Reducing health inequalities for those with severe mental illness and complex mental health- looking at the bigger picture

A proactive, outreaching, and engaging holistic trauma-informed approach to reducing the health inequalities of those living with severe mental illness (SMI).

The Team:

Jodie Hall Clinical Lead OT & Physical health pathway lead

Health Coaches

Linked in with the wider Primary Care Community Mental Health MDT.

Ambition:

Adults with SMI are statistically significantly more likely to die prematurely than adults who do not have SMI; from often preventable illnesses and diseases. 5x more likely to die before the age of 75- up to 20 years younger. 4 times as many adults with SMI in the most deprived IMD quintile die prematurely than adults with SMI in the least deprived quintile, 37 % of the population of Sheffield live in the most deprived decile. The data shows that people with SMI are more likely to die prematurely than people who do not have SMI, and the gap between these 2 groups has continued to increase in recent years.

In Sheffield the uptake of the SMI APHC as of the end of March 2018/19 we were at 18.5%, with only 1,102 people on Sheffield GP SMI registers having had all core 6 elements. With ongoing work on the accuracy of the SMI register, Sheffield now at 3,367 people on Sheffield GP SMI registers, with 60.8% at the end of Q4 2023 having received their SMI check: this is 2,265 more people from 203 checks in 2019 a 1015.76% increase in completion of all core 6 completed. The work that the team has engaged in has influenced change in practice.

Created an evidence-based tool to find and support those living with potentially poor physical or mental health, poor well-being, or isolation With the tool gives a clinical rationale as to who we most need to assert the service offer too- and how we identify them.
Find those not "furthest aware from accessing care", for example not responding to appointment letters, not contactable and not attending other appointments/ screenings etc to make contact with them and explore how their needs could be best supported.

The service is developed with experts by experience, and real-time individuals that the service is being created for. Developed a service that offers tailored support to meet the individual and local needs of the population-which may vary from one group to another.

There was appreciation given that patients often live with other long-term conditions (LTCs) and multi-morbidity, therefore aimed to make every contact count through reasonable adjustments for access, but also emphasised on booking in LTC reviews, cancer screening and any other appointment that the patient may require with the practice/ relevant service.

To support with the "bigger picture" for the population group the service has developed pathways into smoking cessation service, benefit and finance support, employment support and vocational rehab, local organisations for socialisation, peer support, physical activity etc.

Outcome:

The team has directly worked with over 1000 patients. Those who have been engaged with the service are over 40% non-white British ethnicity and the service demonstrates a true ageless service with the eldest individual 103 years old.

Improved accessibility and demonstrated on both a local and national level the need for proactive outreach for this population group.

The SMI APHC appointment outcomes:
- Health appointments with GP for unmedicated/managed hypertension, patients subsequently have commenced hypertension medications.
- Appointments with GPs for out-of-range blood results and have engaged with follow up actioned accordingly
- Linked individuals in with VCSE organisiations- health, activities, and socialisation
- Facilitated health and well-being group- with the aim of sustained behavior change to live a healthier life. Individuals have gone on to join gyms and lost weight by healthier eating and increasing activity levels. Reporting significant improvement in Reqol scores and quality of life.
-Identified safeguarding concerns and linked individuals in with relevant services
- Acutely unwell patients linked in with acute secondary care mental health services
- Identified needs of the individuals that could be supported with wider clinical MDT- opened up to 1:1 support from OT, Mental health practitioners etc.

Wider Service Outcome:
- The health inequalities risk identifier tool shared on NHS Futures
- The team showcased the serious mental illness health inequalities tool at the national Community Mental Health Team transformation celebration event in London last week.
Claire Murdock, national director for mental health, was keen to share the innovative work which has prompted the promotion of the new tool and the sharing of it to services across the country. The aim is for general practices and mental health services to be more aware of the patients with the greatest barriers to accessing healthcare and act to break down these barriers.
-Development of systmone and EMIS clinical system templates to improve the experience for both clinicians and patients
- New templates developed have also improved the ability for information sharing, running reports, and increasing accuracy of audits.

- Health Inequality risk matrix tool has been made available on NHS Futures for other services nationally to download.
- Aim to develop a systmone and Emis template for the health inequalities tool which will also be shared on NHS futures and free of charge.

Patient feedback:
" you have really changed my life", "it feels like you really care", "thankyou for your support and caring about me", "thankyou for all of your support", "I don't ever have my bloods taken, but you made me feel so comfortable and I trusted you to do so", "I wasnt aware that I was able to have this check, thank you for telling me about it and doing it, I'll come again in future". "thankyou for your support, I dont know what you did but youve changed the way I think about things and changed my life. I have lost 4 stone and go to the local boxing gym 3 x a week and cook healthy meals at home with my family now, my sons enjoy this and prefer it to the takeaways".

GP Practice Feedback:

"Thank you so much for all your help, you have been amazing working with us, it was really a pleasure"
"Patients were able to be seen much sooner given current/ongoing access constraints. We would welcome the service back if it was offered again in the future. "

"impressed that the team go above and beyond for the patients."

"Thank you for helping with our SMI register, all SMI figures have decreased, your team saw a lot of complex patients in a short space of time. Your support is very much appreciated. Ambah has been talking with colleagues at different points which was great as it showed a consideration for how our practice does things. "

"Excellent service manged to complete most of our SMI patients including a very complex patient who will not engage with the practice"

"I think it's great - having dedicated clinics for the SMI checks helps us and reception organise the check much better and for patients I think it's working well that they have a dedicated slot with a health coach for the PH Health Check. Health Coach has been great too and even noticed a BT a patient had the day after her appointment which was no longer needed so prevented the patient from having a double appointment/wasted trip!”

"you have been able to reach patients who wouldn’t normally engage with the surgery or DNA"

"Always found the health coaches to go above and beyond to ensure all patients were contacted and seen"

"The practice has benefited greatly from this service as we don’t have the capacity to provide the level of support to these patients as you have"

"The support to both patients and practice has fantastic. You have been able to provide focused care to a cohort of patients that we are not always able to reach."

"patients have attended who are difficult to engage with."

"From start to finish, this has been a brilliant service. So helpful and useful to the practice"

" Excellent service, Health Coach went above and beyond to contact patients and try and book them in"

https://www.shsc.nhs.uk/news/new-tool-developed-break-down-barriers-mental-health