Thousands of patients could be saved thanks to Bradford scheme

Thousands of people with serious mental illness (SMI) could now be saved from an early death thanks to an innovative scheme in Bradford helping to lead the parity of esteem agenda.

A new system is being used across Bradford and Airedale in 80 GP surgeries with 5,000 patients with serious mental illness; across five new clinics; and within hospitals with 200 plus beds in order to help improve the physical health of patients.

The template system, produced in bespoke versions for primary and secondary care IT, makes sure patients get key physical checks they are entitled to such as blood pressure pulse and respiration, height weight and body mass index (BMI) and blood tests.

Kate Dale, mental health nurse and physical health project lead for Bradford District Care Trust (BDCT) which is behind the scheme, said: “We know that patients with SMI are at risk of dying up to 25 years younger than the general population due to physical health problems.

“In our experience, the priority for these patients is their mental health and issues such as obesity, possible diabetes, cardiac risk and other lifestyle factors have not routinely been taken into consideration.

“The types of medication patients are prescribed can lead to weight gain that may not be monitored, leading to the possibility of undiagnosed diabetes, raised blood pressure and other physical health problems. If this tool was used nationally it could save many thousands of lives.”

The template includes: taking blood pressure, pulse and respiration, height weight and body mass index (BMI), blood tests and electrocardiogram (ECG), lifestyle assessment to include diet, exercise and smoking status, any issues relating to sexual dysfunction and referral to appropriate services if needed.

“Our data entry template system has seen a huge change in the perceptions and practicalities around treating this group of patients in primary and secondary care and we would be delighted to share it with the whole country and help save lives, reduce the risk of chronic physical health problems and ultimately lead to this population living healthier,” said Kate.

Dr Geraldine Strathdee, National Clinical Director for mental health for NHS England, said: “Improving the physical health care of people with mental illnesses is a major priority for NHS England and partners. The Bradford tool is a terrific, practical support tool to help every GP and practice nurse, and every psychiatrist and specialist mental health nurse to tackle one of the greatest ‘parity’ inequalities in British healthcare.

“The Bradford Care trust has now skilfully adapted the template for use in its secondary mental health care inpatient and community services. In addition, what is very impressive, is the close collaboration between mental health and GP leaders across Bradford.”

In 2009 an audit was carried out in Bradford looking at the base line physical health measures used in primary care and found the measures did not reflect patient’s needs.

In 2012 the SystemOne electronic Mental Health Physical Review Template was developed and introduced into primary care. It has now been published and gradually rolled out across all 80 GP surgeries. During the annual physical health check it helps support doctors and practice nurses structure how to detect the possible additional problems these patients may experience.

In 2014 following recommendations in The Antipsychotic Shared Care and Physical Health Guidance, which highlights the specific responsibilities of both primary and secondary care staff, BDCT published the RIO version of the template onto the secondary care IT system.

Last November, secondary care services opened five clinics which are now taking referrals from psychiatrists, doctors and advanced nurse practitioners and run eight sessions a week to carry out the baseline checks and monitor patients initiated onto anti-psychotic medication. Patients are monitored until stable enough to return to the care of their GP.

There has been significant uptake in use of the template in the five clinics and within the in-patient services which have more than 200 in-patient beds.

“Patients really do value being asked about their physical health,” Kate said. “If we can monitor patients from the outset of treatment, then we can make sure we can understand and capture any changes. We can offer education in terms of patients understanding the impact of antipsychotic treatment and for example: patients will understand that some medication will make them feel very hungry and we can talk about a healthy diet.

“In the long term this approach to caring will reduce the risk of long term physical health complications and this population will experience a longer and healthier lifespan.

“It has taken a lot of relationship building in order to roll this work out across primary care and more recently in secondary care. This has included developing the template for different IT systems and engaging with everyone around why we need to do this, but it has been worth it because we know it will save lives.”

