rethink mental illness - lethal discrimination
TRANSCRIPT
7/27/2019 Rethink Mental Illness - Lethal Discrimination
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Lethal
discrimination
W hy p e op l e w i t h me nt al i l l ne ss ar e d y i ng
ne e d l e ssl y and w hat ne e d s t o c hange .
September 2013
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Who we are
Rethink Mental Illness is a charity that believes a better
life is possible for millions of people affected by mental
illness. For 40 years we have brought people together to
support each other. We run services and support groups
across England that change people’s lives and we
challenge attitudes about mental illness.
Contents
Summary 1
Foreword 2
The problem 3
Recent policy developments 4
Why are people with mental illness dying too soon? 5
Smoking 5
Obesity 6
Accessingphysicalhealthcare 7
Poorphysicalhealthmonitoring 8
ActionsfortheNHS 8
ActionsforGovernment 9
Change is possible 11
How Rethink Mental Illness is tackling this 13
Conclusion 14
Acknowledgments
WewouldliketoofferourthankstocolleaguesfromboththeRoyal
CollegeofPsychiatristsandRoyalCollegeofPhysiciansfortheirreports‘Wholepersoncare:fromrhetorictoreality:Achievingparitybetween
mentalandphysicalhealth’and‘SmokingandMentalHealth’.Thispaper
hasdrawnontheirworkandwewouldliketoacknowledgethis.
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Foreword
The fact that people with serious mental illness die an average of 20 years
earlier than the rest of the population, the majority from preventable causes, is
one of the biggest health scandals of our time, yet it is very rarely talked about.
Imagineforamomentthatthischillingstatistic
appliedtoanyothergroupofpeople,suchas
residentsofaparticulartown.Therewouldbe
publicoutcry.Questionswouldbeaskedaboutwhy
thesepeoplearebeingsobadlyletdownbyhealth
servicesandpoliticianswouldcallfortargeted
support.Butthissimplyisn’thappeningforpeople
withmentalillness.
Thefactsarestarkandshocking.Oneinthreeofthe100,000peoplewhodieavoidablyeachyearhave
amentalillness.Weknowthatpeoplewithmental
illnessarethreetimesmorelikelytodevelopdiabetes
andtwiceaslikelytodiefromheartdisease.More
than40%ofalltobaccoissmokedbypeoplewith
mentalhealthproblems.
Despitetheindisputableevidencethatpeoplewith
mentalillnessareoneofthemostat-riskgroupsin
oursocietywhenitcomestoavoidabledeaths,theGovernmentisfailingtotakermaction.
TheHealthSecretaryJeremyHuntwantstoreduce
the100,000avoidabledeathsperyearinEnglandby
athird.Yethisrecent‘calltoaction’onaddressing
avoidableprematuremortalitybarelytouchesonthe
physicalhealthofpeoplewithmentalillness,although
itdoesacknowledgethe‘shamefulinequality’of
outcomesrelatedtosmoking.
Whensuchstarkevidencehasbeenpresentedforotherconditions,suchasdiabetes,actionhas
followed.Thesameisnottrueformentalhealth.
Failuretoaddressthisissueamountstolethal
discriminationwhichiscostinglives.Weurgethe
SecretaryofStateforHealthtoactnowandpublish
anavoidabledeathsstrategythatwillchangethis.
AyearagotheNHSmandatesetaneedtoachieve
changeinthisarea.Howprogresstowardsthiswillbe
measured,whenitwillbedeliveredandhowitwillbe
fundedhasyettobedened.IfthisisaGovernment
priority,whyarewestillwaiting?
Somesaythisissueissimply‘toodifcult’totackle,
butinrealitytherearesimple,cost-effectivesolutions
detailedinthisreport,whichcouldsavethousands
oflives.TheyaresmallthingslikeofferingtargetedsupporttogiveupsmokingandensuringGPscarry
outbasicphysicalhealthchecksonpatientswith
mentalillnessandactontheresults.
Weknowwhattheproblemisandweknowwhatthe
solutionis.AllweneednowisfortheGovernment,
localauthorities,clinicalcommissioninggroups,
healthandwellbeingboards,serviceprovidersand
individualclinicianstofacethisissueheadonand
takeactionwhichwillsavethousandsofpeoplewithmentalillnessfromdyingtoosoon.
Professor Sue Bailey
PresidentoftheRoyalCollegeofPsychiatrists
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The problem
Thereisextensiveevidencethatpeoplewithserious
mentalillnesses,suchasschizophrenia,areatrisk
ofdyingonaverage20yearsprematurely.2,3
Comparedwiththegeneralpopulation,theyhave:
• 2timestheriskofdiabetes.4
• 2-3timestheriskofhypertension.
• 3timestheriskofdyingfromcoronary
heartdisease.5
• 10-foldincreaseindeathsfromrespiratorydisease
forpeoplewithschizophrenia.6
• 4.1timestheoverallriskofdyingprematurely
(thanthegeneralpopulationagedunder50).
Manyoftheprematuredeathsofpeoplewithserious
mentalillnessaretheresultofpoormedicalcare
thatfailstomonitorriskfactorssuchassmokingand
obesity.Theyareavoidable.Yetdespitethesepoor
outcomes,theNHSisnotprovidingthecarepatients
needtostaywell.
