The Serious Mental Illness (SMI) & Physical Health Project – Sheffield (NO LONGER OPERATING)

‘The Serious Mental Illness (SMI) and Physical Health Project’. We are a partnership of service users and health and social care professionals who have come together through Right First Time, a Sheffield Health and Social Care partnership which aims to reduce unscheduled care and build community resilience and self-care.


  • From start: Yes
  • During process: Yes
  • In evaluation: Yes


  • Peer: Yes
  • Academic: Yes
  • PP Collaborative: Yes

Find out more

What We Did

Our service is ‘The Serious Mental Illness (SMI) and Physical Health Project’. We are a partnership of service users and health and social care professionals who have come together through Right First Time, a Sheffield Health and Social Care partnership which aims to reduce unscheduled care and build community resilience and self-care.


People with serious mental illnesses (SMI) such as schizophrenia and bipolar illness have some of the worst rates of early death and reduced life expectancy of any section of the population. People with a diagnosis of schizophrenia die 15-20 years earlier than the general population mainly because of cardiovascular disease. In Sheffield the early death rate is high compared with other cities: Sheffield 988 per 100,000; Manchester 498 per 100,000; Birmingham 643 per 100,000.

Through public health colleagues in our partnership group, we identified that people with a serious mental illness in Sheffield were more at risk of an acute hospital admission than the general population. This is a major health inequality which is recognised nationally and internationally (Shiers and Kendall 2012; Disability Rights Commission 2004). GPs are expected to monitor the physical health needs of people with SMI and to develop care plans for those at greatest risk of hospital admission. There are good guidelines available but locally and nationally we recognised that the health checks and care plans were not taking place effectively. 
Where we started in 2012 
We held workshops for interested health and social care staff and also consulted Sheffield based service users via a local service users network (SUN:RISE) and psychiatric inpatient service users. They told us that: Health and social care staff lacked knowledge about co-existing physical and mental health needs; Physical health was trivialised by health and social care staff when mental health diagnosis known; Users wanted health checks, exercise, healthy food and lifestyle information.

Positive comments‘It’s a good opportunity to monitor my medication and side effects’. Negative comments‘Physical Problems are not taken seriously as they know I have a mental health problem’.

We used this feedback to shape the purpose and work plan for our project group, which includes service users, mental health staff (psychiatrists, psychologists, Occupational Therapists, nurses), GPs, Commissioners (Local Authority and Health), Public Health and Acute Trust staff. We have had a project manager funded by health providers in Sheffield to support this cross organisational work.


To develop an approach to improve the physical health of people with serious mental illness and in doing so reduce the inequalities in the morbidity and mortality rates for this group of people.

What have we been doing? We aimed to:

Develop Annual Physical Health Checks and Care Planning process for patients with SMI and to share these; Compare the care provided to patients on GP registers with mental health trust patients to make sure we have the same approach and no one misses out; Agree the mental and physical health input into the developing Integrated Care Teams (ICTs); Increase the physical health knowledge of both patients and staff coming into contact with this group of patients.

What we have done

Used Sheffield’s risk stratification algorithm developed in public health to make the case for our work. This enabled us to do an in-depth analysis of co-morbid physical health conditions among the Sheffield population with Serious Mental Illness from GP electronic records. GPs and other clinicians can identify people at especially high risk who of cardiovascular disease are not getting the best treatment.

Developed a Care Planning Template for use across based on the NICE guideline tool. Every GP has access to this on their computer and we are working to have the same for mental health staff.
• Conducted a baseline audit of physical health screening and care plans in 3 GP Practices and a Community Mental Health Team.

Secured pilot funding for a Community Development Worker (CDW), to supporting people with SMI at risk of acute hospital admission in 3 General Practices at risk of hospital admission.
• Increased access to local health and lifestyle information – among people at risk of hospital admission initially in three general practices – including smoking cessation.

We have produced a myth busting leaflet in partnership with pharmacy about smoking cessation and are involved in a funded research project on smoking in people with mental illness.

We commissioned an evaluation of the project by Dr Tom Ricketts.

