Integrated care to address the physical health needs of people with severe mental illness: a rapid review

Article history

The research reported here is the product of an HS&DR Evidence Synthesis Centre, contracted to provide rapid evidence syntheses on issues of relevance to the health service, and to inform future HS&DR calls for new research around identified gaps in evidence. Other reviews by the Evidence Synthesis Centre are also available in the HS&DR journal.

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 13/05/11. The contractual start date was in May 2015. The final report began editorial review in September 2015 and was accepted for publication in January 2016. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

none

Copyright statement

© Queen’s Printer and Controller of HMSO 2016. This work was produced by Rodgers et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Physical health of people with severe mental illness

People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. 2 Physical health and mental health are closely linked, and demands have been repeatedly placed on the NHS to deliver an equal response to the treatment of each. 4,5 Many patients with SMI remain underserved. In 2014, the National Audit of Schizophrenia revealed that only 33% of people with schizophrenia were adequately monitored for diabetes mellitus and cardiovascular disease, just 52% had their body mass index recorded and 36% of service users received an intervention to address impaired control of blood glucose on an annual basis. 6 Another review found that one-third of patients with SMI are seen only in primary care. 7 These recent reports indicate serious shortcomings in the physical-health monitoring and integration of services for this population group.

Services for mental health conditions have traditionally been separate from general health care for physical conditions but there is increasing emphasis on developing a whole-system approach to improve integration between the two, with particular focus on patient-centred development and delivery. 4 This is not new, a focus on patient-centred delivery of health services for people with mental illness has been advocated for many years. In 1991, the Department of Health introduced the ‘Care Programme Approach’ (CPA), which was subsequently updated in 2013. 8 The CPA is a national system setting out how secondary mental health services should help people with mental illness and related complex needs. Those eligible for CPA are entitled to a full assessment of health and social care needs, a care plan (overseen by a care co-ordinator) and regular reviews of health and progress, although Mental Health Trusts do not have to follow this guidance and may adopt their own policy. The personalisation agenda for people with serious mental illness also featured in the National Service Framework for Mental Health in 1999. 9

In 2006, the Department of Health produced a commissioning framework entitled Choosing Health: Supporting the Physical Needs of People with Severe Mental Illness. 2 This described the nature of pilot health improvement programmes in which a lead mental health nurse practitioner attached to an existing team [e.g. primary care team or community mental health team (CMHT)] would be responsible for conducting physical health checks, in-depth consultations (including providing relevant information, signposting, exploring broader health-related issues such as employment or education), referral to screening and health promotion services, and establishing specific one-to-one or group health improvement interventions. The prerequisites for this type of programme were defined2 and evaluations have emerged since. 10,11 However, there seems to be little available evidence of their wider implementation.

In terms of existing guidance and incentives to address the treatment and management of people with SMI, National Institute for Health and Care Excellence (NICE) guidelines for various mental health disorders include those for psychosis and schizophrenia,12–15 and a Commissioning for Quality and Innovation (CQUIN) incentive is currently in place for secondary health-care providers to improve the physical health care of people with SMI. 16 This CQUIN helps ensure service users have their physical and mental health diagnoses recorded, and aims to promote effective communication between primary care, specialist mental health services and service users. In addition, in the latest proposal announced by NICE to improve the quality of care by family doctors, consideration is given to the introduction of new quality indicators to identify and support people with SMI who are at risk of cardiovascular disease. 17 These indicators will inform negotiations for the 2016/17 Quality and Outcomes Framework (QOF).

Integrated care

Service integration (i.e. breaking down the barriers in how care is provided between family doctors and hospitals, between physical and mental health care, and between health and social care) is a key step in the proposed system change for the NHS. 5 Service integration encompasses the concept of integrated care; a potentially complex intervention with many different components. As yet, integrated care is not well defined and the terminology to describe the concept is diverse (e.g. collaborative care, holistic care, patient-centred care).

The present focus on improving integrated care for people with mental health needs appears to be from the perspective of access to health services for an acute or chronic physical health condition. 18 Information about the converse of this (i.e. addressing the physical health-care needs of patients with SMI at point of access in the mental health service setting) seems lacking. The latter represents the primary focus for this rapid review.