Forexample,NICEguidelinesstatethateveryonewith
schizophreniashouldhaveannualphysicalhealth
checks.YettherecentNationalAuditofSchizophrenia
foundthatjust29%ofpeoplearereceivingthis. 7Even
verycheapandbasiccareisnotbeingprovided,such
asweighingpeopleandtakingtheirbloodpressure.
Just56%ofpeoplewithschizophreniaareweighed
byhealthprofessionals,withsomeNHSTrusts
weighingjust30%ofpatients.8Weoftenhearthat
psychiatricwardsdon’tevenhavescales.It’sabout
timetheydid.
Furthermore,evenwhenhealthchecksareprovided
andproblemsarediscovered,thisdoesnotalways
resultinaction.TheAuditfoundthatwhenpatients
werefoundtohavehighbloodpressure,just25%of
themwerethentreated.
The‘inversecarelaw’iswellknown,where“ the
availability of good medical care tends to vary
inversely with the need for it in the population
served ”.9Nowhereisthismoreevidentthaninthetreatmentofthephysicalhealthneedsofpeople
affectedbymentalillness.
Whensuchbasiccareisdenied,itisnotbecause
oflackoffundingorNHSreorganisations.Itis
becausethephysicalhealthofthesepatientsisnot
deemedimportant.Thissystemicdiscrimination
iscausingthousandsofpeopletodietoosoon–
changeislongoverdue.
2. NewmanSC,BlandRC.,1991.Mortalityinacohortofpatientswithschizophrenia:arecordlinkagestudy.Can J Psychiatry 36,pp239–45.
3. BrownS,KimM,MitchellCandInskipH.,2010.Twenty-veyearmortalityofacommunitycohortwithschizophrenia.British Journal of
Psychiatry 196pp116–121;ParksJ,SvendsenD,SingerPetal.,2006.MorbidityandMortalityinPeoplewithSeriousMentalIllness.13th
technicalreport.Alexandria,Virginia:NationalAssociationofStateMentalHealthProgramDirectors.
4. RoyalCollegeofPsychiatrists,2013‘Whole person care: from rhetoric to reality. Achieving parity between mental and physical health ’,
OccasionalpaperOP88.
5. Osborn,DPJ.,2007Physicalactivity,dietaryhabitsandcoronaryheartdiseaseriskfactorknowledgeamongstpeoplewithseveremental
illness:acrosssectionalcomparativestudyinprimarycare.Social Psychiatry Psychiatric Epidemiology pp787-93.
6. Mentalhealthandsmoking:apositionstatement(2008),FacultyofPublicHealth.
7. RoyalCollegeofPsychiatrists,2012. Report of the National Audit of Schizophrenia (NAS) 2012.London:HealthcareQuality
ImprovementPartnership.
8. RoyalCollegeofPsychiatrists,2012.Report of the National Audit of Schizophrenia (NAS) 2012. London:HealthcareQuality
ImprovementPartnership.
9. HartJT,.1971Theinversecarelaw.Lancet Feb27;1(7696)pp405-12.
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Recent policy developments
ThisGovernmenthasmadeapromiseinthe
NHSMandatetotransformtheNHSsothatmental
andphysicalhealtharetreatedequally,andthe
NHSOutcomesFrameworkincludesanindicator
toreducetheunder-75excessmortalityrateinadultswithseriousmentalillness.However,how
progresstowardsthiswillbemeasured,whenit
willbedeliveredandhowitwillbefundedhas
yettobedened.YetwhentheHealthSecretary
publishedhis‘calltoaction’toreduceavoidable
prematuremortality,10hebarelymentionedthewidely
acknowledgedissuesaboutprematuremortalityin
mentalhealth.
Hestatedthattwothirds(around103,000)ofthe
deathsamongtheunder75sareavoidable.Asaroundathirdofthosedeathsarepeoplewithmental
healthproblems,weknowthattheHealthSecretary
willnditmuchhardertoreduceprematuremortality
ifhedoesnotaddresstheneedsofthisgroup.
TheGovernment’spromisestotackleavoidabledeathsandimprovementalhealthcarehavebeen
welcomed.WhiletheNHSMandatedemands
improvementsinthisarea,theNHSOutcomes
Frameworkonlymeasuresratesofmortality,not
causesofdeathorco-morbidities.
NHSrecordstelluswhenpeoplehavedied,butdo
verylittletohighlightat-riskgroupsandensurethey
areofferedtargetedsupport.Moremustbedone–
urgently–toprioritiseinterventionsthatareknown
towork,andwhichcanpreventtheonsetofthepoorphysicalhealthassociatedwithmentalillness.
10. DepartmentofHealth,2013.Living Well for Longer: A call to action to reduce avoidable premature mortality.
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Why are people with mental illness dying too soon?
The causes of poor physical health will vary from person to person, but there
are common factors which contribute to the poor physical health of people
affected by mental illness, outlined below.
