slam physical healthcare

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Physical health and

wellbeing handbook orservice users and carersLooking afer your physical

wellbeing in hospital andat home

Us together

Working together



At SLaM, we are dedicated to giving you the bestpossible care and we work to look afer yourphysical and mental health together. Your physicalhealth is very important and can ofen affect yourmental health so we’ll always look afer both. This booklet has been produced by staff and

service users at SLaM and is in two parts. The firstpart is about what physical health tests we cangive you while you’re in hospital and why they areimportant. The second part is about looking aferyour physical health and wellbeing at home.We’ve included a summary o the tests you canhave and there’s also a sheet or you to write down

your test results and notes on your progress.



Contents

Looking afer your physical 5

wellbeing in hospital

Timeline o physical health checks 6

Why do I need to have my physical 8health checked?

What physical health checks can I 10expect during my hospital stay?

Physical health checks during 12your inpatient stay

Who is this inormation shared with? 32

What else can I do to support my 33wellbeing whilst in hospital?

Smoking cigarettes during your 34hospital stay

Diet and exercise during your 36hospital stay

What happens when I am discharged? 37

Looking afer your physical 39

health at home

What physical health checks can 40I expect when I am at home?

What physical health problems 41might I be at risk o?

What positive action can I take 41to improve my health?

Taking control o smoking 42

Taking control o cholesterol 46

Taking control o blood sugar 47

Taking control o weight 48

Taking control o blood pressure 50

Attending or health screening 51check ups

Taking control o oral health 52

Taking control o the use o substances 53

Taking control o sexual health 56

Taking control o medicines 57

Pull out health tracker 60

Useul resources 62

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Lookingater your

physical

wellbeing inhospital



Timeline o physical health

6

TEMPERATURE

BLOOD PRESSURE

BREATHING

WAIST SIZE

AMOUNT OF OXYGEN IN YOUR BLOOD

BLOOD AND URINE

HEIGHT AND WEIGHT

WHAT & HOW MUCH YOU EAT/DRINK

PHYSICAL EXAMHEART RATE

TEMPERATURE

BLOOD PRESSURE

BREATHING

WAIST SIZE

AMOUNT OF OXYGEN IN YOUR BLOOD

HEIGHT AND WEIGHT

BLOOD TESTSHEART RATE

Looking afer your physical wellbeing in hospital

FIRST 72-HOURS

OF ADMISSION

DURING YOUR

TIME IN HOSPITAL



checks

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BLOOD TESTS

FOR SUGAR AND

CHOLESTEROL

REVIEW OF PHYSICALCHECKS

YEARLY CHECKS OF

HEIGHT AND WEIGHT

BLOOD TESTS FOR SUGAR

AND CHOLESTEROL

CHECK SMOKING, PHYSICAL

ACTIVITY AND ALCOHOL USE

BLOOD PRESSURE

AT

HOME

THREE MONTHS

AFTER NEWMEDICATION



We do this so we can: • identify and treat any early signs

of physical health problems

• prevent or treat any physical healthproblems associated with medicinesyou take for your mental healthcondition

• continue any care and treatment youmay have been getting from yourfamily doctor or another hospitalservice before you came into hospital

• put you in touch with a GP if youdo not already have one

• keep you safe

You, your nursing and medical team

need to get a good idea of howhealthy you are when you rst comeinto hospital. This is important, assometimes physical health conditionsmay be causing or contributing to yourmental health symptoms. Assessingyour physical health is just as importantas assessing your mental health.

Why do I need to havemy physical healthchecked?


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Physical healthchecks during your

inpatient stayIn this next section, we explain a bit more aboutthe tests we will offer you, why the test is being

offered and how it will be carried out.



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1

Temperature

Why do we do this?Body temperature can be affected ifyou have an infection, by taking certainmedicines, if you are dehydrated andeven if you are very emotional. We needto know if your temperature is too low,normal or too high because this can helpus plan your care and treatment.

What happens?A nurse will take your temperature at leasttwice a day in the rst few days of your

stay. We will check your temperature usingan electronic thermometer which is placedin your ear for a few seconds. The nursewill tell you what the result is and writeit down on a chart. We will continue tomonitor your temperature regularly if youare prescribed certain medicines (such asclozapine) or if you feel or look unwell.

