Improving the provision of physical health checks for people with severe mental illness provides an opportunity to make a major difference to the health and wellbeing of this vulnerable group, write Drs Kallol Sain and Sweta Patil.
This cross-sectional study was carried out to assess current available facilities in the out-patient-clinics to carry out the necessary monitoring as stipulated by the trust clinical governance committee and guidelines.
The pilot sites have proven that a physical health monitoring clinic has improved the healthy life style of this group of patients. This has been reflected in the reduction of alcohol and drug intake, smoking cessation, reduction of BMI etc. The Department of Health recommended the setting up of the nurse led clinic supported by doctors, either a psychiatrist from the community team or a GP. It is also becoming mandatory to offer the opportunity and organise the monitoring for these patients (box 1, attached right).
This is routine and regular monitoring on an ongoing basis. These opportunities can be offered from primary care team or from secondary care team depending on the service agreement, shared care policy and commissioning agreement.
The other important issues are the base line monitoring and physical examination of the newly diagnosed mental illness. According to the diagnostic pyramid, it is essential to exclude any medical illness particularly neurological and endocrinological illness.
We decided to organise a cross-sectional study to assess current available facilities in the out-patient-clinics to carry out the necessary monitoring as stipulated by the trust clinical governance committee and guidelines clinics within the selected area.
We expected that this audit, in turn, would reflect the quality and standard of physical health monitoring clinics and facilities available to deliver the service as per DH recommendation. Moreover, it will be clear that the psychiatrist, as a doctor, would be able to deliver good medical care to the patients. In patient units were excluded from this study.
Data collection was done in a format to check the availability and standard of instruments required for a comprehensive physical examination was prepared. This data collection tool was developed according the trust policy of physical health check and the required / mandatory clinical documentation of physical examination as a part of new assessment in the community. The equipments list was classified as estate facilities and instruments (see box 2, attached right).
In addition to the availability of equipment, we checked the standard of the equipment to make sure that they are functioning appropriately (see box 3 and chart 1, attached right). We also gathered the information of the designated person who would be responsible for monitoring the standards, ordering equipments and overall functioning.
Following the audit we have made a number of recommendations:
1. Allocation of Designated Person for each local Physical Health Clinic Responsible for maintaining and managing the clinic
2. Redefining the role of these clinics which would include
- Administration of Depot & Monitoring Mental state and Side effects
- Blood Monitoring ( Routine, Clozapine, Lithium)
- Physical Examination
- ECG Monitoring
- Health Education and Health Promotion
3. Regular Health & Safety Monitoring: Separating the clinical areas from Medication storage area.
4. System of regular calibrating the equipments to assure the quality and accuracy
5. Regular training on Physical Health Issues (refreshers course in physical Health for Psychiatrist)
6. Improving communication with GPs to reduce duplication of same work
The lack of initiative to deal with basic physical health issues in mental health professionals is multi-factorial. Primarily, most of the mental health trusts are separated from the acute trust. That leads to development of belief system among the mental health professionals that dealing physical health issues is not their responsibility.
The current commissioning process is also a big factor in the current climate of financial difficulties. There is no clear guideline for responsibility of cost for the investigations. So naturally, secondary health care services are very reluctant to organise any required investigations and referral to specialist medical colleagues without GPs’ agreement. That has already reflected in the delay in the process of investigating the illness by the secondary care as it is almost a business model.
Lack of training and proper arrangement of continued professional development for advancement of basic medicine has left the psychiatrist in a vulnerable situation. It is probably partly because of the lack of use of skills to deal with abnormal findings. These have led to lack of leadership from psychiatrist within their own organisation to set up a robust system.
Some of the recommendations above can be implemented quite easily without any extra cost implication. This responsibility lies on the management board. But leadership should be taken by the psychiatrist.
The biggest hurdle is national agreement of commissioning process. Review of payment by result policy, and giving clinical freedom to all doctors to act in the best interest of the patients, would make the doctors more responsible.
The complex issues of confidentiality can be addressed via information governance. The personal history, and information obtained for psychiatric or other purposes, can be populated in separated non-accessible zones. This will definitely reduce the risk of accidental drug interactions and wastage of time and money. The communication among the clinicians will be more streamlined to treat the patient holistically.
As part of revalidation process we recommend the compulsory CPD programmes as basic doctors at least once a year on different relevant, common medical problems. The royal college of psychiatrist and GMC have the major responsibility to implement.