Physical and mental health services must be better integrated

The NHS Five Year Forward view set out a vision for the future, in which services are better integrated to support the complex and ongoing needs of patients.

In particular, it highlighted the need for better integrated physical and mental health services to support people with long-term conditions.  

The King’s Fund has subsequently published a report on this “new frontier” of integrated physical and mental health care.

The report found that people with long-term physical health conditions are two to three times more likely to experience mental health problems. 

Despite this revelation, the detection of mental health problems together with other conditions, and the provision of support for the psychological aspects of physical illness, are not of a consistently high standard.

Patients and practitioners alike tend to focus on physical symptoms during consultations, the report said.

Failure to address these issues is costing the NHS more than £11billion and care is less effective than it could be, according to the King’s Fund.

Joint migraine and mental health issues, typically depression and anxiety, are common among migraineurs.  

Last October the All-Party Parliamentary Group on Primary Headache Disorders met in the House of Commons to discuss the benefits and challenges of an integrated approach to primary headache disorders and mental health.  

Expert witnesses provided compelling evidence of the need to improve clinical care and support for patients experiencing simultaneous conditions and symptoms.  

People with migraine are three times more likely to suffer from depression and patients with depression are three times more likely to have migraine.   

Yet there is no routine screening for anxiety and depression among migraine sufferers in general practice, while this screening does exist for other conditions.  

There is considerable variation in support and services available across the country for those patients with complex support needs.

This depends often on the understanding of individual health practitioners, clinical commissioning groups’ funding priorities and referral pathways.  

Chronic migraineurs, those who experience headaches on 15 days or more a month - at least eight migraines - are more likely to have concurrent depression.  

However, the lack of coding of chronic migraine by GPs in primary care means that many patients do not receive the timely interventions needed.  

This exacerbates poor health and wellbeing in patients with this chronic and highly disabling form of the condition

The current approach sees patients slip through the gaps of support and risks worsening their condition and symptoms.  

Medication overuse headache and increased anxiety are common outcomes for patients who do not have adequate information and support to understand and self-manage their migraine.  

This has huge knockon implications for overstretched neurology services and patients requiring support for their condition outside primary care.  

Referral to secondary care and brain scanning are commonly associated with high levels of anxiety by the patient, rather than related to the severity of the pain.  

Headache accounts for one in three new referrals to neurology and is the most common neurological reason for A&E attendance, despite the fact that approximately 97% of cases can be managed in primary care.

There is a real opportunity for the NHS to improve support for migraine patients, and reduce the strain on neurology services, by equipping primary care practitioners with better training and education on migraine and headache.  

Prevention and early intervention are key to identifying and supporting patients experiencing simultaneous conditions and symptoms.  

It is crucial that coping strategies and support are appropriate, and local pathways set up to refer patients in a timely manner.  

The challenge comes in not only integrating clinical care, but also service design, clinical guidance, pathways, funding, audits and health professional training, besides tackling overarching issues of stigma around migraine and mental health.  

The impact of co-morbidities on neurology services is by no means a problem isolated to migraine and headache.  

The latest NHS England GP patient survey shows those with long-term neurological problems report some of the worst states of pain and highest levels of anxiety or depression, with the lowest health outcome scores of any long-term conditions.  

This presents a huge problem for under-prioritised and overstretched neurology services.

Comorbid mental health problems raise total health care costs by at least 45 per cent for each person with a long-term condition and co-morbid mental health problem.  

Between 12 percent and 18 percent of all spending on long-term conditions is linked to poor mental health and wellbeing – at least £1 in every £8 spent on long-term illness.  

Initiatives to improve the management of headache and migraine in primary care have proven to be cost-effective and lead to greater patient satisfaction than neurology referrals.

With the right approach and fundamental resources in place, the gains from an integrated approach will be highly beneficial for migraine and headache patients.

However, unravelling the current system is likely to be slow and complicated.  

The benefits to the NHS that come from addressing migraine and headache disorders in primary care will not come until the Department of Health and NHS England recognise and prioritise neurology across the country.  

There is a long way to go before full integration can be successfully achieved.

 

You can read more about The Migraine Trust's work here.

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