157 - 164: The Challenge of Developing Person-Centred Services to Manage Comorbid Mental and Physical Illness

Other chapters in this book have described the nature and magnitude of the problems facing healthcare in addressing the problem of multimorbidity, and the challenges posed by comorbidity of physical and mental health problems in particular. At the heart of this challenge is the need for us not to lose sight of the needs of the person who is seeking help for his/her ailments, from the macro-level of designing healthcare systems to the micro-level of interaction between doctor and patient within the consulting room.

Heath systems are increasingly fragmented. Even the British National Health Service, which historically has a strong orientation to primary care, has become less integrated in the way it delivers care. At the organisational level this is reflected in an ever-increasing number of different ‘providers' being ‘commissioned' to deliver care - some profit-making, some not-for-profit - and each one of them requiring an army of administrative staff (and not a few lawyers) to negotiate the detailed contracts, performance management and financial arrangements that go with them. Hospitals are moving to take over and develop community resources such as services for older people to integrate them ‘vertically', but in doing so loosen the ‘horizontal' ties they have with other services, the most important of these being primary care. Within primary care, a payment-for-performance system called the ‘Quality and Outcomes Framework' rewards doctors according to criteria based on single diseases rather than management of multimorbidity [1].

Take for instance John, who is 58 years old and has multiple health concerns, diabetes, coronary heart disease, arthritis and severe depression following the death of his wife. In the past he went to his general practitioner when he did not feel well, but now he does not know where he should go. There seem to be far more doctors at the practice than there used to be, but he does not seem to know any of them very well, and it seems harder to see the same doctor each time than it once was. According to the practice website, the doctors now have particular expertise in certain diseases (such as diabetes or coronary heart disease). Does that mean he should go and see different doctors for each problem? He is called in for appointments with the practice nurse to review how he is doing with his diabetes as she works her way through the patients on the diabetes register. Next week he may be asked to come in for a different review appointment for his cardiovascular disease, generated by another disease register to meet the needs of reporting in the Quality and Outcomes Framework. John's experience is of being ‘under surveillance' and ‘monitored' [2] rather than being an active participant in care. The practice has put up a sign saying it is now run by Angel Healthcare Providers for the NHS. Are not they a commercial company?

In addition to these ‘review' appointments at the general practitioner practice, he has outpatient appointments with specialists at the hospital every now and then, for his mental health and arthritis, but each doctor he sees pays attention only to their own specific area of expertise. The psychiatrist John sees never seems to know what blood tests his doctor has done recently for his diabetes, which is not well controlled at the moment, and says that their computer systems ‘don't talk to each other'. Nobody seems to be able to help him prioritise one appointment above another if they clash and he cannot make it to both; attending all of them is a great deal of work [3], sometimes rather like a full-time job. When he missed an appointment once, he was discharged from a clinic and his general practitioner had to re-refer him. He no longer works, but he does not think he would be able to anyway, as all this ‘self-management' takes so much time.

It sometimes feels to John as though nobody is actually interested in finding out what is worrying him about his health in the midst of all this frenetic yet increasingly fragmented ‘provider' activity. He muddles through somehow. His daughter is worried about him, but she is not sure which doctor is the right person to tell and neither is John.

There is nothing unusual about John's story. In some countries his story would even be more complex as he might also have to become involved in discussion with insurance companies about the cost of his care. John has access to more scientifically informed healthcare than at any period in the past. Yet the expansion in specialist information which has been generated has come without an improvement in our ability to integrate this knowledge optimally to meet John's personal needs. The World Health Organisation (WHO) [4] has drawn attention to this characteristic trend that is shaping health systems today:

• A disproportionate focus on specialist, tertiary care, or ‘hospital centrism': in member countries of the Organisation of Economic Cooperation and Development (OECD), the 35% growth in the number of doctors between 1990 and 2005 was driven by a nearly 50% increase in specialists compared with a 20% rise in general practitioners [5]

• Fragmentation as a result of the multiplication of specialist programmes and projects built around ‘priority programmes' focussed on single-disease control

• The pervasive commercialisation of healthcare in unregulated healthcare systems

In an editorial article in Annals of Family Medicine, Kurt Stange [6] highlighted the consequences of our increasingly specialised and fragmented healthcare systems (table 1). For the person with multimorbidity, the primary care professional, doctor or nurse, is a key person in helping them to navigate an increasingly complex landscape [7].