General approach

This project was resourced as a rapid review of current practice and recently published evidence. There is no generally accepted definition of the term ‘rapid review’ and a number of other terms have been used to describe it as one that incorporates systematic review methodology modified to various degrees. Our intention was to carry out a review using systematic and transparent methods to identify, appraise and produce a synthesis of relevant evidence from 2013 to 2015. Our approach was necessarily pragmatic and iterative in nature. Inevitably the process would be less exhaustive and the outputs somewhat less detailed than what might be expected from a full systematic review.

The results of this rapid review should also be viewed in the context of evolving UK policy and the likelihood of ongoing change in relation to developing models of integrated care. Recent initiatives are summarised in Box 1.

Research questions

We sought to address the following four questions:

1. What type of models currently exists for the provision of integrated care specifically to address the physical health needs of people with SMI when accessing mental health-care services?

2. What are the perceived facilitators and barriers to implementation of these models?

3. How do models implemented in practice compare and contrast with those described in the literature?

4. Can we identify high-priority areas for either further primary research or a full evidence synthesis?

Scope and definitions

The focus of the review was NHS health-care services that included steps to address the physical health needs of people diagnosed with SMI. We focused on where these services were provided in the mental health-care setting. We used the NICE definition of SMI to cover schizophrenia, schizotypal and delusional disorders, bipolar affective disorder and severe depressive episode(s) with or without psychotic episodes. 1 We adopted a broad definition for physical health outcomes, including the assessment and modification of cardiometabolic risk factors, anthropometric measures and physical functioning.

We did not consider the various interventions or services aimed at the broader needs (i.e. beyond health) of this group of people, or the integration of services spanning non-NHS settings (e.g. social care, education, employment, housing and voluntary sector provision).

Data sources

We considered two main data sources: conversations with our advisory group (comprising field experts and service users in the area of mental health) and the published literature.

Inclusion and exclusion criteria

Study selection and data extraction

Electronic search results were loaded into EndNote X7 (Thomson Reuters, CA, USA). At the initial screening stage, the results were divided between three reviewers to eliminate obviously irrelevant items. Decisions were recorded as ‘include’, ‘reject’ or ‘maybe’. A second screen was carried out by three reviewers independently, to arrive at a definitive list of ‘includes’ and ‘rejects’. Full-text copies were ordered for the included records. Papers identified from other sources (e.g. field experts) were added to the EndNote library and assessed in the same way.

A data extraction template was developed and piloted on 12 papers by three reviewers (see Appendix 4). Details included population and setting, approach to integrated care; Mental Health Foundation factors covered (1–9), barriers and facilitators to implementation, and details of evaluations. Revisions to the template were made where necessary. Subsequent data extraction was carried out by one reviewer and checked by a second reviewer. Disagreements were resolved by discussion or with the involvement of a third reviewer.

Quality assessment

Given the lack of detail reported in the studies and the lack of comprehensive evaluations, we did not assess the included papers for methodological quality; our aim was to describe interventions and their implementation rather than establishing risk of bias in their evaluation.

Synthesis

We carried out a narrative synthesis, building on the 2013 Mental Health Foundation inquiry. 28 This was a substantial piece of work based on a literature review on integrated health care and mental health care, three expert seminars attended by 31 people and a call for evidence on the best ways to integrate care that led to over 1200 responses. The scope of the enquiry incorporated both health and social care, and identified nine structural and organisational arrangements at the heart of good integrated care for people with mental health problems (Box 2).

The majority of the recent evidence identified in this rapid review relates to complex and/or multicomponent programmes that incorporated several of the nine factors key to good integrated care (see Box 2). 28 We used these nine factors as a guiding framework to help answer our four research questions and to explore the elements of interventions or care models. We also discuss further issues to emerge from the evidence; for example, we incorporated in our synthesis any other relevant factors identified during data extraction and from discussions with advisory group field experts and service users, particularly wider-system factors that might underpin the successful implementation of integrated care interventions.

Advisory group

We spoke to 13 field experts (five provided detailed information) and two service users involved in the area of mental health services. We used their insights primarily to extend our working knowledge of the topic area and understand more clearly some of the issues arising from the published literature.

