Physical health overhaul for patients with mental illness
A support, time and recovery worker has dramatically improved the physical health of patients being treated for mental illness by overhauling screening, monitoring and support.
Amanda Derbyshire, who works for the Halton and Warrington Early Intervention Team at 5 Boroughs Partnership NHS Trust, established and developed a physical health and wellbeing pathway for patients after an audit showed screening was poor.
Amanda Derbyshire. Picture credit: David Gee
Her work has seen her shortlisted for the RCN Healthcare Practitioner Member category of the Nursing Standard Nurse Awards. The winner will be announced at The Savoy in London on May 1.
‘We know from national research about the importance of physical health needs,’ says Amanda. ‘People with mental illness are at increased risk of physical ill-health, especially individuals with schizophrenia or bipolar disorder, who die on average 16-25 years sooner than the general population. Yet less than 30% of people with schizophrenia receive annual physical health screenings.
‘It was paramount we took action immediately to improve our service users’ physical health care and to establish and develop a system to help monitor it.’
First, she liaised with GP surgeries and care co-ordinators to compile service users’ physical health records. Only 6% had received a baseline comprehensive health screening, falling to just 3% at the two-year stage of their treatment. Amanda says: ‘I would be asking the GP, what measures have you got on this patient? And they would reply, what patient?’
She used the Royal College of Psychiatrists’ Lester cardio-metabolic tool - a simple assessment and intervention framework focusing on smoking, lifestyle, BMI, blood pressure, glucose regulation and blood lipids - for patients receiving antipsychotic medication as a template and combined it with the trust’s own comprehensive physical health assessment document.
Next she established a steering group linked to primary care, secondary care and included service user representatives and produced an educational DVD, featured on the trust’s website, and a GP leaflet detailing the importance of physical health screenings during treatment for a severe mental illness.
And as there was no IT structure available to record and track screening results, she created her own evidence-based database, embedding best practice guidelines. ‘It highlights when service users' screenings are due to both myself and their care coordinator to ensure the appointment is booked,’ says Amanda. ‘It is a great system that I can pass on to people who need it. It was submitted to NICE and has been published as an example of best practice.’
Amanda Derbyshire at work. Picture credit: John Houlihan
After training to improve her clinical skills, she developed health and wellbeing clinics. ‘It had been difficult to get other people to do the screenings - with the clinics I knew I could make a real difference. I also organised screenings in people’s homes that were carried out with local wellbeing nurses,’ she adds. ‘Some patients were more willing to see them as I was seen as mental health practitioner.
‘GP surgeries are supposed to do the screenings but they are often missed. But the clinics mean we can make sure the patient is screened and then send a corresponding letter to the GP. Some GPs don’t want us involved but I tell them that these are our patients and it matters. They are welcome to do the screenings themselves but it has to be done.
‘Primary care nurses also at first did not like us ‘taking over’ but they have come round now that they can see things are not being missed. In Halton I share the work with the wellbeing nurses, they will go out and see difficult patients and we swap information.’
Amanda signposts people for smoking cessation or gym membership where required, and holds regular and ongoing weight management/healthy lifestyle sessions - particularly for those who may be obese and need encouragement and support to adopt a healthier lifestyle (see case study, below). As a result of the screening programme, a number of clients with issues such as significantly raised blood pressure, undiagnosed high cholesterol and weight management problems have now had them addressed.
A re-audit shows an impressive dramatic increase in adherence to screenings - from 6% to 94% overall. Follow up as well as baseline screenings are completed and all results recorded and shared with GP practices. Intervention plans are initiated immediately, with weekly follow up appointments and screenings.
Attitudes in the early intervention team have also changed. ‘Initially the team was not sure what I was doing and why, although my manager was completely on board. They were focused on only the mental health aspect of their service users’ treatment. Now the whole team is on board and want the screenings for their patients.’
The Nurse Awards judges were extremely impressed by Amanda’s work and thought it could be replicated in other areas, such as for people with learning disabilities. ‘She has stepped up and gone well beyond her role,’ says Joanne McDonnell, NHS England senior nurse for mental health and learning disabilities.
Amanda already plans for the future of her service. Picture credit: John Houlihan
RCN professional lead for healthcare assistants and assistant practitioners, Tanis Hand, adds: ‘This is an amazing piece of work. It is very difficult to change the ideas of mental health patients.’
The trust plans to introduce a similar assistant practitioner role in each early intervention team. Warrington adult services matron David Hindley expects them to follow Amanda's example.
‘Since Amanda has developed her service, the quality of physical health screenings, monitoring and management of the health and wellbeing of our patients has improved dramatically.
‘She has worked tirelessly to establish and enhance the links between early intervention and primary care, and has been able to design a fluid and effective series of in house well-being clinics, outpatient screening services and effective communication links with physical health and public health colleagues.’
Amanda already plans for the future of her service: ‘We want to create a one-stop shop for physical screening instead of sending people to different appointments.
‘I am also hoping to facilitate a service user-led health and wellbeing group, so they can work together and take the initiative for themselves. ‘People will come in to talk to them and I will be there to support them but they will take control.’
But she is most proud of changing people’s ideas and perspectives around the physical health of mental health service users. ‘So many people were against it at the beginning - even the patients, parents and carers. But their opinions are changing which is so important as many are on medication that will affect their physical health so they need to make changes now.
'If you are determined and work hard and keep knocking on doors eventually you will get through. I know I’ve done my job and made a change to someone’s life.’
A comprehensive one-year screening was carried out on a 34-year-old man with first episode psychosis. His blood results showed very high cholesterol levels. He smoked, was drinking and had a poor diet.
Amanda saw the service user mainly at home but sometimes in the community on a one-to-one basis for six months, weekly for the first two, gradually moving to fortnightly and then monthly.
Her advice and support included:
- Information and advice on ways to reduce smoking, attending initial cessation services with him.
- Monitoring alcohol consumption levels.
- Weekly diet and nutrition monitoring through food diaries, and advice and information on cholesterol reduction. Amanda referred him to a local authority’s diet and exercise programme, accompanying him on initial appointments and supporting gym sessions by training with him.
- Home visits with a medicine management specialist to discuss his current medication and the impact of any additional medication required if the service user did not make lifestyle and health changes.
- Involving carers in some home visits to help them understand the plans and be able to support their son.
‘The result was a complete change in his lifestyle and outlook on life,’ says Amanda, clearly proud of the service user’s achievements. ‘He stopped smoking and greatly reduced his alcohol consumption. His diet has changed dramatically - he has lost 6.5 stone - and he now volunteers for a charity and attends the service user social inclusion group. He walks his new dog twice a day, goes on daily bike rides and his cholesterol levels are low enough to avoid additional medication.’