise across service settings); 7) navigators (e.g. named care co-ordinators); 8) research (e.g. to ascertain the best way of delivering and evaluating integrated care); and 9) reduction of stigma.

What are the implications?

While this review highlights some potential areas for service improvement, there is a lack of quality research to evaluate such approaches. Much of the literature is descriptive or fails to provide useful information on barriers and facilitators. Services are not described in enough detail to allow successful models of care to be set up and piloted elsewhere.

Some areas for future developments were suggested by service users. These include improving appointment-booking arrangements, making mental health inpatient environments more conducive to good physical health, and giving greater attention to the sexual health of people with severe mental illness.

 

Citation and Funding

Rodgers M, Dalton J, Harden M, et al. Integrated care to address the physical health needs of people with severe mental illness: a rapid review. Health Services and Delivery Research. 2016:4(13).

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme (project number 13/05/11).

 

Bibliography

Bradford DW, Cunningham NT, Slubicki MN, et al. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: a systematic review. J Clin Psychiatry 2013;74:e754–64.

Joint Commissioning Panel for Mental Health. Guidance for commissioners of primary mental health care services. London: Royal College of Psychiatrists and the Royal College of General Practitioners; 2012.

Mental Health Foundation. Crossing Boundaries. Improving Integrated Care for People with Mental Health Problems. London: Mental Health Foundation; 2013.

NHS Choices. Mental health. London: Department of Health; 2016.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Commentaries

Expert commentary

The rapid review highlights that there are currently no clear solutions to integrated physical health care for people with serious mental illness.

Lack of clarity of roles and responsibilities exist at service and commissioning level. Mental health stigma and the associated paternalistic and pessimistic attitudes found in health care settings (physical and mental health care) also need to be challenged. Service users and carers need to be at the centre of development of new ways of working. Sexual health (which has been omitted from the physical healthcare agenda) certainly needs addressing within the umbrella of improving physical health and recovery in general.

There is a clear need for sharing of good practice, and more robust evaluation of models of care that show merit.

Professor Elizabeth Hughes, Chair of Applied Mental Health Research, University of Huddersfield