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Bringing together physical and mental health 1 2 3 4 5 6 7 This allows the service to provide support to people with a wider range of mental health problems, and presents greater opportunities for skills transfer. The team provides brief psychological therapies as well as interventions targeting social problems. In addition to seeing patients directly, an important part of the role of mental health staff in the 3DfD team is to provide formal and informal training to diabetes physicians and nurses – for example, in motivational interviewing techniques, basic principles of cognitive behavioural therapy (CBT), and general training in mental health. An evaluation found significant improvements in glycaemic control among those using the service, as well as reduced psychological distress and a reduction in emergency attendances and unscheduled admissions (see Appendix A). Another example of integration in the context of community-based multidisciplinary teams is the new persistent pain pathway in Oldham mentioned earlier (see Appendix B). The service uses biopsychosocial assessment to understand the medical, psychological and social needs of each patient, with a range of interventions then being delivered as appropriate by physiotherapists, psychological therapists, pain nurses or, for those with higher levels of need, by a liaison psychiatrist, clinical psychologist or pain consultant. As with several of the services described in this section, one reported benefit of the persistent pain pathway is that providing psychological support within the same care processes and facilities as other aspects of musculoskeletal care removes the stigma associated with seeing a mental health professional. The 3DfD and Pennine MSK examples are both disease-specific approaches focusing on a single condition or (in the case of chronic pain) a set of related symptoms. An alternative approach to integration is to target interventions by population group rather than by condition (Curry and Ham 2010). This is the approach currently being taken in many of the NHS England vanguard sites and elsewhere, in particular those developing multispecialty community providers (MCPs) or primary and acute care system (PACS) models. Although the terminology adopted varies by site, many are establishing integrated neighbourhood teams to create a forum for multidisciplinary case management of high-cost patients, particularly frail older people and people with multiple long-term conditions. In most cases, there is mental health representation within these integrated teams. What is not yet clear is how effectively these teams will provide a platform for integration of mental and physical health, or the extent to which the mental health or psychological aspects of care will feature as a prominent part of multidisciplinary case discussions. So far, there appear to be Integrated service models: current developments and trends 51
Bringing together physical and mental health 1 2 3 4 5 6 7 relatively few examples within the vanguard sites of co-morbid mental and physical health problems being identified explicitly as a priority target group, although the Fylde Coast MCP is one exception (see box below). An important question in establishing integrated teams of this kind is the extent to which the target group is defined using risk stratification tools to identify those at highest risk of avoidable hospital admission, versus defining target groups a priori – for example, selecting groups known to experience poor health outcomes and health inequalities. Both approaches have merits, but if case identification is based solely on risk stratification, there is a risk that certain groups that are in clear need of integrated care may be under-represented, including people with severe mental illnesses and poor physical health. Integrating mental and physical health in NHS England vanguard sites The 14 multispecialty community providers (MCPs) and 9 primary and acute care systems (PACSs) being established as part of NHS England’s vanguard programme create an important opportunity to embed mental health within integrated community teams. Most MCP and PACS sites are including some degree of mental health representation within local integrated neighbourhood teams. Examples include Stockport Together MCP, North East Hampshire and Farnham PACS, and Salford Together PACS – all of which have focused largely on older people initially, with plans to expand to other population groups over time. In Salford, adult and older adult mental health services will, from 2016, be brought together with other health and care services in an integrated care organisation funded through a prime provider contract, with Salford Royal NHS Foundation Trust acting as prime provider and sub-contracting with Greater Manchester West Mental Health NHS Foundation Trust. The scale of structural change involved may vary between areas. In Southern Hampshire MCP, the current ambition is that a wide range of mental health services for older people, Improving Access to Psychological Therapy (IAPT) services, and part of the existing community mental health teams will be folded into the neighbourhood multidisciplinary teams once these have achieved a sufficient level of maturity. A different model is being developed in West Cheshire MCP, where the planned approach involves the mental health trust providing expertise for integrated care teams as a sub-contractor, without structural change that would involve providing services on this footprint. continued opposite Integrated service models: current developments and trends 52
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