Policy: P15 Physical Healthcare Policy

Policy: P15 Physical Healthcare Policy Version: P15/04 Ratified by: Trust Management Team Date ratified: 15 th April 2015 Title of originator/author: Director of Primary Care Title of responsible Director Medical Director Date issued: 14 th May 2015 Review date: April 2018 Target audience: All staff Trust wide Disclosure Status B Can be disclosed to service users and the public EIA / Sustainability P15 - EIA form.doc Other Related Procedure or Documents: M15p - National Early Warning Score Policy (previously MEWS) West London Mental Health NHS Trust Page 1 of 15

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all relevant policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 15

P15 - PHYSICAL HEALTH POLICY Version Control Sheet Version Date Title of Author Status Comment P15/01 06.02.09 Deputy Director of Nursing New Policy as working document Approved at Feb 09 ED meeting. Under consultation ending 3 rd April 09 P15/02 11.06.09 Deputy Director of Nursing P15/03 2.4.12 Director of Primary Care New Policy issued Revised Policy Following consultation the working document policy was reviewed and approved at 22.05.09 CSSG meeting. Policy takes into account new NHSLA criteria 11.04.12 19.06.13 Re-issued 19.06.13 Ratified on 11.04.12 at Trust Management Team Meeting Additions made at 4.4 & 7.2 P15/04 April 2015 Director of Primary Care Approved at April TMT subject to EIA being completed. Issued 14 th May 2015 West London Mental Health NHS Trust Page 3 of 15

P15 - PHYSICAL HEALTH POLICY Content Page No: 1. Summary... 5 2. Introduction... 6 3. Scope... 6 4. Definitions... 8 5. Duties... 9 5.1 The Board... 9 5.2 The Accountable Directors... 9 5.3 Clinicians and Health Professionals... 10 5.4 The Physical Health Assessment:... 10 5.5 All Staff... 11 6. Systems and recording... 12 7. References and further reading... 12 11. Monitoring and governance... 12 12. Fraud statement... 14 13. Supporting documents... 14 14. Acronyms... 15 West London Mental Health NHS Trust Page 4 of 15

P15 - PHYSICAL HEALTH POLICY 1. Summary Aim and Objectives of the physical health policy A population based approach to assessing physical health risk Details of assessments Links to other policies/guidelines Monitoring and governance West London Mental Health NHS Trust Page 5 of 15

2. Introduction 2.1 This policy describes the approach that will be taken towards improving the physical health of those people who are receiving care from the Trust. 2.2 The policy is wide ranging, since people in contact with the Trust, covers people of all ages: children, adolescents, adults and older adults. It also includes those who experience a wide range of mental health services, from occasional community contact, to those who are long term residents in secure units. 2.3 This policy takes a population based approach, similar to the approach taken by public health specialists considering the needs of a vulnerable population. This policy however will also include other policies and guidance that take a more focused view of specific areas of care, such as incontinence, pressure sores, first aid and basic life support. 2.4 The policy will also describe the governance arrangements for physical health care within the Trust, where it fits within the newly developed governance structure, and how the Board can be assured that the Trust is providing the best available care. 3. Scope 3.1 The Government s 2011 mental health strategy [No health without mental health DH, 2011 London] makes explicit the relationship between physical and mental health, and describes six outcomes that must be achieved. One of those outcomes is: Fewer people with mental health problems will die prematurely, and more people with physical ill health will have better mental health. 3.2 This physical health strategy addresses how this outcome-based, national policy is operationalised within the West London Mental Health Trust. 3.4 The health needs of people who live in our local catchment areas are represented in the public health assessments of our partner Local Authorities and Clinical Commissioning Groups. These groups take a population based approach to improving the health of the population for which they are responsible. The strategy that the Trust implements, must therefore compliment the work being performed by the other bodies. 3.5 At Risk Populations Taking a population based approach to the provision of physical health care within WLMHT, allows a simple needs assessment to be made, similar to the more sophisticated exercise undertaken by local authorities and CCGs. Such a needs assessment identifies a number of different populations that have different health needs. West London Mental Health NHS Trust Page 6 of 15

