Integrating mental & physical healthcare (the obstacles & how to overcome them)

Transcription

1 Integrating mental & physical healthcare (the obstacles & how to overcome them) Alison Creed Award Lecture 2016 Professor Michael Sharpe Oxford Psychological Medicine

2 Declaration of Interests Paid by University of Oxford and Oxford University Hospitals Unpaid council member of APM (USA) Small amount of royalties from text books A belief in the benefit of integrating mental and physical health care

3 Outline 1. The separation of mental & physical 2. The need to (re)integrate mental into physical healthcare 3. What would integration look like? 4. Obstacles to integration 5. Overcoming the obstacles to integration in Oxford 6. The example of cancer outpatients

4 The separation of mental & physical

5 The idea of mind-body dualism Cartesian Dualism (early 17 th century)

6 Medicine of the body The Anatomy Lesson of Dr. Nicolaes Tulp (Rembrandt 1632)

7 Medicine of the mind Lunatic asylums (18 & 19th century) Sigmund Freud (early 20th century)

8 Modern medicine of the body

9 Modern medicine of the mind

10 Care of body & mind are separate Physical Mental

11 We need to (re)integrate mental and physical healthcare because

12 They are not separate populations

13 The mental health of the physically ill is neglected (Treatment received by 1,538 patients with cancer & major depression) Walker et al Lancet Psychiatry 2014

14 Integrating mental into physical care would improve care What patients want patient-centred holistic care Better outcomes Both mental & physical As well as better quality of life Reduced costs The reduction in unnecessary medical care offsets cost

15 What would integrated care look like?

16 Integration

17 In practice, there is a continuum of integration Coordinated care Co-located care Integrated care Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Minimal collaboration Patients referred between providers on different sites Basic collaboration Providers periodically communicate about shared patients Basic on-site collaboration Providers based at the same site & communicate but have separate cultures & records Close collaboration & shared records Providers have some face-to-face communication about shared patients and feel part of a team Close collaboration approaching integration Treatment planning for shared patients, but separate planning for other patients. Integrated practice for all patients Single team with a single treatment plan. Patients experience their care as a single system treating the whole person.

18 Usual non-integrated care (Level 1 & 2) Completely separate mental and physical healthcare services Separate systems, records and cultures The patient has two different teams

19 Mental health Liaison Services (Level 3 & 4) Linked (to varying degrees) mental and physical health care Separate systems, records and cultures The patient has two quite separate, but communicating, mental and physical health care teams

20 Fully integrated care (Level 6) A single combined mental and physical health care service Same systems, records and culture The patient has only one healthcare team

21 Three obstacles to achieving full integration

22 1. Profound inertia Resistance to change Too much work Fear Loss of power & money

23 2. Complete Lack of Vision What it would look like? I cant see it What s wrong with what we have? We have always done it like this

24 3. Cultural & organisational separation That is a different world They are not like us We have a different system That wouldn t work here

25 Overcoming theses obstacles to integration How it happened in Oxford

26 Oxford University Hospitals NHS Foundation Trust A large acute NHS Trust Has four hospitals Employs 12,000 staff Provides both local and national services

27 1. A crisis in care overcame the inertia

28 2. The organisational leaders provided vision Trust Chairman - Dame Fiona Caldicott Senior hospital manager - Mr Paul Brennan Commissioner Dr Stephen Richards Senior Physician Dr John Reynolds

29 3. The wall separating mental & physical healthcare was breached

30 The result: Integrated Psychological Medicine 10 consultant psychiatrists and 30 psychologists Employed by the acute trust Working as members of clinical teams Emphasis on enabling medical and nursing staff by providing Training & supervision Consultations for complex patients

31 Psychological Medicine

32 The example of cancer outpatients

33 Integrated care works like a pit crew Collaborative team working A systematic approach Toward a common aim

34 Usual care Nurse Primary care doctor Physician

35 Integrated care Specially trained nurse Primary care doctor Physician Psychiatrist/ Psychologist Shared guidelines and communication

36 A randomised trial of integrated care for depression in cancer outpatients Multi-centre clinical trial 500 patients with major depression & cancer Good prognosis cancers Treatment response is 50% reduction in depression severity 6 months from randomisation Integrated care 50% drop in depression score Usual Care 50% drop in depression score Sharpe et al, Lancet 2014

37 Depression outcomes Absolute difference = 45% (95% CI: 37% to 53%) Odds ratio: 8.5 (95% CI: 5.5 to 13.4) NNT: 2.2 SES: 1.1 p<0.001

38 Other outcomes

39 Cost Integrated costs approximately 600 more per patient treated Cost-effectiveness 9,000 per extra quality adjusted life year (QALY) UK NICE threshold 20,000 per QALY Cost offset When all costs considered, may be cost saving Duarte et al, JPR 2015

40 Summary 1. The separation of mental & physical 2. The need to (re)integrate mental into physical healthcare 3. What would integration look like? 4. Obstacles to integration 5. Overcoming the obstacles to integration in Oxford 6. The example of cancer outpatients

41 Conclusions: integrated care offers Parity of esteem of quality and access to care Better patient outcomes at a similar or reduced cost Loss of stigma for mental illness A positive image of psychiatry and psychology in medicine.

42 Will the 21 st Century be the age of (re)integration? Will we reintegrate mental & physical care - in both directions? Will organisational integration occur? Will we see a new era for those working in psychosomatics? Or will 17 th century Cartesian dualism prevail?

43 Thank you for listening