Smoking
Peoplewithmentalhealthproblemsconsume
almosthalfofalltobaccoinEngland(42%),11and
are70%morelikelytosmokethanapersonwithout
mentalhealthproblems.12Inmentalhealthunits,it
isestimatedthat70%ofpatientssmoke,with50%
describedasheavysmokers.13
Theyalsohaveincreasedlevelsofnicotine
dependencyandareatevengreaterriskofsmoking-
relatedharm.14Despitethis,onlyaminorityofpeople
withamentalillnessreceiveeffectivesmoking
cessationinterventions.15
Peopleaffectedbymentalhealthproblemshavethe
samedesiretoquitaseveryoneelse.However,their
smokingratehasbarelychangedinthelast20years,
whiletherateinthegeneralpopulationhasfallen
dramaticallyfrom45%in1974to20%in2010.16
Thereareanumberofbarrierstopeoplewithmental
illnessaccessingsmokingcessation,includingstaff
attitudesandinexibleservicetargets.In2012,The
SchizophreniaCommissionheardevidencethatsome
healthprofessionalsdonothelppatientsgiveup
smokingbecausetheybelieveitisthe‘lastpleasure
theyhave’.17Webelievethisattitudeisunacceptable
andiscostinglives.
Similarlyweareconcernedthatsomeservices
havesuchrigidperformancetargetsthatthereis
noincentiveforthemtosupportsomeoneaffected
bymentalillness,whomighttakelongertoquit.
Performancetargetsshouldbedesignedsothat
servicesareencouragedtosupportthepeoplewho
strugglehardest.Addressingthesebarriersand
offeringtargetedsupportshouldbeapriority.
Itisessentialthatsmokingcessationservicescheck
thementalhealthstatusoftheirclients,asevidence
suggeststhatthisisnotbeingroutinelyundertaken. 18
Alongsidethis,allsmokingcessationstaffneedto
havementalhealthtrainingtoensuretheyofferthe
appropriatelevelofsupport.
Targetedsupportwouldsavemoneyaswell
aslives.£720m19isspentannuallytreatingsmoking-
relatedillnessesinpeopleaffectedbymental
healthproblemsthroughhospitaladmission,GPconsultationsandprescriptions.Providingsmoking
cessationsupportforthisgroupisoneofthemost
costeffectiveinterventionsintheNHS. 20
TheRoyalCollegeofPhysiciansandRoyalCollegeof
Psychiatrist’sreport,SmokingandMental
Health,recommendsthatbecausesmokerswith
amentalillnessareusuallymoreheavilyaddicted
tonicotine,theyshouldbeprescribednicotine
replacementtherapyproductstosupportattemptsto
stopsmoking.
11. McManusS,MeltzerH,CampionJ.,2010.Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey .
London:NationalCentreforSocialResearch.
12. CentersforDiseaseControlandPrevention,2013Adultsmoking:focusingonpeoplewithmentalillnessVitalSigns,February.
13. JochelsonJandMajrowskiB(2006).Clearingtheair:debatingsmoke-freepoliciesinpsychiatricunits.King’sFund,asreferencedinMental
HealthNetwork,NHSConfederation(2013),‘SmokingandMentalHealthbrieng’,Issue267.
14. LawrenceD,MitrouFZubrickSR.,2009.Smokingandmentalillness:resultsfrompopulationsurveysinAustraliaandtheUnitedStates.BMC
Public Health9:285.
15. RoyalCollegeofPhysiciansandRoyalCollegeofPsychiatrists,2013.Smoking and Mental Health.
16. Jarvis,M.,2003.MonitoringcigarettesmokingprevalenceinBritaininatimelyfashion. Addiction,98,pp1569-1574.
17. SchizophreniaCommission,2012.TheAbandonedIllness.
18. McNallyL&RatschenE.(2010),Thedeliveryofstopsmokingsupporttopeoplewithmentalhealthconditions:AsurveyofNHSstopsmoking
services.BMCHealthServicesResearch;10:179.
19. RoyalCollegeofPhysiciansandRoyalCollegeofPsychiatrists,2013.Smoking and Mental Health.
20. RoyalCollegeofPhysiciansandRoyalCollegeofPsychiatrists,2013.Smoking and Mental Health–£8,000perquality-adjustedlife-year(QALY)
gainedforlifetimenicotinepatchuseand£3,600perQALYforinhalators.
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Tailoredsupportisalsoimportantbecause
medications,suchasclozapine,areaffected
bynicotineintake.Medicationdosagesmaythereforeneedtochangeinparalleltosmoking
cessation.However,NHSStopSmokingservices
donotcurrentlyrecordwhethersomeoneisusing
medicationforamentalhealthcondition.This
needstoberecordedifprescribingcliniciansand
smokingcessationservicesaretoworktogetherto
dothissafely.Equally,GPrecordsshouldrecordthe
smokingstatusofpeoplewithmentalillnesssothat
theyareofferedtheappropriatesupporttogiveup.