The Alma Ata Declaration [8] defined primary care thus: ‘the role of primary health care as the local, universally available, essential, first point of contact with the health system, based on practical, scientifically sound and socially acceptable methods and technology at a cost the community and country can afford'.

Numerous studies from multiple countries have shown that when systems are organised around primary care, outcomes are better with improved equity and lower costs. For example, when people have a primary care doctor as opposed to a specialist as their personal physician, their mortality risk drops by nearly 20% and their costs are about one third less [7].

The WHO views the development of primary healthcare as one of the key challenges for health system reform [4]. More than 30 years after the Alma Ata Declaration, the vision of primary care for all has yet to be achieved, but according to Gunn et al. [9] the generalist holds the key to providing truly personalised care (p. 111):

A fundamental role of the generalist is to balance the biotechnical with the biographical. The generalist must know and understand how each life story and social context are constantly influencing and being influenced by physical and emotional health. To achieve the balance between the biotechnical and biographical aspects of each interaction, the generalist must have the skills to reach a mutual understanding of the priorities and challenges that individual patients face when managing their health.

This very personal model of care is nevertheless greatly challenged by the forces such as those described above [1], which seek to fragment the process and provision of care in the belief that this will lead to improved quality of care [10]. Innovations such as the Quality and Outcomes Framework in the UK focus on single diseases rather than multimorbidity, and solely on disease-centred outcomes rather than also taking into consideration the patient's goals. This is particularly problematic when managing people with complex comorbid and multimorbid conditions [1].

Across the world, providers of primary care include not only doctors who have received specific vocational training in family medicine (including general internal medicine and general paediatrics in some countries such as the USA), but also non-physician primary care providers (such as nurses and physician assistants). Non-primary care physicians, in particular gynaecologists but also other specialists including psychiatrists, may also provide patient care services that are usually delivered by primary care physicians. These may focus on particular needs related to care such as prevention or chronic care, but they do not provide these services in the context of comprehensive, first contact and continuing care which is what characterises family medicine. Nevertheless, it is crucial that such specialists have a basic understanding of the diseases that are comorbid with those in which they specialise; for example, the need for psychiatrists to understand the role played by cardiovascular disease in the excess mortality and morbidity of people with a diagnosis of severe and enduring mental illness [11].

However, a crucial challenge faced by those seeking to develop services for comorbid physical and mental health problems is that patients themselves vary in how much they want to share their emotional problems with those caring for their physical health problems. Mental health problems still carry significant stigma, and additionally a person may feel that, in wanting to raise ‘personal' issues, there is a sense that the professional is trying to dismiss the severity of physical symptoms or talk about issues which do not seem to the patient to be relevant to the problem they present. This is something we have particularly observed when patients present with what seem to the doctor to be ‘medically unexplained symptoms' [12]; however, in a recent study of the implementation of a new model of care for depression and cardiovascular disease, uncertainty was also raised by some patients (and professionals) about how much they wanted physical and mental healthcare to be more integrated [13]. We have also noted that both primary care doctors, ostensibly providing holistic care for the person, and patients with long-term conditions may collude to avoid discussing emotional problems, preferring instead to keep to the ‘safer ground' of physical health and ‘normalising' the distress associated with conditions, such as diabetes and cardiovascular disease, rather than daring to try and raise the possibility that this might be ‘depression' [14]. These form significant barriers to both detecting and managing emotional problems in the setting of long-term conditions and mean that professionals need to work hard to engage people sensitively in talking about their emotional problems (see below).

Similar barriers occur in the detection and management of physical illness in people with long-term mental health problems. Many people with severe and enduring mental illness do not feel stigmatised when receiving treatment in the setting of primary care [15], but some undoubtedly do [16]. In the UK, a significant minority do not attend their general practitioner for the routine physical health checks for which general practitioners are now financially rewarded. The degree to which people with severe mental illness receive equivalent physical healthcare to the general population from either primary care [17] or alternatively within mental health services [18] remains debatable.

In recent years, numerous disease-management programs, incorporating clinician interventions (education, feedback, reminders) and/or patient interventions (education, reminders, financial incentives), to improve quality of care and outcomes for people with long-term conditions have been described in the literature. These programs, the best known of which is the Chronic Care Model developed by Wagner et al. [19] in Seattle, have been developed and extensively evaluated for single conditions, but less commonly for diseases in combination. A recent systematic review of complex interventions for patients with multimorbidity identified 10 randomised controlled trials, of which only 3 provided data on mental health outcomes [20].