How has our work made a real difference?

Key impacts and the difference made by the project has been to build consensus, recognise evidence and form a shared vision across providers, commissioners and citizens in Sheffield about the importance of physical health to people with serious mental illness (see example in evaluation section below from work with Sarah Platts, Community Development Worker), and also GP testimony. This impact is further described in the sustainability section.

Going forward

Some of our ongoing work is described in the sustainability section below. We are also in the process of producing an e-learning programme for health, social care and voluntary sector staff. This is being jointly developed with service users, health and social care staff.

Wider Active Support

We worked with a wide range of partners at different levels and in different settings. The project steering group had a wide membership as listed at the start, including two Citizen’s Reference Group members who are key members of the project group. Other members include GPs, Local Authority Public Health, Commissioning Support Unit, Commissioners (CCG and Local Authority), and acute and mental health provider Trust clinicians.

At a strategic level we had support from health and local authority commissioners and the work of the group was identified in the Sheffield mental health commissioning plans.

Working directly in the community, our training events were run for primary care, mental health, acute and local authority. We needed GP, community mental health and local authority support to ‘host’ the specialist community development worker, who was funded, managed and supervised by the mental health trust initially, but needed access to information across three organisations. Her role has been viewed very positively by GPs and the local authority. Her post, which was a 2 day a week pilot has been expanded and is now jointly funded by a group of general practices and the city council.

Our Citizens Reference Group/user members had good local and national links with other service user groups and attended a national service user network conference feeding back the national service user standards for use locally.

The main people involved are:
Fiona Goudie, Clinical Director Strategic Development, Sheffield Health and Social Care NHS FT on behalf of the Right First Time Partnership
Lisa Youle, Project Manager, Right First Time
Jonathan Mitchell, Consultant Psychiatrist, Sheffield Health and Social Care NHS FT, Karen O’Connor, GP
Sarah Platts, Community Development Worker
Sarah Pollard, Primary Care Development Nurse Lead (CVD), NHS Sheffield
Robert Carter, Senior Commissioning & Contracts Manager, NHS Sheffield Clinical Commissioning Group
Moira Leahy, Consultant Clinical Psychologist, Sheffield Health and Social Care NHS FT Eleni Chambers, Citizens Reference Group
Susan Smith, Citizens Reference Group
John Soady, Public Health Principal
Lorraine Jubb, Strategic Commissioning Manager, Sheffield City Council.
Steven Haigh, Programme Director Right First Time

And the following people are members of the steering group who have contributed to the direction of the project: Liz Johnson, Professor Tim Kendall, Nicholas Bell, Rachel Dillon, John Wolstenholme, Gwyneth De Lacey, Salim Matta, Paul McCormick, Julie Edwards, Sue Martindale, Avril Kuhrt, Geoff Schrecker


Service users were initially consulted for their views in order to shape the objectives of the project. A number of local groups were contacted including a service user network SUNRISE and day service and inpatient user groups.

Two service users were recruited as part of the project group from a broader cross city group called the ‘Citizen’s Reference Group’, which was established as a reference group across the Right First Time Programme. During the course of the project the service users liaised with other users and carers from a variety of other organisations, including local GP Patient Participation Groups and Healthwatch Sheffield, and attended different events such as a national service user networking meeting. Their involvement not only influenced the project on an ongoing basis, with direct input into decision-making but also influenced the thinking of the project and programme leads about the different levels of involvement that were appropriate in different circumstances. As part of their work on the group they carried out an evaluation of involvement using the NSUN Involvement Standards, which was then used to improve their experience and effectiveness.

The learning about different approaches to the centrality of user/carer experience ensured that a new city wide project – the production of Sheffield’s Prime Ministers Challenge Wave 2 application had service user involvement on the Project from the outset.

Looking Back/Challenges Faced

Service users engaged in co-designing and project plan at the outset – using a co- production model rather than mainly consultation.
• Realised that the screening tool is not enough.