What do the results mean?Normal temperature is around35-37°C. A high temperature is a

normal response to an infection andcan be easily treated with uids andcareful monitoring.




Blood PressureWhy do we do this?We measure blood pressure so we can seehow well this part of your circulatory systemis working. A nurse will measure your bloodpressure at least twice a day for the rst fewdays and regularly throughout your stay.

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• If the nurse is measuring your bloodpressure by hand, she will place a

stethoscope on your arm just belowthe cuff and listen to your pulse whilstthe air is being let out. If it ismeasured electronically the machinedoes this and there is no need tolisten through a stethoscope

• It is best to do this three times to getthe most accurate reading

• The nurse will tell you the result and

write it down on a chart

What do the results mean?• Blood pressure is measured in

millimetres of mercury (mmHg).Ideally, our blood pressure shouldbe lower than 120/80 mmHg

• The rst number is called the systolicblood pressure. It is the highest level

your blood pressure reaches whenyour heart beats

• The second number is called thediastolic blood pressure and is thelowest level your blood pressurereaches as your heart relaxesbetween beats

• High blood pressure is diagnosedif readings on a number of separate

occasions consistently show yourblood pressure is 140/90 mmHg orhigher. If this happens, your doctorwill discuss treatment options suchas having further tests to nd outthe cause or prescribe a medicineto lower you blood pressure backto a healthy level. Later in thebooklet, we discuss some ideas for

keeping your blood pressure in ahealthy range.

A blood pressure that is too low can leadto things like fainting and falls, whereas

a high blood pressure, if untreated forlong periods may cause problems suchas kidney damage or stroke. We usuallycannot tell if our blood pressure is toohigh as there are no obvious signs andsymptoms. The only way we know is bymeasuring it. Some medicines can causelow or high blood pressure, so before wecan give you certain medicines, we need

to check if your blood pressure is okay.

What happens?Blood pressure can be measured eitherelectronically or by hand (manually).

• We will ask you to sit down withyour arm supported on a table orarmrest. Sometimes we will checkyour blood pressure lying downand standing up

• A cuff is wrapped around yourupper arm

• The cuff is inated and you will feelit tightening

• The air is then slowly let out ofthe cuff

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Why do we do this?The amount of oxygen in our bloodis affected by such things as smoking,asthma or dehydration. We need to

know if the blood is carrying enoughoxygen throughout your body, butparticularly to your brain and heart.

What happens?We take an estimate of the amount ofoxygen in your blood (also called oxygensaturation) by placing a small device(called a pulse oximeter) on one ofyour ngers. The device shines a lightthrough one side of your nger and adetector measures the light that comesthrough the other side. Blood cells thatare full of oxygen absorb and reect

light differently than those with notenough oxygen. Anything that absorbs

light can give a false reading (such asdark nail varnish). Also, movementcan give a false reading so you will beasked to keep your hand still while theoximeter is clipped onto your nger.The nurse will tell you the result andrecord your results on a chart.

What do the results mean?Normal readings are 94-100%. If yourreading is below this, your doctorwill discuss treatment options suchas having a blood test to check thisfurther or prescribe oxygen therapy.

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The amount o oxygenin your blood

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PulseWhy do we do this?We check your pulse to measure yourheart rate – how many times yourheart beats in a minute. Our heart ratecan be affected by things such as toomuch activity, anxiety, side effects ofmedication, too much tobacco, caffeineor alcohol, heart disease, dehydrationor an overactive thyroid gland.

What happens?A nurse will measure your pulse byplacing two ngers on the inside of yourwrist. The nurse will tell you the resultand record your pulse on a chart. The

doctor who admits you will also want tolisten to your heart using a stethoscope.As well as checking how fast your heartis beating, we are also checking to seeif your heartbeat is strong or weak andhow regular it is.

What do the results mean?Most adults have a resting heart ratebetween 60 and 100 beats a minute.The tter you are the lower yourheart rate will be. If your heart rate is

consistently over 100 beats a minute,your doctor will discuss treatmentoptions with you, such as havingfurther tests to nd out the causeor recommend medicines to loweryour heart rate.