Angela Moulson Clinical Specialist Lead Adult Mental Health and LD Bradford and Lead GP for this project has been crucial to the project’s success. She said: “We have been delighted to be part of this project and are so pleased to now see the improvements for patients being realised.”

Categories: HomeMental healthNews



  1. donnna davies says:

    Hi Kate,

    I would love the opportunity to discuss further. We are attempting to set standards in our Trust around physical health checks to reduce premature mortality from CVD and looking at the Lester Tool but open to other suggestions and ideas.

    Many thanks Donna Davies
    Health Facilitator

  2. claire england says:

    dear kate i am a lead nurse in derbyshire i have recently recieved funding to pump prime for parity of esteem to address physical health care of our patients in the crisis and hometreatment i would be grateful for any information of how the Bradford model was implemented i look forward to hearing from you
    many thanks claire

  3. Dr Yvain Rumalean says:

    To whom it may concern,

    Beyond some recognition of the increased awareness and dangers of overmedicalisation/ over diagnosis, what is being done to reduce this risk in mental health?

    I have some suggestions.

    Yvain Rumalean
    Consultant Psychiatrist NHS
    Consultant Forensic Legal Medicine London Met Police

  4. Student Nurse says:

    Dear Kate, I too would like to know why you chose to develop a new tool for your community clinics rather than using those produced by Rethink and also the Leicester tool? I am a student nurse and have a great interest in this area as it is my dissertation topic.
    Could you contact me to discuss further, please

    Kind Regards

  5. Friederike Stenning says:

    Yes! One person replied asking for invovlement of physiotherapists! Firstly that means I am not the only one thinking that diagnosing so-called ‘secondary’ physical health issues is not enough but that we need to DO something about them as well and secondlyI am not the only one writing a reply to that effect.
    To be honest, I still think that physiotherapists within mental helath have got much too low a profile and that it isn;t well enough known by far that physiotherapists are actually working more hoslistically than a lot of other health professions.
    I will ask Kate for a copy of the tool and see whether we cannot include some kind of action / management plan following the diagnosis that includes physiotherapy in some kind of form – and there are many forms about, not ‘just’ exercise prescription.


  6. Marrisa Carroll says:

    Dear Kate, Can you advise why you chose to develop a new tool for your community clinics rather than using those produced by Rethink and also the Leicester tool?

    • kate.dale says:

      Hi Marrisa
      Please send me an email and I am happy to help. I will explain in full and send you all outr information.

  7. Dear Kate
    Interesting article. I would really like to talk to you about a similar initative that the British Heart Foundation (BHF) funded in Bolsover.
    I would also be happy to share the evaluation and learning with you or any other readers posting on this site. Through this initative, a new resource was prooduced entitled ‘Every Day Trimuphs’ by BHF in partnership with Bolsover Council. This resource is a guide for keeping a healthy heart for people with a mental health problem. Kate as you point out people with a severe mental health condition have a greater risk of developing coronary heart disease than the general population. This booklet helps mental health service users take small steps towards a lifestyle that’s good for your heart and is full of useful facts, practical tips and advice.
    here is the link to review the resource
    Please feel free to contact me at my email address
    Good luck with the project .
    Stephanie Dilnot BHF Area Development Manager

  8. James says:

    Why has it taken so long for the NHS to recognise the link between physical and mental illness? I really do applaud this scheme, but adopting a holistic approach to combat mental illness should already be standard practice across the NHS. I find it incredible that in 2015 we are only now beginning to provide the appropriate care for those affected by mental health issues.

    As a service user in Bradford I have been left dismayed at the lack of support for my physical health needs from the mental health services. Quite often people with mental health problems find it difficult to access the services they require from the NHS, so I truly hope this scheme is a success and is just the start of a more holistic and integrated care system.

  9. Anthony Lacny says:

    Dear Kate Dale c/o NHSE
    Many congratulations on this acknowledgement of your great work over the last few years. My Trust are currently upgrading to an ‘Open RiO’ system and I wondered if it woud be possible for us to adopt the RiO version of your template?

