Shared learning database

5 Boroughs Partnership
Published date:
January 2014

The project is based on inter-agency collaboration, utilising public health, pharmacists, service users and carers, health and wellbeing practitioners, primary and secondary care agencies working together in an aim to develop a database with the objective of reducing the mortality rates of service users with a diagnosed severe mental illness through a structured physical health screening, monitoring and intervening process. The project offers a physical health intervention framework for service users who have been prescribed antipsychotic medication. Additional contributors: Dr Javed Latoo; Jane Neve, Amanda Derbyshire and Rachael Kane.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

1. To contribute to a reduction in the mortality rate in people, aged 75 years or less, who have a severe mental illness (SMI).
2. To promote a more integrated approach to the physical health care of people with a SMI.
3. To focus on improvements in the following areas: screening and monitoring, targeted (early) prevention, interventions, collaborative care between primary and secondary care.
4. Shared decision making between primary and secondary care.

Reasons for implementing your project

Having a mental health problem increases the risk of physical ill health (Mental Health Strategy for England 2011). People with serious mental health problems, such as schizophrenia or bipolar disorder die on average 16 - 25 years sooner than the general population. NICE recommends GPs and other primary healthcare professionals monitor the physical health of people with psychosis or schizophrenia when responsibility for monitoring is transferred from secondary care, and then at least once a year. The health check should be comprehensive, focusing on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease.

Before the initiative physical health was not perceived as a priority within the team. Physical health screenings were unsystematic as were referrals to support such as Fresh Start, Recipe for Health, smoking cessation, drug and alcohol services, carers centres were also ad hoc. Physical checks were not consistent and only at the request of the doctor prior to the commencement of medication. Service user's often refused or lacked interest to attend physical health screenings. The team's links with primary care and wellbeing nurses were poor. Early intervention (EI) letters to GP's did not always highlight physical health concerns. In Patient Units physical health screenings needed to improve as did the recording systems. Furthermore SMI registers were not up to date in GP surgeries). We were also involved in on-going discussions in respect of whose responsibility it was for carrying out the physical health checks - primary or secondary care.

In order to improve efficiency and quality we needed to find a comprehensive assessment tool that was Trust approved. We required a documentation system and a formalised system of highlighting when people where due a physical health assessment. This required a more robust approach to ensure service users attended for screening and any health concerns identified were followed-up. Links with primary care needed to improve with regards to communication and the unnecessary obstacles, which were making it difficult to access test results. The links within secondary care agencies needed to be improved such as the community to in-patient and vice versa. We also identified additional skills needed within the team such as, venepuncture and ECG training.

How did you implement the project

To bring about the changes required to achieve our goal we used the Plan, Do, Study, Act (PDSA) model. This was useful for clarifying issues and actions required. Initially we had 8 first stage PDSA's that we worked on and these led to positive outcomes around establishing physical health as a priority within the team, involving primary care and health promoting agencies and establishing an in-house database. In addition we focused on the care plan approach and had several secondary PDSAs on going.

We established a local project group, which met on a monthly basis, which included: business manager, nurse consultant, team manager, occupational therapist, support, time and recovery (STR) worker, pharmacist, social services, public health leads, wellbeing nurses, consultant psychiatrist and service user representatives. To keep costs to a minimum we used existing Trust material, the starting point of which was the 5BP Comprehensive Physical Health Assessment. This included areas such as: smoking, diet, exercise, sexual health, sleep, dental, optical, ECG, and bloods. We also devised and implemented an in-house database in which results could be recorded using Microsoft Outlook.

In order to maximise the impact of the project we contacted all relevant GP?s and wellbeing nurses within the localities and passed on the initial baseline results. We saw a further opportunity to publicise the project through the creation of a GP DVD and information booklet for inclusion on the Trust's GP website and Clinical Commissiong Group (CCG) newsletter. We were fortunate to establish and develop wellbeing nurse led clinics in Halton and physical health clinics in Warrington which were STR led at no additional cost.

We established access to test results from the pathology labs for both localities. We made links with both the Medical Director and CCG leads within our Trust. We also saw an opportunity to utilise the role of the relationship managers within 5BP to reinforce links with local GP surgeries. We used the care programme approach to highlight physical health/wellbeing issues, and reinforced the need for annual physical checks.

Key findings

In order to monitor and evaluate progress we used statistics from the baseline audit to set up a database and then re-audited in November 2013 (see results table below).
-4 weeks November 2012: 4 (7.4%) May 2013: 19 (66%)
-3 months November 2012: 3 (5.5%) May 2013: 18 (72%)
-12 months November 2012: 4 (7.4%) May 2013: 21 (77%)
-24 months November 2012: 2 (3.7%) May 2013: 15 (95%)

The results show a significant increase in people having 6 physical health screenings in the dates specified above.

Quantitative evidence via our recording systems shows that people are receiving screenings and this is demonstrated by the increase in figures shown above. The recording system in-house has proven to be robust and comprehensive. We are looking to incorporate this or something very similar in our new electronic recording system.

Awareness of the importance of physical health screenings has risen among professionals, carers and service users. We've established better links and working relationships with primary care. We also feel that secondary care agencies are now more aware of the requirements for physical health screenings, which is reflected in the discharge letters that we are receiving from inpatient units. In terms of cost efficiency and productivity we believe we have demonstrated short-term savings in financial terms in respect of increased attendance at GP screening clinics and our own physical health clinics. We expect this will produce longer-term savings in the wider health economy. In summary we believe the project has been successful, especially in monitoring the effects of medication on physical health and in identifying, dealing and managing identified health issues such as smoking, BMI and exercise regimes - ultimately decreasing the morbidity rate of people with a SMI.

Key learning points

- Starting point is to ensure that the project team understands the aim and objectives of the task in hand. Once this has been clarified the project team must communicate with staff and make sure they are in agreement and have the same desires to succeed and achieve the optimum outcomes.
- To have the support of the senior management team in house, and encourage the involvement throughout in order to deal with the wider issues such as involvement with primary care partners, social care and health promotion.
- To get the basics rights in terms of meeting on a regular basis with the desired membership of the project group. Utilise the PDSA (Plan, Do, Study, Act) model and make sure targets are set and achieved efficiently.
- Do a scope of what is already available in terms of physical health screening clinics via help promotion and the health and wellbeing nurses. Often we found that services were duplicated and we were able to streamline not only secondary care but primary care also, therefore, saving money for both sectors.
- We struggled to engage GPs across both localities as our project aims were not included in QOF targets. This continues to be an issue although engagement has appeared to increase in the last couple of months.
- It is necessary to contact and engage local commissioners from CCGs as soon as possible in order to utilise their skills in dealing with primary care agencies.
- To accept that physical health screenings are an on-going concern and as such the process will need continued investment in both physical and financial resources.

Contact details

David Hindley
Team Manager - Early Intervention in Psychosis Service
5 Boroughs Partnership

Primary care
Is the example industry-sponsored in any way?