The Atlas of Shared Learning

Case study

Cardiovascular screening of patients with serious mental illness

Leading change

A mental health nurse at Bradford District Care NHS Foundation Trust (BDCFT) led a project to improve physical health for people with a serious mental illness (SMI). The project introduced the a screening tool, aligned to the ‘Lester tool’, which was designed to increase the identification of cardiovascular illness, delivering service improvement in the physical health of SMI patients and removing unwarranted variation between physical and mental health, within both primary and secondary care services.

Where to look

Improving life expectancy of people living with SMI is a national priority in the Five Year Forward View for Mental Health. Evidence indicates that people with SMI have significantly shorter life spans than the general population, with cardiovascular disease (CVD) being a particular risk factor (Improving the physical health of people with serious mental illness: a practical toolkit, NHS England 2016, Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs, NHS England 2018). A BDCFT nurse recognised this unwarranted variation among the SMI patients seen by the Community Mental Health team, recognising that routine screening for cardiovascular illness was less common with SMI patients than for other risk factors, such as suicide risk, especially in secondary care.

What to change

The nurse led on an audit to review SMI patient experience and medical practice across Community services. Results from an initial audit conducted across primary care highlighted potential missed opportunities for patients with SMI to receive a Cardiovascular Risk Score and an effective review of their physical health.

This led the team to start to develop and implement service improvement for these patients with SMI. The nurse and a multidisciplinary team introduced the Lester tool, which helps frontline staff make assessments of cardiac and metabolic health, helping to cut mortality for people with mental illnesses.

The team designed, developed and implemented a digital template for the primary care information system with the aim of seeing if SMI patients offered the template-based screening received better or worse quality care than patients who were not offered the template-based screening in a side by side comparison.

The BDCFT nurse worked with a Psychiatrist GP Lead and Data Quality Specialist to develop and implement a computer based template for the primary care information system to carry out a high quality annual physical health check using the standards recommended by the Lester Tool. The nurse focused on the cardiovascular risk assessment element of the computerised physical health check template. It was piloted in six GP practices and then rolled out across Bradford and Airedale.

The initial findings suggested that by making a computerised health screening tool available, teams could carry out higher quality physical health reviews and detect more patients at risk of significant cardiovascular illness. Where the template was not used, there was identified unwarranted variation in the uptake of cardiovascular screening for SMI patients. Identified within the pilot, three quarters of patients with a template-based medical review received effective cardiovascular screening and subsequent referral to further specialist support as needed.

The use of an electronic template more than doubled the rate of uptake of recommended Lester Tool standards and the detection of significant cardiovascular risk in line with the Five Year Forward View for Mental Health. The nurse’s evaluation identified clear opportunities to improve health screening for people with SMI. Alongside the effective roll out of the Lester Tool within general practice, the nurse lead encouraged partners within secondary care to utilise the Lester Tool. This ensured a reduction in the duplication of screening and provided more effective patient focused care, supporting healthier and longer lives for SMI patients.

How to change

The computer based template is now a core tool across all GP practices in Bradford and Airedale. All patients commencing on a prescription of antipsychotics are referred for appropriate baseline physical health checks and ongoing monitoring, until stable enough to return to the care of their GP. Care staff undertake the screening tests, having been supported to also perform phlebotomy and ECGs in line with the Lester Tool, and to give lifestyle advice (including referrals to further services where needed). Care staff work with a Mental Health Nurse specialising in physical health to support the development across inpatient and community services.

The Mental Health Physical Review Template (aligned to the Lester Tool) has now been adapted for primary and secondary care, community and inpatient settings. It guides clinicians through completing a comprehensive check, to ensure effective interventions and decisions are made.

The template is supported by guidance on the specific responsibilities of both primary and secondary care staff when carrying out physical health checks. The Yorkshire and Humber Academic Health Science Network (YHAHSN) has enabled further development and is promoting a national roll out.

Adding value

Better outcomes – Following implementation of the template, the number of annual physical health checks in primary care increased. Quality of care has improved, resulting in better outcomes for SMI patients, supporting not only cardiovascular interventions, but extending into reduced smoking and supporting weight loss.

Better experience – The extension of the approach into secondary care has supported a more holistic approach to care, where mental and physical health are no longer considered separate. This has made a significant contribution to parity of esteem for people with Serious Mental Illness.

Better use of resources – The template has supported the prevention of ill health in a high-risk group and has helped to improve and standardise practice. Yorkshire & Humber Academic Health Science Network (YHAHSN) commissioned an economic evaluation by the York Health Economic Consortium, which showed the incremental cost benefit of the health check intervention over 10 years as £237.51 per patient (£11.3m in total).

Challenges and lessons learnt for implementation

  • Promotion of the template strongly influenced whether practices adopted it. Practice nurses responded positively to hearing why physical health checks were so vital for people with SMI.
  • Secondary care staff from support workers to consultants initially lacked confidence in their skills to deliver physical health interventions such as ECGs and Phlebotomy. Training and other support were therefore essential.
  • Adaptation of the template to work across different IT applications has been challenging, though possible. However, interoperability remains an issue both locally and nationally.

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