The National Institute for Health and Care Excellence (NICE) recommends in its guidance CG178 recommendation 188.8.131.52, annual physical health checks for people with serious mental illness (SMI).
Evidence shows that people with SMI die up to twenty years younger than the average population. Preventable cardiovascular disease (CVD) is the major cause of death, along with endocrine disease and respiratory failure. Evidence also suggests that these individuals receive a lesser standard of health promotion and physical health care and despite national awareness and guidelines early mortality rates have not improved.
Bradford District Care NHS Foundation Trust (BDCFT) supported a project to improve the physical health of people with SMI. In 2012 the electronic mental health physical review template was developed within SystmOne enabling primary care teams to carry out a high quality, systematic annual physical health checks, including a calculation of the risk of dying from Cardiovascular Disease (CVD) known as a QRisk2 score.
Aims and objectives
An initial audit was conducted looking at base line physical health measures used in primary care, results showed that the current measures did not reflect the patient's needs and that essential checks were not taking place.
Following implementation of the template, the number of annual physical health checks carried out increased and the quality improved, resulting in significantly better quality outcomes for this client group. The template became part of routine care and is used by GPs and Practice Nurses across all 80 GP practices in the locality.
The success of the project led to a decision in 2014 to develop physical health monitoring within secondary mental health services to reduce the traditional approach of treating mental and physical health separately with services designed around conditions rather than patients. This led to improved communication between primary and secondary care and reducing the risk of overlap and duplication ultimately leading to shared care.
NICE Clinical Guidance CG178 Psychosis and schizophrenia in adults: prevention and management, recommendation 184.108.40.206 states; “The secondary care team should maintain responsibility for monitoring service user’s physical health and the effects of anti-psychotic medication for at least the first 12 months or until the person’s condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared care arrangements”.
Physical health monitoring in secondary care in Bradford consists of five physical health / wellbeing clinics within Community Mental Health Teams (CMHTs). All patients initiated on antipsychotics are referred for appropriate baseline physical health checks and ongoing monitoring until stable enough to return to the care of their GP. Band 4 Associate Practitioners (APs) carry out the baseline tests and are trained to perform phlebotomy, electrocardiogram (ECGs) and give lifestyle advice including appropriate referral.
The Mental Health Physical Review Template has now been adapted for primary and secondary care and for community and inpatient settings. The SystmOne and EMIS version of the templates are available for use nationally. The RIO version can be replicated and meets the required CQUIN targets. All the templates are aligned to the nationally recognized Lester Tool. All the information is stored centrally within SystmOne EMIS and RIO.
Reasons for implementing your project
Individuals with SMI, specifically schizophrenia experience poor physical health. The NICE clinical guideline on psychosis and schizophrenia management recommended physical health checks (CG178). However, current measures to implement this recommendation, such as financial incentives to general practices, have a limited impact and reach.
It was recognised within Bradford and Airedale at the start of this project in 2009 that the process of annual physical health checks for those individuals with SMI was limited both in the information required and within the physical health check.
As a result of this recognition and work undertaken locally on a national pilot (The Wellbeing Support Programme), the evidence-based electronic template was developed for use in general practice initially for SystmOne, to enhance service provision for the physical health needs of those with SMI.
Additionally there were incentivised clear standards set out in the local quality outcomes framework (QOF) relating to the recording and ongoing management of those with SMI.
In order to determine the impact of existing initiatives, it was felt appropriate to undertake an audit of current practice specifically against NICE guidance, with a focus upon existing services in Bradford and Airedale for the promotion of physical health in those with SMI.
An audit was undertaken of existing services commissioned by Bradford and Airedale for the promotion of physical health in those with SMI, against the standards set out in NICE CG82 Schizophrenia: Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care, in order to make recommendation for quality improvements (where appropriate).
For the purpose of the audit of the 80 GP practices across Bradford and Airedale a random sample of 12 general practices were selected (n=12). From each practice a further 20% random sample of working age adults of mixed gender were selected from each SMI register. The timeframe for the audit was a two month period in the summer of 2009.
Therefore the total number of patients included in the audit was 104 (n=104).
The full audit report is available on request. The outcome of this audit highlighted that there were some positive results in terms of the physical health monitoring for patients with SMI, however there were areas for concern to include: none of the patients who were audited had been given a CVD Risk Score or a Prolactin Level.
