The physical health template for Severely Mentally Ill (SMI) patients was developed in Bradford by Primary and Secondary Care with academic and data quality support. It provides a systematic way to record all necessary cardiometabolic metrics as well as a host of other information relating to screening as in the excellent Lester tool and important measures such as prolactin in patients on antipsychotics. In fact it could be seen as the practical way to deliver the Lester tool, which has been incorporated into the template with the help of NHSIQ.
What We Did
The physical health template for Severely Mentally Ill (SMI) patients was developed in Bradford by Primary and Secondary Care with academic and data quality support.
It provides a systematic way to record all necessary cardiometabolic metrics as well as a host of other information relating to screening as in the excellent Lester tool and important measures such as prolactin in patients on antipsychotics. In fact it could be seen as the practical way to deliver the Lester tool, which has been incorporated into the template with the help of NHSIQ.
The information collected is coded, retrievable, measurable and can be audited. Its SMART.
Kate Dale’s secondment from Bradford District Care Foundation Trust (BDCFT) to the Primary Care Trust to embed the template in SystmOne in Primary Care in and train our nursing staff was crucial in making it work. She visited around 60 out of 82 practices. Those practices that had the training did better in using the template.
I worked across Primary and Secondary Care as a GP, GP with Special Interest in Mental Health and Clinical Specialist Lead in Adult Mental Health & LD for the Bradford Clinical Commissioning Groups(CCGs), so am in a position to drive this at all levels. I am well known in Primary Care and at CCG board level for this been my passion and have presented it at boards and at clinical meetings at regular intervals.
This template is transferable to other IT systems and is now on RiO,( the BDCFT Secondary Care IT system) where Kate has again trained clinicians and physical health clinics are up and running. Information is shared electronically between inpatients and Primary Care.
Traditionally mental and physical health has been treated separately with services designed around conditions rather than patients. BDCFT have invested in two Band 7 Mental Health Nurses specializing in Physical Health to ensure the appropriate training and development exists and continues across both inpatient and community services; a Mental/Physical Health Project Lead for Community and a Mental/Physical Health Project Lead for Inpatients. There are 5 clinics in Community Mental Health Teams, Early Intervention in Psychosis and Child & Adolescents Mental Health Services also have access to the Physical Health Teams.
Staff working in the clinics have been trained how to perform phlebotomy, Electrocardiograms (ECGs), base line tests and lifestyle advice to include appropriate referral.
ECG machines have been purchased along with necessary IT equipment to use these in clinics. Service Level Agreements (SLA) have been set up in order for the results to be stored in the “Cloud” and then interpreted by Cardiology experts. Clinic staff have been trained by the Mental/Physical Health Project Leads to carry out ECGs and some clinic staff have decided to expand their knowledge and continue to attend further modules to include learning how to interpret the results. Nursing staff are attending Phlebotomy training in order to take blood samples in the new Physical Health/Wellbeing Clinics within the CMHTs and within the inpatient setting. There will be a medical device inventory with medical physics department checking and calibrating the equipment as required. BDCFT have a protocol/algorithm and care pathways to ensure good safe practice. All appropriate mandatory training is kept up dated for clinical staff to include Basic Life Support and Advanced Life Support depending on level required.
The same processes and systems have been rolled out in the in-patient environment supported by the Mental/Physical Health Project Lead for Inpatients who will educate the staff in using the template on RIO. All secondary Care Health Care Support Workers have been trained in physical health monitoring and recognizing the deteriorating patient within the Calderdale Competency Framework; this includes the support of qualified staff mentors within each area ward or department.
In 2013 BDCFT developed The Antipsychotic Shared Care and Physical Health
Monitoring Recommendations with myself which highlights the specific responsibilities of both Primary and Secondary Care staff when carrying out physical health checks. These guidelines are in line with the Mental Health Physical Review Template.
BDFCT are working with this shared care protocol in order to truly manage the physical health of patients and are now focusing on new systems and processes to ensure effective communication of the physical health results between primary and secondary Working jointly will lead to a better standard of care and improved physical health care to this population of patients who have SMI.
BDCFT have funded to further enhance the qualified nurses in recognizing when a mental health patient may be deteriorating physically. This training is delivered within the ‘Recognizing and Assessing Medical Problems in a Psychiatric Setting (RAMPPS)Framework’.
In view of the success in rolling this work out across primary and secondary care for both community and in-patients, this is a true demonstration offering a standardised systematic approach to caring for the physical health needs of this population. This will enhance effective communication between Primary and Secondary Care, reducing the risk of repetition or overlap.
Wider Active Support
Initially the collaboration and support between Primary and Secondary Care with Dr Yeomans at Leeds & York Partnership Trust and Kate Beedle at the Commissioning Support Unit was pivotal in the projects success. This project has had local support from CCGs, BDCFT and the Local Medical Committee. Nationally it has had support from Dr Geraldine Strathdee previous Clinical Director for Mental Health at NHSE, NHSIQ, SystmOne, EMIS and RiO. Most recently the Academic Health Science Network in Yorkshire & Humber have supported further regional roll out of the project.
