Using a digital physical health screening template to facilitate integrated care for people with mental health problems

Abstract

Introduction : People with diagnoses of severe mental illness (SMI) such as schizophrenia and bipolar disorder die 15-20 years earlier than the general population, mainly from natural causes. In particular, they have an increased risk of cardiovascular disease (CVD) This health inequality was reviewed in 2006 by the Disability Rights Commission in a report called ‘Equal treatment: Closing the gap’. Deprivation and lifestyle were major factors, but not sufficient to account for the health inequalities. The report proposed that ‘Diagnostic Overshadowing’, or clinical blindness to physical problems in people with mental illness was a form of inadvertent discrimination by health professionals that led to under-diagnosis, under-investigation and under-treatment of potentially preventable or treatable physical disease in people with mental illness. Challenges in integrating care across primary and secondary providers are likely to contribute to this inadvertent discrimination. Recognising that poor access to health care is key factors in determining higher death rates, the NHS in England has put in place financial incentives for both primary and secondary care providers to improve physical health screening for people with SMI. However, very different incentive schemes have been implemented for primary and secondary care and many improvement programmes do not focus on integrating care. For example, the Royal College of Psychiatrists has made recommendations to address physical health inequalities through better training of psychiatrists and better collaboration with primary care. Although there are areas of good practice, the systematic prevention and treatment of physical disease in people with SMI has received relatively little attention. Health screening using a paper based template is one possible mechanism and has been promoted by the Royal College of Psychiatrists (using the Positive Cardio-metabolic Health (Lester) Algorithm) and Rethink, a campaigning mental health charity. Furthermore, it is recognised that paper based templates may not support the behavioural changes required to achieve systematic improvements in screening and treatment: Paper templates are difficult to implement in practice busy practice and provide a barrier to collaboration between primary and secondary care. Despite the introduction of financial incentives, screening rates remain lower than for people without an SMI condition. Description of practice change implemented : This study took the step of integrating a standard health screening tool into the primary care digital information system, so it could be automated, in the hope that this would facilitate the practice of physical health screening in SMI. Secondary care providers worked in partnership with primary care to develop a physical health screening template for use within primary care information system. The impact of the tool was evaluated its introduction across the city of Bradford against standards recommended by the National Institute for Health and Care Excellence (NICE) for physical health and cardiovascular risk screening. The study examined whether SMI patients offered the template-based screening received better or worse quality care than patients who were not offered the template-based screening in a side by side comparison. Key findings : The baseline measures showed that 10% of SMI patients were excluded from the SMI register and only a third of people on the SMI register had an annual physical health check recorded. The new computer-based physical health screening template was taken up by 75% of GP practices and was associated with better quality screening than usual care, doubling the rate of cardiovascular risk recording and more than doubling the early detection of high cardiovascular risk. Uptake of the template was about 1 in 5 of all annual physical reviews, which is encouraging given that there was no incentive to use the template other than to improve quality of care. Use of the template was associated with more than double the rate of adherence to the NICE standards in relation to the calculation of cardiovascular risk. The template was also associated with more than double the rate of detection of significant cardiovascular risk. The study found that the practices that received promotion of the template to were more likely to use it, so stronger promotion of a computerised physical health check template could increase the uptake. Highlights : These findings suggest that by making a computerised health screening tool available, GP teams were aided to carry out higher quality physical health reviews and detect more patients at risk of early cardiovascular death. The computerised physical health screening template has potential to support the behavioural change identified by the Royal College of Psychiatrists required for systematic improvement in practice; both by improving screening within secondary and primary care settings and by supporting collaborative working across primary and secondary care. It is interesting that this digital template has been more successful in supporting behavioural change than the use of financial incentives alone. Further investigation of the factors contributing to success of the digital template would be relevant to other health improvement initiatives. There are a number of possible success factors in this case: The template was designed by practising clinicians, taking into account the length of a primary care appointment; it aligns to other requirements and incentives and clinicians received face to face mental health training and practical IT support to implement the template. Informal feedback has suggested that the combination of a pragmatic digital template and face to face training were essential to success. Conclusion : The digital template is now being incorporated into all of the main NHS electronic care records systems and secondary care providers are beginning to use the template to support physical health screening of inpatients. Work is underway, using Quality Improvement methodology, to enable dissemination and spread of the template and associated change in practice Work is underway to examine whether patients with positive screening findings go on to receive appropriate interventions.