A community mental health team improving SMI physical health checks

This case study is an example of the collaborative work taking place to deliver physical health support services for people living with severe mental illness (SMI). It is one of a collection of case studies that support our guidance for integrated care systems on Improving the physical health of people living with severe mental illness, published in January 2024.

Organisation: Central and North West London NHS Foundation Trust.

Aim and rationale

In response to not meeting the CQUIN to improve the physical health of people living with severe mental illness (SMI), the trust developed a project to ensure all service users in touch with the community mental health team (CMHT) and inpatient services receive annual physical health checks and follow-up intervention if required.

Development and implementation

  • A QI project started in 2018 to develop a process and protocol for delivery of physical health checks within mental health services in Milton Keynes.
  • Two physical health nurses were recruited to the CMHT to deliver physical health checks and to upskill the mental health workforce to deliver the checks. Physical health checks are offered to everyone in touch with community mental health services in Milton Keynes, not just those on a primary care SMI register.
  • Staff are encouraged to offer physical health checks to everyone on their caseloads. To avoid duplication, the GP tab journal is reviewed to identify those who have had a full or partial physical health check from primary care, and records are updated accordingly.
  • As well as inviting people in for SMI health checks, the service takes a Making Every Contact Count approach and offers checks when patients attend a service, including depot and clozapine clinics.
  • Information about the checks and results are directly entered on SystmOne directly by the physical health nurses, and this is flagged with patients and their GP surgery so follow-up interventions can be arranged by primary care and other services.

Overcoming challenges

  • Resource for so many patients was limited. The physical health nurses were pulled into assist with wider staffing issues, rather than having their time dedicated for this work.
  • Some staff were slow to engage with the process and the necessary culture change. This challenge was partly overcome by explaining roles and responsibilities.


  • High rates of delivery of the health check in 2022/23:
  • 81% of CMHT patients received a full physical health check and 14% a partial check
  • 71% of inpatients received a full physical health check and 27% a partial check.
  • Positive outcomes from the check include staff identifying when service users need an urgent specialist appointment or GP appointment, and service users have lost weight as well as reduced their cholesterol, blood pressure and blood sugars.
  • The service has been running for 5 years, and service users report they appreciate the continuity of care and the holistic focus of the checks.


  • Ensure that there is a strong focus on upskilling the wider mental health workforce to deliver physical health checks, as it is unsustainable to rely on a small dedicated resource. Ensure training for this is delivered regularly and revisited to maintain staff confidence.
  • Provide holistic checks that are tailored to the individual to ensure they have a positive experience of the check and increase the likelihood they will engagein future years.


Sarah Higgins, Mental Health in Milton Keynes, cnwl.cmhhub@nhs.net