Feedback from Staff has been positive from the start both in Primary and Secondary Care “The template is easy to follow and actually saves time, its self-explanatory and we don’t want to lose the opportunity to use it” (This was quoted during the pilot phase by 2 Practice Nurses) Secondary Care Nursing staff have commented that before the RAMPPS they were wary of Physical Health problems, but felt empowered after training to recognise these in SMI patients.
GPs are supportive as it has helped them achieve Quality Outcome Framework (QOF) points, so earn money and improve patient care.
Patients and carers have commented that they are really pleased that Physical Health problems have been addressed as well as their Mental Health problems.
Looking Back/Challenges Faced
From the very start of this project in 2008 we have worked through many different challenges, to include influencing change, culture, workload and communication.
Effective communication and relationship building have been crucial to this process. We have duplicated an electronic data entry template onto various IT systems, these systems do not talk to each other this being the biggest hurdle we have faced and continue to face. We physically post information at the moment from the community clinics, however BDCFT have successfully developed an E- Discharge from in-patients to the GPs, hopefully this will be developed for community as some stage soon as receiving 8 pages of health checks and manually inputting them is painful.
We are asking people to embrace change through training and education. We are gathering outcome data from different IT systems.
One challenge was in the issue of abnormal results if tests had been requested by BDCFT clinicians the LMC in line with British Medical association (BMA) initially wanted BDCFT clinicians to act on them, however after negotiating between CCGs, the Medical Director of BDCFT and myself a compromise was agreed. BDCFT staff contact the patient and if necessary facilitate an appointment in Primary Care. This is a pragmatic solution as most BDCFT clinicians don’t manage diabetes or cardiovascular risk routinely.
When QOF for Mental Health was decimated the challenge was to keep Primary Care on board due to the pressure we are under. In Bradford we came up with a Local Incentive Scheme (LIS), which incentivised Practices to continue using the template, this kept our health check numbers up. Now NHSE have advised CCGs to put money into this area.
The fact that everything we have delivered within this project is relatively simple, systematic, standardised and measures centrally will support sustainability. The data entry templates are systematically reviewed.
The Physical Health/Wellbeing Clinics in secondary care are managed with the CMHTs. BDCFT are helped by a Commissioning for Quality and Innovation incentive for Physical Health checks on SMI patients. The outcome data is published on a monthly basis with Secondary Care and the outcome data for primary care is quarterly.
There is a shared care protocol which offers clarity on who is responsible for the physical health check who when and what.
Despite Kate been more national than local these days because of BDCFTs commitment to the project it has been demonstrably sustainable, also the CCGs showed commitment in terms of the LIS.
I will continue to drive for improved Physical Health Care for SMI patients and indeed this is embedded in the Bradford Airedale Wharfedale & Craven Mental Health and Wellbeing Strategy http://www.bdct.nhs.uk/wpcontent/uploads/2016/12/MH_strategy_v6_clickable.pdf
Am biased but its brilliant! Due to local and national support this project is definitely sustainable.
Evaluation (Peer or Academic)
Extrapolating the findings for the Yorkshire and Humber Region
The model calculates the benefits per patient (not per health check). Consequently, it can be used to estimate the potential benefits for a given number of patients in a selected cohort, providing they fit the eligibility criteria.
Physical health checks are intended for patients on the severe mental illness (SMI) QOF register. If all patients eligible for a health check received the equivalent intervention as the health checks provided by the providers included in this evaluation, the potential benefits of £283.46 per patient can be modelled as follows:
Benefits for all patients on the SMI register in Yorkshire and Humber region
Value of incremental benefits over 10 years
STP area Number on SMI register All three domains*
Humber Coast and Vale 10,581 £2,999,290
South Yorkshire & Bassetlaw 12,477 £3,536,730
Total for Yorkshire & Humber 46,746 £13,250,621
Initial evaluation from early days 2009
Table 1. An audit of quality of annual screening health checks (N/A = not available)
Recordings present Baseline (n=104) Re-audit (n=27) with template Improved?
BMI (body mass index) 77% 100% Yes
Weight advice given 52% 100% Yes
smoking status 79% 100% Yes
smoking advice 87% 100% Yes
alcohol status 55% 100% Yes
drug use status N/A 100%
blood pressure 74% 100% Yes
FBC (full blood count) N/A 100%
LFT (liver function tests) N/A 100%
glucose 45% 89% Yes
TFT (thyroid function) 38% 89% Yes
prolactin 0% 82% Yes
cholesterol 39% 78% Yes
triglyceride 38% 75% Yes
Qrisk2 calculation 0% 48% Yes
In terms of the LIS we have seen an increase from 1% in Bradford District CCG of the 6 actions from the template to 19% over the year. I am awaiting final figures from year end which I suspect will increase. In my own practice its 75% of my total SMI register which includes patients in remission.
Kate and I have presented on the project at many events. I get places like Bolton she gets Barcelona!! Although London has figured prominently I shared at the West London Group and last year at the Health and Social Care event at the Excel.
Locally through the AHSN the project has been shared in Wakefield most recently and York.
The template is available nationally on SystmOne, EMIS web and RiO.
In terms of SystmOne the template has been copied 34 times, is in use in 610 organisations and across 59 CCGs and has been used 2600 times.
In EMIS web up to February 2017 73 CCGs are using the template and it’s been used 1033 times.
The template has been cited by the Kings Fund and NHSE in case studies in terms of integrating Physical and Mental Health Care.