SMI (Severe Mental Illness) Physical Health Improvement

Reducing the Health Inequality

This page has been put together to be your resource for SMI physical health improvement. It includes details of what is required, links and downloadable local and national resources. We hope it is useful. If you require any further information, or have any suggestions for developments, please contact Ian Popperwell (Transformation Project Manager) ian.popperwell@nhs.net by email or via MS Teams.

SMI refers to all those people who have received a diagnosis of schizophrenia or bipolar affective disorder, or who have experienced an episode of non-organic psychosis. They will have received these diagnoses as a patient of AWP and are placed on the GP practice’s QOF register.

Why a Physical Health Check?

People with severe mental illness (SMI) face one of the largest health inequalities in the country. They are less likely to have their physical health needs met than the population as a whole, they die on average 15 to 20 years earlier, and two thirds of these deaths are from avoidable physical illnesses including heart disease and cancer. The population have considerably higher incidence of smoking, obesity, diabetes and COPD.

The disparities in health outcomes are partly due to physical health needs being overlooked. People living with SMI have not consistently been offered appropriate or timely physical health assessments despite their higher risk of poor physical health.

They are not being supported to use available health information and advice or to take up tests, screening and interventions that reduce the risk of preventable health conditions.

The Requirement

To address this, the Five Year Forward View for Mental Health required that 60% of the SMI population should receive a full annual physical health assessment and appropriate follow-up care. As this was not achieved the completion of full sets of six physical health checks the majority of the cohort has become a high NHSE priority across the country.

In April 2022, NHSE introduced a new system of reporting the SMI physical health check data as actual numbers rather than percentages. For BNSSG, this means a minimum number of 5,344 people (out of the c. 8,000 register) should have received full sets of physical health checks over a twelve month period.

The CCG (in collaboration with One Care) have released a new EMIS search that better matches the Ardens search used by the large majority of GP practices.

The six checks are: BMI, blood pressure, blood lipid, blood glucose, smoking and alcohol use.

However, targets in themselves only have meaning if they result in an improvement in health. The health checks therefore need to be followed up and accompanied by paying detailed attention to their results, to addressing difficulties and to offering health improvement and lifestyle advice.

Rolling Annual Measurement

It is important to note that the SMI figures don’t work on a financial year, but use a rolling annual measurement, which means that rather than starting again for the new year on 31st March, the figures each month represent the number of full sets of checks done in the preceding 12 months (so you build / maintain, rather than restart).

See the linked document for further detail:

Understanding the Data

Health Improvement

Health checks in themselves serve no purpose unless they are accompanied by the follow-up onward referrals for screening and treatment, health improvement interventions and lifestyle advice indicated by their results to achieve measurable improvement in health.

Onward referrals to necessary primary and secondary care based treatments and to social prescribers will ensure that the physical health checks result in health improvement.

Invitation Letter EMIS / template

An invitation letter template and leaflet was co-produced within the SMI Physical Health Steering Group and has been published by One Care to practices, and is called ‘CCG BNSSG SMI HC invitation letter and leaflet’.

This letter and accompanying leaflet should be sent out and should replace all previously used invitation letters used by practices.

If practices contact the people on their SMI register by phone, then the letter and leaflet should form the basis of the phone call.

QOF Personalised Care Adjustments (formerly exception reporting)

There are two relevant QOF ‘personalised care adjustments’ that have taken over from the former exception codes:

• No response - The patient has not responded to invitations for the intervention described in the indicator (a minimum of two invitations for the intervention in the preceding 12 months, except for the cervical screening indicators where women should receive a total of three invitations for screening).
• Opt out - The patient has chosen not to receive the intervention described in the indicator.

There are some provisos that mean that these personalised care adjustments need to be treated with a level of caution:

• We have found that many practices are still using their own invitation letter template (or making phone calls) that are less than clear about what the SMI physical health check is, why it is there, what people can expect, who will do it, how long it will take, what will happen as a result of it – what the patient will get out of it. It has emerged that despite commonly expressed beliefs to the contrary, most people with SMI do attend their GP practice but the opportunity to give a full health check  is not always maximised.
• The co-produced letter and accompanying leaflet should be sent out as a letter and/or the content used as the basis of a phone call.
• Note that if people opt out following receipt of a letter that doesn’t give clear and full information about the SMI PHC, it is likely that they are opting out of something that they are not clear about and were they to have clear information, may attend for the check.
• Applying personalised care adjustments codes to people removes them from the register and can lead to people who are affected by the health inequality missing out on checks that they need.