TheNHSQualityOutcomeFramework(QOF)and
CommissioningforQualityandInnovation(CQUIN)
paymentscouldbeusedmorewidelyandeffectively
toincentivisehealthcareprofessionalstoprovide
targeted,effectivesupportforthisgroup. 21
Obesity
Peoplewithaseriousmentalillnessareatmuch
greaterriskofobesity.Thisisbecausesomeofthe
medicationstheyuseareassociatedwithweightgain.22Thishasrecentlybeendescribedasan
‘epidemic within an epidemic’23asyoungpeoplewith
emergingpsychosisarequicklygainingweightwhen
usingmedication.Oftenthereissomuchfocuson
managingtheirmentalillness,thatpeople’sphysical
healthneedsareignored.
21. RoyalCollegeofPsychiatrists,‘Wholepersoncare:fromrhetorictoreality.Achievingparitybetweenmentalandphysicalhealth’,Occasional
paperOP88,2013
22. McElroy,SL,2009.Obesityinpatientswithseverementalillness:overviewandmanagement, Journal of Clinical Psychiatry ,70,
Supplement3:12-21.
23. Bailey,Gerada,LesterandShiers,2012.Thecardiovascularhealthofyoungpeoplewithseverementalillness:addressinganepidemicwithin
anepidemicThe Psychiatrist Online October(36)pp375-378.Availableat:www.rcpsych.ac.uk/quality/NAS/resources.
24. LesterH,ShiersDE,RaI,CooperSJ,HoltRIG.,2012.Positive Cardiometabolic Health Resource: an intervention framework for patients with
psychosis on antipsychotic medication.RoyalCollegeofPsychiatrists:London.
25. CareQualityCommission,2011.Community mental health survey 2011.
Bythetimetheyareconsidered,peoplehave
gainedsignicantweightandareatgreatriskof
cardiovascularproblemsanddyingprematurely.Itisthereforeessentialthatphysicalhealthmonitoring
isprioritisedattheonsetofillness.Mentalhealth
providersshouldpromotetheuseofclinicaltools
tosupportthephysicalhealthneedsofpeoplewith
mentalillnessonantipsychoticmedication,suchas
theLesterUKAdaptation–PositiveCardiometabolic
HealthResource.24
Giventhatmedicationplayssuchasignicant
roleinweightgain,itisimportantthatpeopleare
givenaccessibleinformationaboutmedicationand
potentialside-effectsbeforemedicationisprescribed.
Thiswouldallowpeopletobemoreawareofthe
risksandwhattheyshouldbelookingoutfor,and
howtheirphysicalhealthwillbemonitoredalongside
theirmentalhealth.Howeverthisiscurrentlynotthe
case.ArecentCQCsurvey 25ofcommunitymental
healthservicesfoundthatonly44%ofpeople
feltthesideeffectsofmedicationhadbeenfully
explainedtothem.Ifpeoplearen’tequippedwith
theappropriateknowledge,theyandtheircarerscannotmakeinformeddecisionsabouttheircareand
treatment.Theyalsocannottakestepstomitigatethe
side-effectsoftheirmedicationandphysicalhealth
complicationscandevelop.
“ It’s so sad when one has cared for an 18-year-old at the time of their rst psychotic illness and then one doesn’t recognise themwhen one meets them again ve years later because they are
10Kg heavier. Psychiatrists need to take more responsibility for thephysical health of their patients because some GPs and hospitalphysicians don’t like treating people with psychosis.”
ProfessorSirRobinMurray,ChairoftheSchizophreniaCommission
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“My son was a t and active teenager who
enjoyed many sports at school and would
walk 15 miles easily. He was over 5ft 10in
and weighed less than ten stone. At 19, he
was admitted to a psychiatric unit and givenhaloperidol which increased his appetite. He was
then diagnosed with schizophrenia, and given
olanzapine, after which the weight piled on.
Now, at the age of 33, my son has diabetes and
has been prescribed statins. We all wish we had
known the potential side-effects of olanzapine
and that another drug with less drastic
drawbacks could have been available.”
Anonymous,RethinkMentalIllnesssupporter
Accessing physical health care
Thereareanumberofbarriersforpeopleaffectedby
mentalillnesswhenaccessingphysicalhealthcare
andmonitoring.
AlthoughGPsareobligedtoofferpeoplecertain
physicalhealthchecksannuallyaspartoftheQuality
OutcomesFramework(QOF),thisisnotaawless
system.SomeofthetestsintheQOFareonlyofferedtopeopleover40yearsold,meaningtherecould
besignicantdelaysinaddressingphysicalhealth
concernsifpeoplehavebeentakingantipsychotic
medicationsincetheir20s.
Practicescanalso‘exceptionreport’oromitpeople
fromtheirQOFresultsincertaincases.Exception
reportingformentalhealthisparticularlyhigh
comparedwithotherhealthconditions.In2011/12
theexceptionreportingratewas11.8%,comparedto0.5%forcancer.26
Thesehighexceptionratesaresometimesputdown
toaperceivedreluctanceofpeoplewithmental
illnesstoengagewithGPs.However,peoplecannd
itverydifculttoaccessGPsurgeries.Theymightbe
anxiousaboutattendingormightstrugglewiththe
earlymorningbookingsystembecauseofmedication
side-effects.GPpracticesneedtomakesure
reasonableadjustmentsareinplacesothatpeople
arenotmissingoutoncrucialcare.