How did you implement the project
The project lead gained support form the Lead GP with specialist interest in Mental Health and Learning Disabilities (GPWSI) who was key to providing excellent “buy-in”. Whilst this was a nurse-led project having a GPWSI was vital. The GPWSI shared the same passion and was and still is consistent in offering support both locally regionally and nationally. We gained the same support from the data quality specialist who developed the technical side of the template and supported the project from local role out to the regional and national picture.
The change in culture was the most challenging part in terms of agreeing responsibilities. Historically it was viewed that any physical health issue should be dealt with in primary care despite the fact that often anti-psychotic medications are initiated in secondary care. Sharing the care and ensuring these patients receive a comprehensive physical health check needed to be “a bottom on a seat” either in primary or secondary care. Effective communication between primary and secondary care is necessary in order to avoid duplication or overlap and ultimately ensure we truly care for patients holistically. We are also faced with interoperability problems, as we work on so many different IT clinical systems and “Morrison’s doesn’t speak to Sainsbury’s”.
Having accepted we need to share this responsibility has without doubt changed the way we now communicate between primary and secondary care in Bradford and Airedale. Clarity has supported this through agreed “Shared Care Guidance” has cleared the way forward and been adopted by many other areas across the UK. The success in Bradford and Airedale has given other mental health services and primary care services across the UK the confidence to move forward in sharing this care.
Bradford and Airedale we were one of the first secondary care services to invest in work to specifically improve the physical health for people with SMI. During the initial success and the base line evidence report (available on request) the work began to spread, supported by BDCFT. It was at this point when the Academic Health Science Network (AHSN) Yorkshire & Humber were invited to support further role out regionally and nationally. The AHSN have been supporting this work over the past 3 years with outstanding results. Patients with SMI are receiving a comprehensive physical health check and uptake of usage of the template is growing both locally and nationally.
It is reasonable to say from a project lead's point of view that it was always an ambition to improve the physical health for people in the Bradford and Airedale region, however this project has exceeded any expectations as the work has been nationally, which is fantastic!
National spread: The template is now being implemented by GP practices in 129 CCGs across England. The work was referenced as case study in a January 2018 Kings Fund report entitled Adoption and spread of innovation in the NHS. It is also referenced as a support tool in forthcoming NHS England commissioning guidance for CCGs entitled Improving physical healthcare for people living with severe mental illness (SMI) in primary care
We have results that demonstrate huge improvements in terms of how many people with SMI now receive a comprehensive physical health check (approx.10’000 checks completed on patients over 4 years) and appropriate referral and follow up advice and care. We can monitor how many patients are receiving the physical health check each month or quarter and this has increased by thousands as a result of the implementation of the “Bradford Template”.
We have gathered interest regionally and nationally offering training across the UK. The AHSN Yorkshire & Humber have funded an E-Learning Module in order for Clinicians to access this training on line, which is also CPD recognised. There are 1000 free places.
The AHSN Yorkshire & Humber have also funded a cost effective analysis through York University to provide evidence of the long term benefits of this work which concluded: If we were to carry out 47,000 physical health checks across Yorkshire & Humber for people with SMI then the savings over the next 10 years would be £11.3 million to the local health economy.
There is evidence to suggest that people with SMI have a significant impact on accident and emergency departments and this project will look at the impact this has on improving this in the future. The project will look at much more patient focussed outcomes in the near future.
Key learning points
This project has taken 15 years to reach this stage. If you are passionate don’t “give up” - there have been many moments when the project has not been a “priority” due to limitations on NHS resources which are extremely restricted and expectations are high with the limitations.
The project lead firmly believes the relationship with people were absolute key the success of this work. The project lead will admit that skills in terms of academia lacked and she makes no apology for this, however describes herself as running this project like a “dog with a bone” focussed and determined to get this work on the map and “make a difference”. It has to be questioned why people are dying up to 20 years younger than the general population? It is a good example of real need.
Avoid reinventing new knowledge avoid going over history and try to move forward in terms of delivering something that will truly make a difference. Use established evidence.
Try to build a small team of passionate people who are likely to sustain their interest for the long haul. Avoid the risk of being “precious” about the work give everyone involved the opportunity to have a say and participate particularly when you reach success.
Be open to observation and look at what is going on across the UK and wider, avoid “reinventing the wheel”. Communicate with as many other organisations as possible and share knowledge.
Above all do not underestimate the relationships you build along the way, remember to recognise all those who supported the work and provided information in order for the project to move forward.
Feedback how things are progressing for example: communicate with practitioners how their efforts are making a difference to patients and what they are doing to support improvement, people need to know how valued they are, I do as I am sure most people do especially within the health care environment here resources are completely stretched and we are asking them to go the extra mile.