People diagnosed with a mental illness have shockingly bad physical health compared to the rest of the population. And a report by the Disability Rights Commission accuses the health service of blatant discrimination in not ensuring their health needs are met. Adam James looks at improvements being made, and examines whether it will be enough to prevent the NHS being sued.
Lauren Chadwick was diagnosed with manic depression in 1987. Statistics show she is significantly more likely to have heart disease, suffer a stroke, obesity, respiratory disease or, indeed, develop cancer.
Not that Lauren’s GP was aware of this. For the six years Lauren was his patient, he never gave her a full physical check-up. If he had he might have found the cancerous tumour the size of an egg in Lauren’s breast. Eventually, it was a nurse at Lauren’s new GP surgery who found the lump. Within five day chemotherapy, radiotherapy and surgery were organised for the cancer which had spread to other parts of the 41 year old’s body.
Lauren, now 56, feels “extreme anger” towards her first GP. “I did feel let down,” she says. “I felt that he would not have treated me like that if I didn’t have a mental health condition.”
The experience of Lauren [not her real name] is common, it seems. A hard-hitting Disability Rights Commission (DRC) report released in September complained of a culture among health professionals of “complacency” and “lazy fatalism” of accepting that people with mental health problems (as well as the learning disabled) “just do” die younger, are incapable of looking after their health or attending GP appointments.
The DRC’s report was based on its own quantitative research into eight million primary care records, plus qualitative research with one health board in Wales and three England primary care trusts (PCTs). This provided “the strongest evidence base [of its kind] anywhere in the world”, said the DRC
It found that people with mental health problems, particularly those diagnosed with a severe mental illness (SMI) have higher rates of obesity, smoking, heart disease, diabetes, respiratory disease, and stroke than the rest of the population. Specifically, it found that women diagnosed with schizophrenia are 42% more likely to get breast cancer. The investigation also revealed an alarming new finding – that people diagnosed with schizophrenia are 90 per cent more likely to have bowel cancer, the second most common killer disease in Britain.
Yes, the poor socio-economic status of SMI people is one cause for this inequality, said the DRC. But it also accused the health service of blatant discrimination. The DRC reported, for example, that almost half of respondents in its survey complained of “barriers” when arranging to see their GP – such as derogatory reception staff, inflexible appointment systems, lack of knowledge on the side-effects of powerful psychiatric medication, or being struck off from GP lists for being too demanding.
These findings should make policy-makers sit bolt upright in attention. Indeed, the DRC’s call to arms is that professionals and organisations providing GP and primary care services should “act now” to tackle inequalities in primary healthcare provision for SMI people. The DRC’s report, entitled Equal Treatment: Closing the Gap, calls nationally for SMI people to be specifically targeted for health checks and for an end to “diagnostic over-shadowing” whereby professionals effectively ignore an SMI person’s physical ill health by presuming every ailment is related to their mental ill health.
The government says it recognises the problem. Infact, the health minister Rosie Winterton said she agreed with the “broad thrust” of the raft of DRC recommendations.
Moreover, in August the Department of Health sent best practice guidance to PCT managers on how to improve the physical health of SMI people. £7m was also allocated to eight PCTs to employ “well-being” nurses to work in partnership with GPs, health and mental health staff to deliver health checks and blood tests to SMI people, advise them on diet and exercise, and support them to access primary care services. The initiative was heralded as part of the government’s bid to make mental health nurses work “holistically” with patients.
The guidance showcased eight Well Being pilot projects which, from 2004 to this year, were provided (for free) to the NHS by pharmaceutical firm Eli Lilly. Working alongside a PCT, one Well Being nurse ran health check-ups and health living advice either at SMI people’s home or clinics. The nurses also organised healthy living groups. As published in the guidance, some of the projects led to a reduction in alcohol of 57%, 32% in smoking reduction, and a 60% increase in activity levels, as well as boosting patient self esteem.
“The results have been absolutely outstanding,” says Mark McKeown, manager for the Well Being pilots.
“Because of the nature of mental illness, people are loathe to go to GP practices because when they go the focus always ends up on their mental health, even though they might of gone, for example, because of problems with their tonsils.
“Plus, even with the best will in the world GPs don’t have time to spend time with [SMI] people. A GP could not do in seven minutes what we do. The Well- Being programmes are offering a service which makes sure [SMI) people do not fall through the loop.”
McKeown enthuses that improving the physical health of SMI people could be “the next big thing” in mental health. Yet it might be fear of ending up in court that, ultimately, drives the NHS to provide better primary care to SMI people.
