People with a severe mental illness die 15 to 20 years earlier than the general population, mainly from natural causes such as cardiovascular disease, endocrine disorder and respiratory failure. In the vast majority of cases, these early deaths could be avoided through timely diagnosis and treatment.
In the early 2000s, Kate Dale, a community psychiatric nurse at Bradford District Care Trust, became increasingly concerned about the physical health of her patients. When she joined the NHS in the late 1970s, she remembered regular physical health checks being carried out for patients in mental health hospitals. But mental health teams now showed limited interest in their patients’ physical health, with a prevailing view that this was the responsibility of other services.
Over the 2000s, Kate retrained so that she could take blood, carry out physical health assessments, monitor diabetes, and advise on smoking cessation, weight loss and other lifestyle changes. In two years, she carried out regular health checks for 150 patients on anti-psychotic medication. The initial outcomes were astonishing: large numbers of patients with high-risk cardiovascular scores or undetected diabetes, many of whom had received no previous treatment or support.
For most of the 2000s, Kate pursued a personal mission to improve physical health care for patients with mental health problems. She carried out physical health checks and gave smoking cessation and lifestyle advice across 500 square miles of the Yorkshire Dales – all of this with, at best, the acquiescence of her line managers, and at worst discouragement from those who would have preferred her to stick to the day job. There were no changes to her responsibilities as a community psychiatric nurse and she continued to manage a full caseload.
In 2008, Kate took a secondment to assess the support GPs were offering to patients with severe mental illness in primary care. With support from Dr Angela Moulson, the lead GP for mental health and learning disabilities in Bradford and Kate Beedle, a data quality specialist, she started reviewing the records of 105 patients with severe mental illness in 12 local practices. The results were far from encouraging: none of the 105 patients had received a Qrisk2 score for risk of cardiovascular disease or a prolactin test. Only a minority had received cholesterol, triglyceride, glucose or thyroid function tests, all standard and essential tests for people on anti-psychotic drugs and at greater risk of high cholesterol, diabetes and sexual dysfunction.
Over the next few years, Kate worked with a consultant psychiatrist, Dr David Yeoman, along with Angela Moulson and Kate Beedle, to develop a user-friendly template within SystmOne (and later EMIS and RIO) to make it easier to carry out high-quality health checks for patients with severe mental illness.
Practitioners are led through a simple, two-page questionnaire, consistent with NICE guidance and the ‘Lester Tool’, which prompts them to order the right blood tests; check blood pressure, pulse and respiration; carry out an electrocardiogram and measure body mass index and other interventions. Once this is done, the tool highlights particular health risks, for example calculating a QRisk2 score for risk for cardiovascular disease, and prompting appropriate action such as prescribing statins or providing support for smoking cessation, weight loss or other changes. GPs automatically collect data for their Quality and Outcomes Framework returns.
Having developed the tool, Kate delivered half-hour sessions at 48 of Bradford and Airedale’s 80 GP practices in 2011 and 2012 to explain the importance of the tool and how GPs and practice nurses could use it. Uptake was rapid, with 60 of the 80 GP practices using the tool in the following 12 months. There was also evidence of improvement in the quality of GPs’ health checks, in particular a 100 per cent increase in patients diagnosed with significant cardiovascular risk. One patient struggling with severe anxiety and depression received a standard thyroid test for the first time, revealing hyperthyroidism. Two years later, she was free of depression and living a happy life.
Following these successes in primary care, Kate returned to Bradford District Care Trust where she supported the establishment of physical health and wellbeing clinics in Bradford’s community mental health teams and use of the physical health checks template for inpatients. In line with NICE guidance, all patients who start anti-psychotic treatment are referred for physical health checks and monitoring until they return to primary care. This has led to substantially higher levels of attendance at health checks than was the case when patients were routinely referred back to their GPs. The trust needed to train mental health nurses to oversee the service and new associate practitioners to run the physical health and wellbeing clinics, perform blood tests and electrocardiograms, give advice on lifestyle and smoking cessation and make appropriate referrals.
In 2015, the Yorkshire and Humber AHSN put in place a project team and provided funding for further development of the template and more extensive implementation in West Yorkshire. For example, it funded Kate to support initial implementation at new sites such as South West Yorkshire Partnership NHS Foundation Trust, where she has supported adoption within one major clinic and trained trainers who are now supporting adoption on ten more sites. The AHSN has also developed an e-learning module to support adoption.
At the same time, the AHSN has been building the evidence base on the effectiveness of the tool. Overall, organisations that use the tool are more likely to carry out health checks for patients with serious mental illness, more likely to carry out effective health checks with the right tests, and more likely to take appropriate action, for example prescribing statins or advising on lifestyle choices. One pilot site saw a fourfold increase in the number of health checks completed after introduction of the template.
At the same time, this tool, like others, is only as good as the system using it. Overall improvements in health and wellbeing clearly depend not just on initial diagnosis but on the effectiveness of multiple, interrelated services and interventions to respond to patients’ needs. Like other innovations in this study, the introduction of effective health checks is having a domino effect, requiring changes to staff roles, new services to respond to previously neglected patient needs, and continued testing and experimentation as refinements are made. There is unlikely to be the same type of evidence as for a new drug since the product is ill-defined and constantly adapting.
As for Kate, she describes herself as a dog with a bone for close to two decades. Even now, she depends on securing small funding allocations from clinical commissioning groups to take the template to new sites. Allocations of funding have been promised and then withdrawn. However, the North East and North Cumbria AHSN has recently committed to funding implementation in its region, with other AHSNs actively considering funding the scheme.
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