Literature

The search strategy retrieved 2742 records. Seventy records were included on the basis of screening titles and abstracts. Thirty-eight were retained and data were extracted after reading the full paper; 32 were rejected. A further 10 papers were identified, four following discussions with field experts and six from the retrieval of relevant primary studies from rejected reviews. Seven of these 10 papers met our inclusion criteria and were included and data were extracted; three were rejected. In total, 45 papers describing 36 approaches to integrating physical health needs into the care of people with SMI were included in this rapid review (Figure 1).

FIGURE 1.

Flow of identified literature.

Some papers were retrieved outside the database search strategy (i.e. from website searching and via field experts) and had publication dates prior to 2013 (i.e. prior to our electronic search start date). Brief data extraction tables for all included studies are available in Appendix 5. For detailed information, readers are advised to consult the full reports.

The included papers comprised a range of study designs including systematic reviews and other literature reviews, various primary studies, book chapters, conference abstracts and dissertations, policy and guidance documents, feasibility studies, descriptive reports and programme specifications. We identified 27 papers reporting on 25 distinct evaluations of programmes or interventions,2,27,29–53 few were described in detail and fewer still were comprehensively evaluated. Details of study characteristics are presented in Appendix 5.

Table 1 presents a classification of the included publications showing our interpretation of how the programmes or interventions correspond with the nine factors of good integrated care. 28

Information sharing systems (13 studies)

To properly integrate care, the Mental Health Foundation inquiry identified the need for a compatible information system within and across different care organisations that could establish individual electronic records of service users’ integrated health and social care needs and interventions. The proposed system would also have the ability to anonymise and aggregate health and social care records to inform a needs assessment of the local population. 28

One of the quality indicators in the General Medical Services contract is the establishment and maintenance of a register of people with SMI. It also requires the establishment of a comprehensive care plan and recording of physical health-related measures (e.g. blood pressure, alcohol consumption, cervical screening, lithium monitoring) for a defined proportion of SMI service users. 70 The collection and maintenance of such information necessarily requires an adequate information technology (IT) infrastructure.

Like the General Medical Services contract, the US SAMHSA’s Primary and Behavioural Health Care Integration (PBHCI) funding programme recommends a registry/tracking system for all primary care needs of, and outcomes for, clients with serious mental illness. 58,71 However, PBHCI grantees have noted both technical and legal barriers to implementing the required shared information systems. For example, web-based registry software has thus far proved to be inadequate, resulting in organisations relying on less-useful paper or Excel-based versions (Microsoft Excel^®, Microsoft Corporation, Redmond, WA, USA). 58

Shared protocols (10 studies)

Despite noting difficulties around dissemination, communication and ‘territorialism’ relating to the use of shared protocols, the Mental Health Foundation inquiry was broadly supportive of such protocols within and between the organisations that support people with mental health problems. 28

Joint funding and commissioning (eight studies)

The Mental Health Foundation report concluded that separate funding streams hinder integrated care, while pooled funding and services commissioned across boundaries increase the likelihood of service users receiving better care. 28 A recent review of 38 schemes that integrated health and social care funds challenged the assumption that integrated funding leads to better health outcomes and lower costs. Rather, improved integrated care tends to uncover unmet needs, with total care costs likely to rise. Nevertheless, better integration may still offer value for money if additional costs are offset by improvements in quality of life. 79

Much of the US literature has focused on overcoming funding barriers in the provision of collaborative stepped care. This has recently included the provision of integrated primary care services for people with SMI within community mental health centre settings, funded through the SAMHSA PBHCI programme. However, alternative administrative arrangements can include global payment systems for physical, mental and dental care for Medicaid beneficiaries (via co-ordinated care organisations) and self-contained systems (VA, Department of Defence, private insurers). 27,52,58 Although the organisation of services may vary across PBHCI grantees, receipt of funding is contingent on community mental health centres establishing a formal link with a primary care partner.

Some of the problems noted in the US literature – such as insurance companies refusing to pay for lipid panel orders for service users not taking second-generation antipsychotics44 – may not be directly relevant to the UK, but such observations highlight how fragmented funding can undermine the implementation of integrated care programmes.

