Introduction

In many countries around the world, mental health remains a fairly low priority for social and political action. People with chronic serious mental illness in particular are marginalised, stigmatised, discriminated against and shunned. This is more obvious in cases with serious severe mental illness in comparison with common mental disorders. Frustratingly, this disparity leads to a serious lack of parity in training as well as actual financial resources. Availability of psychiatric services becomes an issue as well as geographical and emotional accessibility to services. In most countries psychiatric services are largely based in urban areas, indicating a disparity in favour of those who may be able to pay.

Certainly in the West this disparity may reflect Cartesian dualism, where mind and body are seen as somewhat separated. But in India, for example, the Ayurvedic health care system sees the mind and body especially in a jointed manner, with external factors including environment and weather as causing ill health along with various dietary factors etc. What can Western medicine learn from the Ayurvedic systems?

There is little doubt that the relationship between mental and physical health is complex and one affects the other in a myriad of ways. Underpinning the bi-directional link must be at the core of every therapeutic interaction. In many countries there is very little direct link between physical and mental health care, but this inter-relationship confirms the impact on the individual and their social functioning. Furthermore, the impact of social factors and social inequalities deserves further urgent attention if biopsychosocial models are to be followed. Multiple morbidities and co-morbidities in patients with chronic severe mental illness need careful assessments and therapeutic interventions. The international literature on integrated health care is vast. In this paper we provide a very selective review to emphasise the need for developing one-stop services where both physical and mental health needs can be assessed and dealt with.

Integrated Health Care

By separating physical and mental health often one of the two aspects is looked into in service planning and delivery. By integrated care it is quite possible to develop services which will be both effective and efficacious. Furthermore, integrated care can also be seen as a major public health issue by destigmatising mental illness and better educating the public about health. Better and improved outcomes follow integration along with a reduction in health risk behaviours [1]. Costs to the health care system are also significant – by interacting with and exacerbating physical illness, co-morbid mental health problems raise total health care costs by at least 45 % for each person with a long-term condition and co-morbid mental health problem. This suggests that between 12 % and 18 % of all NHS expenditure on long-term conditions is linked to poor mental health and wellbeing – between £8 billion and £13 billion in England each year [2].

A link has been demonstrated between social inequalities and health in general [3]. Regrettably, this report does not cover mental health extensively but a recent report sees the integration of mental, physical and social care as an essential feature of a health system that expects to reduce inequalities in health care and provide the best possible support to individuals [4]. In the UK, among many other countries, social care, physical health care and mental health care delivery all exist in silos. Goodwin et al. [5] emphasise that improving integrated care is a ‘must do’ priority particularly when, as mentioned above, shrinking resources make it imperative that we look at different ways of health care delivery for the most vulnerable and ignored ill individuals. They define integrated care as an approach that seeks to improve the quality of care for individual patients by ensuring that services are well co-ordinated around their needs.

Integrated healthcare, or ‘integrated care’, has been defined in 175 ways [6]. It is worth looking at what the WHO has to say about this:

Integrated service delivery is ‘the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money’ [ 7].

It is also worth emphasising that it is about where services are delivered. The Department of Health [8] proposes that integrated care must be multi-faceted, integrating physical and mental health with social care and public health. Integrated care can also be seen as an organising principle for care delivery which aims to improve patient care and experience through improved coordination. Integration also means that those involved with planning, financing and providing services have a shared vision [9].

At the heart of integrated health care lie communication (across providers as well as with the patient and their carers), collaboration (across disciplines and specialities) and comprehensive care, along with continuity of care [10]. Lloyd and Wait [11] propose that integrated care means different things to different stakeholders. For example: to the patient, it means a process of care that is seamless, smooth and easy to navigate; to the provider, it means working with professionals from different disciplines and specialities; to the manager, it means managing a professionally diverse staff; and to the policymaker, it means merging budgets and undertaking policy evaluations. Integration also means that innovations and interventions in any one domain may have repercussions on other domains. In the UK, the King’s Fund (a think tank on health matters) proposed that integration is also about dissolving the borders between primary and secondary care [12]. Thus when policy documents are being prepared it is important that the integrated health care is understood in many facets and clearly defined.

