The cost of co-morbidity

Source: National Health Executive May/June 2012

A new report by the NHS Confederation’s Mental Health Network demonstrates the economic return on treating the emotional and psychological wellbeing of patients with long term conditions. NHE spoke to its outgoing director Steve Shrubb.

Co-morbidity is expensive, damaging to patients and widespread. With so much at stake, the need to integrate care for both physical and mental health is incredibly important.

The NHS Confederation’s Mental Health Network has published a new report on co-morbidity, demonstrating the financial benefits of treating mental and physical health conditions simultaneously. Tangible examples of how to implement effective care for patients suffering multiple issues is the best way to facilitate a wider roll-out of integration, they suggest.

NHE heard from director of the network, Steve Shrubb – who is leaving the post to become chief executive of the West London Mental Health NHS Trust – about the value of distributing this evidence and the opportunity clinical commissioning groups (CCGs) now have to integrate mental and physical care.

Shrubb said: “Its proving to be really successful. People are wanting to understand and wanting to use it; the outcome’s really simple, to get out into the NHS evidence-based innovations which do two things: improve the quality of people’s lives and outcomes, and save money. It is as startlingly straightforward as that.”

Statistics of risk

The research indicates that people with one long-term condition are two to three times more likely to develop depression than the rest of the population. People with three or more conditions are seven times as likely. Over 15 million people in England – 30% of the population – have one or more long-term physical health conditions, such as diabetes, chronic obstructive pulmonary disease (COPD) or coronary heart disease.

These are stark statistics, and the higher risk runs both ways. Having a mental health problem increases the possibility of developing physical ill-health, and co-morbidity delays recovery from both. The report states: “There are clear links between investment in treating co-morbid mental health and physical health problems and potential gains in all of the QIPP elements.”

The prevalence of co-morbidity is understandable when the considerable emotional adjustment that accompanies diagnosis of a long-term condition is taken into account.

Co-morbidity can often lead to poorer health outcomes, higher use of healthcare resources and wider costs to society in terms of unemployment and absence. “Between £8bn and £13bn of NHS spending in England is attributable to the consequences of co-morbid mental health problems among people with long-term conditions,” the report adds.

Double whammy

While the situation may seem bleak, this report highlights the cost savings and improved patient outcomes that can be achieved through better integration of care.

Shrubb said: “The savings are phenomenal!”

If the NHS worked to manage mental and physical health, it could achieve “hugely better outcomes in terms of the person’s recovery and also in much cheaper ways of providing high quality care”, he added.

“It’s kind of a double whammy really: the patient benefits, and the system benefits because it costs less.”

A wealth of evidence has been collated in an accessible format, to make it as easy as possible for other trusts to implement.

This involved case studies to give real-life examples of how treating co-morbidity can be achieved, particularly those with a robust economic perspective to them.

The focus on financial outcomes is essential, Shrubb said, as this is entwined with quality of treatment. “You cannot separate the cost of delivering healthcare from the quality of delivering healthcare. You can’t talk about quality in isolation from cost.”

He added that in a time of recession, money becomes even more important when managing care. Schemes that can demonstrate a clear return on investment are likely to receive an easier reception when the NHS is struggling to make savings of £20bn.

“I have this motto,” Shrubb said. “Never let a good crisis pass you by. Whereas it would have been a bit more difficult to embed this stuff three or four years ago when the NHS was the recipient of huge growth, it is a bit easier now. People are prepared to listen.”

Grasping the opportunity

In line with a growing understanding of the importance of mental health, awareness around co-morbidity is now increasing, Shrubb suggested, although for patients, it has always been obvious.

“Patients have always known it. I think they think ‘it’s about time’. But I also think clinicians are beginning to realise that the silos they work in are not good for the patient but also not good for them.”

Now the timing is right, accessible information and clear examples of how care is delivered are vitally important.

“One of the opportunities that CCGs [have] – let’s see whether they grasp it – is because they’re run by clinicians, one would assume that they would quickly see the value of comorbidity and that one set of contracts for mental health and then a completely separate set for acute care isn’t good maths.”

Although there is now growing recognition, Shrubb believes we are not yet at a “tipping point”, where the majority of commissioners and providers consider integrated care as a core component of their work, rather than an optional extra.

Change within the NHS to a new structure will present a challenge to services, but Shrubb was optimistic about the take-up of treating comorbidities by CCGs.

He said: “There’s going to be a period which is fairly chaotic; I think we have to be realistic, in any wholescale change, even ones that are well thought through and planned – and you could argue this one isn’t. So there’s going to be a period of disorganisation or a lack of organisation.

“But I think you will see some of the better CCGs saying ‘we need to do this from the word go’, ‘we need to set off with integration as a central part of our commissioning’. I think within the next 12 months we’ll start to see really big examples of this stuff. It’s very difficult to argue against it. I’m hoping that if you’re a GP and running a CCG that you’ll see integration of services to meet the needs of comorbid problems as absolutely obvious.”

Adoption, adaption and spread

Indeed, treating co-morbidity does seem the obvious way to improve outcomes. Yet there have been many barriers to this conclusion, not least the pooling of supporting evidence. The way services have traditionally been commissioned is often quite separate – as Shrubb put it, “to the extent that they were different individuals, in different teams, in different parts of the PCT”.

He added: “Getting adoption, adaptation and spread in a large scale system like the NHS has always been difficult.

“If you layer onto the top of that the work that ‘Time to Change’ and other anti-stigma programmes have been doing, it’s becoming more and more acceptable to talk about mental health in the same breath as you talk about physical illness.

“We’re nowhere near there. I’m not suggesting we’ve got a country where there isn’t discrimination against mental health, but it has become more acceptable and that has laid the foundations for this.”

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