Encouraging take up by citizens and proactive promotion and intervention by GPs takes time and effort to build and sustain relationships. We are in discussions with the Commissioners about this as we want to create an incentive, drive culture change and increase knowledge and relevance of the screening tool; We should have started the e-learning work sooner – money came close to the end of the project and sustained Project Management support is proving difficult; Having a project manager was critical to the initiative as the project cannot be driven on good will alone and progress needs to be tracked and outcome data recorded. Now we no longer have a project manager we are doing our best to keep driving the initiative forward.

 Allowing sufficient time for the pilot to run to understand the key findings, embed the learning and ensure integration of specialist areas of work (i.e. SMI) within the overall care planning and community support worker process; Getting the health template onto every GP computer in the city took longer than expected. It was a success because of the tenacity of group members and the project manager. There is an ongoing challenge to get GPs to use the health template to screen and offer interventions. We are doing this through running GP master classes and by being involved in the city’s integrated care planning programme. This scheme encourages GPs to screen people most at risk of acute hospital admission.

Engagement with people with serious mental illness in the community was time consuming for the community development worker initially, particularly with people who felt they had been marginalized and ignored by health and social services in the past; In the last twelve months our partnership between SHSC and the National Centre for Sport and Exercise Medicine (NCSEM) has grown and strengthened. The NCSEM Sheffield is one of three network partners (the other two are East Midlands and London) that make up the London 2012 Olympic Legacy NCSEM Programme. The core themes include: physical activity in disease prevention, exercise in chronic disease management, mental health and wellbeing, sports injuries and musculoskeletal health and performance health. Under the banner of Move More the work of the NCSEM focuses on making a significant difference to the health and wellbeing of the population of Sheffield through physical activity. As health partners we have been able to co-locate some of our services on their sports centre sites. We are delivering psycho education programmes on assertiveness, understanding stress and anxiety and managing low mood. We have piloted a physical exercise programme for people with dementia and their carers, and we are starting an activity programme for young people newly diagnosed with a serious mental illness. We are also working on a football based intervention focusing on the role football can play engaging and delivering a service to men with severe mental health problems. This partnership means we are participating in research and evaluation as well as challenging stigma by enabling us to promote physical and mental health integration in positive and lifestyle sustaining environments.


We are now working with a wider group of general practices to validate the approach, using the risk stratification, the care planning template across primary and secondary care and the learning about how a community development worker might improve access to health screening, interventions and self-managed lifestyle changes.

In addition, the model of having a Community Development Worker (CDW) focusing on physical health promotion and illness prevention for people with serious mental illness (SMI) has been incorporated into the city’s integrated commissioning plan for Keeping People Well (KPW). The lead Commissioner – Lorraine Jubb – is using the recommendations of the evaluation and key learning from the project to develop community support worker (CSW) and life navigator roles and to ensure parity of esteem. Values based recruitment approach has ensured that people recruited to these posts are committed to meeting the needs of people with mental health needs.

We have continued to embed the Community Development Worker (CDW) role with support from Sheffield City Council who have continued to fund this vital role. The post is currently based in the Clover Group of GP Practices in Sheffield who work with some of the more vulnerable and disadvantaged populations in the city. The post holder also links into one of our Community Mental Health Teams to assist in ‘stepping down’ service users from secondary into primary care. There is a key role for the CDW in working with service users stepped down from secondary care to support re-integration into communities and help develop resilience and self-care to promote good physical and mental health.

At the start of the project, smoking was identified as a key issue. This proved to be so important that it became a separate project which has resulted in the Trust’s Board of Directors’ committing the Trust to going completely smoke free on 31 May 2016. As part of this, Nicotine Replacement Therapy will be available to in-patients, smoking cessation support will be available to service users and staff and the activities programmes on the in- patient wards are being reviewed to provide ‘alternatives to smoking’ activities.