Whenpeopledoaccesshealthservices,their
physicalhealthneedsareoftenignoredorseen
asamanifestationoftheirmentalhealthcondition,
ratherthanaseparatehealthissue.This‘diagnostic
overshadowing’iswelldocumented27andleadsto
physicalconditionsbeingundiagnosedanduntreated,
whichcanprovefatal.Concernsraisedbycarerscan
alsobeignored.
Thislethaldiscriminationhelpstoexplainwhypeople
withsevereandenduringmentalillnessappear
toaccesssignicantlylowerquantitiesofseveral
commonmedicationsforphysicalhealthconditions. 28
26 NHSInformationCentre,2012.Quality and Outcomes Framework Achievement, prevalence and exceptions data 2011/12.
27. Thornicroft,G,Rose,D,Kassam,A.,2007.Discriminationinhealthcareagainstpeoplewithmentalillness.International Review of Psychiatry ,
April19(2),pp113-22
28. AshighlightedinRoyalCollegeofPsychiatrists,‘Wholepersoncare:fromrhetorictoreality.Achievingparitybetweenmentalandphysical
health’,OccasionalpaperOP88,2013,referringtoMitchellAJ,LordO,MaloneD.Differencesintheprescribingofmedicationforphysical
disordersinindividualswithv.withoutmentalillness:meta-analysis.Br J Psychiatry 2012;201:435–43.
“It seems that once you have a mental healthdiagnosis any physical symptoms you experienceare instantly assumed to be part of yourdiagnosis. Once that assumption is made it isdicult to get anyone to attempt to disprove it.”
AnonymousRethinkMentalIllnessmember
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Poor physical health monitoring
Peoplewithseriousmentalillnessneedcomprehensive
physicalhealthmonitoringatleastonceayeartohelp
withriskfactors,suchasweightgainassociatedwithantipsychoticmedication.However,therecentNational
AuditofSchizophrenia(NAS)revealedthat,onaverage,
only29%ofpeoplehadreceivedafullcheckofBody
MassIndex(BMI),smoking,bloodpressure,blood
glucoseandlipidsintheprevious12months.Insome
Trusts,thisnumberwasbelow15%.Wewouldliketo
seemoretraininginphysicalhealthcareandhealth
promotionforallmentalhealthpractitioners.Mental
healthnursesshouldbeabletoprovidebasicphysical
healthcareandprogressionthroughtrainingshould
dependuponthis.
Thislargevariationinresultsshowsthatthereisan
inconsistentapproachacrossthecountryandthat
physicalhealthisnotbeingproperlyprioritised.
Certainaspectsofphysicalhealthcare,including
weightorBMI,wereonlycheckedinaroundhalfof
cases,withsomeNHSTrustsweighingjust30%
ofpatients.29Thisisparticularlyworryinggiventhe
linkbetweenmedication,weightgainandhealth
problems,suchasheartdisease.Evenwhereproblemsareidentied,actionisoftennottakento
addressthese.TheNationalAuditofSchizophrenia
showedthatonlyoneinvepeoplewithraisedlipid
levelsandoneinfourpeoplewithhighbloodpressure
wereofferedthenecessaryintervention.
RethinkMentalIllnesshasbeenholdingsummits
acrossEnglandtodiscusstheseissueswithhundreds
ofpeopleaffectedbymentalillnessandwithhealth
professionals.Againandagain,wehaveheard
thatthephysicalhealthcareofpeopleaffectedbymentalillnessisfallingthroughthegapsbetweenGP
servicesandsecondarymentalhealthcare.Itisoften
unclear,bothtoprofessionalsandpeopleaffected
bymentalillness,whoisresponsibleforcoordinating
thissupport.Asaresult,nosupportisoffered.This
responsibilityneedstobeclariedsothatpeople’s
physicalhealthisn’toverlooked.Toolslikethe
IntegratedPhysicalHealthPathwaycouldsupport
professionalstoagreeprocesseslocallysochecks
arenotmissed.30
ACTIONS FOR THE NHS
• Commissionersandserviceproviders
needtobeclearabouttherespective
responsibilitiesofprimaryandsecondary
careservicesformonitoringandmanaging
thephysicalhealthofpeoplewithmental
healthproblems.
• Everyonebeingprescribedantipsychotic
medicationshouldbegivenclearand
accessibleinformationabouttherisksand
benetssotheycanmakeaninformed
choiceaboutmedication.Physicalhealth
monitoringshouldstartfromthevery
beginningoftreatmentwithidentiedhealth
needsquicklyactedupon.
• EachCCGandmentalhealthprovider
shouldworkwiththelocalDirectorofPublic
Healthtoensurethattargetedsmoking
cessationservicesandsupportareboth
availableandpromotedtosmokerswith
schizophreniaandpsychosis.
• Allsmokingcessationservicesmustcheck
thementalhealthstatusoftheirclients.
Theirstaffneedtohavementalhealth
trainingtoensuretheyoffertheappropriatelevelofsupport.Theyshouldalsorecord
whethersomeoneistakingmentalhealth
medication,toensuredosagesarechanged
asnecessary.
