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Physical and mental health are related, with one affecting the other. Preventing, treating and managing physical health conditions also requires improving mental health and wellbeing. Equally, preventing, treating and managing mental health problems requires addressing physical health. Both of these aspects are addressed here.
Being in good mental health brings resilience to cope with difficulties, have good relationships with others and an ability to think clearly, participate in decision making, and have optimism, sense of control and self efficacy. These are important for staying healthy.
Poor physical health, long term conditions and disability are risk factors for poor mental health. Those with long-term physical conditions such as diabetes, arthritis or asthma, are also likely to experience mental ill-health, such as depression and anxiety.
Mental health problems are common, experienced by up to one in four of the population. Problems are often hidden, stigma is still widespread and many people are not receiving support from services.
Mental health problems start early in life and can be prevented through action at a policy level, creating mentally healthy environments in schools, neighbourhoods and workplaces and in providing services to individuals and families that promote mental health, help identify signs and symptoms early on and access support when needed.
People with serious mental health problems die prematurely. The life expectancy of someone with a serious mental health problem such as bipolar disorder or schizophrenia is 15 to 20 years less than the general population.
This is mostly from preventable physical health problems such as cardiovascular disease and cancer.
Associated risks include:
- health-risk behaviours such as poor diet, physical inactivity, smoking
- wider determinants e.g. Unstable employment and housing
- poor access to physical health care and health promotion services
In addition, stigma and discrimination associated with mental illness can stop people getting the help they need.
A person with a serious mental illness is more likely to have a co-morbid physical health problem when compared to the general population.
As part of the Five Year Forward View the need to ensure parity of esteem for mental health is essential to have improved patient experience and better outcomes for users. The Five Year Forward View for Mental Health states that by 2020/21, at least 280,000 people living with severe mental health problems should have their physical health needs met. The King’s Fund report Bringing together physical and mental health argued that mental health care should not only be as good as services for physical health but that mental health care should be provided as part of a unified approach to health.
The Five Year Forward View for Mental Health has also prioritised the prevention of mental health problems and suicide. PHE’s Prevention Concordat for Better Mental Health aims to support prevention and promotion in every local area across England. This includes health and care service providers having the capacity and capability to deliver a range of approaches that promote mental health and prevent mental health problems.
All healthcare professionals have a responsibility to promote physical health and mental health and reduce the risks of premature death due to preventable and treatable conditions and illnesses.
Facts about mental health
In any given year, one in six adults experiences at least 1 diagnosable mental health problem.
Mental health problems are the second leading cause of morbidity in England.
Mental health problems are unevenly distributed across society with disproportionate impacts on people living in poverty, those who are unemployed and those experiencing discrimination.
People with a long-term condition are 2 to 3 more times likely to develop a mental health problem. Those with more than one long-term condition are 7 times more likely to have a mental health problem.
Loneliness and lack of social interaction are risk factors for physical and mental health – it increases risk of premature mortality by 30%.
Individual characteristics such as control, self-efficacy and resilience, as well as the social characteristics described as ‘social capital’, such as social networks, can protect health from the effects of stressors in some circumstances, and thus positively influence health outcomes.
Half of all mental health problems have been established by the age of 14, rising to 75% by age 24. One in ten children aged 5 to 16 has a diagnosable problem such as conduct disorder (6%), anxiety disorder (3%), attention deficit hyperactivity disorder (ADHD) (2%) or depression (2%). Children from low income families are at highest risk, three times that of those from the highest.
Two thirds of people with serious mental health problems will die prematurely due to treatable physical conditions such as cardiovascular, respiratory and infectious diseases.
People in contact with specialist mental health services (per 100,000 service users, compared with the general population) have a higher death rate for most causes of death, in particular:
- nearly 4 times the rate of deaths from diseases of the respiratory system at 142.2, compared with the general population at 37.3
- just over 4 times the rate of deaths from diseases of the digestive system at 126.1, compared with the general population at 28.5
- nearly 3 times the rate of deaths from diseases of the circulatory system at 254, compared with the general population at 101.1
Within these disease areas specific conditions that accounted for a high proportion of deaths among service users (under the age of 75) were:
- diseases of the liver at 7.6% of deaths (1,430 in total)
- ischaemic heart diseases at 9.9% of all deaths (1,880 in total)
People with mental health problems are 3 times more likely to smoke than the general population.
Core principles for healthcare professionals
All healthcare professionals are routinely in contact with people who are at risk of, struggling with or recovering from a mental health problem.
All healthcare professionals have a responsibility to promote the mental wellbeing of people they are in contact with as part of their treatment and care, and to help prevent mental health problems.
All healthcare professionals have a responsibility to promote the physical health and well being of individuals, at risk of, or living with, mental health problems.
