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Improving Physical Health Outcomes for people with Mental Health Conditions

Mary DochertyMary Docherty

News and updates from today's conference chaired by Dr Jonathan Campion Director for Public Mental Health and Consultant Psychiatrist South London and Maudsley NHS Foundation Trust & Visiting Professor of Population Mental Health University College London the conference took a practical case study based approach to assessing, monitoring and improving the physical health outcomes of people with mental health conditions. There was a focus on early intervention, through learning from organisations that have succeeded in addressing the challenge of improving the physical health of people with mental health conditions.

Improving Physical Health Outcomes for People with Mental Illness

Mary Docherty Clinical Advisor on Improving Physical Health Care for People with SMI NHS England

  • increasing early detection and expanding access to evidence-based physical care assessment and intervention
  • what does good evidence based physical healthcare look like?
  • the national picture and moving forward

In her presentation Mary talked about NHS England recommending physical health assessments for people living with serious mental illness (SMI) and the CQUIN Process, saying; "physical health CQUIN is essential and brilliant but so difficult to implement. But it matters". She also commented that there is a huge amount of discussion required with CQUIN but the outcome is worth it. 
Mary said there has been an increase in people receiving the full set of physical health checks and that the NHS England priorities over the next 6 months for the Physical Health SMI programme include publishing the national commissioning guidance and supporting material for CCGs.

Pre conference abstract

The Five Year Forward View for Mental Health recommended that NHS England should ensure that by 2020/21, 280,000 more people having their physical health needs met by increasing early detection and expanding access to evidence-based physical care assessment and intervention. NHSEs Mental Health Clinical Policy and Strategy Team have embarked upon a programme of work to support this goal. In this update we outline:

  • The current national picture and key challenges
  • The work programme’s aims
  • Consider standards and quality- what does good physical health care looks like?
  • Current and evolving incentives and levers
  • What NHS England is doing to support delivery

Full powerpoint presentation

Bringing together physical and mental health

Dr Vivek Srivastava MD FRCP (Glasg) Consultant and Honorary Senior Lecturer Chair Pan London Acute Medicine Network NCEPOD Report Author

  • treat as one: learning from the NCEPOD report
  • changing the way we work: implementing the recommendations
  • our experience

In his presentation Dr Srivastava demonstrated their study on the quality of mental and physical healthcare provided to patients with significant mental health conditions who are admitted to a general hospital. They found prevalence of smoking was very common. Dr Srivastava highlighted mental health conditions recorded in the ED and questioned whether the figures would be acceptable if you replaced the term Mental Health with shortness of breath or chest pain.  He found that numbers drop off of the mental health recorded at initial assessment from the physical health recorded at initial assessment, he said the percentage of patients who were not reviewed by liaison psychiatry but should have been is unacceptable.
Dr Srivastava brought the delegates attention to a YouTube video that they have just produced, NCEPOD Mental Health 

Pre conference abstract

Treat as One: Bridging the gap between mental and physical healthcare in general hospitals.  A report by the National Confidential Enquiry into patient Outcome and Death (NCEPOD)

This study aimed to identify and explore remediable factors in the quality of care provided to patients with significant mental health conditions who were admitted to a general hospital with physical illness.

A total of 552 case notes were analysed representing hospitals from across the UK.  Most admissions to hospital (351/552; 63.6%) occurred through the Emergency Department (ED), while 80 (14.5%) patients were referred by their GP and 57 (10.3%) were transferred from a mental health or another general hospital.  We found that 164/413 (39.7%) of patients were current smokers, 104/552 (18.8%) had a history of alcohol misuse and 88/552 (15.9%) of substance misuse. These figures are significantly more than the prevalence in general population.

Clinical notes in the ED notes did not mention the mental health condition in 47/96 patients at triage and 24/47 patients at a subsequent senior review. Of the 351 patients presenting to the ED, 55 were referred to liaison psychiatry. The lack of liaison psychiatry input in the ED affected the overall quality of care of 20 patients.

On subsequent admission to a hospital ward the medical clerking lacked adequate mental health history in 101/471 (21.4%) patients. In addition, medicines reconciliation occurred at this stage in only 206/531 (38.9%) patients and mental health medications were prescribed in 331/431 (72.2%).