3.5.1 There is a group of service users whose public health needs are omitted by these population based approaches those who have been resident in a hospital for over two years. Such service users are removed from GP lists of registered patients, and are therefore invisible to the various national preventative programmes run by Public Health England. 3.5.1.1 The consequence is that WLMHT is solely responsible for providing for the physical health (as well as the mental health) of some 500 people in the forensic units at St Bernard s and Broadmoor Hospital. These service users represent some of the most vulnerable population groups, which associated with their enforced admission, makes management of the overall health of this group extremely problematic. Fortunately it is a well defined group which makes implementation of interventions a little easier. 3.5.2 In-patients who have been admitted for a shorter period of time, and whose mental health care is influenced by a co-existing physical health care problem. This group also includes those service users whose mental health care could give rise to a physical health care problem a common example is that one of the acknowledged side effects of anti-psychotic medication is the development of obesity and diabetes. The presence of diabetes significantly increases the risk of a cardiovascular event. This is a larger group than the long term inpatient group, is well defined, but does change over time. 3.5.3 People in the community who are in contact with various community teams. This is a much larger and less well defined group that by definition changes frequently. Working with other public health providers to improve the health of this group is essential to manage this vulnerable group. 3.5.4 People in the community who are not in contact with the Trust. There is a wealth of evidence that demonstrates that people with long term conditions, and other less well defined physical health conditions, also have mental health needs. The Trust needs to work with public health providers, and clinical commissioners and providers to address the needs of this much larger group of people. 3.5.5 Like most public health approaches, it is proposed to use a stepped care approach to health care delivery. This model stratifies increasing risk of physical ill health into a number of categories, which is associated with both the numbers in each group, and the type of health intervention needed to address the needs of that group. The stepped care approach is shown graphically below: West London Mental Health NHS Trust Page 7 of 15

There are a relatively small number of service users in the highest risk level of care the forensic long term service user population; increasing numbers are found in the lower levels of care, and the size of the population increases as the risk diminishes. The type of intervention needed therefore is a consequence of the identified need; in the highest risk category a different type of intervention is needed to that in the lowest risk. Interventions are needed in all levels of care, but the emphasis and objectives are consequently different. 4. Definitions 4.1 Service users have a right to have their physical health needs met. They have a right to access services and information that will help them live a healthy life, and to have a similar life expectancy as the general population. 4.2 The aim of our physical healthcare strategy is to: Achieve the same overall physical health outcomes for those people in contact with the Trust, as those in the general community without a mental illness. The objectives of the strategy are: 4.3 Improve the physical wellbeing of mental health service users by promoting healthy lifestyles West London Mental Health NHS Trust Page 8 of 15

4.4 Improve and develop clinical practice, ensuring that staff have the necessary knowledge and skills to provide and promote good physical health. 4.4.1 Ensure compliance with national and local guidance, guidelines and Policy, so that delivery of physical health care interventions are up to date and fit with emerging research findings. 4.5 Ensure our structures and governance arrangements for physical health care are fit for purpose. 5. Duties 5.1 The Board 5.1.1 The Board has a duty to ensure (through performance monitoring of clinical outcomes) that all appropriate care is provided for those people who are long term residents of the Trust, and for whom the Trust is the only provider of health care. 5.1.2 The Board has a duty to ensure (through performance monitoring) that there is effective communication between the Trust and primary care services, for those service users for whom the Trust provides mental health care, but is not the sole responsible provider of physical health care. 5.1.3 The Board has a duty to ensure (through performance monitoring and leadership) the implementation of national public health policies, that will improve the health outcomes of the vulnerable population groups for which the Trust provides mental health care. Such policies include food and nutrition, exercise, and smoking cessation/prohibition. 5.1.4 The Board has a duty to ensure that sufficient resources are available so that physical heath care services can be delivered to a level that is clinically safe, and will deliver the outcomes that are required in this policy. 5.2 The Accountable Directors The Medical Director and the Director of Primary Care are the accountable directors. 5.2.1 To support and facilitate the effective communication with primary care services for those service users whose physical health care is the responsibility of their general practitioner (and his team), so that relevant information about the mental and physical health care is shared effectively between clinicians and health professionals. 5.2.2 To support and facilitate effective working with voluntary and statutory bodies in the wider community so that there are effective and evidence based mental health interventions to prevent mental ill-health. West London Mental Health NHS Trust Page 9 of 15

