There is a large group of people in this country for whom average life expectancy is hugely less than the rest of the population. The drivers of this life expectancy gap (up to 18 years) range across all causes of death. This group also ends up utilising emergency acute hospital care at a rate that is up to 3 times that of the rest of the population. And we know who is in this group…we don’t need ‘predictive algorithms’ to try to find them. They are people in our care …people in contact with our mental health services.
The phrase ‘Cinderella service’ is oft applied to mental health in the UK in respect of the lack of funding that it receives in comparison to physical health treatment services – “parity of esteem” in national policy language. What’s less globally appreciated, although well recognised by front-line workers, is the wide inequality in health outcomes that people with mental health difficulties experience. The best intelligence we have however on the extent of the inequalities comes from international or niche population studies into life expectancy and mortality experiences. As a result, local areas struggle to make the case for further investment and/or greater integration of physical and mental healthcare services.
Re-cap of the commission for STP insight packs.
In January 2017, NHS England commissioned the Strategy Unit to undertake detailed analysis of linked datasets across Mental and Physical health. Building on work done in 2016 with the Black Country STP, the work would produce an insight pack for each of the 44 STP in England detailing:
- the life expectancies of mental health service users compared to the general population
- their causes of death
- their utilisation of acute physical health services compared to the general population
- opportunities for (improved) integration of mental and physical health services
The 44 STP reports were completed and published in May 2017 and circulated by NHS England to specific STP leads across the country in a password protected format. Additionally, the Strategy Unit received over 100 requests for packs after inclusion in HSJ articles and Royal College of Psychiatrist newsletters. We were asked to speak about the work and findings at a range of STP board meetings, predominantly in the Midlands and North of England, and at several conference events addressing the integration of mental and physical healthcare.
We know from feedback from many frontline professionals, STPs and professional bodies that this work has been seen as useful and powerful for local areas. There has been a general plea, though, that a national level comparison would also be helpful to set context. On the 1-year anniversary of the work we are responding to this request by publishing our own national overview on our website.
For England, our analysis shows that:
- There is a 19-year difference in male and 16-year difference in female life expectancy for patients in contact with specialist mental health services when compared to the rest of the population. This varies substantially between different and sometimes neighbouring areas of the country.
- Age-adjusted mortality rates are higher for the mental health population for all underlying physical causes of death and are 2-3 times higher for the high-volume causes of death – cancer, heart disease and respiratory disease.
- Mental health service users use acute physical health care services disproportionately – 7% of the total population but make up 17% of all A&E attendances and 24% of unplanned inpatient admissions.
- The difference in spend on acute physical healthcare for mental health services compared to the rest of the population is around £1.5 billion. Much of this service use could be prevented with improved detection, prevention and management of physical health needs alongside management of mental health needs.
What is clear from our analysis, and that of others such as the Kings Fund, are that as well as suffering from Cinderella syndrome, there are two other ugly sisters of a problem in Mental Health – first, the gross and unacceptable inequalities in the physical health of patients with mental health difficulties; and second, very few proven solutions (and insufficient priority to devise and test them) to fill the yawning gap of integration in physical and mental health.
Measuring the impact of our work – have the right people seen it and how have they acted on it?
Whilst there was clearly a great deal of interest in the findings of our analysis at both a national and local level, what reach and meaningful impact did the work really have?
As an agency within the NHS our purpose/mission is largely to inform and support evidence-based high-level decision-making around long-term approaches to health and care. Through client feedback we know we are providing a valued service however we face a continuing challenge to demonstrate to ourselves our real impact on patients and services (the ultimate test).
As the anniversary of the report publication passes, we have attempted to capture some of that ‘unreachable insight’ by surveying all those we know have received or requested at least one of the STP packs.
We asked them briefly;
- How important the analysis was to them
- How would they rate the quality of the work
- Whether they thought the reports would have tangible impacts or directly influence service change
- What would be a reasonable value to place on work such as this to a single STP (they were not charged, NHS England commissioned the work on behalf of all STP)
- Over 90% stated the analysis was very or extremely important
- 96% rated the quality high or very high
- 84% felt the reports would have some tangible impacts on services
- The (mean) average for willingness to pay was £31k, ranging from £2k - £100k
This is interesting…we are an internal ‘consultancy’ in the NHS and charge for our work to cover our salaries, our utilisation rate, our overhead costs and generate a small margin for reinvestment in innovation…the actual costs of us delivering these 44 bespoke STP reports on behalf of NHSE was £3,400 each. We think this should tell people something about how to benchmark ‘consultancy pricing’ of analytical projects and also how to extract national benefit from collective commissioning of high quality analysis from a single internal NHS source.
What’s next for this work and related work?
There is still a question over whether the analysis is worthy of a full-update and refresh or whether the case for investment is compelling enough already. We are always keen to hear views on that
Meanwhile, through specific follow-on discussion with users of the packs we will continue to work on this important agenda through various projects e.g. 'Rapid Assessment Interface and Discharge' Service and IAPT evaluations; developing community monitoring services for dementia patients; developing GP toolkits/checklists; developing monitoring frameworks for measuring (the success of) integration services etc…
We continue to look to find people, organisations and systems driven by the same determination to tackle the gap our work lays bare. We are always keen to make links and to find ways to take work forward so please get in contact if that is you via the contact us section.
With thanks to the Nuffield Trust for their work on this topic which prompted us to dig deeper; to the Black Country STP and MLCSU for supporting the initial version of the report; to Professor George Tadros, clinical and other colleagues who helped us to refine our approach (too many to name); to NHSE and their advisors for commissioning and supporting the work in its national form; and to the team involved in the STP pack production at The Strategy Unit.