Jennifer Dixon, Chief Executive of the Health Foundation, reflects on the relationship between mental and physical health and the need for better integration of care.
The past five years have seen much discussion about the effect of societal changes on the health of the population in the UK. This has been prompted by a stalling growth in healthy life expectancy since 2010 and a growing gap in levels of health and disability between the most and least deprived populations. For example, one recent study showed that age-standardised rates of years of life lost were twice as high in Blackpool as in Wokingham(1).
The long list of structural changes commonly discussed include the wider determinants of health. In particular: the impact on the economy of austerity following 2008; the changing nature of work (stagnating wage growth, loss of traditional blue-collar employment and growth of highly insecure jobs); the widespread use of social media; family breakdown; inequalities in wealth, and demographic change.
The increase in mental health conditions
Given such stressors, it is perhaps not surprising that mental health conditions appear to be increasing in the UK population, particularly in deprived populations and women. There are two waves. The first is in young people, where prevalence has slightly increased over the past 20 years – a pattern also seen internationally. Young women have higher and increasing rates of common mental disorders and self-harm, and since 2007 the gap between genders has increased. The second is in older people, especially those over 70 years of age, who are increasingly living with various forms of age-related cognitive impairment, including dementia. The rising prevalence is mainly due to increased numbers of older people in the population.
The best estimates of the proportion of adults (aged 16 and over) having a mental or emotional problem in England come from the Adult Psychiatric Morbidity Survey (2)
- One in six (17%) adults 16 years or older met the criteria for a common mental disorder (such as anxiety or depression) in 2014, an increase since 2000 mainly in women.
- 39% of adults aged 16–74 years with a common mental disorder were accessing mental health treatment in 2014 – up from 24% in 2007.
For the young, the best estimates come from the Mental Health of Children and Young People in England, 2017 (3):
- One in eight (12.8%) 5- to 19-year-olds had at least one mental disorder - a rate slightly increasing over the past 20 years. The highest rise in prevalence was in women aged 17–19 years (now nearly one in four, or 23.9%).
- Emotional disorders were the most prevalent type in 5- to 19-year-olds (8.1%) and are the main group to have risen since 1999.
- The prevalence of disorders increases with age: 5.5% of 2- to 4-year-olds compared with 16.9% of 17- to 19-year-olds.
- 28.5% of children and young people aged 5–19 years were reported to have had contact with professional services (20.9%) or informal support (18.2%); 4.5% of children had had contact with a mental health specialist.
Use of NHS-funded health care
Identifying the extent to which people with a mental health condition use NHS-funded health care or other public services is far from straightforward. Many people are cared for in the community by general practice or other providers. The routinely collected data are either of poor quality, not accessible, or difficult to link up to show a complete picture of the care received by individuals. It is also difficult to link data on the use of other public services by people with mental health conditions to NHS data.
NHS Digital provides the most detailed picture of the NHS-funded health care received by people who used secondary mental health services in England. However, the data on the use of this care are grouped together for people who have a mental disorder, learning disability or autism. In 2017/18, 4–5% of the population had contact with such NHS-funded care for these conditions. There is a bulge at 16 years (12% women, 9% men) and 17 years (11% women, 8% men) were in contact with services, then a decline, and then a steep rise for people 80–89 years (women 12%, men 11%) and 90 years and older (women 18%, men 16%). It isn’t clear yet if the ‘teen bulge’ will be carried forward as the cohort ages.
The link between mental and physical health
It has been known for some time that people with a mental health condition are more likely to have a physical illness and die earlier. The Strategy Unit’s fascinating analysis linked NHS hospital episode statistics data on the use of NHS-funded care in NHS Trusts for individuals with ONS data from death certificates, and compared the mortality of those with recorded mental health problems to those without (4). Life expectancy at birth for people who became mental health service users was calculated to be a staggering 19.1 years shorter for men with a mental health condition and 16.1 years shorter for women, relative to those without. This is roughly double the gap in life expectancy between the most- and least-deprived populations in England. The shortest life expectancy for mental health users was in populations living in Cornwall and in the north east and north west of England.
Between 2006 and 2015, the sustainability and transformation partnership (STP) areas with the biggest drops in life expectancy for mental health service users were Durham, Darlington and Tees and several STPs in the Midlands. Conditions causing death that were more common in mental health service users included ‘external causes’ (such as injury, poisoning, suicide), cancer and circulatory, respiratory and digestive disorders. In other words, people with a mental health condition often have other significant conditions too – a fact known for some time. In his Harveian Oration in 2016, Chris Whitty noted that people with multiple conditions had ‘non-random series of predictable disease clusters’. The single most common condition in a cluster is depression.
According to the Strategy Unit’s model, a young person with a first episode of psychosis, but initially physically well, is more likely to gain weight, smoke, abuse substances and live unhealthily, increasing their risk of a range of illnesses at a relatively early age. Unsurprisingly, people with mental health conditions use more health care relative to people without. A&E attendance and unplanned hospitalisation rates are 2–3 times higher (especially for people with personality disorders) and use of diagnostic services twice as high. There is much less difference for planned care.
Improving the integration of mental and physical health care
These figures say nothing about the quality of care received or access to care, which we know need to improve significantly, or do more than hint at opportunities for prevention. The close relationship between mental and physical ill health has led for many to call for the NHS to integrate care around the person, rather than treatment in specialist silos, and to pay far more attention to risk factors and preventive health care. As Whitty noted in his Oration, ‘as a generation we have been more effective at tackling the biological rather than behavioural drivers of disease’. This orientation is reflected in the volume and nature of scientific inquiry into disease, as well as the approach to treatment.
The Strategy Unit usefully sets out what STPs can do in practice to address mental and physical health together. The progress made in the last 5 years in dementia care shows that it can be done. Hopes are high for the forthcoming NHS 10-year plan and, assuming integrated care is still being pursued with vigour, new service models treating mind and body together must surely be a priority.
Several areas of the country are pioneering this type of care, for example as part of NHS England’s Improving Access to Psychological Therapies and Improving Physical Healthcare for Serious Mental Illness programmes, and careful evaluation will be important. This isn’t just an issue of parity of esteem, important though that is, but one of comprehending the nature of ill health and wellbeing to be more effective in reducing mounting risks in the future.
Jennifer Dixon (@JenniferTHF) is Chief Executive at the Health Foundation