Several advisory group field experts discussed funding issues related to the integration of Healthy Living Services for people with SMI. One such existing service comprises dietitians, physiotherapists and healthy living advisors who provide advice and support (on healthy eating, physical activity, smoking cessation, sensible alcohol use) for service users in inpatient units. In addition, a health improvement specialist oversees public health work within the trust and supervises the healthy living advisors. The latter role is partly supported by local authority public health funds. The field expert considered commitment from both health and public health arms necessary to support and fund such a model, given the health inequalities in this population and the need for prevention as well as intervention. This was echoed by another respondent who noted that Public Health England might also have a significant role to play in terms of health-needs assessment for this population. In the current NHS commissioning structure, local secondary care, community and mental health services are typically funded through local CCGs, whereas local public health services are supported by local authority funding. Close co-operation of local (and possibly national) commissioners will be necessary to facilitate the kind of Healthy Living Services described here.

In July 2014, NHS England announced a new Integrated Personal Commissioning (IPC) approach to providing care for people with complex needs, including those with significant mental health needs. IPC aims to move the balance of spending power to the individual, in terms of people being able to shape their own health and social care delivered (as appropriate) by various combinations of local authority, NHS and voluntary sector providers. The success of this approach will depend to some extent on the ability of individuals with SMI to negotiate their own integrated care. As noted by the Mental Health Foundation, arrangements will be needed to ensure that disadvantaged individuals are able to benefit from IPC, to avoid the risk of further exacerbating their experience of inequality.

Colocation of services (19 studies)

The Mental Health Foundation inquiry looked at evidence on community-located psychiatric services, mental health professionals in primary care and merging of entire trusts or funding bodies. It concluded that the colocation of primary care and specialist mental health staff could provide significantly improved integration of care for people with mental health problems, but only if the staff understand their roles and responsibilities and work willingly and collaboratively together,28 emphasising that people rather than organisational systems or structures are primarily responsible for the successful integration of care.

Much of the published evidence on colocated care identified through this rapid review was concerned with primary care professionals providing clinics in community or inpatient mental health settings. 32,37,41,52,58,63,67,69 However, these might also be considered ‘liaison’ services that happen to be colocated; other publications have described similar clinics within virtual ‘Health Home’ organisations where colocation is not strictly necessary. 62 Therefore, issues relating primarily to liaison are discussed in Liaison services (17 studies).

Where factors relating to colocation were discussed, these broadly supported the Mental Health Foundation conclusions around staffing, highlighting the need for willing, interested, committed and passionate staff67 plus commitment from leaders and administrators. 37 These themes recurred repeatedly in both the literature and our discussions with field contacts and are further discussed in Chapter 6.

In addition, some studies highlighted the need to plan for, and provide sufficient physical space for, any primary care services to be located in a mental health clinic. 58,61 Others highlighted the need for colocated care sites to be both highly visible and easily accessible, including open-access arrangements that allow walk-in care for people with SMI. 41,58

Multidisciplinary teams (19 studies)

As acknowledged by the Mental Health Foundation inquiry report, the principles of multidisciplinary care are already well established in mental health services through the use of CMHTs and the CPA. CMHTs can include professionals such as psychiatrists, psychologists, community psychiatric nurses (CPNs), social workers and occupational therapists. Assertive Outreach and Crisis Teams also typically involve multidisciplinary teamwork. In addition, healthy lifestyle services may include healthy living advisors, dietitians, physiotherapists and health improvement specialists, whose work may be further supported by pharmacists (e.g. through prescribing nicotine replacement therapies).

Liaison services (17 studies)

The Mental Health Foundation inquiry was strongly supportive of the concept of liaison services – both psychiatric liaison services in physical health-care settings and physical health care in mental health settings. 28 In addition, advisory group service users told us that they would like to know that there is someone with responsibility for the physical health needs of SMI service users, particularly in the inpatient setting.

One advisory group field expert described the emergence of physical health clinics in the NHS intended to meet NICE recommendations on physical health monitoring and screening for SMI users in secondary care. We also found several published descriptions of primary care clinics or placement of physical health practitioners in inpatient51,69 and outpatient29,52,56–58,63,67 mental health settings. While the US PBHCI model typically involves the placement of primary care specialists in behavioural health facilities, this can also take the more indirect form of consulting primary care practitioners supporting psychiatrists who provide medical care for common conditions (e.g. hypertension, diabetes mellitus, dyslipidaemias). 58 Field experts also described existing services such as dedicated GP sessions on forensic wards and in-reach specialist diabetes mellitus nurses.

