Improving physical health outcomes for patients with Serious Mental Illness The Primary Care role Dr Sian Roberts GP Chiltern and Aylesbury Vale CCG Mental Health Clinical Lead
What is a Serious Mental Illness? schizophrenia bipolar affective disorder Patients with psychoses
The facts People living with SMI: life-expectancy is reduced by an average of 15 20 years mainly due to preventable physical illness. 2 x risk of obesity and diabetes, 3 x the risk of smoking, hypertension and metabolic syndrome 5 x the risk for dyslipidaemia than the general population. less access to planned physical care and less access to cancer screening and early intervention than the general population. 3.2 x more A&E attendances and 4.9 x more unplanned inpatient admissions than the general population with significantly higher length of stays. use more emergency hospital care than those without mental ill health.
Mental Health Five Year Forward View Goals To improve access to: physical health checks AND follow up interventions for people with SMI To improve quality of physical health checks AND follow up interventions for people with SMI Target NICE evidence based screening and access to physical care targets ; 2017/18 2018/19 30% of the population with SMI on the GP register 60% of the population with SMI on the GP register This is to be delivered across primary AND secondary care
Defining the Clinical Responsibilities Primary care ; % of people on GP SMI register who received full physical health check: 53% in 2013-14 35% in 2014-15 Secondary care CQUIN; % cardiometabolic assessments completed within inpatient wards; 38% in 2014-15 55% in 2015-16
Current NHS Levers and Incentives Primary Care Secondary Care NHS Health Check GMS contract ; Annual Medication review Smoking /Alcohol LES LTC ;Monitoring ( IHD, Diabetes, CVA etc) QOF ; MH targets and lithium monitoring National performance monitoring and regulation eg. NHSI, CQC National financial levers : CQUIN driving improvement in the physical healthcare for people with SMI CCGs will have key role to incentivise integrated and collaborative models of improving physical health care across primary and secondary care services
NHS Health Check 40-74 years old patients with no pre-existing metabolic/cardiac disorder every 5 years. QRISK is calculated
QOF 2017/18 : Mental Health MH001. register of patients with SMI and other patients on lithium therapy MH002. % of patients with SMI who have a comprehensive care plan documented in the record, in the preceding 12 months MH003. % of patients with SMI who have a record of BP in the preceding 12 months MH007. % of patients with SMI who have a record of alcohol consumption in the preceding 12 months MH008. % of women with SMI aged 25-65 that have an up to date cervical screening MH009. % of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months MH010. % of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding 4 months SMOK002 % of patients with any or any combination of the following conditions: CHD, PAD, stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, SMI with a smoking status in the preceding 12 months
Antipsychotic monitoring Following initiation of an antipsychotic, baseline and the first year of monitoring should be carried out by secondary care After one year, primary care should monitor as part of the annual medication review. BP BMI/ weight, HbA1c/ fasting glucose Lipids Monitoring for depot medication is the same as for oral medication Note that ECG and prolactin monitoring are not required for monitoring in primary care and should only be done if clinically indicated.
SMI and Physical Health monitoring in Primary Care Summary Every adult on SMI register to have annual BP smoking status alcohol status (QOF) AND Adults on antipsychotics should also have annual; weight, glucose lipid monitoring (GMS) Patients on Lithium should also have annual TSH, U+ E s lithium levels 4 monthly ( QOF) Patients not on medications nor receiving other LTC reviews, to prioritise inviting to an NHS health check (LES)
Other opportunities to consider Read Coding- record secondary care biophysical monitoring done on primary care systems Health Pods in the Surgery ( or at the pharmacy) Health education printed on the Repeat Prescription slip as prompt to patients Consider flagging notes of patients with SMI as a prompt to health processionals Digital Interoperability of secondary /primary care systems Make Every Contact Count ; Psychiatrist, CPN, Practice Nurse, GP, Social Worker, pharmacists etc to educate and signpost regarding physical health Consider an audit for CPD /appraisal purpose. VTS GPs may perform this.
Thank you Any Questions?