    Kind regards

    Anthony Lacny
    Nurse Consultant Early Interveniton and AWP Non Medical Prescribing Lead

    • Kate Dale says:

      Hello Anthony,
      Please let me know if you require me to suport you further Anthony, we have already met in London last week, howevere please feel free to ask for further support.

  10. Bernadette Knight says:

    Please advise where I can view or get a copy of the template?
    Thank you.
    Bernadette Knight

  11. Dr Liz England SWB CCG Mental health Clinical Lead says:

    How do we get more info on this? Has it been written up at all? I don’t want Kate Dale to be bombarded with requests but I would be very keen to know more and to see how it could be rolled out across other areas. I am currently looking at thos very problem with West Midlands SCN so there is lots of work going on but needs co ordinating maybe?

  12. Irene Stratton says:

    The title of this article could have been “Thousands of patients might not be saved due to Bradford scheme”.
    There’s no proof here that measuring the risk factors will lead to reductions in the death rates.
    A recent review by Chesney et al (World Psychiatry 2014;13:153–160) estimates the reduction in life expectancy in those with serious mental illness as 10 to 20 years but much of this is not due to the risk factors being measured here but to suicide. The diagnoses with the highest all-cause mortality ratios were substance use disorders and anorexia nervosa.
    It is far more difficult to intervene in these patients than in those who do not have serious mental illness and in those who do not have mental health problems initiatives to encourage changes in diet and exercise are difficult to implement.
    Please run these articles past a statistician before publishing them or include some mention of research that supports the headlines!

  13. Lee Walker says:

    As one of the new practitioners running one off these clinic’s, I couldn’t agree more that this service is long over due as people with mental health problems seem to drop through the cracks all to offen and this service going to make big change and not only improve life’s and save lives.
    I would recomend the rest of the NHS in country should be embracing this new service.

  14. Caroline says:

    Get your physiotherapists involved . They are great motivators for people who need support to exercise but may also have low motivation plus long term musculoskeletal problems and high levels of weight gain.

    But when will we stop using BMI which has been shown to be less than helpful for anyone either tall or shorter than average !!

  15. Dr Darlington Daniel says:

    It makes my really glad to see that the physical health care of patients with mental health problems is being given the long over due attention and priority with excellent initiatives such as this (The Bradford scheme).

    In my trust, NELFT, an Intergrated Physical Health Monitoring service is being developed with collaboration between primary and secondary services. With the projected activity level in our project plan and with good uptake, there should not be any patient with mental health problem with undiagnosed Coronary heart disease, diabetes, chronic respiratory diseases or cancers by July 2017.

    I’ll be very grateful if I can visit your scheme in Bradford to see what you’re doing and share ideas.

  16. Helen Fessey says:

    Glad to see that Bradford is pioneering the care for people suffering from serious mental illness. There is the need to address not only a person’s mental ill health but their physical health too

  17. Kelly Anderson says:

    Hi, i would be really interested in hearing more about the project I work as a practice improvement practitioner in the NHS and we are looking for ways to improve the physical health monitoring of patients with mental health difficulties. Please could someone contact me regarding where i can find more information and possibly visit to look at the system.


  18. Lynsey Beswick says:

    This is really good to hear. Unfortunately these factors were not taken into account sooner. My sister was previously living in mental health facility for 10 years and all they cared about was her mental health, whilst her physical health suffered. She went in a healthy size 12 and smoking 10 a day to being discharged morbidly obsese at size 22, smoking 40 a day with severe asthma. Just six months of living in the community and she died aged 29 from pneumonia – with her smoking and asthma cited as secondary causes. I have no doubt it could have been preventable if the focus was on her health as whole and not just her mental illness. Her mental illness seemed to act as a barrier at times as she struggled to articulate herself. Lets hope this good common sense approach to focus on overall health within mental health services is rolled out elsewhere in the UK to ensure people are fit not just mentally but physically too.