Another element of the project is being sustained through ongoing research collaborations. SHSC is a site for a large multi-site randomized controlled trial evaluating smoking cessation approaches for people with SMI (the SCIMITAR+ trial). This is led by Professor Simon Gilbody from University of York. Dr Tom Ricketts is a co-investigator and local Principal Investigator. Moira Leahy is a local collaborator. Dr Ricketts is also the local lead for the mental health and co-morbidity theme of the NIHR Yorkshire & Humber Collaboration for Leadership in Applied Health Research and Care (CLAHRC). The CLAHRC in Sheffield is collaborating across organizational boundaries to evaluate the impacts of co-morbidity between long term conditions and depression, and approaches to integrated care.

Good progress has been made on the e-learning module which we have been developing with the support of Medipex and Dynamic. We are creating a 25 minute e-learning module which will include service users, clinicians and an editable action plan for learners. We are looking at having this e-learning module available to every GP Practice in Sheffield, and Trust wide. In addition, we are looking at whether it would be possible to roll this out nationally via the Academic Health Science Network and Medipex.


This was an ‘Implementation Evaluation’ carried out by Tom Ricketts via Collaboration for Leadership in Applied Health Research and Care (CLAHRC).

He interviewed key stakeholders and project group members. The benefits of the project’s partnership, service user involvement and stakeholder involvement were emphasised. There was support for the SMI specific community development worker (CDW) role.

The limited quantitative information yet available regarding the benefits for patients of this approach was emphasised, although there was positive feedback from involved GPs (see appendix 5) and the Community development worker herself. Describing her work with someone with a diagnosis of bipolar disorder known to the GP but not the mental health services, she said:

“P’s recent care plan highlighted that her BMI (body mass index) was high compared to previous reviews. I gave P information about the local health walk group and information about the social café. P was interested but apprehensive. I suggested I could meet her and we could go together. I had already met with the volunteers who ran this group and knew how welcoming they were to new people. We attended the health walk the following week. I stayed for the session but stood back and let her find her own feet. P said she had enjoyed herself. The following week I rang P to remind her about the walk. P is now attending these sessions independently, getting fitter as well as establishing friendships”

There was feedback regarding some of the barriers to implementing enhanced approaches for the SMI population. The enhanced profile of the SMI – physical health issue was discussed by some participants with regard to the benefits of the project.


We have already: Run workshops and presented at a city wide Physical Health Conference event called ’20 Years Too Soon’; Contributed to GP master class and PLI events; Secured resources to develop an e-learning package that can be used by all health and social care professionals which raises awareness about reduced life expectancy, provides information about recommended screening, joint working and how their role could improve the health of people with SMI; Shared our learning with Public Health England; Users have attended SUN:RISE (service user network) to talk about our partnership work; Been shortlisted as finalists in the Medipex NHS Innovation Awards 2014; Had an article in Your Voice (user-led mental health magazine); Provided feedback on Sheffield’s Integrated Commissioning plan about the importance of parity of esteem within integrated commissioning; Ensured mental health user involvement at the outset of the development of Sheffield’s Prime Minister Challenge fund bid (which was successful).

Is there any other information you would like to add?

“I have been a member of the RFT Project 4 work stream as a clinical GP Principal, and member of NHS Sheffield CCG Mental Health Commissioning Team. I have really enjoyed this role as we have achieved some important goals and the varied contributions from colleagues has offered us all valuable learning which has informed my practice as a GP and Commissioner.

Co-production with all partners has been an important and prominent feature. There has been good engagement, and the work has been seen as a priority by Health and Local Authority Commissioners, Service Users and Providers from different backgrounds. These included the main providers of Mental Health and Physical Health, Exercise specialists, Dieticians, Psychologists, Community Nursing, Smoking Cessation, Pharmacy, Substance Misuse/Alcohol Services and others. Our dedicated Mental Health CSW contributed to the work after being recruited by the project. We also presented our work at a learning event for local Primary Care Teams and Community Nursing teams, introducing our CSW and the dedicated Mental Health template for care planning.

The physical health of those with Mental Illness is now an identified commissioning priority for NHS Sheffield Mental Health Commissioning Team. We are actively engaged in citywide work around this and related topics, and take every opportunity to embed the learning from this project into all areas.”

Dr Karen O’Connor


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