The PHIT Clinic began life as a pilot project in November 2015. The clinic was originally established to improve the screening and monitoring of physical health assessments for those patients commencing an Atypical medication. In respect of making a difference to those who use it and work in it, we recognised that fundamental to the success of the project was communication with GPs.
What We Did
The PHIT Clinic began life as a pilot project in November 2015 following the National Audit of Schizophrenia (NAS) 2014, and as a result of the poor compliance achieved by the Trust in the Cardio-Metabolic CQUIN In-Patient Audit in 2014/15 (15%), 2015/16 (26%) and (54%) for the Early Intervention service.
The pilot was based on the principles of the successful ‘Don’t Just Screen – Intervene project led by our Early Intervention service in 2013-2015, namely that life expectancy for adults with Psychosis and/or Schizophrenia is between 15 and 20 years less than for people in the general population and that physical health problems such as cardiovascular and metabolic disorders, such as Type 2 Diabetes, are more prevalent in this group
The clinic was originally established to improve the screening and monitoring of physical health assessments for those patients commencing an Atypical medication. Initially this clinic was designed to run for six months, one day per week, and was managed by one Band 6 Senior Nurse Practitioner (RMN) and one Band 4 Support, Time, Recovery worker, whose main role was to cover 3 days Clozaril monitoring and one day depot Clinic.
In time, following the poor CQUIN results and based on research evidence, the main role of the clinic evolved into that of a more comprehensive physical health assessment service based within the Hollins Park Hospital site in Warrington
In January 2016, following an initial poor uptake in November and December 2015, the concept of the clinic was successfully re-launched via a series of communication exchanges with community and in house teams. As a result and following a local audit in May 2016 engagement rates were found to be much improved. This, in addition to the positive feedback from service users, carers and staff, support from senior managers plus a half day workshop shop held for the other localities within the Trust, to promote the ‘Warrington model’ meant the clinic was extended to become a two day per week service.
The clinic covered the following areas within Warrington services: In-patient Wards (two, one male and one female); Early Intervention Psychosis Service; Recovery Team. Based on the Lester tool the following Cardio-metabolic parameters for both screening and interventions were assessed: Smoking status; Lifestyle (including exercise, diet alcohol and drugs); Body Mass Index; Blood pressure; Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate); Blood lipids.
In respect of making a difference to those who use it and work in it, we recognised that fundamental to the success of the project was communication with General Practitioners. The practitioners within the clinic were well aware that appropriate sharing of information between primary and secondary care about diagnosed physical and mental health conditions was essential for safe practice.
To this end we have begun to develop a communication process/pathway which directly links our clinic to the specialists at our local General Hospital. This means in addition to having access to the ICE reporting system which holds blood results, the Clinic can also access advice from other specialists should this need arise.
This is a work in progress but we are keen to establish a firm agreement between primary & secondary in regards to the development of a recognised pathway and feel that this is a massive step in the right direction. In essence this means clinic staff can access and pass on blood results to GP’s immediately as they can to Psychiatrists and liaise with specialists at the General Hospital if abnormal results are flagged up which has led to many examples of intervening early for individuals
At the outset of the project the outstanding annual health check amongst Warrington service users open to the Recovery Team alone exceeds 320. The clinic has now made a significant impact on this number which has meant the numbers has reduced by a third. As a result the quality of life for numerous service users has been enhanced by the early identification of various physical disorders within the target population
Historically, no one service had taken full responsibility for the checks therefore individuals were being missed altogether, partially completed or invited in more than once for the same thing by different agencies. The improved communication channels and links with primary care has meant that a more structured and robust process is now in place and screening engagements rates within the clinic currently stand at 90% completed. This in turn has led to assuring and ensuring checks are completed in a consistent manner leading to an improved quality of care for the service user.
Wider Active Support
From the outset the PHIT project has been a collaborative venture in partnership with our local CCG lead, lead GP for mental health in Warrington, public health department and statutory and non-statutory bodies within the town.
Earlier this year the CCG commissioned a report into the mental health services provided by 5BP. One of the ‘big ticket’ items as they were named was the interface between primary and secondary care. A working group was formed with representatives from all interested parties which was a ‘first’ in Warrington as it allowed GP’s, other primary care workers, voluntary services and ourselves to meet face to face in a collaborative manner with a common goal. This group served as a booster for our already established pilot as it gave us a platform to further explore joint ways of working with our partners, skill sharing opportunities and to discuss innovative service improvement ideas
A key role within the project is that of the Warrington mental health lead who is one of our younger GP’s. Her enthusiasm and drive has been harnessed and she is very proactive in championing the PHIT Clinic amongst her GP colleagues as well sitting on the working group. The practitioners from the Clinic have also spent time in various local surgeries in discussions with GP’s and practice staff with Senior Managers also spending time with the Patient Clinical groups (PCG’s) within them
We have a healthy relationship with our local Public Health lead and one of the most influential and useful groups from a PHIT Clinic perspective is the Health Prevention & Promotion Group, led by Public Health but attended by many support services within the town with an active interest in the physical health of the those with mental health problems. This forum allows us to communicate our services and gives us the opportunity to learn and share others experiences and initiatives, all for the benefit of our service users.