One feasibility study noted that service user anxiety about seeing someone other than a psychiatrist could be a barrier to the implementation of a weekly primary care service on acute psychiatry wards and highlighted the importance of the primary care doctor being perceived as professional, kind and understanding. 69

One US study described a half-time primary care clinic within a community mental health clinic, staffed by two nurse practitioners and one family physician. Referral was informal, with a mental health provider directly placing their service user on the clinic schedule or discusses the referral with the primary care nurse liaison. Although referral criteria were not formalised, the aim was to capture people with a chronic medical illness who are unable to navigate a traditional primary care setting. 63

Navigators (15 studies)

One of our advisory group field experts noted that continuity of care is particularly important for the SMI population, but noted that such continuity is becoming increasingly rare within primary care. In response to observations of this nature, several models have proposed the role of a single named individual who can help people navigate their way through complex systems.

Among these is the existing CPA model, which aims to ensure people with mental illness receive a care co-ordinator who can arrange a full assessment of both their health and social care needs, and then help develop a plan to address those needs. Care co-ordinators may be a CPN, social worker or occupational therapist.

Although navigators or care co-ordinators are generally thought to negotiate the boundaries between health, social care, education and housing sectors, this role can be just as important for helping people with SMI negotiate boundaries within heath care, between physical and mental health services, or between primary and secondary care. At the core of the Manchester Mental Health and Social Care Trust pilot was the CPHC role. In the pilot, this CPHC role was undertaken part time (0.4 hours whole-time equivalent) by care co-ordinators already working within the CMHT. The authors stated that it was essential for the CPHCs to also continue in their care co-ordinator role in order to retain their skills, continue to have contact with service users and colleagues, and to allow access to relevant meetings and discussions with other CMHT staff. CPHCs also felt that respect was a key facilitator for gaining the trust and support of other care co-ordinators. 46,47

The Manchester model differs from some other ‘navigator’ programmes in the literature in that the CPHC role was deliberately focused on facilitating communication between services without the additional responsibility of undertaking physical health checks or other clinical tasks. By contrast, a US evaluation of a transitional care (‘TCare’) model for people with SMI being discharged from hospital to community care employed a psychiatric nurse practitioner (trained in medical and psychiatric assessment/treatment/prescribing) as the navigator. 64 The intervention consisted of 10 components: (1) co-ordination of care by a psychiatric nurse; (2) a plan developed prior to hospital discharge; (3) home visits from the nurse for approximately 90 days post-hospital discharge and available 7 days a week; (4) co-ordination with physicians in the community, including accompanying service users on visits; (5) inclusive focus on health needs of the service user; (6) involvement of both service user and family in care through education and support; (7) early detection and quick response to health-care risks and symptoms; (8) service user, family caregiver and providers functioning as a team; (9) collaboration of nurse and physician; and (10) information sharing among all team members. Interestingly, this evaluation noted difficulties in engaging mental health case managers with the TCare programme. The authors attributed this to case managers’ heavy caseloads forcing them to focus on dealing with crises at the expense of clients who are seen to be already receiving some form of service. This observation would appear to support the idea that physical health navigators should have a role that can be influential in the wider co-ordination of services for people with SMI.

A US pilot programme, ‘The Bridge’, aimed to use a time-limited peer health navigator intervention to give clients the skills and experience to self-manage their health-care activities to the greatest degree possible. 31,43 The intervention comprised four components: (1) service user health assessment and health navigation planning; (2) co-ordinated linkages/activities to help service users navigate the health-care system and follow-up/adherence to treatment plans; (3) consumer education including partnering with medical care providers, treatment compliance, self-advocacy and interaction skills, health and wellness, and benefits and entitlements; and (4) cognitive–behavioural strategies to support health-care use behaviour change and behaviour maintenance. The 6-month intervention included a 4-month phase of intense contact between service user and navigator, followed by a less intensive ‘monitoring’ period. Although the intervention appeared to improve some aspects of physical health and health-care utilisation, the pilot included only a single peer navigator, who had been involved in the intervention development, and received both extensive training and close supervision. There are a number of questions about whether or not such a model could be generalisable or sustainable in addition to ethical concerns around duty of care and accountability. However, particularly in the USA, ‘peer navigation’ remains an area of interest. 53