Engaging Patients and Good Practice

It has been commonly thought that people with a severe mental illness are intrinsically very difficult to engage, which was the main cause of our lower position. However, the new information coming through is helping us gain a greater understanding of how small changes in practice can lead to substantial improvements in engagement and performance. Below are some good practice resources to help GP practices engage patients with SMI, and remove the barriers to their engagement:

• BNSSG PHY SMI - Dispelling Myths

Using our emerging evidence to question some of the established myths about SMI patient engagement in physical health.

• SMI Physical Health Improvement: Good Practice Guidance

This is a set of good practice guidelines for primary care and AWP staff involved in physical health checks and health improvement. It is split into headings of communications, administration & systems, achieving full sets of health checks, patient engagement, follow-up and health improvement, equality considerations and getting the checks recorded into EMIS. It has been put together to address the barriers that have been encountered and using local and wider ideas of what constitutes good practice.

• Principles of engagement resource

A useful resource from the Equally Well organisation on good practice in patient engagement in physical health.

Resources

The following documents are available to download as resources to support your work on undertaking sets of physical health checks towards the health improvement of people with SMI. They include local and national documents and short definitions to draw on.

1.  Integrated CMHP and SMI PH principles

These principles have been co-produced by the Community Mental Health Programme SMI Physical Health Steering Group. Rather than a separate set of principles to work to, we have integrated them with the Community Mental Health Programme’s own principles.

2.  SMI cohort (QoF register) definition

This provides the definition of who is on the SMI register.

3.  SMI physical health checks definition

This lists the specific health checks that comprise the SMI Physical Health Check.

4.  NHSE SMI toolkit

An NHSE practical set of guidance on improving the physical health of the SMI cohort.

5.  Improving the physical health of people living with severe mental illness (SMI)

Guidance for integrated care systems.

6.  10 key actions: Improving the physical health of people living with severe mental illness (SMI)

NHSE Publication - Tackling the physical health inequalities faced by people living with severe mental illness (SMI) requires a comprehensive and integrated approach.

Online Resources

• Patient-focused resources

Rethink: support for patients’ engagement with health checks

Severe mental illness and physical health checks (rethink.org)

• Cervical screening: support for people who find it hard to attend - GOV.UK

Guidance on support for people who find it hard to attend cervical screening due to having a mental health condition, or having experienced trauma or abuse.

Cervical screening: support for people who find it hard to attend - GOV.UK (www.gov.uk)

• Promoting good physical health

Severe mental illness (SMI) and physical health inequalities: briefing (27 September 2018)

Severe mental illness (SMI) and physical health inequalities: briefing - GOV.UK (www.gov.uk)

• Competency framework

Health Education England: Physical health competency framework for mental health and learning disability settings

Physical health competency framework for mental health and learning disability settings (e-lfh.org.uk)

• NICE guideline (cg178) - Psychosis and schizophrenia in adults: prevention and management

Psychosis and schizophrenia in adults: prevention and management (nice.org.uk)

• Cancer screening and patients with SMI

Public Health England’s (PHE) report on Severe mental illness (SMI) and physical health inequalities highlights that people with a recorded diagnosis of SMI are more likely than the general population to experience poor physical health and to die prematurely.

Severe mental illness (SMI): inequalities in cancer screening uptake report - GOV.UK (www.gov.uk)

• Mental health friendly cancer screening - University of Surrey

A website dedicated to providing information to health and social care professionals involved in providing health checks to people who might find taking part in them difficult.

Mental health-friendly health check resources for health and social care professionals | University of Surrey

• Cervical Screening Leaflet - Jo's Cervical Cancer Trust

Some women feel anxious because they have a mental health condition, had a traumatic experience
in the past, or for another reason.

cervical-screening-and-SMI-2019-lowres.pdf (surrey.ac.uk)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.