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Title: Physical health checks in serious mental illness : a programme of research in secondary care
Author: White, Jacqueline
ISNI:       0000 0004 5371 3151
Awarding Body: University of East Anglia
Current Institution: University of East Anglia
Date of Award: 2015
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Background The physical health of people with serious mental illness [SMI] represents a significant public health challenge. It is estimated that they have a mortality rate two to three times greater than in the general population and the mortality gap is widening. Although suicide makes a significant contribution, cardiovascular disease [CVD] is the primary cause of death. A higher than expected prevalence of physical comorbidities in people with SMI has been identified in almost every system organ class [SOC] of the body with considerable overlap between them. This indicates multiple genetic, environmental, psychological, social, behavioural and system (of care) risk factors. A lower than expected incidence of comorbidities in the health records of people with SMI in primary and secondary care in the United Kingdom [UK] points to considerable under-diagnosis and treatment and presents an opportunity for intervention. There remains a paucity of evidence to support interventions that can be successfully implemented to make a difference to physical health outcomes in this vulnerable population. The SMI Health Improvement Profile [HIP] was developed by the author and two colleagues as a complex but pragmatic intervention to target physical wellbeing in SMI through the existing role of the mental health nurse in secondary care. The HIP Programme (the HIP and HIP training) is intended to support the mental health nurse working with people with SMI to undertake a structured health check and negotiate and implement an individualised physical health care plan as a result. Aim The aim of this research is to enable mental health nurses in secondary care to address the physical health needs of people with SMI by implementing a nurse-led structured physical health check and care planning process. Methods This project used a programme of research to evaluate the impact of the HIP Programme on care processes and patient outcomes that included: 1. A systematic review of the efficacy of educational interventions for healthcare professionals. 2. Description of the development of the HIP Programme and a pilot study to test the clinical utility and effectiveness of the HIP Programme in 31 patients in a nurse-led outpatient clinic. 3. A clinical audit of the use of the HIP in 108 patients. 4. A cluster RCT of the HIP Programme across four National Health Service [NHS] sites. 5. A process observation in a subsample of patient and nurse participants from the cluster randomised controlled trial. 6. Evaluation of evidence of impact from national and international dissemination of the HIP and the HIP Programme. Results 1. The systematic review identified that there was no evidence examining how to train healthcare professionals to deliver a structured health check for people with serious mental illness [SMI]. 2. The pilot study identified that the HIP was acceptable to people with SMI and healthcare professionals and that two mental health nurses could successfully implement the HIP following brief training. 3. The audit showed that it was possible to identify comorbidities in people with SMI using the structured health check in secondary care and that change in health behaviours and outcomes was possible. 4. The cluster RCT in community mental health teams across four NHS sites demonstrated no difference in health outcomes between HIP Programme and Treatment As Usual [TAU] patients at 12 months. Despite acceptable levels of patient attrition in the trial, rates of implementation of the HIP by nurse participants was very low. 5. The process evaluation highlighted the complexity of the processes we were trying to change. Barriers included service redesign and resource issues coupled with the time taken to complete the HIP and care plan. Nurse participants reported that they did not work with the same patients with SMI for long enough to follow through a (12 month) plan of physical health checks and intervention. There was a perception of structured physical health checks and care as a (new) extension to an already pressured role where mental health risk assessment and management takes priority over physical health risk. 6. The HIP is being used widely in practice but this is largely in inpatient services. Where it has been repeated at 12 months, improvements in some metabolic parameters have been seen. Discussion The need for better care for the physical health of people with SMIs is evident. This program of research developed a package of training and tool to support a structured health check and care planning process for people with SMI in secondary care. The cluster RCT did not demonstrate benefit on patient (quality of life) outcomes. Substantial structural barriers prevented the patients from receiving the intervention from the mental health nurses involved in the trial, despite the positive attitude of the nurse participants towards the importance of a physical health care role. Despite this disappointing finding the intervention is being used in practice across the United Kingdom [UK] and internationally with demonstrated benefits, including the achievement of commissioning targets for health screening and signs of improvement in some outcomes where it has been used in the same person over time. This programme of research demonstrates the challenge of conducting useful RCTs in rapidly changing service environments in the NHS. Future research should develop the intervention beyond the nurse and patient dyad to target the system barriers and levers to implementation.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available