Healthcare professionals should:
- be aware of relevant policies and guidance on physical health for people with mental health problems and on improving mental health within everyday practice
- understand the mental and physical health needs of individuals, communities and population and the services available in their local area
- think about the resources available in health and wellbeing systems
- understand specific activities which can prevent, protect, and promote mental health and wellbeing and prevent, protect, and promote the physical health of people experiencing mental health problems
Healthcare professionals should be aware of the interventions for promoting mental health and wellbeing at a population level and improving the physical health of people with mental health problems, which include national and local strategies, targets and multi-agency action on prevention of mental health problems and suicide, promotion of mental health, reduction of health inequalities and stigma and reducing the premature mortality of people with mental health problems.
Local authorities, NHS and other healthcare providers should:
- build prevention and health promotion into their day-to-day work
- take action to address wider determinants of mental health such as reduce poverty, violence, improve housing and employment
- develop integrated systems to identify people with long term conditions who may experience mental health problems
- provide accessible information and resources to support mental health and wellbeing within the community, including services to signpost to
- support the development, promotion and access of e-learning and training
- provide and promote healthier lifestyle choices within mental health settings including healthier food options, access to physical activities, and support to reduce and stop smoking
- provide accessible information and resources on physical health and wellbeing for people who experience mental health problems
- be aware of services to signpost patients towards healthier lifestyles (local authorities often have a section of their website which provides information on what’s available locally, although mental health services may have to create service directories to enhance accessibility)
- work with relevant local services to improve housing and employment of people with mental health problems, and tackle stigma and discrimination and reduce overall health inequalities
Community level interventions may be based around a specific geographic locality or outside of hospitals environments. Healthcare professionals can promote mental health and wellbeing interventions by:
- working collaboratively with local authorities, primary, secondary and specialist services to achieve a truly whole person approach to care and prevention, including physical and mental health
- forging links with local services (including voluntary and community) and encouraging and supporting patients to link in with their local community health and wellbeing initiatives for example, that enhance social connections, reduce isolation, improve confidence and resilience
- working with community members and groups to support them to take action on improving mental health and wellbeing
- working collaboratively with services and communities to develop community-centred approaches including peer support and community engagement in decision-making
- working collaboratively with colleagues and other teams to raise awareness of mental health and reduce stigma associated with mental illness
- knowing who or where to get further advice from to support healthy lifestyles for people with mental health problems such as local authority services via public health initiatives namely exercise on referral and adult weight management programmes and stop smoking services; and specialist services (diabetes services)
- knowing who or where to get further advice from, such as local authority and voluntary services, to support welfare and social issues such as debt, domestic violence, housing
Healthcare professionals should provide information, advice and support around mental health and wellbeing, where appropriate, refer to specialist services as part of routine daily contact with individuals. Healthcare professionals can have an impact at an individual level by:
- promoting mental health and psychological aspects of care alongside physical health care and prevention
- be aware of the life course approach to promoting good mental health and the benefits of intervening early particularly in childhood and teenage years to prevent mental illness
- be aware of the mental health problems that may be faced during pregnancy and post-birth (‘perinatal’)
- establishing positive relationships with individuals who have mental health problems and be able to signpost individuals, their families and carers for further help, resources or guidance about mental health problems
- be aware of the importance of families, carers, friends, social networks and wider community for individuals experiencing mental health problems
- be able to use basic coaching techniques in supporting an individual who may be in mental distress and understand triggers and responses to stressed or distressed behaviours
- be able to identify co-morbid conditions and understand the links between alcohol, substance misuse and mental health
- know the steps that an individual may take in promoting positive mental health through self-care e.g. eating habits, increased physical activity, sleep, recreational activities, personal social and community relationships, spending time in nature, mindfulness and meditation
- Be able to identify risk factors and indicators for potential self-harm and suicide and support individuals who may present with suicidal thoughts and referral appropriately
Healthcare professionals should provide information, advice and support around physical health and wellbeing of people with mental health problems, where appropriate, refer to specialist services as part of routine daily contact with individuals. Making every contact count is an opportunity to educate and empower individuals to make positive lifestyle choices and changes for their own health and wellbeing.