• Allmentalhealthprofessionalsshould
receivebasicphysicalhealthtrainingaspart
oftheirmandatorytraining.Mentalhealth
nursesshouldbetrainedtocarryoutsimple
physicalhealthchecks.
• RatesofpeopleaccessinginterventionsincludedintheQualityandOutcomes
Framework(QOF)tobeinlinewithpredicted
prevalenceoftheillness.
Evidencealsoshowsthatpracticenursesconsulted
withpeopleaffectedbymentalillnessonlyoncea
year,comparedwiththegeneralpracticepopulation
rateofalmosttwiceayear.31Practicenurseshavea
crucialroletoplayinhealthpromotionandpreventionand,giventhehigherriskofarangeofphysicalhealth
problems,thisisamatterofconcern.
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ACTIONS FOR GOVERNMENT
TheGovernmentsaysmentalhealthisoneofitstoppriorities,butthishasnottranslatedintoaction
ontheground.
TheDepartmentofHealthandPublicHealthEnglandneedto:
• PrioritisetheneedsofpeopleaffectedbymentalillnessintheHealthSecretary’sforthcoming
strategyonprematuremortality.Asignicantproportionofavoidabledeathsarelinkedtomental
illhealth.Thismustberecognisedandactedupon.
• HoldNHSEnglandtoaccountfordeliveringprogressonreducingtheprematuremortalityof
peoplewithmentalillnessinlinewiththeNHSOutcomesFrameworkandthecommitmentinthe
NHSMandate.Denetheprogresstobemade,howlongitwilltakeandhowitwillbemeasured.
• Takeactiontoensurethateverysmokeraffectedbymentalillnessisofferedtailored‘quit
smoking’supportandinterventionsinlinewithNICEguidance.
• AmendNHSandCCGoutcomesindicatorstomeasureaccesstoproveninterventions,notjust
physicalhealthchecksandratesofdeath(e.g.proportionofpeoplewithmentalillnessaccessing
smokingcessationservices,proportionofeligibleindividualsaccessingEarlyInterventionfor
Psychosisservices).
• AmendtheQualityOutcomesFramework(QOF)toensurethatphysicalhealthscreeningis
availableforpeopleassoonastheytakecertainmedications,notjustattheageof40.
• NHSEnglandandCCGsshouldconsideranannualmortalityreviewbeingincludedaspartof
theircontractformentalhealthtrusts.CommittosustainingtheNationalAuditofSchizophrenia
foraminimumofafurtherveyearstomonitorimpact,andextendtheremitoftheauditto
includeallinpatientsettings.
29. RoyalCollegeofPsychiatrists,2012.Report of the National Audit of Schizophrenia (NAS) 2012.London:HealthcareQualityImprovementPartnership.
30. RethinkMentalIllness,2012. Integrated Physical Health Pathway .
31. ReillyS,PlannerC,HannM,ReevesD,NazarethI,LesterH.,2012.Theroleofprimarycareinserviceprovisionforpeoplewithseveremental
illnessintheUnitedKingdom.PLoS One (7).
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Case study: Tracey Butler (39), Hampshire
0 Rethink Mental Illness. Lethal discrimination.
Tracey developed type 2 diabetes when she was just 22 years old after her
GP failed to properly monitor the side-effects of her antipsychotic medication.
She thinks medical professionals do not take her physical health concerns
seriously because of her mental illness.
“Ihaveschizoaffectivedisorderandborderline
personalitydisorder,andwasrstprescribed
antipsychoticsinmyearlytwenties.AfterI’dbeen
takingthemforaround18months,Istartedtonotice
theimpactitwashavingonmyphysicalhealth.I
feltcompletelyexhaustedallthetime,thirstyand
dehydratedandIconstantlyhadtoruntothetoilet.
IwenttomyGPbecauseIwasconvincedsomethingwaswrong.Buthedismissedmyconcerns,he
wouldn’tentertaintheideathattheremightbe
somethingseriousgoingon.
Aboutayearpassedandthesymptomscontinued
togetworse,beforeIwasnallydiagnosedwithtype
2diabetes.Mydiabetesconsultanttoldmethatthe
symptomsIhadgonetomyGPaboutwereclear
earlysignsofthecondition.Healsosaidthatitwas
theantipsychoticsthathadcausedmydiabetes.
Seventeenyearslater,Istillhavetogoregularlytothe
diabetesconsultant.
WhenI’munwell,I’mnotgreatatlookingaftermyself.
ItcanbequiteabigundertakingtogotoseemyGP,
andIreallydoneedthemtotakemeseriously.As
soonasamedicalprofessionallooksatmyrecords,
theysee‘borderlinepersonalitydisorder’ashingup
onthescreenanditfeelsliketheystoplisteningto
me.TheyjustthinkI’mneuroticorparanoid.
Therealsodoesn’tseemtobeanycommunication
betweenmyGPandmypsychiatrist.Ithinkitwould
makeabigdifferenceiftherewas.