Integration Between Mental and Physical Health

There is clear evidence that a broad range of social and economic inequalities affect people and can cause physical and psychiatric illnesses. Social justice plays a key role [13]. People with severe enduring mental health problems are at higher risk of developing physical health problems, including iatrogenic conditions such as metabolic syndromes. Those with chronic physical problems are also likely to develop psychiatric problems such as depression, which can interfere with recovery. As noted above, the social determinants of mental health and illness are similar to the determinants of physical health and illness.

The model of holistic care recognises four systems centred on the person – organs, the whole person, behaviour and social role function – and four contextual factors that influence these systems – personal factors, physical environment, social environment and time [14]. A holistic approach also looks at choice and quality of life. As pointed out earlier in this paper, certainly Western allopathic approaches to health care are dominated by a simple Cartesian dualism. On the one hand, there are psychological disorders occurring in the mind and these are somewhat abstract and, on the other, physical with biological underpinnings. However, mental illnesses of several kinds also have underlying physical causations. As Friedman and Di Matteo [15] go on to argue, this mind–body dualism is oversimplified, leading to excessive concern with the body. However, this also leads on to a sense of identity of the self which often gets embedded in the physical body itself. Although it may be misrepresented, holistic medicine addresses the whole person - body, mind and spirit - using integrated conventional and alternative therapies along with focusing on patient education [16].

However, integrated care can only be delivered if the health care professionals are trained appropriately [17]. People with serious mental illnesses have higher rates of morbidity and premature mortality compared with the general population [18]. Effective management of individuals with severe mental illness (SMI), whose physical health is often very poor, requires a holistic approach that offers reliable symptom control, but also addresses other clinical, emotional and social needs [19].

Brimblecombe et al. [20] found that, to improve physical well-being of mental health service users, nurses should take responsibility for promoting healthy lifestyles and educating patients and their families. Thus public mental health starts to take on a major role and, because public health strategies tend to focus on physical health and overlook the importance of both mental illness and mental well-being, it is critical that mental health is at the heart of public health policy, thereby leading to healthy lifestyles [21]. This report notes that depression is associated with increased mortality in many chronic conditions, such as cardiovascular disease, cancer, respiratory disease and metabolic disease. This variation can be up to three times higher. It is also known that depression doubles the risk of later development of coronary heart disease after adjustment for traditional factors. Increased rates of stroke, colorectal cancer and back pain are related to depression. People with schizophrenia and bipolar disorder die an average 25 years earlier than the general population, largely because of physical health problems. Schizophrenia is associated with increased death rates from cardiovascular disease (two-fold), respiratory disease (three-fold) and infectious disease (four-fold). One-third of people living with psoriasis experience depression, anxiety and suicidal ideation [22].

Ways to Integrate Services

Bearing in mind that we are referring to integration between mental health and physical health, within health services, across health, social care and other services and between statutory services and voluntary agencies (NGOs), a number of factors must be taken into account.

Recruiting the Right People

The attitudes of staff and patients are incredibly important in linking physical and mental health. Formal educative or re-educative programmes can be very helpful in affecting attitudes [23]. Similarly, Lester [24] has argued that inter-professional education is important. Institutional cultures may stop integration from happening and therefore part of the challenge is also to do with educational learning by the institution to change its attitudes and work habits. Cultural obstacles related to integration of hospital and community care must be overcome [25]. These authors argue that what is needed is a substantial cultural shift in the acute hospital sector and the development of a more holistic approach towards the care of the person.

Information Systems and Information Sharing

A major challenge to integration is better and integrated information systems and sharing of information, which may impede confidentiality. Using simple measures as notebooks which belong to patients and which they carry with them may be a simple but elegant solution. Using tele-health and tele-care systems, it has been shown that bed days can be reduced by 14 % and emergency admissions by 20 %, leading to a substantial reduction in mortality rates [26].

