By Dr Rhiannon England, GP Clinical Lead for Mental Health, City and Hackney CCG and Dan Burningham, Mental Health Programme Director
The recent targets set by NHS England for serious mental illness (SMI) annual physical health checks may seem difficult to obtain and provoke questions about clinical value. Let us tell you how you can do the first and how we can convince of the second!
In City and Hackney we knew that the physical health of our patients who have serious mental illness was a priority that we had to address. With a cohort of 4626 (the fourth highest in the UK) not only do we have high levels of deprivation, but lots of social determinants of poor mental health and despite our relatively low excess morality data for SMI, the inequality between those with mental illness and no mental illness is still unacceptably stark.
To improve the uptake of health checks we took a four-pronged approach by:
Improving access for patients
We set up a primary care alliance of providers consisting of: the GP Confederation which represents all City and Hackney practices, Family Action and Core Sport (voluntary sector organisations working in primary care), East London NHS Foundation Trust- our local MH Foundation trust, and the Clinical Effectiveness group (CEG) an academic based organisation which has worked in the east end for many years improving primary care quality.
We commissioned a mental health dashboard which pulls data from EMIS IT system and is now comparable to all the other long-term condition dashboards that have helped East London be a top scorer in long term conditions QoF management for some years. It felt appropriate to have some practical parity of esteem- even though we are only looking at the tip of the iceberg in serious mental illness- as all other long-term mental illnesses also show excess mortality. The dashboard is used for payment and for feedback to practices. Good quality data is the key to improvement.
We have incentivised primary care to complete the physical health checks required by NHS England and have started a communication campaign to ensure that patients know that they should have annual checks, and why.
Removing system barriers to help overcome cultural barriers
People with serious mental illness may lack the confidence to use existing exercise and lifestyle services. By commissioning Core Sport specifically to provide diet and exercise facilities for people with serious mental illness and ensuring activities were co-led by service users, we have enabled patients to feel supported and enabled GPs to feel more confident that the referral will be taken up.
We have established compulsory training through a long term, systematic approach using local clinicians: 4 hours per year is built into the Mental Health CCG contract with the Confed. This means that we can tailor our needs and requirements by ensuring the NHSE health checks form part of our annual training with GPs, Health Care Assistants and Practice Nurses.
Finding a local solution to multiple IT systems
If you find that your provider uses a different system from primary care it really is worth considering commissioning Health Care Assistants to work in secondary care doing heath-checks and using the primary care IT system. This breaks down the barriers between primary and secondary care and prevents duplication. It is cost effective but does require information governance compliance with practices, which can be set up but requires a lot of persistence. The effect of just two Health Care Assistants across Hackney has been fantastic and they can do home visits for patients who will not access primary care.
So, why should you really want to do this (apart from it being a target to hit)?
We are proud because of our longstanding work on long-term condition management, City and Hackney have a comparatively low excess mortality for patients with serious mental illness. This is particularly notable as there are high levels of deprivation and a high prevalence of psychosis in our area. This has been achieved over a long period of concentrating on long term conditions overall – and we think that concentrating on patients with serious mental illness will further reduce the inequality between those with mental illness and those without. We would suggest that you look at your excess mortality figures for Serious Mental Illness from PHE Fingertips (even though a bit out of date).
No money and no time? Don’t worry, small changes really do matter, just follow these steps;
- Get your clinical leads to ensure that the primary care template is completely robust and has easy template links to referral options with auto-populated electronic referral forms. This will make your GPs lives easier.
- Run a training session for all primary care to win hearts and minds. Clinical buy in is vital. By improving serious mental illness health check compliance, GPs will improve their serious mental illness QoF scores and improve their long-term condition management
- Ensure that your provider contracts include providers to be compliant with NICE recommendations for antipsychotic initiation and this includes bloods and ECG with all results copied to GPs. How many secondary care staff can take blood? How many need training? Why are they not doing full NHSE health checks on inpatients at the very least (and communicating this to primary care)? Why are Clozapine patients not getting full NHSE health checks when they get bloods done anyway?
- Challenge your local lifestyle change providers to tailor their offer for people with serious mental illness, for example, smoking cessation or exercise on prescription. This will ensure that referrers and patients are happy to use the services. Ensure that their commissioners (usually Public Health) have contractual requirements in place to include patients with serious mental illness.
Get everyone who matters in a room and listen to all the barriers, acknowledge them and set everyone the ambition to overcome them!
Winner of HSJ Awards, 2019
City and Hackney CCG, East London FT, City and Hackney GP Confederation, Core Spot and Clinical Effectiveness Group, An alliance model for primary care SMI physical health, won Mental Health Innovation at this years HSJ Awards.
City and Hackney CCG has the fifth highest prevalence of serious mental illness in England, but last year used a collaborative approach to achieve the highest SMI physical health check coverage in the country. The Primary Care Mental Health Alliance brings together GP practices, the secondary care mental health trust, healthcare informatics, Core Ports (for diet and exercise) and the CCG. The alliance structure has enabled people and data from different organisations to be integrated and has created a seamless pathway for physical health checks between primary and secondary care.