Mental health risk assessments were recorded in only a third of patients (161/476). An adequate risk management plan should be available to the treating team, but was provided in only 106/224 (47.3%) of these patients. Assessment and management of mental capacity often requires careful attention in this group of patients. However, it was noted in only 66/479 (13.8%) patients during initial assessment.

Liaison psychiatry team reviewed 256/552 (46.4%) patients during their hospital stay. There was room for improvement in the following aspects: mental health risk assessment (22/125; 17.6%), mental capacity assessments (11/53; 20.8%), prescription of medications (11/48; 22.9%) and advice to nursing staff (20/86; 23.3%). However, the first assessment by liaison psychiatry was substantially delayed according to the reviewers in 74/199 (37.2%) patients. This impacted the quality of care in 22/51 patients. The most common reason for the delay in the liaison psychiatry assessment was that “the liaison psychiatry team would not attend until the patient was declared medically fit” (26/74). 

In this study, 65/541 (12.0%) patients were detained using mental health legislation. In 15/65 of these patients appropriate process and documentation were not completed.  Delayed discharges occurred in 65/443 (14.7%) patients.  Discharge summaries lacked the mental health diagnosis in 95/343 (27.9%) and details of the mental health medications in 90/308 (29.2%). We found that no discharge summaries were copied to the relevant out-of-hospital psychiatry consultant. 

The overall quality of care was rated “Good” in 46.0% (252/548) of cases reviewed. Examples of good clinical practice were noted in 17.9% (93/521). However, 23.7% (130/548) of the case had room for improvement in clinical care and 16.1% (88/548) had room for improvement in the organisation of care. Room for improvement in both clinical and organisational aspects of care was noted in a further 11.7% (64/548) of the cases reviewed.

Full powerpoint presentation

Ensuring effective assessment and monitoring of the physical health needs of every person

Dr Shubulade Smith Consultant Psychiatrist and Senior Lecturer Kings College London

  • how do you change the culture to raise the profile of physical health
  • ensuring every person is assessed for physical health
  • developing effective physical health monitoring for patients on antipsychotic medication
  • promoting good physical healthcare for people on the wards
  • our experience and services

Dr Smith made the following remarks;

- we need to prevent physical health problems as ‘they are bound to happen’
- for 150 years we’ve known that people with mental illness are more prone to physical health problems 
- the problem is not getting better, Year on Year it’s getting worse
- an example of a 25 year old with serious mental health illness who over 4 years of hospital admissions showed dramatic weight increase and deterioration of ‘heart age’. This is shocking
- physical health problems are part and parcel of having a mental health disorder
- the Mind/body dichotomy has to come to an end
- Dr Smith demonstrated QRISK3
- need to monitor guidelines, no shortage of guidance out there

Future conferences of interest:

Improving Mental Health Crisis Care
Friday 24 November 2017 
De Vere West One Conference Centre, London

Eating Disorders Summit: Implementing the new NICE guidelines
Monday 27 November 2017 
De Vere West One Conference Centre, London

IAPT: Improving Psychological Therapies for Older People
Monday 27 November 2017 
De Vere West One Conference Centre, London

Dual Diagnosis: Implementing the NICE Guidance
Friday 1 December 2017 
De Vere West One Conference Centre, London

New Savoy Conferences presents Disrupting IAPT: can digital pathways 'change the game'?
Wednesday 6 December 2017 
Manchester Conference Centre, Manchester

Mental Health Support for Asylum Seekers and Refugees Providing Emotional First Aid for Refugees: Third Annual Conference
Thursday 7 December 2017 
Manchester Conference Centre, Manchester

Deprivation of Liberty Safeguards: Towards Liberty Protection Safeguards: Implications of the 2017 Law Commission Report
Friday 8 December 2017 
De Vere West One Conference Centre, London

Improving Psychological Therapies For Mental Health Trauma National Summit 2017
Friday 8 December 2017 
De Vere West One Conference Centre, London

Achieving the 5 Year Forward View in Perinatal Mental Health Services
Monday 15 January 2018 
De Vere West One Conference Centre, London

Masterclass: Deprivation of Liberty Safeguards
Monday 22 January 2018 
De Vere West One Conference Centre, London

Smoking Cessation in Mental Health
Monday 29 January 2018 
De Vere West One, London

6 November 2017


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