VCSE organisations supporting people living with SMI to improve their physical health

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: North East London ICS, City and Hackney Psychological Therapies and Wellbeing Alliance, and Core Arts and Sport.

Core Sport offers a wide range of physical and heath-based activities and one-to-one support tailored to the needs of people with severe mental illness (SMI).

Aim and rationale

A voluntary, community and social enterprise (VCSE) called Core Sport was commissioned to work with clients with severe mental illness to tackle the physical health inequalities they experience. The programme particularly aims to reach individuals who may find it difficult to engage with their physical and mental health through usual routes such as their GP.

Development and implementation

  • The Patients Know Best platform had been introduced in City and Hackney following feedback that patients found it difficult to access care plans. These plans were felt to be one-off assessments which were not reviewed or shared between services. The platform allows patients to access all their patient data and share the data with relevant services.
  • When primary care conducts an SMI physical health check and enters data onto EMIS, this data flows directly onto the platform. At this point a primary care clinician can also refer someone (using a direct referral form on EMIS) to Core Sport for physical and heath-based activities.
  • The patient can choose to share their Patients Know Best record with Core Sport, and information about activities undertaken with Core Sport can be recorded on their record which can be accessed by primary care and any other services they have shared access with.
  • The Core Sport team can deliver SMI physical health checks for those who struggle to access a GP or feel more comfortable with the Core Sport team. Point of care testing is used and data is sent to GP surgeries to be uploaded into EMIS.
  • Those referred to Core Sport for physical and heath-based activities are also offered a Fitbit and support to set up the device and link it to their Patients Know Best account. Blood pressure monitors are also offered to those who have high blood pressure or wish to monitor this at home.

Overcoming challenges

  • There was concern when the Core Sport programme started that there might be too few referrals from primary care (and a referral from primary care is a programme requirement to encourage engagement with these services). The programme produced leaflets about Core Sport, which those living with SMI can take to their GP and ask for a referral. This bottom-up approach has engaged primary care, and created a virtuous circle with people engaging more with their GP and with physical activity.
  • As the Patients Know Best platform is a digital app, digital exclusion was a concern. Core Sport provides support for people to develop their digital literacy.
  • It took time to train VCSE staff in performing blood tests in a non-clinical environment, and to develop people’s comfort in tests being undertaken in this way.


The Core Sport programme has successfully engaged its target audience; 46% of members are Black men and ~70% are people from Black, Asian and minority ethnic communities.

In 2022/23, the Core Sport programme:

  • delivered 94 physical health checks, with 18 people supported to have a further health check with their GP based on the results
  • engaged 134 new people with the programme
  • supported 55 people to reduce their blood pressure, with 35 achieving a reduction
  • supported 59 people with smoking cessation
  • supported 31 people to achieve a healthy BMI.


  • Co-produce services with users to understand their barriers to physical activity and other heath-based activities, and to design activities that appeal to and work for your local populations.
  • Find creative ways to increase people’s activity that are tailored to their interests and not badged as ‘exercise’, such as gardening; and offer a wide range of activities (from high aerobic such as circuits to stretch and relaxation sessions) and encourage people to explore the full range.
  • Provide positive examples of people’s successes, build social elements into the programme and support peers to start running their own physical activity sessions.
  • Provide flexibility so people can drop into sessions, depending on their fluctuating mental health needs.


Emily Cubitt, Operational Lead, Core Arts, or

Breda Spillane, City and Hackney Psychological Therapies & Wellbeing Alliance,