Standardising the monitoring of SMI physical health to improve interoperability

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.

Organisations: Bradford District Care NHS Foundation Trust, Yorkshire and Humber Academic Health Science Network (AHSN) and Bradford District and Craven Health and Care Partnership.

Action and rationale

A clinical audit in 2009 of 80 local general practices found that the physical health of people living with SMI was not being consistently monitored. The aim was to design and implement a physical health template (with associated training) to improve interoperability between primary and secondary care.

Development and implementation

  • Assembled a working group (GP mental health lead, consultant psychiatrist, data quality specialist, lead pharmacist, mental health project lead) to develop the template, implementation plan and approach.
  • Developed a short, consistent electronic physical health template to prompt clinicians to undertake all the NICE recommended elements of a physical health check.
  • Working to ensure availability within SystmOne for primary and secondary care using ASSIST GP.
  • Developed framework of training across primary and secondary care to support implementation.
  • Promoted annual physical health check for patients in primary care via educational and training events aimed at GPs, practice nurses and managers, supporting practices to load the template onto the system. A local incentive scheme helped increase use of the template.
  • The physical health template guides GPs in collecting relevant clinical information relating to physical morbidity and health risks, without the need to learn detailed Quality and Outcomes Framework (QOF) requirements. This helps GPs submit QOF data returns, with the prospect of individual practices driving the provision of quality care and the potential for PCNs to centralise data going forward.
  • Bradford District and Craven Health and Care Partnership can run quarterly reports, reviewing implementation across primary care.

Overcoming challenges

  • When the work began, the physical health of people living with SMI was often not prioritised in primary care appointments. Considerable work was needed to educate people and to overcome concerns about the work for stretched primary care systems with a group that was perceived as ‘hard to reach’. While the structured template was appreciated by many, this needed to sit alongside education on the importance of the physical health of people living with SMI.
  • Many felt that patients living with SMI needed to be seen by a GP and not the wider primary care workforce. However, practice nurses and healthcare assistants (HCAs) are often well placed to conduct physical health checks and we provided training to build their confidence in working with these patients.
  • Secondary care often has stronger relationships with people living with SMI and more time to do outreach. Primary care working with secondary care is key to increasing patient interaction with primary care.


  • The template has been rolled out to all GP practices in Bradford and Airedale and is being reviewed for use across secondary mental health services in the area.
  • Outcomes are monitored centrally and anonymously, with feedback provided to practices to drive performance improvement.
  • Data is extracted quarterly on the six core elements of the check, plus the six further indicators recommended for a comprehensive check.


  • Ensure training is provided on how to use templates.
  • Maximise the role of GPs in championing and leading engagement.
  • Ensure a clear, agreed shared care protocol with clarity on who is responsible for follow-up of test results.
  • Ensure appropriate sharing of information to reduce risk of overlap and duplication.


Kate Dale, Bradford District Care NHS Foundation Trust,

The Link Between Physical and (Severe) Mental Health, with Kate Dale – YouTube

The template can be found in SystemOne under Template > System Wide > Other > Mental Health Physical Review