An advisory group service user contributing to this rapid review described her CPN providing the co-ordinating role between mental and physical health care, particularly in terms of support and signposting to mainstream services. However, she also described being dropped from her dental practice because of missed appointments as a result of mental illness episodes. She had to be forceful in explaining the difficulties, but remains without dental care for the time being. Although she feels confident at speaking out when things are not right, not everyone is able to do this. This raises questions about the extent that navigators such as care co-ordinators in the CPA model should engage in advocacy for service users, particularly when dealing with services less accustomed to SMI. One study of the CPA found that failings were often because of the care co-ordinator having insufficient authority to exert control over other care professionals to ensure care is properly integrated. 80

Research (six studies)

A review of factors that influences integrated health and social care published by the Social Care Institute for Excellence81 concluded:

The evidence base underpinning joint and integrated working remains less than compelling. It largely consists of small-scale evaluations of local initiatives which are often of poor quality and poorly reported. No evaluation studied for the purpose of this briefing included an analysis of cost-effectiveness. There is an urgent need to develop high-quality, large-scale research studies that can test the underpinning assumptions of joint and integrated working in a more robust manner and assess the process from the perspective of service users and carers as well as from an economic perspective.

The Mental Health Foundation enquiry echoed these conclusions, recommending that more research into how best to support people with complex, comorbid needs is required that addresses both effectiveness and economic assessment of integrated care models. 28

Similarly, most of the programmes identified through our update searches and contact with field experts have been either not evaluated, or evaluated only on a small scale within a local context.

Future evaluations of programmes to improve the physical health of people with SMI will need to have sufficiently long follow-up to collect meaningful physical outcomes, and/or collect appropriate process and surrogate outcomes. One advisory group field expert described developing a bespoke outcome measure based on the Theory of Planned Behaviour to allow healthy living advisors to measure impact on service-users’ attitudes towards healthy living, perceptions of social pressure/support and perceived barriers to healthy living.

Reduction of stigma (eight studies)

Other factors emerging from the evidence

What types of models currently exist for the provision of integrated care specifically to address the physical health needs of people with severe mental illness when accessing mental health-care services?

The majority of service models identified in this review were multicomponent programmes incorporating two or more of the factors that have previously been identified as facilitators of integrated care: information-sharing systems; shared protocols; joint funding/commissioning; colocated services; multidisciplinary teams; liaison services; navigators; research; and reduction of stigma.

The majority of programmes were in community and/or secondary care mental health settings in the UK, North America or Australia.

Programmes rarely focused on a single delivery component, rather most described the complex interaction of multiple components. However, few programmes were described in detail and fewer still were comprehensively evaluated. This raises questions about the replicability and generalisability of much of the existing evidence.

One of the few clearly described and evaluated programmes was that piloted by Greater Manchester Collaboration for Leadership in Applied Health Research and Care, which evaluated the impact of introducing a core time-protected CPHC role to improve communication between primary care and CMHTs. Other ingredients of the programme were multidisciplinary team meetings, targeted training, physical health assessments and shared information resources. The team behind this programme has produced guidance for future implementation that other sites could use to replicate or further refine this promising approach. 46,47

Many other variants of the ‘navigator’ model have been described in the literature, although where evaluations were available, these tended to be somewhat superficial with little clarity about implementation. However, the available evidence suggests that any individual tasked with co-ordinating care needs to be empowered with the authority to influence other care professionals. Although peer (as opposed to professional) navigator models have also been proposed, both the ethics and the sustainability of such approaches need to be considered carefully.

What are the perceived facilitators and barriers to implementation of these models?

As has been previously noted, a fundamental requirement for successful integration of physical and mental health care is having the right people with the right skills and attitudes in place. The Mental Health Foundation emphasised the need for strong leaders, along with committed and willing staff, supported by cross-boundary interprofessional training and ongoing professional development. 28

Our findings further underline the importance of considering the impact of any planned structural changes on the attitudes, skills and behaviours of the people interacting within and across health organisations, be they health professionals or service users. Many of the factors that authors, experts and service users identified as facilitators were those that either empowered individuals and/or minimised the effort needed for individuals to provide integrated services.

Wherever possible, training for mental health professionals who fail to address the physical health needs of their service users should aim to increase self-confidence in their own skills and give greater clarity about their responsibilities in relation to physical health. Care co-ordinators/navigators may have an empowerment role by providing advocacy for service users in certain settings, and might themselves benefit from greater formal authority over care integration. All health professionals will need time to undergo training and to collaborate on service user care, which can be difficult in clinical settings with heavy caseloads. Management commitment to protect time and (where necessary) resources for such activities has been raised as a potentially worthwhile investment.

