Mental Health in Scotland: Improving the Physical Health and Well Being of those Experiencing Mental Illness

Annex A Practice Examples

The following good practice examples offer insights to approaches for better outcomes for this care group and their families.

NHS Grampian

Additional developments have arisen including a walking group and smoking cessation interventions. Clinic staff also suggests local opportunities for men and women looking to take part in organised sport.

Community Mental Health Teams ( CMHTs) in Fraserburgh and Peterhead have introduced annual Lifestyle Clinics for patients known to be suffering from Schizophrenia or Bipolar Affective Disorder. The clinics have been running for over three years and have been well attended.

Fraserburgh and Peterhead CMHTs created registers of patients with the relevant diagnoses. Following a team "away day" and wide consultation a protocol for screening measurements was developed.

Blood pressure measurement, urinalysis, ECG, BMI calculation, side effects screening and a series of blood tests are performed at an annual clinic to which every patient on the register is invited.

Clinics are run jointly by CMHT staff and practice nurses. All clinics are held in the GP surgeries. CMHT members facilitate attendance for their outpatients.

Where lifestyle screening highlights a risk factor further input is arranged (community dietician, exercise groups or smoking cessation advice etc). CMHT members also help with follow up appointments with GPs if abnormal results are shown from tests.

Outcomes to date:

• Attendance rate over 70% in year one in one centre indicated the feasibility of the initiative;
• Joint working between general practice and CMHT staff has consolidated shared care for this vulnerable patient group;
• Many treatable physical illnesses have been highlighted and brought to the attention of the primary care team; and
• Introduction of health screening to a group of patients who traditionally do not attend for such opportunities.

More details available from:

Dr Carol Robertson or Dr Ross Hamilton
Consultant Psychiatrists
Royal Cornhill Hospital
Aberdeen
AB25 2ZH

T: 0845 456 6000
Carol.robertson@gpct.grampian.scot.nhs.uk
Ross.hamilton@gpct.grampian.scot.nhs.uk

Greater Glasgow and Clyde

Glasgow and Clyde experience - GMS contract/Mental Health interface

In Glasgow, GPs from the GMS contract group helped determine what can be most usefully achieved for patients under the current Mental Health Indicators. Evidence based guidance notes for GPs around the mental health indicators have been produced.

This guidance was circulated to all GPs in Glasgow and Clyde in January 2007, following the approval of the GMS contract group, the Mental Health Partnership and the CHCP Clinical Directors group.

Relevance to Mental Health Services Staff

Glasgow and Clyde recognises the importance of Mental Health Services staff sharing relevant clinical information with primary care colleagues.

This includes:

• Details and results of any physical reviews carried out on patients with severe and enduring mental illness;
• Care Plans, including those completed as part of the Integrated Care Pathway ( ICP) and Care Programming ( CPA);
• Other clinical information relevant to patients' care plans - which may include outpatient arrangements, Key worker details etc, as is standard for Community Mental Health Team contacts; and
• Collaboration in maintaining the accuracy of mental health registers in general practice under QOF.

Benefits

More focussed sharing of information regarding patients' care plans;
Improved communications between primary and secondary care;
Reduced likelihood of patients missing out on follow up;
Reduced likelihood of inaccurate information; and
Patients receiving improved health assessments in Primary Care.

Next Steps

Ongoing work with colleagues in General Practice to ensure application of the QOF Mental Health Indicators helps to improve the health and well-being of patients with severe and enduring mental health problems.

Reviewing related practice in mental health care to ensure there is good accordance with the evidence based approach adopted in primary care. (E.g. ICP reviews, health and wellbeing clinics).

Consideration of training and I.T. needs.

More details available from:

Dr Moira Connolly
Consultant Psychiatrist
Clinical Director in Psychiatry, West Glasgow and Lomond Area
Gartnavel Royal Hospital
1091 Great Western Road
Glasgow
G12 0XH

Tel : 0141 232 2001 or 0141 232 3759
Moira.Connolly@ggc.scot.nhs.uk

Colin McCormack
Head of Mental Health Services
South East Glasgow CHCP
Citywall House
32 Eastwood Avenue
Glasgow
G41 3NS

Tel: 0141 636 4129
colin.mccormack2@ggc.scot.nhs.uk

NHS Lothian

NHS Lothian has published a series of " Don't Panic" guides (currently on issue 7) keeping GPs and others up to date with changes to the QOF indicators and related issues.

