Improving the physical health of patients with

severe mental illness in primary care.

Rhiannon EnglandGP Clinical lead

City and Hackney CCGRhiannon.england@nhs.net

What’s needed to tackle this? (ignoring social determinants)

• Confidence, capacity and competence in primary care. The physical health care issue is mainly a primary care duty as long term care needed.• Challenges of old stereotypes: patients with mental illness don’t get

better, (it’s a long term condition, right?) they can’t stop smoking, they don’t want to get fit, don’t tell them about medication side effects as they will stop the drugs.• Active interest from secondary care and a change in old models of split

medical and psychiatric care.• Data exposing the issue and challenge through parity of esteem.• CCG commitment to mental health• National changes in nurse and psychiatry training.• Improve QoF requirements for mental health in primary care.

How have we tackled this?

• 1. Training: addresses competence.• 2. Local data and data collection: addresses confidence.• 3. IT systems- new EMIS templates completed and MH dashboard

under construction. (MH will at last have the same level of accurate data as diabetes/COPD etc!)• 4. MH contract with Confederation: addresses capacity.• 5. Voluntary sector: community links.• 6. CQUIN with our provider.• 7. Five to thrive- overarching wellbeing banner.

1. Training

• This year (15/16) 4 hours mental health mandatory training for every practice written into GP contract- at least 1 clinician per practice and commitment to disseminate to rest of team. Incentivised.• Topics: suicide and risk, prescribing and monitoring and recovery

principles.• Number trained= all 35 practices covered.• Attendance=57 GPs 2015/16• Tension in using compulsory training- but overall locally GPs keen for

training and happy to have this provided locally from local clinicians- so voted positively.• GPs consulted over next year’s topics- so training is needs focused.

2. Primary care data C&H• 1.5%: Average practice prevalence for SMI on QoF in C&H.• 35.9%: of SMI register smoke. (10.6% of general local population over 16.)• 42%: of all recorded (85% recorded) patients registered with our

homeless practice smoke.• 3.2%: on SMI register referred to smoking advisors April-Oct 15 Total= 136

patients• 14%: of SMI register have diabetes. (local population prevalence = 7%)• 9%: of SMI/diabetics have a HbA1C>85.8 mmol (10%)

• So- locally, patients with SMI are twice as likely to be diabetic and three times more likely to smoke than non SMI.• Most diabetic/SMI patients have fairly reasonable or well controlled

diabetes.

But: what are people dying from?

Source: http://www.rightcare.nhs.uk/atlas/maps/Atlas_290915_Mental.pdf

Primary Care: Diabetes

• The issues: people with SMI are more likely to become diabetic. People with diabetes who have mental health problems eg anxiety and depression, have poorer diabetic control.• The response: next year we will provide practices with their

SMI/diabetes/poor control breakdown- ie who has poor control, what is the connection with SMI.) • PHQ9 on the diabetic template now.• Stratified targets for improvement and intervention: eg screening all

poor control patients (HbA1C>10) and referring for psychological therapy, social prescribing, voluntary sector, smoking advisors etc. where indicated.

3. IT systems

4a. MH Contract: Enhanced Primary Care “extra health check”

• EPC is a step down service from secondary care for stable patients needing extra support, but can be provided in primary care.• GP contract requires GPs to do an “extra health check” appointment

in addition to Qof requirements and to complete the physical health care section of the patient’s recovery care plan which is also on EMIS. This is incentivised but no target imposed.• “Five to thrive” on every recovery care plan- five ways to wellbeing.• Most of these patients will be on antipsychotic medication and so will

be on a register for screening.

EPC: the reality

• Very successful in step down- >1000 patients discharged over 3 boroughs in last 3 years, 650 in Hackney 2015/16.• But GP claims for extra HC low, although more GPs are now aware of

recovery care plans because of training.• Much better understanding and acceptance that physical health can

be improved- so hearts and minds winning over feeling nothing can change.• As yet no objective data showing better health outcomes for EPC

patients - data is being collected.

4b.MH Contract: Antipsychotic drug monitoring

• Based on NICE guidance.• Secondary care agreed to do initiation screening and care to 3

months minimum including bloods and ECG.• Primary care to do annual screening.• Baseline audit completed: eg 29.5% of patients on antipsychotics

have had a HbA1C in the last year (sample size= 733)• Training completed.• EMIS template page added: see screenshot• No target for this year.• Issues with NICE- we do not want people staying in services too long!

Current problems for managing antipsychotic drug screening in primary care: target groups

Patients not on SMI register

but who have a MH diagnosis eg PD, PTSD

Patients on antipsychotic

drugs

Patients on SMI register

5. Voluntary Sector: Core Sports

• Core Arts is a voluntary sector organisation very effective at engaging and retaining SMI patients in Arts programmes.(>90% CCG contracted work is with patients on CPA, CTOs and ASOT prioritised, >80% BME)

• Core sports now has been funded to address physical health issues with this group

• Early days- but again about raising consciousness

Core Sports: case study

In the last 6 months I’s cognitive functioning hasdeteriorated, he requires personal care due toextreme self-neglect, gets support to manage hisfinances, he does not leave his home without beingescorted, has mobility issues, and struggles withincontinence. I was unfortunately banned fromvarious centres he used to access and the LondonFields Lido (swimming) due to his hygiene issues. Ibecame isolated further because of this. I has beensupported by other Core Arts peer members andthe Core Arts sports staff to leave his home andaccess the Core Arts sports program – where hedoes swimming, walking and attends the Core Artssocial club. I is starting to get his confidence back,is socialising again and importantly for him he isaddressing his physical health and hygiene issueswith his allocated OT and care coordinator.

6. CQUIN.

• ELFT CQUIN- 2 year. Health packages for all new psychosis using diabetes as a care model.• Screen all ASOT/CTO patients and results to primary care. (less likely

to attend primary care for annual reviews)• Smoking- in staff and patients.• Smoking on wards.• Health pods in CMHTs.• Lester tool in each consulting room.• Smoking advisors training for SMI work.

Next steps

• Set target for antipsychotic drug monitoring and for addressing at risk of diabetes and raised Q risk patients. (if we have the money)• Blitz on smoking.• Adjust templates to give accurate information on substance misuse

and set target for data provided.• Recruit more peer mentors as health coaches.• Sort IT issues of data sharing!• Press secondary care to embed CQUIN work into usual care.• Training chosen this year: eating disorders, MUS, perinatal, depot.• Continue moaning about need for a change in nurse training

nationally, stopping the physical/mental health split.• Lobby for a MH QoF encompassing depression/anxiety/PD/MUS!