A dedicated physical health check service for people with severe mental illness

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. 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.

Organisations: Sheffield Health and Social Care NHS Foundation Trust, Primary Care Sheffield and South Yorkshire ICS.

Aim and rationale

Uptake of the SMI physical health checks was very low in Sheffield – 27% pre-pandemic and 35% ahead of the rollout of the new scheme. The aim was to develop a service within the primary care mental health team to reduce health inequalities and improve population health, with a particular focus on individuals living with SMI.

Development and implementation

  • The ICS commissioned a city-wide primary care SMI annual physical health check service that sits alongside the primary and community mental health service and is managed by a clinical lead occupational therapist. Four health coaches (equivalent AfC Band 3) work with GP practices on a rotational basis, offering an intensive service to deliver SMI physical health checks.
  • Checks are offered at GP clinics, through home visits and in residential, nursing and supported living accommodation, and reasonable adjustments are provided to support individual needs. Choice is offered in communication method, such as text self-book option, phone with translator, and discussion with carers. Text appointment reminders are sent the day before and if patients do not attend, they are called to explore why and ask if they need further support to rebook.
  • The checks include the ‘core 6’ health checks, plus referral for cancer screening, medication review, physical activity review, nutritional review, illicit drug use assessment and vaccination support. Efforts are also made to ensure the approach is trauma-informed and holistic. Tailored support is provided for other things identified as important to an individual, such as mental health referrals, addressing isolation, access to food banks or employment support.
  • A health inequality risk identifier tool has been created using a peer reviewed paper and Core20PLUS5 approach to identify those most at risk of poorer health and requiring assertive outreach. Work was also undertaken to establish relationships and pathways with VCSE services (including Citizen Advice and employment services).

Overcoming challenges

  • When establishing the service it took longer than expected to access relevant training (such as in phlebotomy) and receive sign off of competencies.
  • Time and effort was needed to establish relationships with both primary care and secondary care services. To build relationships with GP practices, key stakeholders were identified (such as clinical directors, practice manager, GPs) through attending networking events, sharing practice and obtaining feedback from other practices.
  • Access to clinical systems proved challenging. Staff access to SystmOne was arranged and to allow this staff signed confidentiality statements with the GP practices and used NHS OneDrive to share resources, as well as a lone worker app. A standard operating procedure was developed with the primary care mental health service.
  • Given challenges with data collection and the flowing of data, an SMI physical health check template was developed for all relevant clinical systems to standardise communications between secondary care and primary care.


  • The health coach team completed over 1,000 SMI physical health checks in its first 18 months and had contact with over 1,400 individuals on the SMI register.
  • Uptake of the full SMI health check across the city had risen to 61% by the end of 2022/23.
  • The service is reaching a more diverse group of patients than the traditional model, with over 40% of those reached from Black, Asian or minority ethnic communities, with an age range of 18–104 years old.
  • GPs have fed back that the service is reaching individuals who previously were not attending primary care services, especially for blood tests.
  • Patients have fed back that they feel listened to, are important and “people do care about us”.
  • Issues are being identified through checks and patients successfully supported to access follow-up interventions, including: hypertension appointments with a GP, one-to-one health coaching, 6-week healthy living, wellbeing and physical activity group at local sports centre, referrals to weight management and exercise service.
  • The physical health workstream of the community mental health transformation is developing a collaborative place-based local service in each PCN across the city.


  • Co-produce your service with those with lived experience to ensure the service addresses barriers to access and provides an offer that meets the needs of the population.
  • Develop a service that integrates with relevant services to offer a holistic offer, including primary care, secondary care and local VCSE organisations.


Jodie Hall, Primary Care Sheffield, sct-ctr.pcmht-admin@nhs.net