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Monitoring the physical health of people with severe mental illness

Sheila Hardy
Northamptonshire Teaching PCT

The Northampton Physical Health and Wellbeing (PhyHWell) project won the 2010 Nursing in Practice Award for Mental Health and aims to improve the health and wellbeing of people with severe mental illness

Many nurses in primary care are responsible for offering physical health checks to people with severe mental illness (SMI). This is a vital role as, according to research, many people with SMI are not having their physical health monitored effectively.1

Patients included on your severe mental illness (SMI) register will most likely have a diagnosis of schizophrenia or bipolar disorder. Schizophrenia affects approximately 1% of the population, with an onset most common in late adolescence or early adulthood. It is characterised by a range of clinical experiences. Bipolar disorder affects around 1-8% of the population; this variation can be attributed largely to problems in diagnosis. Peak age of onset is between 15 and 19 years. It is also characterised by a range of clinical experiences (see Table 1).

[[Tab 1. SMI]]

[[Tab 2. SMI]]

People with SMI have a tendency to poorer physical health; their life expectancy is reduced by up to 15 years and the most common cause of premature death is cardiovascular disease.4,5 This may be due to a combination of lifestyle factors (people with SMI often eat unhealthy diets, have lower levels of physical activity and are twice as likely to smoke) and the side-effects of antipsychotic medication.6 This group tend not to volunteer symptoms readily; therefore, many illnesses go undiagnosed. In addition, people with SMI who have been discharged from secondary care may not have a named person they can contact should they have concerns about their medication or if they experience symptoms of their mental illness, emotional or social problems.

People with SMI should receive an annual physical health check in primary care unless they have no contact with primary care services.7,8

Purpose of an annual review
Your practice receives payment through the Quality and Outcomes Framework (QOF) to achieve a number of indicators in a percentage of patients with SMI (see Table 2).9 An annual review offers the opportunity for you to:

  • Screen for diabetes, hypertension, raised cholesterol and other conditions, and then offer prompt treatment to reduce the consequences of these conditions.10
  • Use careful questioning to identify undiagnosed minor ailments and offer treatment.
  • Provide ongoing education to reduce the risks associated with poor diet, inactivity and smoking.11 
  • Provide education regarding other aspects of wellbeing, such as sexual health and satisfaction, sleep, dental and eye health, and breast and testicular self-examination.11 
  • Help the person plan their care to prevent relapse and identify key people to be involved in their care.12
  • Carry out a medication review.13

Tools to help you carry out an annual review
As part of the PhyHWell project, a website has been developed which supplies all the relevant tools and guidance that healthcare professionals in primary care in the UK should need when carrying out the physical health check (www.changingmindscentre.co.uk/v/phyhwell_project). By clicking on 'contents' on the orange bar you will be able to access the following sections:

  • Bipolar disorder.
  • Schizophrenia.
  • Medication.
  • Community Mental Health Teams (CMHTs).
  • Mental Capacity Act (MCA).
  • QRISK.
  • Recovery.
  • Tools.
  • Downloads.

The website has been designed as both an educational tool and a reference guide. You can use the website to learn about SMI and its treatment and management before starting to run your own clinics, how to carry out a health check and what to do afterwards.

Learning about the conditions, treatment and management
Bipolar disorder and schizophrenia. This section of the website gives a brief overview of bipolar disorder and schizophrenia to help healthcare professionals who have had no previous training in mental health gain some understanding of both these conditions.

Medication
A description of antipsychotics and mood stabilisers is provided; these are the usual medications prescribed for this group of people. Most of the drugs that you will come across are listed with a link to their Summary of Product Characteristics.

Community Mental Health Teams (CMHTs)
The different types of mental health worker employed in secondary care are outlined, with a description of their role.

The Mental Capacity Act
This section explains how to recognise people who may lack the capacity to make some of their own decisions. It makes it clear who can take decisions in which situations and how they should go about this. It also describes how people can plan ahead for a time when they may lack capacity.

QRISK®2
How to use the QRISK®2 is explained. The QRISK®2 has been developed to provide an efficient estimate of cardiovascular risk in patients from different ethnic groups in England and Wales and includes a social deprivation factor.14 The software development kit (SDK), which includes QRISK®2 and the necessary reference tables, is available under annual license to system suppliers for all clinical computer systems in the UK.15 As people with SMI have a higher risk of cardiovascular disease it is useful to measure their QRISK®2

Recovery
This section describes recovery in the mental health context. Using a recovery approach places an increasing emphasis on self-management and on 'strengths', focusing on what people can do, rather than what they can't and looking at social, as opposed to medical, outcomes. Housing, employment, education and participation in 'mainstream' community and leisure activities become the central objectives. The importance of maintaining hope and high expectations are prominent. Some workbooks/care plans can be downloaded from this section, which you can give to your patients to work through either alone or with help from someone they feel they can trust.

