Summary of the example
The Leicestershire Physical Health Register has been developed by the pharmacy mental health team in Leicestershire Partnership NHS Trust. The register helps clinicians/teams ensure patients with severe mental illness receive the correct physical health monitoring. A pharmacy healthcare team gather healthcare data for cardiometabolic risk and metabolic syndrome screening and related interventions for all patients with Severe Mental Illness (SMI) in Leicestershire Partnership NHS Trust. Where data is missing, the pharmacy team prompts those whose care the patient is under and follows up, including feedback, educational sessions, and advice on referrals for interventions.
Why we think it’s important
Individuals with SMI have a higher risk of many types of physical health problems. Antipsychotics which are used to control psychotic symptoms in SMI are associated with physical side effects including weight gain, dyslipidaemia and diabetes. In addition those with SMI are at risk of physical ill health independent of psychotropic drug therapy. Individuals with SMI have up to 20% shorter life expectancy and a two-three times higher mortality rate compared to the rest of the population. The gap in mortality has been highlighted in key guidelines and exists in those countries where standards of healthcare are considered to be high. Physical comorbidities account for around 60% of the excess mortality that occurs in those with SMI; cardiovascular disease being the most common. Physical ill health in SMI may be due to a genetic predisposition, however, environmental factors and lifestyle factors such as poor diet, smoking, lack of physical activity and obesity/overweight play a prominent part. For those with SMI there is also inequity in access to medical care and quality of care. Additionally, health checks targeted at prevention are carried out less frequently in both primary and secondary care for those with SMI when compared with the general population.
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Aims and objectives of the work
To improve the physical health of individuals with severe mental illness in Leicestershire Partnership NHS Trust (inpatients, early intervention, care planning approach (CMHT)) using the Leicestershire Physical Health Register.
The aim was to improve the rate and quality of:
- physical health monitoring for patients with SMI
- clinical interventions to improve physical health of patients with SMI as identified above; in particular related to cardiovascular disease, diabetes, diet, exercise, smoking, blood pressure
This was a pharmacist lead service with dedicated staff for data collection/administration and accuracy checking. All adult patients with SMI who were inpatients, cared for by community mental health team or early intervention team for the NHS trust were screened for the appropriate blood tests and lifestyle factors as documented in the physical health screen template. All relevant data collected from healthcare records (e.g. pathology reporting system, electronic clinical records) and relevant care professionals (e.g. nurse) were entered into the physical health register. Reminders and follow up for missing data or important clinical interventions were discussed with the relevant care professionals e.g. letter to GP to follow up on cardiovascular risk
There were three major milestones for each patient that needed to be achieved
- Screening: blood tests (HbA1c, Lipids), BP, BMI, smoking, alcohol, illicit substance misuse
- Clinical interventions for any of the above (e.g. smoking cessation/reduction, diabetes review, diagnosis of diabetes, statin therapy for elevated QRISK, diet and exercise)
- Follow up and reminders for any or all of the above that have not already been undertaken by the team looking after the patient
Important key data: the Leicestershire physical health register sends out (annually), 250 reminders for blood tests that haven’t already been done.
Data were gathered annually for 5 years and recorded on the Leicestershire physical health register located in the pharmacy department. On average the number of patients seen annually were: 1200 inpatients, 460 early intervention, first episode psychosis patients, 1500 Care Plan Approach (CPA) patients in community mental health team.
Appropriate screening and related clinical interventions for physical health monitoring in Leicestershire Partnership NHS Trust increased significantly (see attached data collection form Number of patients that received appropriate physical health monitoring).
Clinical interventions were noted for around 90% of patients reviewed, ranging from advice/referral for diet and exercise, smoking cessation, diagnosis of diabetes, QRISK assessment and then statin therapy as a result. Currently, breakdown of data on the individual interventions are not available. Funding permitting, this data will be measured for the on-going project.
Critical success factors include a pharmacist lead service for screening and interventions for physical health monitoring for individuals with SMI can achieve exceptionally high results (e.g. improved from 24% to 100% within 3 years for inpatients).
Characteristics that allowed for this service to run successfully: dedicated staff and resources; a team lead with passion, tenacity and enduring belief about the need and benefits of the service; good working relationships with all care professionals; establish pathways for care.
Unintended consequences: none noted.
Template for collection of cardiometabolic/metabolic data (screening and interventions)
This project has been part of a closely related National CQUIN and achieved notoriety as the trust achieved the highest results in the country against the targets set. Below are a few links:
National guidance, data and publications
The Chief Medical Officer’s Report (England) of Public Mental Health Priorities (2013) highlighted that around 60% of the excess deaths that occur in patients with SMI are avoidable. In the UK over the past 5 years, much attention has been paid to the mental health of the nation with two paralleled ambitions: that those with mental ill health have better physical health and to reduce death due to physical health problems in those that have mental ill health. The Five Year Forward View for Mental Health (2016) recommend improved access to physical health checks and proactively working for disease prevention.
The National Institute for Clinical Excellence (NICE) Quality Standards for psychosis and schizophrenia in adults (2015) outlined recommendations for patients to have specific comprehensive physical health assessments which will enable health and social care practitioners to offer physical health interventions of necessary. The American Diabetes Association and the American Psychiatry Association published joint guidelines (2004) which clearly stated the need for routine monitoring for people taking antipsychotics.
In addition patients being treated with antipsychotics are required to have metabolic parameters assessed throughout treatment as per manufacturers guidelines.
Regional Medicines Information Manager, London Medicines Information Service