In order to give some background to my recent blog post on the five recommendations to Kent, Surrey & Sussex on improving the physical health of those with serious mental illness (SMI), I agreed, and felt it necessary to, post the context and additional findings here as well. As I stated before, the information came from numerous open discussions with people from a variety of sources including (but not limited to); service users, third sector, frontline staff, national arms-length bodies and a swathe of clinicians, leaders and managers at various strata in the healthcare system.
I appreciate that the content of this may only be of interest for those with a strong stomach for minutiae, but I believe that without this, some of the deeper reasoning for the recommendations may not be clear. As always, the inferences in the text are broad so as to ensure privacy to sources
The presence of Sustainability and Transformation Partnerships (STP’s) has little noticeable influence on day-to-day practice of clinical and frontline staff.
Some clinical teams feel physical health assessment and interventions are not considered a high priority or part of the core functions of a team. This has been attributed to: availability of staff, recruitment issues, lack of time to spend on physical health and lack of availability of material resources with which to carry out specific physical health checks. Whether this has any correlation with clinicians’ own physical health status or wellbeing at work has yet to be evaluated.
There remains a lack of communication between primary and secondary care providers as to a correct method of communicating and recording completed physical health checks so that a full record can be established by NHS Digital.
Whilst the physical health of patients with SMI is considered a high priority by many within the system, approaches of teams to address the physical health of clients vary considerably, especially with regards to the availability or understanding of existing physical health related training from providers.
There is little evidence that large scale providers within the regions communicate regarding the wider needs for training and education of staff on physical health; whether there are joint needs, pre-existing training or how teams investigate need.
Where previous initiatives have been introduced and established within a team, commitment to maintaining its inclusion on on-going practice has diminished once the initiator has left the team. Similarly, when projects or initiatives are passed to colleagues or persons leave a role, significant delays can arise in implementation.
Service Users have experience and opinions of the annual physical health check that may vary from the anticipated viewpoint in a negative manner. They are also varied in content and subjective in nature.
The completion of the bloods-related elements of the PHC remain a challenge. This has been attributed to many factors including; varying skill sets in teams, reduced phlebotomy training and verification, patients handed blood test forms repeatedly but not attending phlebotomy clinics at other locations.
Information of note
The figure of 280,000 more physical health checks (PHCs) in the Five Year Forward View for Mental Health (FYFVMH) equates very closely to the number of service users currently under secondary care in England
NHS England’s Mental Health Programme uses data from NHS Digital on the Sustainability and Transformation Partnership (STP) commitments to increasing numbers of required PHCs over the timescale indicated (30% in 2017/18 to 60% in 2018/19 of those on the SMI register, Office of National Statistics (2016))
o Kent & Medway STP: 4,342 in 2017/18 to 8,765 in 2018/19
o Surrey Heartlands STP: 1,901 in 2017/18 to 3,835 in 2018/19
o Sussex & East Surrey STP: 5,561 in 2017/18 to 11,213 in 2018/19
o Data is also available for each Clinical Commissioning Group (CCG) in England
Data is yet to be established regarding PHCs carried out, reported or recorded, in the year 2016-17.
Early Intervention in Psychosis (EIP) Teams in Kent, Surrey and Sussex will conduct an initial staff attitudes survey with regards to physical health interventions, to be completed by November 2017.
There may be a significant number of physical health checks performed in secondary care that are not recorded in a way that can be recognised by National bodies charged with reporting overall figures. The scale of this discrepancy requires investigation.
There has been previous work on a similar topic by a previous Darzi Fellow in London, where one outcome was a Physical Health Leads’ Forum for the five Mental Health trusts in the region.
‘Physical Health Check’ contains the six elements of the Lester Tool (NHS England, 2016b) but there is consensus that the remit of ‘physical health’ can extend beyond this to include (not exhaustively) eyesight, mouth-care, foot health, environmental situation and economic considerations, amongst others for various patient demographics as well.
Both service users and some clinician groups have appreciated the dual-accountability for physical health when users are ‘out-of-service’ or under primary care. There is acknowledgement of the boundaries between ‘places of health and care’ where communication between providers can be improved.
Some teams report an inability to locate, or a lack of, equipment to complete the six elements of the Lester Tool
To explore a method to allow access for, and encourage, clinical and frontline staff to engage in the design and implementation of STP’s.
Scope to develop a method of passing information from secondary to primary care in an appropriate way that ensures correct coding and submission to Quality Outcome Frameworks (QOF) data which contribute to the overall sum of PHCs accounted for by NHS England.
To explore what a regional ‘Physical Health Leads’ Forum’ may include and what the needs are to establish communication around this topic. This may include visiting the London Forum as a prototype for the KSS equivalent.
To explore a new model of training delivery around a ‘modular’ scheme for role-specific training in physical health. Teams in different disciplines may draw on certain elements to comprise a baseline ‘essentials’ package with additional, more in-depth sessions and competency as indicated, or requested by staff. This has been supplemented by ideas around a basic introduction of modules, followed by refresher sessions at an appropriate interval.
There have been other initiatives outside the region that have addressed the physical health of this patient group that may yield pertinent information, solutions or ideas in addressing is in KSS (RAMPPS (HEE Yorkshire & Humber, 2016), Central & North West London NHS Foundation Trust, 2017)
Both service users and clinician groups have welcomed the idea of promoting an ‘entitlement’ to a PHC for those on the SMI register. Ways to access those under primary care or those that have fallen out of both services for a multitude of reasons (cultural, language, accommodation, etc) might include places where service users convene as sites for promotion, engaging peer support in areas such as Recovery Colleges, social groups and drop-in cafés.
The effect, perceived or measurable, of a clinician’s own physical health and its effect on their view of a patient’s physical health might be a possible topic for study in the future.
I hope this gives a little more clarity to the initial ‘recommendations’ blog and, as always, I welcome feedback and constructive dialogue around all aspects of this topic.
1. NHS England (2016a) Implementing the Five Year forward View for Mental Health https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf [Accessed 1/9/17]
2. NHS England (2017) Commissioning for Quality and Innovation: Guidance for 2017-19 https://www.england.nhs.uk/wp-content/uploads/2016/11/cquin-2017-19-guidance.pdf [Accessed 1/9/17]
3. Sussex Partnership NHS Foundation Trust (2017) New mental health research published today (29/7/17) https://www.sussexpartnership.nhs.uk/whats-new/new-mental-health-research-published-today [Accessed: 1/9/17]
4. Office of National Statistics (2016) Dataset: Subnational Population Projections for Clinical Commissioning groups in England: Table 3 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/clinicalcommissioninggroupsinenglandtable3 [Accessed: 26/9/17]
5. NHS England (2016b) Improving the Physical Health of People with Serious Mental Illness: A Practical Toolkit https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/05/serious-mental-hlth-toolkit-may16.pdf [Accessed 28/9/17]
6. Health Education England Yorkshire & Humber (2016) Recognising and Assessing Medical Problems in Psychiatric Settings (RAMMPS) https://hee.nhs.uk/hee-your-area/yorkshire-humber/education-training/multi-professional-workforce/clinical-skills-simulation/recognising-assessing-medical-problems [Accessed 28/9/17]
7. Central & North West London NHS Foundation Trust (2017) Improving physical healthcare in mental health settings http://www.cnwl.nhs.uk/news/improving-physical-healthcare-in-mental-health-settings/ [Accessed 28/9/17]