Inviting patients for their annual review
Severe mental illness register
In the 'tools' section, there is a document to help you make sure your register is correct before inviting patients who may not need to be seen.

Setting up your clinics
Every practice has a different way of running clinics; this includes the time you are able to give each patient and the frequency with which the clinics are carried out. The frequency of clinics will be dependent on how many people are included on your SMI register. As an example, if your practice has a population of 10,000 patients, then your SMI register will most likely include around 100-150 patients; you may then want to set aside one morning a week to accommodate this service. Around 40 minutes is the minimum amount of time needed to carry out all the recommended actions. In practice, however, this is not the view of most GP employers; therefore, you should negotiate as much time as you possibly can and adapt the interventions accordingly.

Preparing your computer template
In the 'downloads' section is a specimen computer template. Some of the codes may not match your system but it is a good guide to how you can adapt your existing template. There should be someone in your practice who will be able to do this for you if you cannot do it yourself. There is also a paper template for healthcare professionals who visit patients.

Sending invite letters
Due to the nature of their condition, many patients with SMI would not respond to a letter inviting them to make an appointment. Therefore, it is recommended that you give them an appointment time and date. Telephoning before the date to find out whether they intend to come will prevent a wasted appointment. In the 'downloads' section of the website there is a specimen invite letter which may be helpful. A pre-assessment form is also included which you may choose to send with your invite; if the patient completes it, this will save time during the consultation and will highlight their areas of concern.

Carrying out the annual review
In the 'downloads' section is a copy of the Health Improvement Profile for Primary Care.16 This is a manual that has been developed to guide the healthcare professional through the process of carrying out a health check for a patient with SMI. There is a rationale to help you decide whether each intervention is appropriate for the patient you are consulting with, followed by the recommended action. This section also includes links to relevant leaflets which you can print out for patients and links to useful organisations.

In the 'tools' section are various downloads that can be used during the health check. For example, the side-effect scale/checklist for antipsychotic medication (SESCAM), which has a rating scale for both the healthcare professional and the patient to complete. This provides an objective assessment of the patient's response to their medication.

After the review
If the patient does not attend for their appointment then it is no longer a requirement of QOF to follow them up within 14 days; however, it is good practice that you do. This can be achieved via letter (a specimen letter is included in the 'download' section), telephone call or though their secondary care worker.

If the patient did attend, in order to make sure they are invited next year you should add a recall date to their records. You may wish to inform their secondary care worker of their attendance and findings; a liaison form is included in the 'tools' section.

References

  1. Rethink. Health inequalities are killing people with mental illness. Available from: www.rethink.org/how_we_can_help/news_and_media/press_releases/health_ine...
  2. Stahl SS. Stahl's Essential Psychopharmacology. Cambridge University Press; 2003.
  3. NHS Choices. Bipolar Disorder: Symptoms. Available from: www.nhs.uk/Conditions/Bipolar-disorder/Pages/Symptoms.aspx
  4. Filik R, Sipos A, Kehoe PG et al. The cardiovascular and respiratory health of people with schizophrenia. Acta Psychiatr Scand 2006;113:298-305.
  5. Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005;150(6):1115-21.
  6. McCreadie R. Diet, smoking and cardiovascular risk in people with schizophrenia. Br J Psychiatry 2003;183:534-9.
  7. National Institute for Health and Clinical Excellence (NICE). The management of bipolar disorder in adults, children and adolescents, in primary and secondary care NICE clinical guideline 38. London: NICE; 2006.
  8. National Institute for Health and Clinical Excellence (NICE). Schizophrenia Update. London: NICE; 2009. Available from: www.nice.org.uk/cg82
  9. British Medical Association (BMA). Summary of 2011/12 QOF indicator changes, points and thresholds. London: BMA; 2011.
  10. Hardy S, Gray R. Adapting the severe mental illness physical Health Improvement Profile for use in primary care. Int J Ment Health Nurs 2010;19(5):350-5.
  11. Gray R, Hardy S, Anderson K. Physical health and severe mental illness: if we don't do something about it, who will? Int J Ment Health Nurs 2009;18(5):299-300.
  12. Hardy S. Maintaining physical health in severe mental illness. Independent Nurse 2009;2:26-7.
  13. White J, Hardy S. Managing medications in schizophrenia. Practice Nursing 2010;21(8):393-6.
  14. Hippisley-Cox J, Coupland C, Vinogradova Y et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ 2008;336:1475-82.
  15. Egton Medical Information Systems. QRISK®2. Available from: www.emisonline.com/products/QRisk/
  16. Hardy S, Gray R. Primary Care Physical Health Checks for people with Severe Mental Illness (SMI) - Best Practice Guide: The Health Improvement Profile for Primary Care (HIP-PC) (2nd edn). Northamptonshire Teaching Primary Care Trust; 2011.

Resource
Northampton Physical Health and Wellbeing (PhyHWell) project 
www.changingmindscentre.co.uk/v/phyhwell_project