5.2.3 To provide clinical leadership to mental health teams so that high quality evidenced based physical health care is provided to in-patients and community patients alike. 5.3 Clinicians and Health Professionals 5.3.1 Clinicians and health professionals providing mental health care for those people for whom the Trust is the only provider of physical health care, should know how to access physical health care services, and should understand the inter-relationships between physical and mental ill-health 5.3.2 Clinicians and health professionals providing mental health care for those people whose physical health is provided by a registered primary health care team should know how to contact that team, and have a duty to share information with that team (and vice versa). 5.3.3 Clinicians and health professionals should ensure that for every in-patient: a medication reconciliation occurs within 72 hours of admission. a physical health assessment is carried out within 72 hours of admission to a ward. for service users who are on the Care Programme Approach, at each review there should be a review of the physical health care needs of the service user. CPA reviews usually occur every six months. 5.4 The Physical Health Assessment: 5.4.1 The physical health assessment will consist of: a physical health history that includes significant past medical conditions, significant family history, medication allergies, and enquiries about smoking and substance misuse. a physical examination which should include urinalysis, an ECG, a set of blood tests to include (but not limited to): o full blood count, o renal function, o liver function, o bone profile, o hormone profile including thyroid and prolactin levels, o fasting lipid profile o fasting glucose, and/or glycosylated haemoglobin levels o Vitamin D levels West London Mental Health NHS Trust Page 10 of 15

o Offer screening for blood borne viral disease (Hepatitis B, C, and HIV) The cardiovascular risk should be calculated for each service user, in line with NICE guidelines using an appropriate risk algorithm currently NICE recommend using QRISK2. Children and Young People: Attention should be paid for the need to address the sexual health needs of this group, as well as specific needs of Looked After Children (LAC) 5.4.2 The physical health assessment is recorded in the service user electronic record, using the appropriate form/template. 5.4.3 The assessment will be carried out within 72 hours of admission, and as part of every subsequent CPA meeting, for those who are still in-patients. CPAs usually occur every 6 months. 5.4.4 In those cases where the assessment, and/or review at the CPA identifies physical health needs, the responsible consultant (RC) should ensure that either treatment and advice is provided by the mental health team itself, or by an appropriate referral to: the physical health care service at Forensic Services (Tony Hillis Wing) to the health centre at Broadmoor Hospital to the service user s registered GP to a secondary care specialist team It should be noted that in the Forensic Services, and at Broadmoor all referrals for a routine specialist opinion should be first directed to the primary care service. 5.4.5 If at other times, physical health care needs are identified, the same process (above) will be followed for referral and management. 5.4.6 Management of physical health care needs for service users in the community, is the responsibility of the service user s GP. However this responsibility does not remove the need for the service user s RC to communicate effectively and in a timely fashion if unmet physical health needs emerge during care being provided by the Trust. 5.4.7 Shared responsibility for prescribing various medications, e.g. anti-psychotic medication, lithium etc, are set out in documents agreed between the Trust and the CCGs, and LMC. Those documents include physical health assessments, and should be read in conjunction with this overarching policy. 5.5 All Staff 5.5.1 All staff should be aware that for those who use the services provided by the Trust, physical health care is as important as the delivery of mental health care West London Mental Health NHS Trust Page 11 of 15

5.5.2 All staff providing services and care for people whose physical health care is the responsibility of a general practitioner and his primary care team, have a duty to encourage healthy styles through the provision of evidence based, NICE approved national policies. 6. Systems and recording The electronic health record (RiO7) will need development and adaption to allow a consistent approach to the recording of clinical and physical observational data. Currently all physical health data is recorded in a specific primary care software programme. The software will be accessible to any member of staff, through the RiO viewer, but they will not be able to enter new data. 7. References and further reading The management of long term conditions (LTCs) should be based on the most recent NICE guideline, or equivalent nationally approved document. To ensure that this document remains up to date, the reader is advised to check the NICE website (www.nice.co.uk ) for the most up to date clinical guidelines. NICE also produce guidelines on the management of obesity, smoking cessation, and other forms of behaviour modification which can also be consulted. 11. Monitoring and governance 11.1 Monitoring. 11.1.1 The aim of the physical health care service is to provide clinical outcomes equivalent to that achieved by people in the community without a mental illness. To monitor the progress of this aim, the Trust will monitor simple to collate outcomes, using nationally accepted evidence based measures. 11.1.2 For those service users for whom the Trust is entirely responsible for health care (those at the top of fig 1) the nationally recognised Quality and Outcome Framework (QOF) data is used. 11.1.3 For acute in-service users monitoring of the inclusion of physical health needs within the CPA process, and the monitoring of the physical health assessment within 72 hours of admission will be reported to the physical health care group, as well as monitoring groups. 11.1.4 It should be noted that the National CQUIN for physical health, introduced in April 2014, encompasses those clinical features described in the physical health assessment and management. The achievement of the National CQUIN will be a further measure of monitoring the delivery of high quality physical health care. West London Mental Health NHS Trust Page 12 of 15

