The failure by general hospitals to integrate physical and mental healthcare services is leading to poor care for patients with a physical illness who also happen to have a mental health condition, the latest report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reveals.
The study is the result of an in-depth review into 552 cases (all patients had a physical illness and a mental health condition) where the confidential enquiry looked into the impact a patient’s mental health condition had on the care they received in hospital. Most of the 552 patients had been admitted through hospital emergency departments (ED).
The NCEPOD report comes at a time when health professionals are expressing concerns that patients with a severe mental illness develop medical conditions a decade earlier in their lives than other people, and die 15 to 20 years younger as a consequence*. Also, a significant number of patients in general hospitals with physical health conditions often have more common mental health conditions such as depression and anxiety.
Calling on general hospitals to integrate physical and mental healthcare services as a matter of urgency, report co-author Dr Vivek Srivastava, NCEPOD Clinical Co-ordinator and Consultant in Acute Medicine, says that general hospital staff often don’t have the knowledge or confidence to care for people with mental health conditions appropriately: “Good care was only provided to 46% of patients in this study, showing patients who had a mental health condition suffered the double-whammy of both poor physical and mental healthcare.
“The systems don’t exist to train hospital staff appropriately in the care of patients who also happen to have a mental health condition, so immediately there is an issue with having the confidence to care for this group of patients. Once someone is admitted to hospital it is likely to expose any underlying issue such as a mental health problem, and staff need to have the confidence to deal with this, and have access to and know how to refer to mental health services.”
Dr Srivastava went on to say that as a direct result of poor physical healthcare, patients with a mental health condition stay longer in hospital: “They are often discharged into the community inappropriately and then bounce back in and out of hospital if the underlying health condition is not treated properly.”
One example of poor physical care he highlighted is the failure to provide stop smoking services routinely to people with mental health conditions: “We found high levels of smoking among the patients we reviewed – over a third of them (39.7%) were documented as a smoker compared to 19% of adults in the general population. However, only a minority received effective smoking cessation support. Primary and secondary care services must provide stop smoking services.”
Co-author Dr Sean Cross, NCEPOD Clinical Co-ordinator in Liaison Psychiatry and Consultant Liaison Psychiatrist agrees and expressed serious concern that the health of some patients is so adversely affected: “Our report reveals a massive divide between the physical healthcare and mental healthcare people receive in general hospitals. One in four of us will suffer a mental health condition at some point in our lifetime. General hospitals need to take mental healthcare seriously and understand how to provide holistic care for mind and body.”
Dr Cross also added that mental healthcare often involves use of mental health legislation. “This was not done well in 15/65 patients in the study who were detained under the legislation, either on admission to the general hospital or during their hospital stay.”
Inadequate mental health history was taken by non-mental health clinicians in 21.4% patients at initial assessment and 49.1% during consultant review
46.3% (256) of patients in the study had a review by the liaison psychiatry team during their hospital stay
The first assessment by liaison psychiatry was delayed in a third of those seen according to the reviewers. This impacted the quality of care in 22 patients
Of those patients seen by the liaison psychiatry team, the reviewers judged that their input was adequate in 68.7% of cases
185/231 hospitals had a liaison psychiatry team either available 24/7 in 51.1% hospitals and during extended hours in a further 16% of hospitals
57.3% of hospitals had a policy/protocol specifying which patients should be referred to liaison psychiatry. The liaison psychiatry team was involved in writing/reviewing the mental health hospital policy in 143 hospitals
Only 21/190 (11%) hospitals shared complete access to mental health community records
95/208 (45.7%) hospitals had mandatory training in the management of patients with mental health conditions. There were no hospitals that offered training covering all aspects of management of patients with mental health conditions
Healthcare professionals responding to a separate online survey stated that: 11.4% (151/1323) had no training in basic mental health awareness; 38.9% (497/1276) had no training in management of self-harm; 21.2% (274/1295) had no training in assessing mental health capacity; 41.4% (523/1263) had no training on risk assessment; 58.9% (727/1234) had no training in psychotropic medications; and 19.1% (248/1298) had no training in dealing with violence/aggression.
In order to overcome the divide between mental and physical healthcare, liaison psychiatry services should be fully integrated into general hospitals. The structure and staffing of the liaison psychiatry service should be based on the clinical demand both within working hours and out-of-hours so that they can participate as part of the multidisciplinary team.
All hospital staff who have interaction with patients, including clinical, clerical and security staff, should receive training in mental health conditions in general hospitals. Training should be developed and offered across the entire career pathway from undergraduate to workplace based continued professional development.
Patients who present with known co-existing mental health conditions should have them documented and assessed along with any other clinical conditions that have brought them to hospital. And when seen by mental health services (liaison psychiatry) the review should provide clear and concise documented plans in the general hospital notes at the time of assessment.
National guidelines should be developed outlining the expectations of general hospital staff in the management of mental health conditions, such as the point at which a referral to liaison psychiatry should be made and what triggers the referral.
Record sharing (paper or electronic) between mental health hospitals and general hospitals needs to be improved. As a minimum patients should not be transferred between the different hospitals without copies of all relevant notes accompanying the patient.
NCEPOD Chair, Professor Lesley Regan, said: “For many years mental healthcare in the NHS has been underfunded, and you may rightly conclude from this new NCEPOD report that patients with mental health conditions are seriously disadvantaged when treated for physical disorders in hospital. And, I fear that the patients we studied could well be only the tip of the iceberg.”
She said that a general hospital workforce, including doctors and nurses, has to be educated to understand the gap together with the training and support to have the competence and confidence to bridge the gap at every level of care.
“Treat as One found that in more than a third of the patients whose care was reviewed by liaison psychiatry but delayed, that the liaison psychiatry team did not attend until the patient was declared ‘medically fit’. However, this is a ‘catch 22’ because in many cases the physical illness cannot be treated effectively until the mental illness is recognised.
“This report should be a clarion call that we have a major problem that will be difficult to untangle, and in the meantime we are failing a significant proportion of our patients.”