Inmyexperience,GPsrarelyknowmuchabout
mentalillness.Onetime,myGPcalledmeaftera
routinebloodtest,sayingthatImighthaveatumour
inmybrainbecausetherewasanunusuallyhighlevelofprolactininmyblood.Thissentmeintoastateof
greatdistressandIhadapanicattack.ButwhenI
calledmycommunitypsychiatricnurse,hetoldme
theprolactinlevelinmybloodwasprobablycaused
bytheantipsychotics.Thatturnedouttobethecase
–therewasnotumour,itwasjustaside-effectofmy
medication.Agreatdealofworryandanxietycould
havebeenavoidediftheGPhadknownmoreabout
theside-effectsofthemedicationIwason.”
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Change is possible
There is reluctance from some to tackle this problem, due to a belief that it’s
‘too difcult’. However, some Trusts are getting it right and are proving that it
can be done. Here are some best practice examples:
Lancashire Care Trust
LancashireCareTrusthastakenaproactive,holistic
approachtoimprovingphysicalhealthoutcomes.
BytriallingandadoptingthePhysicalHealthCheck
toolfromRethinkMentalIllnessandembedding
itacrosstheTrust,theyhavedrasticallyimproved
physicalhealthmonitoringandintervention.
TheTrustrstpilotedthePhysicalHealthCheckin
itsrecoveryteam.Theresultswerestartlingand
includedidentifyingundiagnosedhighblood
pressure,diabetesandcancer.TheTrustthen
decidedtoimplementtheCheckandsetitasa
serviceimprovementstandardacrossawiderrange
ofservices.
TheTrustthereforecommittedtoofferingeveryone
usingtheirmentalhealthservicesaPhysicalHealth
Check.Tosupportthis,theTrustofferedtraining,support,awarenessraisingactivitiesandinvolvedall
staff,notjustnurses.Itdevelopedformalguidance
ontheCheckforsocialcarestaffandappointedlocal
physicalhealthleadsacrosstheTrust.
ThecompletedPhysicalHealthCheckisworkedinto
theperson’scareplansothatbothphysicalhealth
andmentalhealthneedscanbetreatedholistically.
Whereissuesareidentied,Truststaffproactively
ensurethatthesearefollowedupandliaisewith
primarycarewherenecessary.Staffmembersatthe
TrusthavehighlightedtherolethePhysicalHealth
Checkhasplayedinidentifyingserious,andpossibly
fatal,healthconditions.TheTrustcollecteddatafrom
thephysicalhealthchecksitundertookin2011/12and
2012/13.Theseshoweda30%decreaseinpreviously
unidentiedhealthneedsinthelatestroundof
checks.ThissuggeststheTrustissuccessfully
catchingthingsearlyandtakingaction.
Lancashire’sfocusonphysicalhealthcontinuesto
grow.FromApril2013,thePhysicalHealthCheck
hasbeenincorporatedintotheTrust’selectronic
records.Thisallowsforbetterrecordingofand
reportingonphysicalhealthneedsandoutcomes.
ThereisongoingworkandcommunicationwithGPs
andotherprimarycareprofessionalsandtheTrust
continuestodriveimprovementsinthephysical
healthservicesitprovides.
Solent NHS Trust
SolentNHSTrustadultmentalhealthservicesare
improvingtheirmanagementofdiabeticpatients
anddevelopingcloselinkswiththediabetesclinic
atthelocalhospitaltoimprovecare.Thisincludes
introducingthesamediabeticpathwayonadmission
asthegeneralhospital.Theunitisalsoarrangingfor
stafffromthediabetesclinictoauditthediabetescareitoffersonmentalhealthwards.
Thetrustisalsolookingatwhatfoodisofferedto
peopleonmentalhealthwards.Atrafclightsystem
outliningthenutritionalcontentoffoodshasbeen
introducedsopeoplecanmakeinformedchoices
abouttheirmeals.Vendingmachinesarealsobeing
stockedwithhealthieroptions.
ThisworkisfacilitatedbytheClinicalMatron
forHealthandWellbeing,whohasbothRGNand
RMNtraining.Bybeingabletotakemoreofa
teachingandadvisoryroleontheward,otherstaff
feelbettersupportedtoaddressphysicalhealth
concernsandkeyworkingrelationshipscanbebuilt
upwithotherservices.
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Barnet, Eneld and Haringey:Early Intervention in Psychosis Service
Inthisservice,physicalhealthisgivenhighpriority.
Ithasaclearprotocolaroundphysicalhealthmonitoringrightfromwhenpeoplerstcometothe
service.InformationisinitiallyrequestedfromtheGP
forthepreceding12monthsandtheserequestsare
proactivelyfollowedup.Ifsomeoneisnotregistered
withaGPorrefusestoattendanappointment,
thereareproceduresinplaceforensuringcrucial
monitoringandassessmentstilltakesplace.Once
theseassessmentshavetakenplace,relevant
informationissharedwiththeappropriateparties.
Severalstaffwithintheservicehavecompleted
aspecialistundergraduatetraining,focusingon
practicalskillsandtheresearchandknowledge
underpinningidentiedinterventions.Thereisalso
adedicatedstaffmemberwhohasresponsibilityfor
keepingarecordofphysicalhealthmonitoringand
anyoutstandingchecks.Theprogrammehasbeen
wellreceivedbytheTrustandtherearehopesthatit
mightbeadoptedbyotherteamsacrosstheTrust.