Healthcare professionals can have an impact at an individual level by:
- understand the burden of avoidable or preventable physical health conditions faced by people with mental health problems, risk factors and wider determinants of health
- developing skills and knowledge to assess, manage and monitor physical health conditions and complete recommended physical health checks by using tools such as the Lester positive cardiometabolic resource (Lester tool), health improvement profiles (HIP), and early warning scoring systems
- knowing about the burden of avoidable or preventable physical health conditions faced by people with mental health problems
- encouraging and supporting individuals to participate in care decisions based on information about treatment and care options and health promotion interventions
- knowing where to direct people for timely diagnosis, intervention and health and wellbeing support
- involving the individual and carers in all treatment planning, making it personal
- referring and supporting people with SMI to take up evidence based interventions to improve physical health
- tailoring support to individuals’ personal lives including encouraging people who are obese or have raised cholesterol levels to make lifestyle changes such as switching to healthier food choices and taking more physical activity, this can help before turning to medication as a treatment option
- guiding individuals through advice and supporting them to access services to improve physical health wellbeing exemplified in discussions on screening, health promotion and prevention
- supporting the uptake of services locally; including flu vaccinations, screening programmes (where eligible) and annual health checks to prevent the development of risk factors, identify long term conditions and reduce complications and avoidable hospital admissions
- Making every contact count by engaging people in conversations regarding physical health and wellbeing at every opportunity, provide support to eat well, exercise, reduce or stop smoking and harmful drinking
Preventing mental health problems and suicide and promoting mental health will impact on overall life expectancy and healthy life expectancy.
There are a number of indicators in the Public Health Outcomes Framework related to mental health and wellbeing:
- school readiness
- adults in contact with secondary mental health services who live in stable and appropriate accommodation and are in employment
- sickness absence rate
- domestic abuse
- violent crime (including sexual violence)
- statutory homeless
- social isolation
- child development at 2 to 2.5 years
- emotional wellbeing of looked after children
- self-reported wellbeing
- excess mortality in adults with serious mental illness
- suicide rate
- health-related quality of life for older people
The Everyday Interactions Measuring Impact Toolkit provides a quick, straightforward and easy way for healthcare professionals (HCPs) to record and measure their public health impact in a uniform and comparable way. The Mental wellbeing impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on adult obesity.
The ultimate measure of physical health outcomes for people with mental health problems is an increased life expectancy and healthy life expectancy.
A Commissioning for Quality and Innovation (CQUIN) has been introduced by NHS England focusing on improving physical healthcare to reduce premature mortality in people with serious mental illness (PSMI). The CQUIN was introduced to support NHS England’s commitment to reduce the 20-year premature mortality rate in people with serious mental illness through improved assessment, treatment interventions and communication between clinicians in primary and secondary care services.
Quality and Outcomes Framework for 2017 to 2018 (QOF) includes several indicators relating to the physical health of people on the primary care register for people with serious mental illness (patients with schizophrenia, bipolar affective disorder and other psychoses). These indicators help identify for example:
- people with SMI who have a comprehensive care plan documented in their record in the preceding 12 months
- people with SMI who have a record of blood pressure in the preceding 12 months
- percentage of patients with SMI who have a record of alcohol consumption in the preceding 12 months
- females aged 25 to 64 years with SMI whose notes record that a cervical screening test has been performed in the preceding 5 years
Physical health screening and monitoring is no longer the sole responsibility of physical healthcare professionals such as GPs and practice nurses in primary care services. Every healthcare professionals has a role to look after the whole person. This integrated approach is supported by Bringing together physical and mental health.
The Mental wellbeing impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on adult obesity.
Examples of good practice
NHS England’s House of Care includes emotional and psychological support, in particular, the mental health and wellbeing of people with ‘physical’ health problems.
The Mental Health Core Skills Education and Training Framework is for staff who need general mental health awareness or have contact with people experiencing a mental health problem.
Training and information for practice and community nurses in mental health and wellbeing is provided by the Charlie Waller Memorial Trust.
Psychological support of people living with cancer was commissioned by London strategic clinical networks.
Five Ways to Wellbeing is a useful solution-focussed framework for working with individuals to take steps to improve their mental wellbeing.
Physical healthcare for people with mental health problems is evidence-based information to help mental health nurses improve the physical health and wellbeing of people living with mental health problems.
Breaking Down the Barriers aims to support the NHS workforce by providing awareness training materials to enhance existing skills, knowledge for early recognition, assessment, management and signposting of mental and physical health needs of patients.
NHS England has produced a practical toolkit for mental health trusts and commissioners, designed to help them improve the physical health of patients with serious mental illness. The toolkit looks at different approaches to implementing the Lester screening tool.
Improving Physical Health for people experiencing Serious Mental Illness (SMI) - Bradford
30 June 2017 by Postive Practice The physical health template for Severely Mentally Ill (SMI) patients was developed in Bradford by Primary and Secondary Care with academic and data quality support. It provides a systematic way to record all necessary cardiometabolic metrics as well as a host of other information relating to screening as in the excellent Lester tool and important measures such as prolactin in patients on antipsychotics. In fact, it could be seen as the practical way to deliver the Lester tool, which has been incorporated into the template with the help of NHSIQ.