The latest guide is available at:
http://www.rcgp.org.uk/pdf/Lothian%20Dont%20Panic%20Guide%207.PDF

Further details from:

GMS.contract@lpct.scot.nhs.uk (with "Don't panic!" in the title line)

NHS Lanarkshire

Guidance has been prepared to support the development of pro-active primary mental health care and assist practices to meet the requirements of GMS ( NGMS). The guidance followed local discussion with primary and secondary care practitioners and is designed to facilitate a co-ordinated approach to delivering the indicators in a consistent, efficient and effective way, inline with appropriate guidelines.

The guidance focuses on the Mental Health, Depression and Dementia indicators.

Separate guidance will be prepared for the learning disability indicators.

The clear systematic guidance offered includes relevant flow charts, read codes and a range of appendices. Links to further information are also included.

The guidance focuses on approaches to improve the health of people with severe/ enduring mental health mental care needs, depression and dementia living in Lanarkshire while also addressing the needs of their carers.

Liaison

Liaison is offered from secondary care services to support practices to implement the Mental Health indicators where the practice has identified a named person within the practice to lead on the mental health indicators.

The liaison focuses on the development of accurate mental health and dementia registers, which the practice can then use to meet the various indicators. The level of liaison will vary but includes:

Each Practice will have a named mental health professional from the community mental health team ( CMHT) as liaison to the practice;

The CMHT will provide a list to each practice, of clients known to them who meet the criteria for inclusion on the mental health register;

The named mental health professional will offer to meet with the practice a minimum of twice a year to update the registers and share information with the practice;

The named mental health professional will also liaise with the practice to advise that they should also request patient lists from older people services, forensic services; and Psychiatric outpatients, resettlement teams and rehabilitation services, amongst others, to identify people for inclusion on the register.

Patient Reviews

Face-to-face reviews focus on support needs of the patient and their carer. In particular the reviews address:

• An appropriate physical and mental health review for the patient;
• The carer's needs for information commensurate with the stage of the illness and his or her and the patient's health and social care needs (if applicable);
• The impact of caring on the care giver and co-ordination arrangements with secondary care (if applicable); and
• Communication and co-ordination arrangements with secondary care (if applicable).

Available Documentation

1. Guidance on putting the primary care registers together
2. Example patient review letter
3. Example annual review questionnaire.
4. Example summary care plan
5. Patient Health Questionnaire - PHQ9 for depression
6. Secondary Care List pro-forma

More details available from:

Kevin O'Neil
NHS Lanarkshire

Tel: 01698 281 313
kevin.o'neil@lanarkshire.scot.nhs.uk

NHS Tayside

In keeping with the National Programme for Improving Mental Health and Wellbeing and the growing evidence base for excess cardiovascular and metabolic problems in people with mental health problems, the Dundee Health Screen Clinic was established in 2002 in a Community Resource Clinic within the city. The Clinic has adopted an integrated Multidisciplinary team approach consisting of medical input along with community nurses, occupational therapists, dietetics and physiotherapy. The initial objectives of the clinic were as follows:

• To provide at least annual health checks to the population prescribed antipsychotic medication;
• To offer advice on healthy lifestyle interventions including diet and exercise; and
• To offer education on mental health issues and medication management.

A pilot was conducted to assess the feasibility of health screening and define best practice. The results confirmed that this population had increased rates of modifiable risk factors and co morbid physical health problems. (Diagram 1).

Modifiable risk factors	Compared to
	Prevalence	Normal Population
Obesity	66% (n= 54/81 BMI > 30)	X 1.5-2
Smoking	71% ( n = 108/152 with 90%>20/day)	X 2-3
Elevated Random Glucose	7%* (n=8/108)	X2
Hypertension	32% (n=49/152)
Elevated Total Cholesterol	60% (n=36/60)	X5
(dyslipidaemia) *Previous history of DM/Impaired Glucose

Davidson S et al. ANZ J Psych. 2001;35(2):196-202. Allison et al. J Clin Psychiatry. 1999; 60(4):215-20. Dixon et al. J Nerv Ment Dis. 1999; 187(8):496-502. Herran et al. Schizophr Res. 2000; 21;41(2):373-8. Allebeck. Schizophr Bull. 1999;15(1)81-89.

The Health Screen is now a coordinated Healthy Lifestyle Programme with clear pathways for care in keeping with the UK Consensus guidance:

Minimising metabolic and cardiovascular risk in Schizophrenia (2007) ²⁴ and the recently released Standards for Integrated Health Care Pathways for Mental Health (2007) ²⁷.

