Inadequate Physical Healthcare Revealed by the National Audit of Schizophrenia
Dr David Shiers, GP Clinical Lead for National Audit of Schizophrenia
Dr Liz England, RCGP Lead for Mental Health and whole person care
Dr Imran Rafi, RCGP Chair of Clinical Innovation and Research
The National Audit of Schizophrenia (NAS) has examined the care provided by community mental health services for people affected by schizophrenia, who are living in the community in England and Wales, based on NICE guidelines (NICE CG 178). The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Psychiatrists in partnership with the RCGP and other organisations. The NAS first round report was in 2012 and the second round report was launched on 10 October 2014.
What we found
The 2012 report highlighted particular concerns about the management and coordination of physical healthcare, alongside some aspects of prescribing practice. The most recent report continues to show disappointingly low levels of recorded cardiovascular and metabolic risk by community mental health teams e.g. relevant family history, smoking, BMI, blood glucose and lipids, BP (figure 1). The likelihood of a patient receiving a comprehensive check is particularly low, with only 9% having all relevant risks assessed (figure 2). Furthermore even when abnormality is identified appropriate intervention may not follow (table 1).
Figure 1: Percentage monitored for each of the six individual Cardiometabolic health risk factors and percentage with all six monitored once in past 12 months.
Figure 2: Percentage of service users with different proportions of Cardiometabolic health risk factors monitored once in the past 12 months.
Table 1: Comparison of NAS1 and NAS2 audits.
The second round of reporting for NAS highlights the unacceptable physical health treatment gap for people with serious mental illnesses like schizophrenia who die, on average, 20 years earlier than the general population. Circulatory and respiratory diseases account for most of this premature mortality, linked to smoking, adverse Cardiometabolic effects of antipsychotics, and social deprivation compounded by health inequalities. Moreover NAS only explored the care of those receiving secondary care services, whereas up to 70% are managed solely in primary care for whom the picture may be even worse. Furthermore those few people in NAS who did receive CVD disk monitoring had little follow-up or evidence of intervention.
What you can do
There are five key areas of current practice which all of us can improve to address these weaknesses, using readily available resources:
1. More integrated working
Agree roles and responsibilities locally and develop protocols for joint working and information sharing. NICE Schizophrenia guidelines recommend GPs and other primary healthcare professionals monitor physical health at least annually.
2. Implement proactive monitoring and intervention
Using the Lester Resource. Designed for primary care, it is quick and easy to use with a core message "Don't just screen, intervene" to prevent avoidable physical co-morbidity.
3. Agree commissioning priorities - robust joint strategic needs assessment (JSNA)
Strategic planning by local health and wellbeing boards is the key to commissioning primary healthcare that is responsive to local needs. New requirements to tackle health inequalities of groups, often previously excluded from primary healthcare services, can encourage integrated primary and secondary care development and innovation utilising local and national levers.
4. Support quality improvement initiatives
The Parity of Esteem report (RCPsych, 2013) encourages holistic integrated physical and mental healthcare led by mental health clinical and commissioning leads at CCG and Trust board level.
5. Develop workforce: primary healthcare training needs assessment
Cross-boundary inter-professional training and education is key to integrating physical and mental healthcare and overcoming poor access, communication difficulties, stigma, and NHS culture.
Useful mental health resources downloadable from the RCGP and NAS websites include:
Primary care can make a critical contribution to tackling this health inequality through an integrated collaborative approach to promoting and monitoring physical health and addressing health risk behaviours. Helen Lester's concluding sentiment from their James McKenzie lecture (RCGP 2012) reflects the implementation opportunity set by the second NAS audit: "there are many things that cost little, that are based on simple observations not rocket science, that we could introduce tomorrow".
Annual Report of the Chief Medical Officer 2013, Public Mental Health Priorities: Investing in the Evidence.
Hoang, U., Stewart, R. and Goldacre, M. J. Mortality after hospital discharge for people with schizophrenia or bipolar disorder: retrospective study of linked English hospital episode statistics, 1999-2006. The British Medical Journal, 2011;343:d542.
Reilly S, Planner C, Hann M, et al. The Role of Primary Care in Service Provision for People with Severe Mental Illness in the United Kingdom.
Stigma Shout. Time to change 2008.
Crossing Boundaries: Improving integrated care for people with mental health problems. Mental Health Foundation Sept 2013.
Integrated Physical Health Pathway. RCGP, RCN and RCPSYCH. [PDF]
NICE guidelines [CG178] Psychosis and schizophrenia in adults: treatment and management.
Lester Resource: an intervention framework for patients with psychosis and schizophrenia. 2014 Update.
Physical and mental health: activate and integrate. The Lancet Psychiatry, Volume 1, Issue 3, Page 163, August 2014.
Whole-person care: from rhetoric to reality Achieving parity between mental and physical health. Royal College of Psychiatrists. Occasional Paper 2013.