What are the barriers and facilitators to access to care for people with co-morbid severe mental illness and obstructive airways disease (Asthma and COPD)?: a qualitative study of patient perspectives and stakeholder feedback

Problem

People with a serious mental illness (SMI- schizophrenia, bipolar disorder, related psychoses) experience premature multi-morbidity and mortality. Research suggests systemic barriers to access and overshadowing by the SMI of physical health needs contribute to health inequalities. Compared to the general population, people with a SMI have a significantly higher prevalence of COPD and Asthma. In 2014, the UK ‘Asthma Deaths Report’ found that 18% of those who died also had mental illness. The UK General Practice Quality and Outcomes Framework (QOF) incentivises an annual health-check (cardio-metabolic/ lifestyle risk factors) for patients with a SMI, and separate structured primary care reviews for people with Asthma and COPD. Our novel research aimed to explore the perspectives of patients with both a SMI and obstructive airways disease (OAD- Asthma or COPD) on access to respiratory care and to discuss the implications with stakeholders.

Approach

Patients with a SMI and with either co-morbid Asthma or COPD were identified by eight practices using QOF registers and invited by letter to participate in a qualitative interview study. A topic guide was informed by a literature review and feedback from patient groups (x2) . Semi-structured interviews were recorded, transcribed and independently analysed (interpretive phenomenological analysis) and continued to data saturation in a purposive sample by patient and practice setting. Results were fed back to a stakeholder group of 18 participants (service users, a charitable service provider, a social prescriber, GPs, nurses, commissioners, researchers) and implications discussed using real-time infographics.

Findings

We interviewed 16 people (seven male, nine female, aged 45-75yrs). The majority lived alone, (10/16), had left school with no formal qualifications (12/16), were unemployed/ retired (15/16) and were current (6/16) or ex-smokers (6/16). Participants described significant disability and poor access to routine primary care. Social capital determined ease of access. Self-management was challenged by poor health literacy and poverty. Smoking cessation was perceived as impossible without psychological support. Service level factors could facilitate access to timely primary care and also continuity. However, there was a lack of proactive self-management and over-reliance on urgent care if service factors were lacking. Physical-mental multimorbidity led to fragmentation of care in speciality silos.The stakeholder group expressed similar concerns and in addition, ‘fear of loss of benefits’ and the 'insecure funding of community organisations'. Potential solutions focused on adequate resources, supported navigation of complex care pathways, relational continuity, individual and community asset-building and the evolving ‘social prescriber’ role.

Consequences

This study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care which builds social capital and tailors support for self-management is needed, alongside enhanced access to primary care for patients with SMI and OAD.