Physical Healthcare in Severe Mental Illness
South London and Maudsley NHS Foundation Trust have recently launched a new five-year Physical Health Strategy and implementation plan with the aim of bridging the 15-20 year mortality gap between those with Severe Mental Illness (SMI) and the general population.
This will require a major culture change which positions an asset-based approach to care at its heart.The strategy sets out steps to spread understanding of physical health among staff; build new and innovative partnership with local community groups, organisations and networks; maximise the opportunities presented by digital technology - including working towards interoperability with GPs and other clinicians, e-diagnostics and e-prescribing; and developing a clear vision as to how service users can benefit from the
Institutes at King’s Health Partners.
In addition, there are a range of projects underway:
Physical Health Plans
There is little understanding of how people with SMI experience their physical health and the support they would like. The barriers to self-managing physical health identified by service users include the debilitating nature of mental illness, having a poor understanding of physical health, the experience of stigma from medical staff and social isolation.
Self-management has been found to improve health outcomes and tools such as Wellness Recovery Action Plans (WRAP) have been shown to be helpful in supporting personal recovery in mental health. The Psychosis Theme of Collaboration for Leadership in Health Research and Care (CLAHRC) South London is currently piloting ‘physical health plans’ (PHPs) in South London and Maudsley NHS Foundation Trust psychosis community services.
PHPs consist of questions regarding physical health needs, for example whether the participant has diabetes and health checks, and if the participant has had their blood pressure checked in the last year, this might lead to the development of an action plan. The use of the PHP aims to address supported self-management and autonomy in service users, and to allow mental health staff to support access to monitoring and interventions for physical health where needed.
Smoking is the single largest cause of preventable death and contributes significantly to health inequalities in the UK. Approximately 60% of people with SMI smoke. Additionally, people with a mental illness who smoke are more likely to be heavier smokers and more tobacco dependent than smokers in the general population, exacerbating the health inequalities already experienced by those with mental illness.
Furthermore, health interventions are less successful for those who smoke; if hospitalised, smokers are more likely to require longer stays and need intensive care after surgery and they also have an increased risk of emergency readmission after discharge. South London and Maudsley NHS Foundation Trust’s ambition is to ensure the prevalence of smoking in people with a mental health condition declines to <5% by 2035 with an interim target of 35% by 2020. A broad range of activity is being undertaken across a number of areas to:
• develop a workforce able to treat tobacco dependency among patients and staff
• develop integrated tobacco dependence treatment pathways
• ensure that smokers within the NHS have access to the medication they need to quit in line with National Institute for Health and Care Excellence (NICE) guidance
• create environments that support quitting through implementing smoke free policies.
During 2017/18, 78% of all South London and Maudsley NHS Foundation Trust inpatients were screened for smoking status. The goal for 2018/19 is to increase the screening rate to 90%.
Read the King’s Health Partners Tobacco Strategy.
Psychosis and Diabetes Study (PODS)
10-20% of people with psychosis and other SMI have diabetes, a major contributor to the mortality gap between those with mental illness and the general population. The Psychosis and Diabetes Study (PODS) aims to integrate diabetes care within community mental health teams (CMHTs) to increase access to specialist diabetes advice and treatment and improve biomedical and mental health outcomes. The project is led by Prof Khalida Ismail, Professor of Psychiatry and Medicine at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, and involves establishing a multi-disciplinary team with mental and physical health clinicians.
These clinicians are piloting a new ‘Diabetes Care Programme Approach’, dietary and physical health interventions, as well as structured diabetes education for service users within the Lewisham CMHT. The staff also receive training on the interplay between mental illness and diabetes, and support to develop new skills. So far, the project has seen service users with diabetes receive one-on-one nutritional sessions with a dietician and support from link workers, who support engagement with the recommendations made by the diabetologist. This has already begun to have an impact, with service users increasing their levels of physical activity, engaging in social activities and taking up better eating habits.
Respiratory Clinics for Addictions
There is significant unmet respiratory need in those receiving additions services, particularly because of smoking tobacco or other inhaled drugs. Breathlessness is not consistently recognised, and this can lead to undiagnosed or late diagnosis of diseases, including asthma, Chronic Obstructive Pulmonary Disease (COPD) and lung cancer.
Dr Caroline Jolley, Respiratory Physician at King’s College Hospital NHS Foundation Trust has set up a lung health clinic with the aim of providing in-reach respiratory diagnosis and treatment within addictions services. The clinic provides a full review and assessment, with appropriate onwards referrals and comprehensive case-noting for all those involved in individual care. Early data from the project has found extremely high smoking rates, 81% of the cohort, with 62% having a chronic cough. Furthermore, whilst only 5.5% had a prior diagnosis of COPD, through the lung health clinic assessment, 36% were diagnosed with COPD.
According to the Lambeth, Southwark and Lewisham Sexual Health Strategy 2014-2017, approximately 10,000 people across Lambeth and Southwark either use drugs problematically, have a serious mental illness or have an intellectual disability. These groups are less likely to use traditional sexual and reproductive health services, and therefore have a high prevalence of Sexually Transmitted Infections (STIs) and HIV, late recognition, unmet contraceptive needs and medically complicated pregnancies. They are likely to be vulnerable and a victim of sexual violence and are often not given the possibility of having pleasurable and safe sexual experiences.
Sexual Health and Reproductive Health Rights, Inclusion and Empowerment (SHRINE) is a multi-disciplinary team, made up of experts from Guy’s and St Thomas’, King’s College Hospital and South London and Maudsley NHS Foundation Trusts. SHRINE has two consultants providing frontline services offering a full Sexual and Reproductive Health service for people with complex needs. SHRINE work creatively and flexibly to reach their target groups, including offering priority access appointment services at Camberwell Sexual Health Clinic, and an assertive outreach service, embedded in two substance treatment providers with the ability to accompany people on a home visit, if the client lives in Lambeth or Southwark.