Patients with serious mental illness (SMI) experience health inequalities. The most notable is a shorter lifespan, reduced by around 20 years compared to the general population. There is also considerable evidence that one of the main causes of early death in people with SMI is cardiovascular disease and other physical causes including cancer.
A Disability Rights Commission Health Inequalities formal investigation found that people with mental health problems have higher rates of obesity, smoking, heart disease, hypertension, respiratory disease, diabetes, stroke and breast cancer than other citizens.
People with mental health problems also experience ‘diagnostic overshadowing’, which is reports of physical ill-health being viewed as part of the mental health problem or learning disability, and so health issues are not investigated or treated.
Responsibility for health promotion and care of the physical health of people with SMI sits with GPs and practice nurses. The NICE Clinical Guidance CG 178, Psychosis and schizophrenia in adults: prevention and management, states: “The secondary care team should maintain responsibility for monitoring service user’s physical health and the effects of antipsychotic 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”.
According to the mental/physical health Quality and Outcomes Framework (QOF) Indicators, the physical health of SMI patients should be reviewed at 12 monthly intervals. This includes use of alcohol, drugs and smoking behaviour, blood pressure, body mass index, blood test for diabetes, cholesterol and cervical screening if appropriate.
There should also be a medication review that includes a check on accuracy of any prescribed medication, side effect monitoring and lithium monitoring.
Yet, in my experience, the priority for these patients is their mental health and issues such as obesity, possible diabetes, cardiac risk and other lifestyle factors have not routinely been taken into consideration.
In 2009 an audit was carried out in Bradford looking at the base line physical health measures used in primary care and found the measures did not reflect patient’s needs. None of the patients in the sample were given a cardiovascular risk calculation, which would be a good way to identify high risk people for prevention. In addition, none of the patients had a blood test for prolactin levels even though elevated prolactin is a significant and common adverse effect of antipsychotic treatment.
This is why a new system was created across Bradford and Airedale - bespoke for both primary and secondary care - to make sure patients get the key physical checks they are entitled to.
The template includes: taking blood pressure, pulse and respiration, height weight and body mass index (BMI), blood tests and electrocardiogram (ECG), lifestyle assessment to include diet, exercise and smoking status, any issues relating to sexual dysfunction and referral to appropriate services if needed.
The SystemOne electronic Mental Health Physical Review Template was developed and introduced into primary care in 2012 and it helps support doctors and practice nurses to detect the possible additional problems these patients may experience. Yorkshire & Humber Academic Health Science Network supported the spread and adoption of the template, including providing an elearning module on the template for primary care staff.
Locally Bradford District Care NHS Foundation Trust has six physical health/wellbeing clinics to include outreach and the template has been adopted across various sites in England.
If we can monitor patients from the outset of treatment, then we can make sure we can understand and capture any changes. We can offer education in terms of patients understanding the impact of antipsychotic treatment and for example: patients will understand that some medication will make them feel very hungry and we can talk about a healthy diet.
Our data entry template system has seen a huge change in the perceptions and practicalities around treating this group of patients in primary and secondary care. It helps save lives, reduce the risk of chronic physical health problems and ultimately lead to this population living healthier lives.
Kate Dale, Academic Health Science Network, Yorkshire & Humber, Mental/Physical Health Project Lead, Honorary Bradford District Care NHS Foundation Trust
This blog is based on a talk given at the GM Conference The ageing patient: midlife and beyond, which took place in October.