We interview Chris Naylor, senior fellow at The King’s Fund, an independent charity working to improve health care in England. Chris conducts research and policy analysis and acts as a spokesperson for The King’s Fund on a range of topics. He has recently participated in the report “Bringing together physical and mental health: a new frontier for integrated care” (March, 2016). The report looks at a third dimension of integration, highlighted in the NHS five year forward view, bringing together physical and mental health.

  1. There is evidence that separating mental and physical health care is no longer affordable for governments or health care systems. However, how far is the United Kingdom or Europe in the implementation of a completely integrated health care systems?

There have been a lot of focus on integrating different parts of the systems. There is a lot done on integrating health and social care and also on integrating primary and secondary health care. However, regarding the integration of physical and behavioural health services, it is something that makes a lot of sense for people but perhaps it hasn’t got as much attention at the policy level. I think it is partly a product of culture, as we tend to see body and mind as different things. In medical professions, psychiatry is often seen separate from medical specialities. There are very different professional cultures in those two communities.

  1. Apart from culture, is there any other challenge for the implementation of an integrated care model?

There are stigmatizing attitudes around people with mental health problems. If we look at mental health care as a routine part of the way you support people, and we don’t even call it mental health, then, I think that this removes the stigma.

 Mental health is being understood as a different thing from physical illness. There is a certain degree of fear around mental illness and this has lots of different effects. One of the consequences is that patients don’t always talk freely about the psychological aspects of health. They feel worried about speaking out about the fact that they were experiencing depression, because they feel that maybe they will be judged, maybe they will be left aside. Another consequence of the stigma is that people not always seek help for the psychological aspects of their illnesses. Also, that mental health professionals are sometimes seen as kind of second-class in the health care system. For me that way of seeing things is another manifestation of these stigmatizing beliefs that exist around mental health. There are also technical and institutional barriers.

  1. At the King’s Fund report “Bringing together physical and mental health: a new frontier for integrated care”, there are defined ten priorities to integrate physical and mental health and primary care is plays an important role on these priorities. How could be primary care strengthened to offer a better treatment to people with severe mental disorders?

Primary care is where most of the mental problems are seen and there is a lot of variation in terms of how effectively mental health is responded to in primary care. There are three areas where I think that we can see an improvement. First, there is the issue of who looks at for the physical health of people with severe mental illness, which is often very poor and sometimes as a direct result of side effects from psychotherapy medication prescribed for severe mental illnesses. There is a kind of a fight between primary care physicians and psychiatrists as to who should be responsible for the physical health of people with severe mental illnesses. My view is that both professionals have the responsibility towards that, and there should be support for improvement in physical health with severe mental illnesses, for example, by making sure that people are giving an annual health check, a screening of physical health problems. Secondly, there is a lot of work done in many countries about collaborative care models that give primary care an expanded role in management of depression and anxiety, working more closely with mental health professionals some of which might be based in a primary care setting. The third reason is in relation to medically unexplained symptoms and physical symptoms that lack an identifiable organic cause. GPs are trained to manage patients with those symptoms effectively, as they are often managed very poorly by the health systems.

Chris-Naylor

  1. More training would be needed to implement a completed integrated health care system….

More training is needed and clearer messages from senior leaders in primary care about mental health. If we look at an organisation like Intermountain in the US, they managed to integrate mental health services into primary care much more effectively over the last 15 years. One of the things that it has been absolutely essential has been having consistent messages from the top of the organisation, the most senior people at Intermountain, saying “mental health is a normal part of health care and it’s part of primary care”. So, that kind of messages and training to clinical and non-clinical staff is important. Sharing the same facilities is not enough, it has to be about working together through consultations or a space of learning from other physicians.

  1. How could local good practices that are happening in different territories be scaled up?

In the UK we have a number of areas in the country called “vanguard” sites that are implementing a small number of models of integrated care, which are being evaluated with the intention that the ones that are successful will be scaled-up quite rapidly. The policy objective is that by 2020 half of the country, or more, should be covered by these new integrated models of care.

Regarding policy, there is the five-year strategy of the NHS, and a five-year strategy for mental health released early this year. This strategy talks about reconnecting mental health with the rest of the health care system, that can’t just be about mental health professionals leading that change, it has to come from the other side too, because what we see often is that mental health professionals are already enthusiastic about this agenda, but I think there is less need seen by the other side. So, if we are going to get anywhere with this agenda, we need to hear more than from mental health professionals, also from hospital leaders, from general practitioners in primary care and others… It needs to be the whole system in order to be successful.