Training

There are two separate but related issues when it comes to training: one is about teaching all health professionals about mental health and the other one is about teaching all mental health staff about physical health. New educational models are needed to better prepare nursing graduates to provide holistic care. The integrated mental health model, which co-locates mental health specialists in primary care sites, is designed to do this [27].

Models of Care

We know that given that co-morbidity is often more common, it is critical to choose from a number of organisational approaches [28]. These include a single integrated care organisation providing both primary care and specialist mental health services using a variety of models, including embedding mental health staff in surgeries and embedding GPs into mental health care settings. Collaborative care models which use a multidisciplinary team are more effective in providing treatments.

It has been pointed out that models of integration which place the service user at the centre of planning and delivery by breaking down diagnostic and organisational silos will have the biggest impact on improving the experience of service users [29]. There are various models of integration varying from formal partnership agreements to frameworks and accountability structures that can reach across boundaries.

The BMA [30] identified the three most important enablers of success in integrating services as (1) good professional relationships, (2) effective clinical leadership and (3) a collaborative culture.

Examples of Good Practice

Plumridge and Reid [31] showed that a consultation-liaison service can produce a sharing of expertise between mental health and acute care staff, increasing the recognition of psychological distress among patients; quicker care for people within emergency units; as well as lead to a reduction in the length of stay of patients with a mental health diagnosis; and fewer re-attendances by certain patients. Ohlsen et al. [32] demonstrated that a nurse-led Well-Being Support Programme can help identify patients’ physical problems and provide prompt referral to suitable specialist services or general practitioners, forging links between primary and secondary care and ensuring that mentally ill patients with physical health problems receive holistic care packages. In the UK, the National Institute for Health and Clinical Excellence [33] also suggests a collaborative care model for supporting people with long-term conditions and co-morbid depression in primary care as part of a well-developed stepped-care programme, to be provided at the primary or secondary care level.

Horvitz-Lennon et al. [10] arrive at very similar conclusions despite the differences in their health care system from that of the UK. They point out that the poor integration of general health and specialist mental health services means the needs of people with a severe mental illness are often not met. They suggest a number of key changes, including improvements to mental health sector information technology and the integration of mental health and general health information systems, along with the education and training of the mental health workforce and educating and helping patients to become more involved in self-care.

Integrated care for people with co-morbid mental health and substance misuse problems [34] reached similar conclusions about the need for system and financial integration in the USA.

Integration Between Social and Health Care

In a country such as India, where most of the social care is provided by the NGOs, it is crucial that they work in tandem with the statutory sector so that integrated services are available to patients and their families. Social care in the informal sector, such as being taken care of by the family, has major implications and thus the training of families becomes important. Again, co-morbidity with learning disability and mental illness will require careful integration with the third sector.

Key Workers

Having an identified key/case/liaison worker or guide who can support the patient to navigate health care across different organisations can be extremely helpful, but in view of the shortage of resources this may not always be possible.

International Scene

Inevitably, there is much global interest in the issue of integration to make services more cost-effective, especially in times of economic downturn. In a report using case studies, WHO [35] noted that integration is possible. In Brazil, primary care practitioners conduct physical and mental health assessments for all patients. They treat patients if they are able, or request an assessment from a specialist mental health team, who make regular visits to family health centres. Joint consultations are undertaken between mental health specialists, primary care practitioners and patients. This model not only ensures good-quality mental health care, but also provides continuity of care as well as a forum for training and supervision, whereby primary care practitioners gain skills that enable greater competence and autonomy in managing mental disorders. In Santiago, Chile general physicians in the Macul District diagnose mental disorders and prescribe medications where required; psychologists provide a range of individual, family and group therapies and other family health team members provide supportive functions [35]. A mental health community centre provides ongoing support and supervision for general physicians. In Iran, general practitioners provide mental health care as part of their general responsibilities and patients receive integrated and holistic services at primary care centres. In cases with complex needs, referrals are made to district or provincial health centres, which are supported by mental health specialists.

