Equally Well UK’s work has successively highlighted the gaps that people with severe mental illness face in accessing adequate support for their physical health. In 2021, I was a case reviewer for the National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD), looking at physical health in in-patients with severe mental illness (SMI). During 2020, as part of my work with a local mental health trust, I conducted a two-week physical health census of 106 mental health inpatients between the ages of 18-94. The results highlighted in this blog are reflective of the situation across the UK as demonstrated in the NCEPOD review of 2022.

The census showed there were high numbers of patients of all ages with physical health problems across the full spectrum of medical specialities. Physical health issues can lead to poorer mental health, as shown by the number of patients where physical health was contributing, or the sole reason for admission. Some patients had no mental health diagnoses but only a physical health problem.

Physical Health Checks

Mental health trusts are mandated to do physical health checks, but despite this some checks were not done well – for instance,  blood sugar levels, despite the high levels of diabetes in patients with SMI. Patients need all 6 checks (as per NHS guidance). However, if they refuse the check, or subsequent management for an ‘abnormal’ result twice, this counts as complete. This skews the data, and the figures for refusal ranged between 5% to 20%.

Management of physical health

Appropriate management of physical health was generally poor, with limited management of smoking, alcohol and substance misuse, lack of referral to dieticians for patients with weight issues or diabetes and inadequate treatment for patients with high blood pressure or diabetes.

Data

The junior doctors all reported significant issues finding data about patients’ physical health and highlighted the additional time taken to find information. In general, practice staff will not have the time to look for data unless it is accessible. Physical health forms are often poorly designed with no comprehensive or contemporaneous physical health information. Shared information from primary and secondary care services is often unavailable, leading to under-reporting of serious health issues or critical medications.

The physical health of inpatients with severe mental illness

During their admission to a mental health inpatient ward, many patients developed physical health issues. Physical health is mostly managed by junior doctors who may have more limited experience, while psychiatric nurses have minimal general medical training, leading to a lack of appreciation of the significance of physical health problems.

Inpatients take a considerable amount of psychiatric and physical health medications. Psychiatric staff have less experience of physical health medicines including side effects. Many patients were under community teams, with previous opportunities to manage physical health. Despite this, there were many inadequately or unmanaged conditions. In the last 12 months, only 45% of younger adults had seen their GP.

Allied Health Professionals report significant increases in younger patients with frailty on the wards. Frailty is a marker for ill health, poor mobility, falls and increased risk of death. Dieticians were concerned that nutritional issues were not being adequately addressed.

In conclusion

Of most concern in this census was the number of younger adults with significant physical health problems who are receiving no, or, suboptimal care for their physical health. This misses the opportunity to offer prevention or intervention to reduce the risk of future ill-health and death. The reasons include lack of psychiatric staff expertise to implement or advocate for physical health care; people with severe mental illness facing barriers to primary and secondary care services; and a lack of sufficient Allied Health Professionals.

Poor recording systems and a failure to share important health details between health providers results in clinical risk, as staff may be unaware of significant physical health issues. Primary care and acute service professionals are known to underestimate physical health symptoms in patients with severe mental illness. Evidence shows, however, that people with severe mental illness are generally willing to get physical health interventions if they are given at the right time and in the right way.

Recommendations

To address these physical health issues, I would recommend some basic and structural changes:

  1. There needs to be clarity about what constitutes an adequate physical health assessment. This assessment needs be recorded in such a way that physical health information can be easily accessed and can be shared in real time between primary, secondary care and mental health services. This would improve patient safety and help services plan for future service needs.
  2. Psychiatric staff need education to ensure they recognise potential physical health issues, treat straight forward illnesses, and can advocate for patients’ care elsewhere in the system. They need access to clear pathways for the management of physical health conditions to support better care.
  3. Given the complexity and range of physical health problems, psychiatric staff need medical in-house advice to support people in both community and inpatient settings. We would recommend the development of robust physical health liaison services using medical consultants and generally trained senior nurses. These teams need a full range of Allied Health Professionals from dieticians to manage patients with diabetes, cardiometabolic syndrome and obesity to physiotherapists for falls, mobility issues and exercise, Occupational Therapists, Speech and Language Therapists to pharmacists to manage the increasingly complex polypharmacy.

Author: Dr Kyra Neubauer, Consultant Physician

About the author: 

Kyra is based in Bristol. She has worked predominantly in Elderly care medicine for the last 30 years and has a particular interest in frailty and liaison services; helping patients and their families access the best appropriate care from health services to maintain independence and quality of life for as long as possible. She has set up specialist liaison services for; stroke, surgery, psychogeriatrics and complex assessment and liaison for frail patients. She has an interest in improving physical health care in patients with serious mental illness. She has been a case reviewer for the National Confidential Enquiry into Patient Outcomes and Deaths on this topic and has a Royal College of Physicians podcast based on work she has done in a local mental health trust.