Factors such as integrated information systems and individual electronic records have yet to be properly implemented because of various technical, legal and organisational barriers. However, these remain the most promising means of simplifying communication and collaboration among professionals in order to provide care for service users across multiple services. We encountered potentially useful local innovations that could not be implemented because of IT incompatibility or inaccessibility issues. Improved communication and understanding between clinical, administrative and technical staff can be crucial in overcoming such barriers to innovation.

Any arrangements that reduce the level of effort necessary to deliver integrated services on a day-to-day basis should be welcomed. The literature identified simple measures such as informal referral procedures, high visibility of sites and open access as facilitators of physical health clinics for people with SMI in mental health settings.

Multidisciplinary teams form an important role in the provision of mental health services, and are ever more likely to continue to do so in the future. However, simply having an appropriate skill mix within a team does not appear to be sufficient for providing integrated care. There often appears to be broad agreement about what needs to be done to improve the physical health of people with SMI, but not who should be responsible. Within multidisciplinary teams, there must be absolute clarity about the aspects of care for which individuals in the team are responsible and accountable, supported by effective communication between team members. We heard several instances where opportunities to intervene had been missed because of poor communication between providers.

Organisational incentives alone are likely to be inadequate unless individuals have the appropriate knowledge, skills, resources and environment to support them. Shared protocols, joint action plans and decision support tools, such as the Lester resource and Rethink Integrated Physical Health Pathway, are promising approaches for clarifying responsibilities and supporting record keeping and communication across boundaries. NHS-specific evidence in this area is expected soon. 65

Field experts and service users described several ways in which the existing organisation of services, and often unconscious assumptions, attitudes and behaviours of health-care staff, can be stigmatising to people with SMI. Concerns such as inattention to the sexual health in people with SMI and inpatient environments conducive to poor physical health do not appear to have been explicitly tackled in the published literature identified in this review. These important concerns need to be addressed.

Greater prioritisation of physical health needs to be embedded in the culture and environment of mental health services. This will require clear strategic leadership and commitment from staff at all levels, backed by appropriate funding arrangements.

How do models implemented in practice compare and contrast with those described in the literature?

In 2013, the Mental Health Foundation concluded that good integrated care appears to be the exception rather than the norm, with isolated pockets of good practice, but overall dissatisfaction with progress being made across the UK. 28 Our field contacts gave the impression that this remains the state of affairs in 2015, describing a small number of high-profile programmes as well as their own efforts to address the physical health needs of people with SMI locally.

The sustainability and effectiveness of these initiatives and models described in the literature are not known. However, there are several high-profile initiatives ongoing and others that have been announced, which may indicate increased activity to progress the implementation of integrated care. It will be some time before these initiatives are fully implemented and even longer before their impact is established.

Can we identify high-priority areas for either further primary research or a full evidence synthesis?

All of the practitioners we spoke to were dedicated to improving their local service with regard to meeting the physical health needs of people with SMI, but not all had plans to formally evaluate or widely disseminate these efforts. This makes it difficult for lessons learned locally to be shared across institutions and the health service more generally.

Most published evaluations were small in scale and/or poorly described. Ideally, future evaluations of efforts to improve physical health care for people with SMI should be on a larger scale and use meaningful, validated measures of success. Future evaluations should also build on the existing literature to learn lessons and prevent research waste through further unnecessary duplication of effort. Much of the recent literature consists of largely independent interventions/programmes based on a similar set of underlying ideas. Replication of locally successful programmes in different settings is legitimate, but all evaluations need to be clear about which outcomes, facilitators and barriers are likely to be context-specific, and which might be generalisable. There is scope for additional research on understanding why efforts to integrate physical health-care needs for people with SMI succeed or fail, using qualitative or mixed-method techniques.

Wherever possible, service users should be involved in the design, conduct and evaluation of programmes as they will provide crucial insights into current service provision that might not be visible to practitioners, decision makers or researchers. For example, service users on our advisory panel identified the need to consider how existing appointment booking arrangements might be improved for patients with SMI; how mental health inpatient environments might be made more conducive to maintaining good physical health; and how to attend to the sexual health of people with SMI. Such concerns have received very little attention in the recent literature.