The DRC warns that if there is no genuine improvement, the NHS could feel the force of the Disability Discrimination Act. From December, a “Disability Equality Duty” means SMI patients could sue trusts for not making “reasonable adjustments” in providing equal access to primary care services.
Such “reasonable adjustments” might mean GPs – or nurses – having to give more consultation time to SMI people with difficulty retaining information, or ensuring that people with agoraphobia do not have to wait in a busy GP waiting room.
“If changes are not being made we do have enforcement powers,” says Liz Sayce, the DRC’s director of communications. “If we find action is not in place nor is robust enough to close gaps of inequality, then there will be process of alerting services that they have those commitments.”
The Department of Health said it is to convene a meeting of senior staff to work with the commission on a response to the report. This will be published early next year.
Meanwhile, concerns have been aired that “well being” nurses will be insufficient to address both the scale of the problem and the “complacency” mind-set within the health service.
For example, Judy Dean, a clinical project manager with Cambridgeshire and Peterborough Mental Health Partnership NHS Trust, has led health improvement programmes for SMI people. This included brokering partnerships with local council services who provided venues for swimming and exercise groups.
Dean is adamant that to affect change for SMI people means making sure everyone involved in a SMI person’s care works holistically. “Appointing well being nurses is not going far enough,” she argues. “It’s an awful lot to expect one individual to do. To have one or two nurses for one PCT is laughable really. The emphasis should be much more on a multi-agency approach, with the person’s care-co-ordinator taking responsibility.”
Dean, who is a nurse, says this would ensure that improving the physical health of SMI people is “part of a full package, and not an afterthought.” She adds: “This is an issue of people’s rights.”
Sayce also insists that improving the physical health of SMI people needs more “mainstreaming”. The DRC report observes that, too often, the health needs of SMI people are “off-loaded” onto specialist services rather than being addressed through primary care. The DRC is also recommending that GP contracts contain incentives to routinely run physical health checks on SMI people.
“New guidance is a worthwhile step…but it’s crucial there’s national leadership on this issue,” says Sayce. She also questions how the 64 PCTs not included in the government’s £7m package are expected to improve their service to SMI people.
“What we are saying to the government and those who commission services is that the evidence [for discriminatory practice] is now here, “ she says. “And they should use this to build action plans that bring about change.”
Tamsin Floyd is a “Well-Being” nurse who for two years worked in Brixton with 200 people diagnosed with a SMI. Attached to a South London and Maudsley NHS Trust community mental health team, Floyd ran a clinic, providing full health check-ups and healthy living advice including examining the side effects of psychiatric medication. A client would be seen around six times over two years. Floyd also ran weekly healthy living groups, providing advice on eating healthily and exercise for 15-20 clients per group. The Well Being programme, funded by Eli Lilly through private nursing firm Inventive Solutions, has now ended. But Floyd is working with South London and Maudsley NHS Trust to train new Well Being nurses
“Some people who came to my clinic had not seen a GP for 10 years. Or I might measure a person’s blood pressure and find it to be so high that I would immediately refer them to a GP for blood pressure tablets.
“It was rare for me to see someone who did not have a physical health need that needed immediate addressing. Of the 200 people I saw, around 10 had a life-threatening condition, such as blood pressure or cholesterol levels that were so high that they could have had a major coronary event, such as a stroke. By picking up high blood pressure for one client, her consultant said I could have prevented her from dieing
“Usually people just needed encouragement or health education. For example, despite presumptions, many people with a SMI do actually want to give up smoking. Also, somebody might be eating a takeaway meal around four times a week, so we might try to bring it down to one takeaway a week.
“A lot of people do not understand the basics of looking after themselves. It’s also about getting people used to going to see their GPs, and hopefully not reliant on seeing me.”
“If this issue effected any other group of people, society would be up in arms.
Killer facts (taken from DRC report, Equal Treatment: Closing the Gap)
- Women with schizophrenia are 42% more likely to get breast cancer.
- People with schizophrenia 90% more likely to get bowel cancer
- People with schizophrenia or bipolar disorder 60% more likely to have ischaemic heart disease; 80% more likely to have a stroke; 30% more likely to have hypertension
- 33 per cent of people with schizophrenia and 30% with bipoloar are obese, compared with 21% of rest of population
- 61% of people with schizophrenia and 46% with bipolar disorder smoke, compared with 33% of the rest of population
- 22% of people with coronary heart disease and schizophrenia die after five years; 8% die in rest of population
- 19% of people with diabetes who have schizophrenia die after five year; 9% die in rest of population
- 28% of people who have had a stroke and have schizophrenia die after five years; 19% of people with bipolar disorder die; 12% of people with no serious mental health problems die
* This article originally appeared in Mental Health Today