We have established excellent links with our local community ‘Hub’ which houses many primary care services especially the Warrington ‘Livewire’ service who strive to promote a healthy lifestyle, to increase participation in activities whilst encouraging reading and learning through the use of free access to books, IT suites and the internet. This relationship allows the Clinic to be aware the many and varied courses on offer and also a direct link to the ‘Livewire’ team if that option be required. In addition we have a close working relationship with our local health watch organisation and regular enlist their help to scrutinise pieces of work such as the clinic.
The Clinic’s work and evidenced base also links in with wider strategic projects, again in collaboration with partner agencies, with arenas such as Shared Decision Making and the Living Life Well project linking in with PHIT. Another area the PHIT Clinic feeds into is as the physical health component to the various Care Pathway work on-going within the Trust at the moment
Finally, we have also utilised the Trusts relationship with AQuA (Advancing Quality Alliance), a service improvement organisation who helped us with advice and guidance around the project management of the Clinic in terms of a project plan and advice around change management techniques and resilience management techniques
Following the publication of the NAS in 2014 one of our Consultants approached service users and staff with the notion of an in house physical health clinic. Positive feedback via various forums from the service users and carers canvassed for their opinion led to the prototype Clinic beginning.
Throughout the Clinics life cycle patient and carer feedback, via the Friends and Family tests and verbal comments received, has been utilised to ensure the service we are delivering is the correct one, delivered in the correct manner with the quality of care assured. Patient feedback has been good and the high engagement rates are a testimony to the fact that the concept works. Future plans to present the clinic to various Patient Advocacy Teams, carer support organisations and wider public domains have been made
The Workshop earlier this year facilitated by one of the Clinic staff proved successful and a launching pad for similar services throughout the Trust. As a result other localities within 5BP are keen to replicate of ‘Warrington model’ clinic format and shadowing arrangements have been put in place so the physical health leads from other areas can see at first-hand how the clinic works. Staff from the clinic are also presenting the audits and service improvement model to senior managers in the coming weeks, with plans to showcase the clinic at various service user and carer events in the coming months
Led by one of the locality Assistant Clinical Directors a Trust Cardio Metabolic CQUIN group has been established with support from locality based cardio-metabolic sub groups. This process allows for dissemination of information back and forth and also feeds into the Strategic Group attended by senior managers and the Board.
On an academic basis we have used the various examples of best practice in the physical health of those with a mental health problem, to enhance the clinics practice. Documents such as the NICE guidance for Schizophrenia & Psychosis, the Rethink/NHS England Toolkit, the Lester Tool and our own Don’t Just Screen experience have all helped to form the service and will help to continue to build it over the coming months.
Looking Back/Challenges Faced
Retrospectively the pre project engagement process should have been much more structured and wider reaching. In reality we launched the Clinic with minimum publicity and therefore met with a degree of resistance, both from a negative/resistance to change stance and from a practical, capacity versus demand angle.
The desire to put the Clinic into place, based on genuine best practice ideologies and a sound evidence base drove the project team to push the local managers to embrace the concept but this approach led to many clinical and resource led discussions which hampered the progress initially. A more robust Project Plan, designed in collaboration with local managers and CCG partners would have better served our cause. In reality the plan as agreed a month into the Project which, as detailed by the early audit results, showed how the poor buy in from colleagues hindered positive results initially.
Establishment of a Project Team earlier than we did would have allowed for a more effective communication strategy/pathway which in turn would have generated interest and expectation. Clarifying clear boundaries and pathways in house and externally plus confirmation of what was expected from our own and co-opted in staff would have made the passage easier.
In Warrington there has been an historic issue around Shared Care protocols and pathways for many years. Recently the collaborative working arrangements and joint ventures have led to a more open and progressive relationship between 5BP and our CCG. At the forefront of this approach has been the Primary/Secondary care interface work which the PHIT Clinic forms part of. Within the locality now we have a jointly led working group, attended by 5bp, CCG representatives, GP’s and other voluntary and statutory organisations focusing solely on enhancing ways of working and designing a system whereby the allocation of work is aligned to resources, best practice initiatives within a financial envelope.
The group has helped develop a series of communication pathways which were previously missing or very ad hoc with no clear definitive process identified. In regards to the PHIT Clinic; the practitioners within it are members of the RiO working group for physical health and regularly input into the design of the electronic recording system which goes live within Adult services later this year. We are confident that the system is comprehensive and will help us collate all the necessary data for dissemination to our primary care colleagues. In addition we are looking towards a system link up with primary care which will hopefully see all health services using the same recording system in the future.
