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Improving the Physical Health of Adults with Severe Mental Illness

News and updates from today's conference chaired by Sean Duggan Chief Executive The Mental Health Network.

Today's conference opened with an update from Dr Vivek Srivastava Acute Physician and Author NCEPOD on 'Treat as One: Bridging the gap between mental and physical healthcare in general hospitals' 

Full powerpoint presentation

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 mental health and physical health 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.

Dr Srivastava's Biography

Dr Vivek Srivastava graduated from Armed Forces Medical College in India and served in the Indian Army Medical Corps.  During this time, he completed his MD, worked in the Faculty of Medicine as Lecturer and contributed to national policy.

Vivek developed the specialty of Acute Medicine at King’s College Hospital, London from 2010 - 2016.  During this time he developed an interest in improving the care of inpatients with coexisting mental health conditions.   He also contributed to innovative teaching projects for junior doctors in medicine and psychiatry. As a result, he leads education and training in the Medicine clinical academic group of King’s Health Partners academic health sciences centre.  This year he has been tasked to lead acute medical teaching to medical students at King’s College London.

For the last three years Vivek has worked as a clinical coordinator of studies at the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).  He co-authored the recent report on mental and physical health (Treat as One) and management of Sepsis (Just say Sepsis). 

In addition, Vivek is an examiner for MRCP clinical exams (PACES) for the Medical Royal Colleges.  He has worked with the GMC as a specialist application evaluator and performance assessor.  After completing a leadership fellows award with the Health Foundation, Vivek obtained funding from them to establish the Pan-London Acute Medicine network that brought together acute physicians across London for sharing good practice and support management skills development for acute medicine registrars. 

The morning continued with a presentation from Mary Docherty Clinical Advisor on Improving Physical Health Care for People with SMI NHS England who gave a National overview on the 'Health of people living with mental health problems'.

Full powerpoint presentation

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 realise 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

Mary Docherty's Biography

Dr Mary Docherty is an Expert Clinical Advisor to NHS England’s Mental Health Clinical Policy & Strategy Team supporting the development of CCG implementation guidance for improved physical health outcomes.

As a previous Darzi Fellow with London’s Mental Health Strategic Clinical Network and Healthy London Partnership’s Mental Health Programme, she developed and is involved in implementing a London wide programme to reduce the premature mortality of people with serious mental illness. She established and runs the London Mental Health Trust Physical Health Leads Network (PHLN).

The morning sessions concluded with a presentation from Chris Naylor Senior Fellow Policy The King’s Fund on 'Bringing together physical and mental health: a new frontier for integrated care' and covered:

• getting the basics right: integrated care from a service user perspective 

• the case for change:10 areas where integration is needed most 

• Integrated service models: current developments and trends 

• implementing change: overcoming the barriers

Pre conference abstract

Bringing together physical and mental health: a new frontier for integrated care

Most efforts to promote integrated care have focused on bridging the gaps between health and social care or between primary and secondary care. But the NHS five year forward view has highlighted a third dimension – bringing together physical and mental health. This presentation will provide a compelling case for this ‘new frontier’ for integration. It will explore service users’ perspectives on what integrated care for physical and mental health would look like, discuss common challenges and pitfalls, and highlight areas that offer some of the biggest opportunities.

Chris Naylor's Biography

Chris conducts research and policy analysis and acts as a spokesperson for the health charity, The King’s Fund. He contributes to The King’s Fund’s work on integrated care and health system reform, and has particular interests in mental health and community engagement. He leads the Fund’s work on integration of mental and physical health care, and co-authored the report ‘Bringing together physical and mental health: A new frontier for integrated care’.  He is also an executive coach and works with leaders in the health system to support change at the local level.  Before joining The King's Fund in 2007, Chris worked in research teams at the Centre for Mental Health and the Institute of Psychiatry.  He has a Masters in public health from the London School of Hygiene and Tropical Medicine.

24 March 2017


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