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Bringing together physical and mental health 1 2 3 4 5 6 7 a biopsychosocial perspective. Other forms of inter-professional training that created opportunities to discuss patient care were also viewed as highly beneficial. The focus of training and skills transfer varied. As well as imparting new knowledge, training can be effective in changing attitudes and challenging stigmatising beliefs (Hardy 2012). Some of the areas seen as particularly beneficial are listed in Table 3. Table 3 Areas where training and development is needed to support integration Focus of development activity Awareness and identification of common conditions and risk factors Communication skills/consultation techniques Understanding who to refer to, what resources are available Teaching specific approaches or clinical skills Challenging expectations, assumptions and stigma Examples • Prevalence and identification of common mental health problems among people with long-term physical health conditions/during the perinatal period • Biopsychosocial assessment • Physical health side effects of psychotropic medication • Motivational interviewing techniques to support behaviour change where motivation is an issue • Ways of exploring psychosocial issues during consultations • Setting more holistic goals with patients • Modelling a more sympathetic approach to managing distress (eg, on acute wards) • Referral criteria for different services • Availability of peer support groups provided by local voluntary sector organisations • How to conduct basic physical health tests eg, spirometry (for mental health nurses) • Mental health first aid • Basic psychotherapeutic techniques (eg, CBT) • Principles of mindfulness • Expectations regarding prognosis • Capacity of mental health service users to quit smoking • Role of mental health professionals in improving physical health, and vice versa In a few examples, training and education went beyond the clinical team and also involved wider support staff. For example, in some practices, the Primary Care Psychotherapy Consultation Service in the City of London and Hackney (see Appendix C) has worked with all practice staff, including GPs, practice nurses and Implementing change: overcoming the barriers 61
Bringing together physical and mental health 1 2 3 4 5 6 7 receptionists, to improve support for people with medically unexplained symptoms and other complex needs. More fundamentally, the workforce development needs that were highlighted by our research also point to the importance of ensuring that professional educational curricula equip trainees with the skills and attitudes needed to support integrated working. These implications are discussed further in Section 6. Finance and commissioning The role played by commissioners The role played by commissioners in our case studies was mixed. In some sites, commissioners had played an enabling role, but in general, innovation had been provider-led. Several of the individuals involved in leading change emphasised how important it was to involve commissioners at the earliest possible opportunity. In cases where commissioners were seen to have played a particularly effective role, this was attributed to a high level of trust in their relationships with providers, built up over several years of partnership working. In some cases, commissioners had developed financial incentives to help bring about changes in practice. For example, commissioners in Bradford and Airedale have encouraged the provision of physical health checks for people with mental illnesses using a locally defined Commissioning for Quality and Innovation (CQUIN) payment, and have also provided funding for a project management team that supported implementation in primary care. It is notable that similar financial incentives used by some other clinical commissioning groups (CCGs) have not always been as effective, suggesting that these need to be combined with practical support on the ground, as in Bradford and Airedale. There was a perception among some of our interviewees that the move to clinical commissioning led by GPs could be credited with an upsurge of interest in liaison mental health and other forms of integration. The hypothesis here is that GPs see the way that mental and physical health interact in their clinical practice, and so are more likely to support the commissioning of integrated services. Clinical leads within CCGs (for example, mental health leads) might therefore be expected to play an important role in bringing about closer integration of mental and physical health. Implementing change: overcoming the barriers 62
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