However, there is now a growing body of literature on interventions for comorbid diabetes and depression. The Chronic Care Model informed the development of collaborative care (table 2) which has been extensively evaluated for the management of depression [21,22].

A recent meta-analysis of 14 randomised controlled trials of interventions for depression in the setting of diabetes with a total of 1,724 patients [22] showed that treatment was effective in terms of reduction of depressive symptoms, but the effect on glycaemic control was substantially smaller. Collaborative care (utilising the components described below), which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population yielded an effect size of −0.292 (95% CI: −0.429 to −0.155, n = 1,133) for depression outcomes. This is a moderate effect size, but the studies were based on community samples with few exclusion criteria (unlike studies of psychotherapies based in specialist settings), indicating this effect size could potentially be attained on a population scale. The authors concluded by saying, ‘improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions.'

Reviewing the literature on the content of these complex interventions, Piette et al. [23] suggested an effective organisational management strategy for diabetes and depression should include all the following elements: (1) systematic identification of patients with diabetes and depression and quality-of-care reviews, (2) proactive patient monitoring between outpatient encounters, (3) intensive efforts to co-ordinate treatment across clinicians, (4) increased access to cognitive-behavioural or related therapies addressing patients' depressive symptoms and diabetes self-care, and (5) an emphasis on promoting physical activity to address both depressive symptoms and physiologic dysregulation.

Katon et al. in the TEAMcare study [24] have now both successfully addressed multimorbidity and improved physical and mental health outcomes. A specially trained and supported case manager was employed to ‘treat to target' both depression and other chronic disease-related outcomes in the primary care setting, achieving significant improvements in both. The TEAMcare nurse was integrated into primary care and supervised weekly by a psychiatrist and primary care physician. The intervention improved glycaemic control, lipid profile, systolic blood pressure and depression symptoms compared to usual primary care.

Implementing collaborative care into routine practice poses challenges. In the USA, the IMPACT model for depression care in older people with comorbid physical health problems has been implemented in a range of healthcare systems across the country [25], and this has also been highly influential internationally. Major changes (including re-allocation of resources) are needed to implement disease management and collaborative care models, and investment in clinical electronic information systems is essential [26]. Re-designed systems and care pathways must implement more frequent follow-up and routine monitoring of outcomes by case managers, promote integration of specialists into primary care to provide supervision and support, and develop self-management systems for patients and professionals. There are also problems in delivering such complex interventions in healthcare systems where the general practitioner works alone without any additional person who might take the role of the ‘case manager'. In these settings a more traditional approach to ‘collaborative care' of developing the skills of the general practitioner in systematically following-up people with common chronic conditions with the support and supervision of specialists may still be the way forward [27].

In the USA the concept of the ‘patient-centred medical home' is a delivery system and re-imbursement reform that aims to reduce care fragmentation and other inefficiencies associated with chronic disease management. Its supporters describe four ‘cornerstones' that serve as the conceptual foundation for a successful medical home: (1) engaging patients actively in medical decision-making and enhancing their access, (2) incorporating evidence-based processes of care into practice, (3) adopting new payment structures that reimburse care activities occurring outside the traditional office visit and (4) enhanced primary care [28]. There is increasing recognition of the crucial role that primary care has in providing both mental healthcare for people with chronic illness and physical healthcare for people with severe mental illness in the ‘medical home' [29].

Finally, from our knowledge of the potential barriers to effective management, it is clear that at a micro-level the attitudes of professionals towards changing practices need to be challenged and knowledge needs to be acquired about common comorbidities they are likely to see in practice. For example, a psychiatrist may not be actively involved in managing a patient's diabetic care, but they should be able to recognise it and be able to work collaboratively with a physician in arranging care. Specific skills will need to be acquired by health professionals across the spectrum (including those who work in mental healthcare who cannot be assumed will possess all of these skills) to optimise the care for people who present with comorbid emotional and physical health problems (table 3). Acquisition of these skills will need to become embedded early in professional training if we are to meet the challenge successfully of developing more patient-centred services for comorbidity in the future.