Outputs from ongoing pilot evaluations by NHS Improving Quality (now NHS England’s Sustainable Improvement Team) alongside the New Care Models Programme Vanguard sites and the IPC demonstrator sites should also inform any future research efforts in this area.

On the basis of the evidence identified in this systematic review, a full evidence synthesis on this topic would not appear to be feasible or appropriate in the immediate future. In addition to the heterogeneity and poor reporting of many studies, any future overview of the evidence on integrated care for people with SMI would need to take into account the various developments in this area, such as the new 5-year Mental Health Strategy for England, new QOF indicators for 2016/17, regional devolution and ongoing work on approaches such as the integrated digital record.

Limitations of the rapid review

This rapid review provides a snapshot of the literature on integrating the physical health needs of people with SMI published since 2013. As might be expected given the narrow timeframe, the volume of literature identified is relatively small. More significantly, much of this literature lacked the depth of description necessary to acquire new insights beyond those summarised in the Mental Health Foundation’s ‘Crossing Boundaries’ enquiry. 28 Much of the available literature was descriptive and, with the exception of the Manchester CPHC pilot, much of the evaluative literature failed to provide additional useful information on barriers and facilitators. In addition, while we emphasised, wherever possible, aspects of the literature that were most novel, interesting or relevant to implementation, our commitment to retaining an objective overview prevented us from speculating or greatly extrapolating from the limited available evidence. Consequently, the weight of attention given to specific interventions in this synthesis was at least partly determined by the amount of available information rather than the inherent value of the intervention.

In order to help interpret and contextualise the literature, we incorporated the input of an expert advisory panel made up of health professionals and service users. Although the insights they provided were extremely valuable, our advisory group were not necessarily representative. For example, all our experts were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. Conversely, this rapid review drew on the literature from a diverse range of settings, some of which might not be considered comparable to the NHS. However, we believe that awareness that certain barriers (such as difficulties in implementing web-based registry software) can transcend different countries and health-care systems is valuable.

Although our focus was to identify the literature relating to people with physical health needs at point of access in the mental health setting, we found that the initial point of access is often not quite so clear cut, especially when patients are invariably referred back and forth between secondary and primary care.

Wherever possible in this rapid review, we have tried to follow the guiding principles of transparency and objectivity that underpin traditional systematic review methodology. However, there might also be an argument for undertaking a more interpretivist approach to exploring this literature. Very few of the interventions described in the literature had any explicit theoretical basis themselves, but it might have been possible to code these studies with the specific aim of developing higher-level concepts and theory. Equally, aspects of this literature could be interpreted in light of several existing theories of behaviour change. Such an investigation was outside the scope and resources of this rapid review.

Contributions of authors

Study selection, data extraction, critical appraisal and write-up of the report were carried out by Mark Rodgers (Research Fellow, Evidence Synthesis), Jane Dalton (Research Fellow, Evidence Synthesis) and Alison Eastwood (Professor, Evidence Synthesis).

All searching was conducted by Melissa Harden (Information Specialist), who also wrote the search sections of the report and commented on the draft report.

Andrew Street (Professor, Health Economics) and Gillian Parker (Professor, Social Policy) provided expertise and advice, contributed to the development of the protocol and commented on drafts of the report.

Data sharing statement

All available data can be obtained from the corresponding author. All data will be shared in a way that safeguards the confidentiality and anonymity of respondents.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

Database search strategies

Database searches were carried out to update the following systematic reviews:

Bradford DW, Cunningham NT, Slubicki MN, McDuffie JR, Kilbourne AM, Nagi A, et al. An evidence synthesis of care models to improve general medical outcomes for individuals with serious mental illness: a systematic review. J Clin Psychiatry 2013;74:e754–64.

Bradford DW, Slubicki MN, McDuffie JR, Kilbourne AM, Nagi A, Williams JW. Effects of Care Models to Improve General Medical Outcomes for Individuals with Serious Mental Illness. Washington, DC: Department of Veterans Affairs; 2011.

The original search strategies from the above reviews were used, but adapted to fit the inclusion criteria of the current review. Adaptations included the addition of terms for depression to cover the definition of SMI used in the current review and the addition of further terms for integrated care.

Guideline searches

Website searches