Integrated care is seen as critical to delivering better quality services for patients and service users and a key element of health policies in the UK. However, the evidence base suggests a fragmented picture, with variations in definitions and implementations limiting what can be learned and applied elsewhere. This new report, Crossing Boundaries: Improving integrated care for people with mental health problems, from the Mental Health Foundation shares the findings of a 15-month inquiry. The inquiry included a review of the evidence base, an expert panel and a consultation resulting in over 1200 responses.
The report states that “integrated care for people with mental health needs remains the exception rather than the rule”. Barriers include cultural issues such as reluctance to share, poorly defined roles and responsibilities as well as infrastructure such as incompatible information systems. The report recommends inter-professional and cross-boundary education and training as essential to overcoming cultural barriers. Enablers include: robust working relationships; strong clinical and managerial leadership; and building a collaborative culture based on shared values. The recruitment and involvement of people with the skills and attitude to collaborate are particularly emphasised.
The report highlights the following critical success factors which need to be addressed to enable truly integrated care:
- Systems to share information: From a service user perspective, this would enable better coordination across services; from a commissioner perspective, aggregated data would facilitate planning. The report touches on sharing of datasets, in particular, primary care; however, there is a recognition of the information governance issues involved.
- Shared protocols: This would enable a clearer understanding of roles and responsibilities across service boundaries.
- Joint funding and commissioning: Ideally, budgets should be pooled to combine health care, social care and other key services such as education. Service users require access to a wide range of services, for example, smoking cessation, exercise therapy.
- Co-located services: The inquiry found an appetite for locating psychiatric services in the community, with many respondents suggesting colocation with primary care; however, the evidence suggests that colocation alone may not enable integration.
- Multidisciplinary teams: The model of psychiatric liaison services is discussed, to emphasise the need for training to help health care workers better understand mental health needs and mental health workers to improve understanding of physical care.
- Navigators: The report recommends the use of a navigator role to coordinate care and provide some continuity.
- Research: Gaps in the evidence base lead the authors to recommend more research on service users with complex needs and comorbidities, including economic evaluations assessing models of care.
- Reduction of stigma: Service users and professionals reported social stigma; the report recommends training and education as a solution, including education in schools to avoid an artificial division between physical and mental health.
The authors discuss the concept of a Mental Health Tsar within Clinical Commissioning Group (or equivalent) or Local Authority boundaries. This role would be a joint appointment responsible for monitoring quality, setting targets and outcomes, leading health promotion and acting as a “focus for cultural change”.
- The inquiry attempts to combine evidence from robust research with the experience of people working in the field and of service users and therefore covers a range of perspectives.
- The report highlights the critical need for integration across health and social care but does not stop there, recommending that “fully integrated services to people with mental health needs goes further, into many other aspects of people’s lives such as education, work, housing and leisure, and individual lifestyles” and that commissioners ensure a wide range of services to enable service users to establish and maintain healthy lifestyles.
- The report emphasises the need for sustainable innovation – in other words, that change should be maintained and whilst strong leadership is critical, integrated care should not be reliant on single individuals.
- Commissioners will need to consult the evidence base and assess what models may best suit their local context. Components of models include: care co-ordinators; case management; joined-up care planning; personalisation; data sharing; community-based teams; quality and finance incentives; training. Service interventions such as Improving Access to Psychological Therapy and disease management can be expanded to address the needs of service users with complex needs and comorbidities. There are also lessons to be learned from pilots and projects which often share critical success factors.
Mental Health Foundation (2013), Crossing boundaries: improving integrated care for people with mental health problems, http://www.mentalhealth.org.uk/publications/crossing-boundaries/