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 the issues, what is required to reduce the health inequality, links and downloadable local and national resources to help improve our practice. We hope it is useful. If you require any further information, or have any suggestions for developments, please contact Sarah Denton sarah.denton4@nhs.net

SMI refers only to 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 (or another mental health trust) and are placed on the GP practice’s SMI register (which was previously funded through QOF). These patients should be offered an annual physical health check.

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. Additionally, where a health problem has been identified, our data shows that the physical health checks are not always followed up with referrals to further tests / scans / treatments / health improvement activities. People are not being supported to use available health information and advice that might help them take more charge of their own health.

The Requirement

To address this health inequality, the Five Year Forward View for Mental Health (2016) introduced an annual physical health check and set annual targets for the proportion of the SMI population that should receive one along with appropriate follow-up care and support.

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

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 only have meaning and impact if they result in a measurable improvement in health. Where the health check exposes emerging health problems, it needs to be followed up by onward referrals for screening, further tests, treatment, local health improvement interventions and lifestyle advice.

Onward referrals would typically be made to primary and secondary care based investigations and treatments, as well as to PCN-based or Public Health commissioned social prescribers, community/health navigators and peer support workers.

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, or if they have specific notes in EMIS that a patient does not read written English or for accessibility reasons, they require a verbal explanation, then the letter and leaflet should form the basis of the phone call.

It is often thought that people with SMI might be anxious or put off attending by being given too detailed information. However, our consultations have shown that far from this, they want to know the reason for the health checks, what to expect, who will be doing it, what they will get out of them etc and are more likely to be put off by vague and unclear information given to them.

Engaging Patients

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.

Personalised Care Adjustments (formerly exception reporting through QOF)

There are two relevant ‘personalised care adjustments’ that took over from the former exception codes – these were used when physical health checks were funded through QOF:

• The patient did not respond (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).
• Patient choice (Opt out) - The patient has chosen not to receive the intervention described in the indicator.

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

• Applying these adjustments to people removes them from being counted for the current year.
• If invitations to the physical health check (in writing or by phone) are not clear about what the SMI annual physical health check is, what it is for and what the patient will get out of it, patients may not feel that they have enough information to respond or to accept the appointment and can consequently have health issues missed.
• In order to reduce the number of non-responses or opt-outs, we recommend the confident and positive promotion of these checks as a means for this group of patients to achieve good physical health.

Good Practice 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. BNSSG PHY SMI - Dispelling Myths

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

2. 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.

3. Principles of engagement resource

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

4. SMI cohort (QoF register) definition

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

5. SMI physical health checks definition

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

6. NHSE SMI toolkit

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

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

Guidance for integrated care systems.

8. 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.