by Laurence Mascarenhas, Associate Director, Mental Health Services, NHiS Commissioning Excellence.
Mental illnesses are very common: For example, one in four British adults will suffer at least one mental health disorder in any given year; 1.2m people in England have a learning disability and more than one million people will have dementia by 2021.*
Yet, according to NHS England, only a quarter of people with a mental illness, such as depression, are receiving treatment, compared to 94 percent for diabetes, 91 percent for hypertension and 78 percent for heart disease in comparable Western countries.
People with mental health problems have a significantly different level of contact with physical health services compared with other patients; they are more likely to access hospital services than people who do not have mental health problems and more likely to arrive at A&E by ambulance.
Ensuring that mental health is given the same priority as physical health is key to tackling such problems and it is now a key Government priority, driven by NHS England’s Parity of Esteem (PoE) Programme.
In this article, I will give an overview of the PoE Programme and explore some of the barriers to implementing it. I will also highlight some of the changes that need to be made and the role that pharma can play in helping to ensure that patients get diagnosed, treated and rehabilitated faster and more effectively.
Why is PoE integral to the future of the NHS?
The PoE Programme, which was originally enshrined in the Government’s Health and Social Care Act 2012, is now a key element of its Five Year Forward View for Mental Health for the NHS in England (MH5YFV).
The MH5YFV calls for transformational change in services and attitude to mental health, and aims to achieve it through prevention, early intervention, access to crisis care on a 24/7 basis and better integration of mental and physical healthcare.
The PoE Programme is also integral to the Dementia Implementation Plan, which sets out more than 50 specific commitments that aim to make England the world-leader in dementia care, research and awareness by 2020.
Some vanguards have been exploring PoE issues. For example, one group is currently investigating the connection between mental health and Medically Unexplained Symptoms. Another vanguard has created a multidisciplinary, multi-agency team to review mental health policy and strategy to identify why patients become ‘repeat attendees’. This is helping stakeholders to understand the relationship between mental and physical health, and social standing.
Sustainability and Transformation Plans (STPs), which are due to be introduced in 2017, will play a critical role in implementing the changes needed to achieve PoE by reversing historic underinvestment in this area, thinking more holistically across mental and physical health, and integrating both services.
What are the key barriers to PoE?
Although the situation is slowly improving, there is still a lot of stigma attached to mental health problems and many people refuse to seek help for fear of discrimination at home and at work. Furthermore, if individuals do visit their GP, opportunities to refer them on to appropriate services are often missed because many GPs do not have the specialist training needed to make a diagnosis.
While it is widely accepted that physical and mental health problems often go hand in hand, they tend to be treated in isolation by healthcare professionals. For example, many patients with long term physical conditions also suffer from mental health problems. However, mental health reviews are not routinely conducted among these patients.
Similarly, people who have mental health problems often suffer from a range of associated physical problems arising from lifestyle issues such as a poor diet, alcohol abuse and smoking. However, they do not receive the holistic care needed.
The fact that the police, Social Services, mental health and other NHS services work in isolation is also a problem. For example, it means that a person experiencing psychosis, or dementia, who might become aggressive or violent as a result of their problems, may find themselves in a police cell when they should either be in hospital, or in an Emergency Department being treated by a specialist mental health provider.
Changes that could help to achieve PoE
Early intervention is key and GPs should be looking to refer patients to services such as Improving Access to Psychological Therapies (IAPTs). This 16-week programme is designed for people with anxiety and depression, and can be accessed via all mental health trusts in England. If one GP in each practice held a specific qualification, such as a mental health diploma, this could dramatically increase the number of patients diagnosed within primary care and referred to appropriate services.
To help people get the holistic care that they need, there should be a more integrated approach to mental and physical healthcare. This would see, for example, those with long-term physical health problems getting regular reviews of their mental health, and people with mental health issues receiving appropriate intervention and support to address associated physical health risk behaviours.
Joined up working between the NHS, police and Social Services is also essential. If the NHS could identify those at the highest risk of suffering a serious mental health episode, such as a Schizophrenic attack, and then share their details with Social Services and the police, these individuals would be more likely to get the help they need in the event of a problem.
There should also be a greater emphasis on rehabilitation; Recovery Colleges should be a key part of the patient pathway to help people get back on track and promote self-care.
How can pharma help?
There are a number of ways in which pharma can help the NHS to achieve PoE in mental health. For example, there is a big role for pharma in funding research and conducting clinical trials to further explore the side effects of drugs that are used for a variety of conditions and are known to cause psychosis. These include drugs for conditions ranging from diabetes to dementia. Pharma should also be consulting with GPs, hospitals, commissioners and patients to fully understand the wider impact of this issue.
The cash-strapped NHS has a culture of prescribing the cheapest drugs. Pharma needs to convince commissioners and providers of the value of alternative mental health drugs, which may be more expensive to buy, but will save money in the long-run because they are proven to have fewer side-effects and will give patients a better quality of life.
Pharma can also provide support with adherence by making medicines and the administration of them more user-friendly. For example, a drug that can be administered via an injection once a month at a GP surgery is more likely to be regularly taken by a patient than a pill they have to remember to take every day.
Pharma could also offer training and support to care workers to help ensure that people with dementia and other people with mental health conditions take their medicines. This could help to reduce the burden of care associated with non-adherence.
Data is key. By analysing the wealth of patient data that already exists, like Hospital Episodes Statistics (HES) data and Mental Health and Learning Disabilities Data, pharma can identify important trends, gaps and needs that will lead to significant improvements in patient care.
For example, Lundbeck is currently working with NHiS to develop a Depression Dashboard to reveal the burden of depression across the NHS – from primary and secondary care to mental health services and secondary acute care. The dashboard, which uses Mental Health and Learning Disabilities datasets, will help the NHS to analyse current outcomes and the cost of managing patients with depression. It will also highlight opportunities to improve patient care and outcomes in this area.
Janssen is working with NHiS on a Mental Health Dashboard. The project involves an analysis of Hospital Episode Statistics and the Mental Health and Learning Disability Datasets to assess current outcomes for patients with schizophrenia and the cost of managing them. The dashboard will help the NHS to better understand the current and future burden of this cohort of patients if they are managed in the existing way, and to see variations in service provision. It will also highlight opportunities to improve outcomes in line with new models of care, detailed in the 5YFV.
Pharma has a major role to play in helping the NHS to achieve one of its key commissioning priorities – Parity of Esteem in Mental Health. To help improve treatments and outcomes, pharma could: fund research and conduct clinical trials to further explore the side effects of drugs; educate commissioners and providers on the efficacy and long-term savings that can be generated from specific drugs, and provide support on adherence. In addition, the industry can harness the power of data to help the NHS identify trends and opportunities to make a real difference to patient care and outcomes.
*Statistics from NHS England https://www.england.nhs.uk/mentalhealth/parity/
NHiS was founded in 2007 in response to a growing need in the marketplace for quantitative and qualitative data to inform service redesign and pathway efficiencies. For details, log on to www.nhis.com