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

Published on 7 July 2016

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.

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

Share your views on the research.

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.

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.

Integrated care to address the physical health needs of people with severe mental illness: a rapid review

Published on 1 April 2016

Rodgers M, Dalton J, Harden M, Street A, Parker G, Eastwood A.

Health Services and Delivery Research Volume 4 Issue 13 , 2016

Background People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors. Objective(s) To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group. Synthesis We conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research. Findings and discussion The synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered. Limitations and future work The literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable. Funding The research reported here was commissioned and funded by the Health Services and Delivery Research programme as part of a series of evidence syntheses under project number 13/05/11

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

Categories

  •   Health management, Mental health and illness