In the USA, another local programme makes mental health care a key component of all primary health care, including prevention [36]. The health care team has primary care physicians, mental health professionals, care managers, community resources, and all the clinical and operational staff at the health centre. Obviously key elements of this approach include integrating mental health specialists within primary care teams with shared electronic medical records. They also tend to use specific screening tools for mental health problems among high-risk groups, exploiting new technologies, e.g. tele-health and tele-care, and making maximum use of extended community resources and peer support. Five key components for successful service integration have been identified: leadership, workflow integration, community resources, information systems, and comprehensive consideration of all financial costs.

Suter et al. [37], within a collection of essays looking at integration programme in Alberta, Canada, set out their Ten Key Principles for Successful Health Systems Integration. These include

  1. 1.

    Comprehensive services across the care continuum

  • Cooperation between health and social care organizations

  • Access to care continuum with multiple points of access

  • Emphasis on wellness, health promotion and primary care

  1. 2.

    Patient focus

  • Patient-centred philosophy; focusing on patients’ needs

  • Patient engagement and participation

  • Population-based needs assessment; focus on defined population

  1. 3.

    Geographic coverage and rostering

  • Maximize patient accessibility and minimize duplication of services

  • Roster: responsibility for identified population; right of patient to choose and exit

  1. 4.

    Standardized care delivery through inter-professional teams

  • Inter-professional teams across the continuum of care

  • Provider-developed, evidence-based care guidelines and protocols to enforce one standard of care regardless of where patients are treated

  1. 5.

    Performance management

  • Committed to quality of services, evaluation and continuous care improvement

  • Diagnosis, treatment and care interventions linked to clinical outcomes

  1. 6.

    Information systems

  • State of the art information systems to collect, track and report activities

  • Efficient information systems that enhance communication and information flow across the continuum of care

  1. 7.

    Organizational culture and leadership

  • Organizational support with demonstration of commitment

  • Leaders with vision who are able to instil a strong, cohesive culture

  1. 8.

    Physician integration

  • Physicians are the gateway to integrated healthcare delivery systems

  • Pivotal in the creation and maintenance of the single-point-of-entry or universal electronic patient record

  • Engage physicians in leading role, participation on Board to promote buy-in

  1. 9.

    Governance structure

  • Strong, focused, diverse governance represented by a comprehensive membership from all stakeholder groups

  • Organizational structure that promotes coordination across settings and levels of care

  1. 10.

    Financial management

  • Aligning service funding to ensure equitable funding distribution for different services or levels of services

  • Funding mechanisms must promote inter-professional teamwork and health promotion

  • Sufficient funding to ensure adequate resources for sustainable change.

Recommendations

The Mental Health Foundation [38] has called for:

  • An increased understanding of the links between physical health and mental health, and that improved mental health reduces the risk of cardiovascular and other diseases

  • Mental health to become an integral part of public health agenda, nationally and locally, and for proper investment in public mental health

  • Regular physical health checks and accessible physical health care for people with severe mental illness

  • Routine assessment of the psychological needs of patients suffering from chronic heart disease and other serious physical conditions.

In respect of partnership working for people with complex needs who require a range of services from a range of professionals and agencies, the guide calls for

  • Increasing recognition of the importance of integrated care requires leaders to be effective across systems, with collaboration and partnership beyond health and social care

  • Clear terms of reference for partnership working and partnership arrangements that all concerned have been involved in drawing up

  • Training, job descriptions, policies, systems and performance management overhauled and revitalised so that they reflect new roles and responsibilities and new ways of working

  • Being clear about the need for willingness and openness to cross professional boundaries and act and collaborate beyond specialisms to solve problems together and achieve the right outcomes for people (rather than passing people around the system).