15 August 2023

Yesterday The Department of Health and Social Care (DHSC) published their Major Conditions Strategy: case for change and our strategic framework. There are many positive take-aways that people affected by bipolar could potentially benefit from, but a specific commitment to the condition is sorely lacking and a major omission.

A joined up approach

The Major Conditions Strategy replaces the previously planned Mental Health Strategy update which had already been extensively consulted on. The new approach makes sense as it takes account of the significant co-morbidities that many of the NHS’s biggest users are living with. This is particularly true for people with bipolar who are more likely to have cancer, and cardiovascular and respiratory diseases, which are all identified in the strategy, and who die 10-15 years earlier than the general population. A more joined up approach to treatment and support is very welcome and will hopefully deliver improved outcomes.

The overall gist of the strategy is prevention, earlier diagnosis and empowering patients to live well with personalised health care and self-management. This aligns closely with the Bipolar Commission’s recommendation to adopt the optimum treatment model for the condition.

There's room for hope

There are certainly several specific hooks that the bipolar community could take hope from. There is a priority on ‘supporting someone through their first incidence of mental ill health’ and seeking to ‘identify opportunities to secure more equitable access to diagnosis’. Both could potentially reduce the 9.5 years delay to diagnosis.

The UK National Screening Committee is also considering how the NHS can undertake more targeted and personalised screening. Given the significant number of people living with bipolar who are misdiagnosed with depression and mis-prescribed antidepressants without mood stabilisers, bipolar should be a top priority for the Committee.

The ideas sound good...

There are numerous references to an increased focus on self-management. This is considered a panacea for many of the NHS’s challenges but people living with the conditions need to be given the basic knowledge of what their conditions are and how they can be managed. Self-management courses are very popular amongst people living with bipolar so a big push in this area would be very welcome.

The focus on personalised care is again extremely welcome – each person living with bipolar is different so will need different options. The preferred model by most of the community is getting support from a named clinician who is an expert in bipolar who will support the individual over ten or 20 years to manage the condition. The most popular clinician is the psychiatrist, though some people say they’d prefer a clinical practice nurse or therapist.

...but how does bipolar fit into the plan?

Early Intervention in Psychosis (EIP) services are rightly referenced as world-leading in providing holistic care to people experiencing a first episode of mental ill health, which can drastically improve health outcomes and prevent lifelong ill health. However, these services are tailored specifically to patients with schizophrenia - not bipolar. An equivalent programme urgently needs to be developed for bipolar - or EIP should be expanded to specifically include bipolar.

Bipolar is a major omission

Importantly the strategy works towards achieving parity between physical and mental health. It acknowledges that introducing access and waiting time standards is an important step towards parity, and that these currently cover only three service areas (NHS Talking Therapies, children and young people’s eating disorders, and Early Intervention in Psychosis). 

Bipolar is again a major omission. Its takes on average 9.5 years to get a bipolar diagnosis. The longer the wait the higher the risk of suicide, with a third of our community reporting that they attempted to take their own life because of the delay. Bipolar urgently needs its own target as resources are always directed towards the conditions with targets.

Will the new physical health checks be effective?

The profiling of 390,000 people with a severe mental illness getting a full annual physical health check in 2023 to 2024 is also welcome but should be caveated that, without an accompanying medication review and advice and support on changing unhealthy lifestyle factors, they aren’t effective.

Our community reports that medication is one of the biggest factors in weight gain and a key reason why our community is 50% more likely to be obese. As a member of our community commented – ‘I don’t need a nurse to tell me I’m overweight. I need support to lose weight’.

No mention of bipolar

Sadly, despite its strengths the strategy doesn’t make any mention of bipolar at all. While this is notionally covered in mental health and severe mental illness, without specific actions it’s a missed opportunity.

Mental illnesses simply cannot be lumped into one. Parity of esteem means specialist clinicians and treatment pathways for different mental health conditions, just like there are specialist clinicians and treatment pathways for physical health conditions. You wouldn’t expect to see the same consultant for a heart condition and cancer, so why are people with different mental health conditions all considered under the same umbrella?

Serious inequities

The category of 'severe mental illness' glosses over series inequities between mental health conditions that have a dedicated care pathway and targets (schizophrenia, psychosis and increasingly, eating disorders) and mental health conditions that don't - including bipolar. This means people living with bipolar are often forced to use inappropriate or generic treatment if they are lucky - and sometimes left to cope with no treatment at all.

Dementia gets 69 references in the strategy and a recommitment of the goal to diagnose two thirds of people living with the condition. Bipolar gets 0 references yet less than half of those with bipolar have a diagnosis.

The strategy doesn’t make a clear rationale for how it will prioritise treatment decisions, or what it plans to cut/phase out to pay for the new approach. We don’t get any sense that it puts the NHS on a sustainable funding model. Bipolar costs the UK economy at least £20bn a year and preventable bipolar relapses cost the NHS an extra £1bn a year. 

A focus on bipolar is a win win for the NHS

People living with bipolar often respond very well to treatment and the ongoing costs of medication, specialist support, lifestyle changes and reasonable adjustments are relatively cheap to implement. A focus on diagnosis, early intervention and self-management and ongoing personalised care for bipolar will mean potentially hundreds of thousands of people with bipolar currently trapped on benefits will be able to get into work and pay taxes to support the NHS. It will also mean the NHS stops wasting – indeed saves - money on inappropriate and ineffective treatments.

Making bipolar a focus of the Major Conditions Strategy is a shot in the arm the NHS desperately needs. This is why the team at Bipolar UK is campaigning tirelessly to get policy and decision makers to understand why implementing the Bipolar Commission recommendations makes sense on all levels - for individuals, the NHS and the UK economy.

You can find the Bipolar Commission's full recommendations on page 24 of the 'Bipolar Minds Matter' report, published in November 2022.