As mentioned previously we were faced with a degree of in house resistance, some of which was based on fear of change, some lack of understanding. The way we tacked this was to actively involve and engage staff members in a series of informal and formal workshops/meetings to explain the nature of the Clinic and how we envisaged it would work in reality. The main challenges from staff came by the way of capacity and lack of resource arguments. The research evidence for the Clinic and the guidelines described earlier was the basis of our proposal and when the local audit provided more data in favour of the Clinic, and, more importantly, allowed the community staff to free up time/reduce the stress levels plus we got positive patient feedback, the resistance succumbed
We have also established a number of shadowing opportunities within the Clinic for those staff in house, both ward and community based, plus members of the primary care teams who show an interest. This has proved quite popular with Student Nurses also expressing a desire to spend time with the PHIT staff. In addition the PHIT staff are attempting to find time to spend within primary care clinics in an effort to increase their knowledge and skill base in regards to physical health issues.
To try and close the gap and increase the understanding and working relationships with our primary care colleagues we are already in discussions to establish community based satellite clinics to be held within our newly formed GP clusters. Two pilot projects are on-going at the moment, the idea being to attempt to combine mental and physical health work. A further ideal is possibly have an RGN based within mental health team should the PHIT Clinic grow as we predict it will.
The Trust Audit Team have developed a monitoring tool which captures all screening results and interventions offered following physical health assessments. It also gives a compliance figure per assessment which evidences the % of screenings and interventions completed, therefore giving data on poor areas of compliance, trends and allowing identification of themes for improvement work. It will also allow for studying of demographics, gender themed trends, diagnostic information, data for primary care use especially in regards to the GP Clusters, thereby providing further evidence for continuation of the clinic
The collaborative work with the CCG has laid the foundations for the future progression of the service especially in regards to Parity of Esteem. In the future we are hopeful of further Investment from the CCG. Internally the physical health of those with a mental health issue is an agenda item at Quality and Safety meetings, discussed at individual Performance & Development Reviews, is a standing item on the Staff Meeting agenda’s and discussed within managerial supervision sessions. As highlighted above we are hopeful of establishing a dedicated resource to further improve the Clinic through the addition of an RGN, more support staff, and to further improve links with primary care and our local general hospital
The 6-month audit of the Clinic by the Trust Audit team found 100% compliance was met against all cardio-metabolic screening and interventions of physical health assessments carried out in the PHIT Clinic.
It also found that referral rates to the clinic were initially good due to the Clinic being utilised by Early Intervention. However the Clinic remained under used by Recovery resulting in an outstanding figure of over 300 physical health checks remaining out of date. subsequent actions have been put in place to ensure all of these outstanding checks are completed as described in other sections. Progress has already been made by the clinic in this identified area with over a third of the outstanding checks already completed and recorded.
The Clinic provides a consistent approach with a dedicated resource and has access to local hospital Pathology Departments blood result recording system (ICE) and has good communication links with the specialist staff there. The Physical health Clinic staff work in a safe and effective and ensure a that all results are recorded in a structured and consistent manner as is custom and practice and have good links with all GP surgeries within Warrington.
As a result of the audit and an identified need for a tracking system to capture all physical health screening and interventions, a monitoring tool how now been produced and is being used across the Trust. This is to capture all physical health assessment parameters, targeting those set out by the Lester tool. This allows staff to keep a track of all assessments carried out, the completeness of those screening assessments and interventions if required, giving an overall compliance figure for each assessment. This not only gives a picture per patient but will identify any gaps in non-completion of any particular screening or intervention within each team, allowing actions to be implemented. As stated the numbers attending the Clinic is in excess of 90%, which is an outstanding rate of engagement.
A 12 month in house audit is planned with the CCG taking an active part in this. Local organisations such as Healthwatch are also keenly interested in the results
In house we have various forums whereby the work of the Clinic is disseminated. Strategically there is the Trust group cardio-metabolic group which feeds into higher management and the Trust board. We have regular meeting with CCG colleagues and members of partner organisations where information is shared.
In house communication papers such as our In View and Connect magazines are distributed monthly and there is a periodic magazine named Reflect which is produced by our service user group which also carries information about service developments. We also have an academic forum where audit and service development work is presented as well as a Research and Audit forum. Staff also regularly present best practice data at the many service user and carer forums a held monthly. The intention is to produce an academic paper based on the PHIT concept within the next 12 months
A member of the PHIT Project team the Health Promotion and Prevention group chaired by the Public Health lead and attended by the local authority, various charities and support services/agencies. This forum again allows for sharing of best practice initiatives.