“The barriers to better physical health care for people withserious mental illness are related as much to communication andknowledge as the obstacles we are already aware of, i.e. diagnosticovershadowing, inexible GP services, medication side eects andmotivational problems. In respect of knowledge, there seems tobe a consensus that mental health nurses lack both the trainingand the condence to manage common physical health problems.However, we’re nearly there.... we know what the issues are, let’swork out a way to tackle them. Let’s enable our service users to
get the physical health care they deserve.”
SueBlakely,SupportingHealthNurse,ManchesterMentalHealthandSocialCareTrust
The Northampton PhysicalHealth and Wellbeing Project
SheilaHardy,NurseConsultantand
VisitingFellowattheUniversityof
Northamptonshire,hasdevelopedtraining
forpracticenursesandcarriedoutresearch
onthephysicalhealthneedsofmental
healthpatients.
Shehasfoundthatcontrarytopopular
belief,patientswithseriousmentalillness
willattendhealthchecks,andproper
traininginthisareaforpracticenurses
increasesthelevelofscreeningandlifestyle
advicegiven.
Thenecessaryguidanceandtools
neededforsettingupanurse-ledclinicand
carryingoutahealthcheckforpeoplewith
seriousmentalillnessareavailableonline
(http://physicalsmi.webeden.co.uk/).This
allowsnursestofollowbestpractice
guidanceeveniftheyhavenoaccesstoformaltraininginthisarea.
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How Rethink Mental Illness is tackling this
Formanyyearstheseriouslyneglectedphysical
healthneedsofpeoplewithmentalhealthproblems
hasbeenapriorityforRethinkMentalIllness.We
havebeenshoutingaboutthisshockinginequalityfor
aslongaswecanremember.Weknowthatchangeonlyhappenswhensolutionsareidentiedalong
withnamingproblems.Inoureffortstoovercomethe
hurdlesthatpeoplefaceinaccessingappropriate
andtimelyphysicalhealthcare,wehavespentthe
lastdecadeinpartnershipwithprofessionalbodiesto
tacklethisissueinpracticalways.
Wedevelopedtoolstohelpprofessionalsassessand
identifykeyphysicalhealthconcerns.Wecreated
accessibleonlinephysicalhealthresourcesand
training,toraiseawarenessandbuildcondencearoundsupportingpeople’sphysicalhealthneeds.
Wewroteguidesforhealthpractitioners.We
createdaPhysicalHealthChecktoolwhichenables
professionalsandpeopleaffectedbymentalillnessto
developplanstogethersothattheycanaddressany
unmetphysicalhealthneeds.
Workingwithpeoplewithlivedexperience,we
producedguidestohelpindividualsgetsupportfor
theirphysicalhealth.Wedevelopedtoolstohelp
peoplespeakoutandcampaignforchange.Werun
adviceandinformationservices.Wehelpasmany
peopleaswecomeintocontactwithandspendthe
littleresourcewehavespreadingthewordaboutthe
importanceofphysicalhealth.
Wewantthosewhocommissionanddeliverlocal
servicestogetaninsightintothephysicalhealth
issuesthatpeopleaffectedbymentalhealth
experiencesowefacilitatediscussionbetween
commissioners,professionalsandthoseaffected.Wecreateopportunitiesfordecisionmakersand
peopleaffectedbymentalillnesstoworktogether
todeveloppoliciesandpracticethatcanleadto
improvementsintheirareas.Andwehavetirelessly
promotedthesetoolsandresourcestoanyoneand
everyoneweencounter.
Wehaverealisedmuchmoreisneeded.Toenable
thesignicantchangethatisurgentlyrequiredinthe
NHSandbeyond,wehavethismonthlauncheda
country-wideInnovationNetwork.Inpartnershipwithmentalhealthproviderorganisations,weare
workingtoembedexcellentphysicalhealthcare
acrossthesystem.
ItistimefortheGovernmenttodoitspart.
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Conclusion
Whiletherearesomepocketsofgoodpracticein
thesystem,mostpeoplewithmentalillnessare
beingbadlyletdownwhenitcomestotheirphysical
health.Thismeansmanythousandsofpeopleare
dyingneedlesslyeveryyearandmanymoreareleftstrugglingwithlongtermconditionssuchasdiabetes.
Manyfactorscontributetothisstateofaffairs,
creatingoneofthebiggesthiddenhealthscandals
ofourtime.
Bynotacting,theGovernmentandtheNHSare
allowingsomeofthemostvulnerablepeopleinour
societytobetreatedassecondclasscitizens.We
wouldneveracceptthisstateofaffairsforother
patientgroups,andweshouldn’tacceptitforpeoplewithmentalillness.Weknowwhatthesolutionsare
andtheyarenotcomplexorexpensive.Allweneed
nowisthepoliticalwill,atbothnationalandlocal
level,tomakechangehappen.
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For more information on our wide rangeof physical health resources, please visit
www.rethink.org/phc.
Leading the way to a better
quality of life for everyone
affected by severe mental illness.
ForfurtherinformationonRethinkMentalIllness
facebook.com/rethinkcharity twitter.com/rethink_
www.rethink.org