11.2 Governance: 11.2.1 It is proposed that the overall monitoring of these outcomes are reported to the Clinical Effectiveness & Compliance Committee, as part of the clinical assurance process. In this way the Board of the Trust, which receives the minutes of that committee can be informed of both the quality and the quantity of provision of physical health care. 11.2.2 The implementation and monitoring of the Physical Health Care strategy will be the main task of the Physical Health Care Group. This group will report to the Clinical Effectiveness & Compliance Committee which in turn reports to the Board of the Trust. 11.2.3 The Physical Health Care Group will be chaired by the Director of Primary Care, and will meet bi monthly. The minutes of the meeting will be sent to the Clinical Effectiveness and Compliance Group as a standard agenda item. 11.2.4 The Medical Director will act as sponsor for the work of the physical health care group, and will assist in the implementation and monitoring of its work. The Medical Director will also ensure that the priorities and work programmes elsewhere in the Trust co-ordinate effectively with this group. 11.3 There are a number of sub-groups that meet to support the work of the physical health care group: The Medical Equipment group. This group will ensure that the physical health care equipment available to staff is of a consistent, and high quality standard. Policies will be developed to ensure that the equipment is up to date and appropriate to the needs of the service users. Resuscitation Group: This advises on the training of resuscitation services, and will ensure that appropriate equipment is provided for resuscitation needs. 11.3.1 These groups will provide regular reports to the Physical Health Group, that in turn will be part of the minutes made available to the Clinical Safety and Effectiveness Group. 11.8 Audits and Reviews of Policies 11.8.1 There are a number of audits and reviews which the physical health care group will be responsible. These follow logically from ensuring compatibility with other physical health care policies Quarterly review of incidents relating to slips, trips, and falls Quarterly review of incidents relating to medical emergencies Quarterly review of incidents relating to incontinence Quarterly review of incidents relating to the development of pressure sores Annual audit of MEWS Annual review of CQUIN targets where appropriate Annual review of incidents relating to Do Not Resuscitate Annual audit of medical equipment West London Mental Health NHS Trust Page 13 of 15

11.8.2 NICE guidelines cover many clinical topics, and it is not always appropriate to conduct audits on each guideline that is published. It is proposed that the physical health care CIG advises the clinical audit team, as to which audits are appropriate to be carried out, and for which conditions. It may well be that audits need to be limited to particular service user groups, to ensure a more accurate focus, and delivery of appropriate recommendations for improvement. 12. Fraud statement N/A 13. Supporting documents 13.1 The following policies are those that relate to physical health care, and need to be reviewed and included in the terms of reference of the Physical Health Care Group: F3; First Aid B4; Basic Life Support S5; Smoke Free P16; Pressure Ulcers F7; Food and nutrition F8; Slips, Trips and Falls M7; Medical Equipment NEWS NEWS policy 13.2 All the above policies need to be included as part of the overall physical health care strategy, and are compatible with both that strategy and national best practice. 13.3 Guidance documents, which will form part of the work of the nutrition steering group: Hunger strike Dysphagia management Weight management West London Mental Health NHS Trust Page 14 of 15

14. Acronyms GP CPA NICE NEWS CQUIN DH WLMHT NHS QoF CIG LMC General Practitioner Care Programme Approach National Institute for Health and Clinical Excellence National Early Warning Score Commissioning for Quality and Innovation Department of Health West London Mental Health Trust National Health Service Quality and Outcome Framework Clinical Improvement Group Local Medical Committee West London Mental Health NHS Trust Page 15 of 15