A database has been set up to record clinical measurements and investigations conducted at the clinic to monitor for Metabolic Syndrome. Results are collected and relevant information fed back to General Practices and specialists to ensure appropriate follow-up. (Diagram 2).

Diagram 2

Blood results	Other Investigations
•Full Blood Count	Waist Circumference
•Urea & Electrolytes	BMI (Wgt/hgt (kg/m2))
•Liver Function Tests	ECG
•Thyroid Function	Vital signs
•Prolactin	Medical History/Lifestyle History
•Fasting Lipid Profile	Rating scales/cardiovascular risk
•Fasting blood glucose level

Of the first 100 patients audited 33% were identified with metabolic syndrome. This figure reflects similar studies conducted in the US and Europe identifying this population as high risk in terms of cardiovascular and metabolic problems such as Diabetes.

Of 100 User satisfaction questionnaires distributed, 46 % were returned by patients who had attended the clinic. 100% agreed the Quality of the Health Screen Clinic was very good to excellent and that the checks were important. 65% agreed to look at lifestyle changes as a result of their assessment.

The Future of the Health Screen Clinic Programme

The future plan is to develop further individualised lifestyle programmes to target high risk individuals identified with metabolic syndrome. The programme will include specialist dietary advice and a specific quantifiable exercise regime which will be monitored and supervised by a key worker along with a dietician and physiotherapist.

The aim of the programme is to improve the outcome for this high risk population by improving their physical wellbeing, life expectancy and their overall quality of life.

More details available from:

Dr Helen Millar
Consultant Psychiatrist
Carseview Centre
4 Tom McDonald Avenue
Dundee
DD2 1NH

Tel 01382 423000
h.millar@nhs.net

NHS Western Isles

The concept of Psychiatric Annual Review Clinics ( PARC) for patients with a severe and enduring mental illness was introduced in response, initially, to the targets and outcomes required from the NHSQISStandards for Schizophrenia.

The diagnostic criteria was extended to include patients with either bi-polar or schizo-affective disorders.

These arrangements have been introduced for Lewis and Harris with a view to wider roll out soon to the Uists and Barra.

Procedure

Three weeks prior to the clinic, pro-forma letters are sent to both the patient and their GP The patient letter explains the format of the clinic, asks the patient to make an appointment with their GP and encourages them to bring their principal carer to the clinic.

The GP letter and a form inviting a written up-date of their contacts with the patient, and current opinion covering any concerns around the patient's physical, mental or psychosocial needs and includes a list of tests that the GP is invited to perform (e.g. Prolactin, U & E's, Blood Lipids, LFT's, TFT's, FBC, B.P and ECGs).

This information is to be returned to the administrator with an up-to-date list of the patient's medication.

At the clinic, the patient has three consecutive appointments, in sequence, with

• A Community Psychiatric Nurse;
• A Specialist Social Work Practitioner in Mental Health; and finally with
• A Consultant Psychiatrist.

The CPN will have the returned pro-forma from the GP and will complete their section to include any outstanding concerns of the patient and/or their carer together with any presenting problems or areas of unmet need.

The CPN will carry out a global rating using the Health of the Nation Outcome Scales ( HoNOS), will assess side-effects using the Autonomic Involuntary Movement Scale ( AIMS) and measure weight.

The patient and their carer will then have an assessment by the Specialist Social Worker, again recorded on the same pro-forma.

Finally, the patient will be seen by the Consultant who will have the completed reports from the other professionals. The consultant will be able to access all of the results of the blood tests that were performed electronically from SCI store

At the end of the clinic the Consultant, CPN and Specialist Social Worker will meet to discuss findings. The completed pro-forma will form the main outcome record for the clinic.

Outcomes

To date, following 6 of these quarterly clinics, a number of positive results are shown.

• 3 patients have had under-active thyroids detected;
• 2 patients have had elective admissions for major changes in medication prompted by side-effects;
• A number of others have had changes made in the community and onward referrals to Social Work, Dietetics and the Mental Health Occupational Therapy Service; and
• Feedback from patients and carers has been very positive with carers, in particular, expressing satisfaction with what they describe as their " MOT Clinic".

Challenges

The main challenge has been securing sign up by all practitioners. Many are now more responsive and we are hopeful for comprehensive engagement soon.

More details available from:

Neil Lawrie
Team Leader CPNs,
Lewis & Harris

Tel: 01851 703069
Neil.lawrie@wiib.scot.nhs.uk