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g y p y g p



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Electrocardiogram

Why do we do this?

Another routine test we carry out tocheck how healthy your heart is, is anelectrocardiogram (ECG). This recordsthe rhythm and the electrical activity ofyour heart. Before some medicines areprescribed it is important to check howhealthy your heart is. The doctor and youwill decide on how often you need tohave this test.

What happens?• The test only takes a few minutes. It is

simple, quick and completely painless

• We will ask you to lie down on a bedor couch. To get the best possiblereading, relax and lie still.

• A nurse or doctor trained to carry

out ECGs will do the test• A number of sticky patches called

electrodes will be stuck onto yourarms, legs and chest

• The electrodes are attached to arecording machine by wires

• When your heart beats, it produceselectrical signals which are picked upby the electrodes and transmitted tothe recording machine

• These signals can be seen on a screenor are traced out on a piece of paper

• The sticky patches are removed andthrown away after the test

• We will tell you the results once thereading has been checked

What do the results mean?

The ECG machine prints out a recordingof the rhythm of your heart. Yourmedical team will read, interpret andinform you about the result. They willbe able to tell if your heart is healthy oris too fast, slow or irregular. If needed,your doctor will discuss treatmentoptions with you, such as further testsyou may need.

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Weight and heightWhy does this matter?Being a healthy weight helps to controlour blood pressure and blood glucose(sugar) levels, and helps reduce the

risk of heart disease and diabetes. Wemeasure your weight at the beginningof your stay so that we know if you arelosing weight or gaining weight duringyour time in hospital. It is not unusual

for weight to increase when you rststart taking medicines for a mental

health problem. We want to try andhelp prevent weight gain from the verybeginning of your treatment.

As well as regular weighing, another wayto check if you are a healthy weight foryour height is by calculating your bodymass index (BMI). This is an estimate ofbody fat. The higher your BMI is, the

higher your risk for certain diseases suchas heart disease, high blood pressure andtype 2 diabetes.

What happens?• A nurse will measure your weight

(in kilograms) and height (in metres)

• Your BMI is worked out by dividingyour weight by your height

• Then dividing the number you getfrom this by your height again togive you a BMI score

• The nurse will tell you the results andrecord it on a chart

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What do the results mean?Your BMI score gives you an idea if you

need to take action about your weight.

There are slightly different guidelinesdepending on your ethnic group. Mostof the research about the health effectsof BMI scores has been carried out

If you fall into the overweight orobese categories and would like help

to reduce your weight and BMI, thenwe can discuss this as part of yourcare plan.

White European population Asian population What does the score mean? What action can I take?

Below 18.5 Below 18.5 Underweight You may need to put on weight

18.5 to 24.9 18.5 to 23 Normal This is ideal, you should aim to stay this way

25.0 to 29.9 23 to 27 Overweight It would be a good idea to try and stop

further weight gain or lose some weight

30.0 and above 27.5 and above Obese Losing weight will improve your health

with people from an Asian background.The World Health Organisation and the

Department of Health recommend thatpeople from an Asian background needto take action when their BMI score isslightly lower compared to people froma white European background.

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Waist size

Why do we do this?Rather than just measuring overall bodysize, in recent years experts now thinkthat measuring waist size may be a betterway to predict if we are at risk of gettingdiabetes and cardiovascular disease. This

is because fat stored around our middleis unhealthier than overall body fat.

What do the results mean?These are the guidelines for how bigour waist should be. The higher thewaist size, the more at risk we are ofdeveloping heart disease and diabetesin the future. As we mentioned earlier

when we discussed BMI scores, thereare different guidelines depending onyour gender and ethnicity.

Ethnicity Gender Take action if your waist size is: White European Men 94 cm (37 in) and above

Women 80 cm (31.5 in) and above

Asian Men 90 cm (35 in) and above Asian Women 80 cm (31.5) and above

What happens?• A nurse will wrap a tape measure

around your waist

• To accurately measure this, the tapemeasure is wrapped around yourwaist halfway between the top of

the hip bone and the lowest rib(it usually crosses your belly button)

• You will be asked to breathe out andhold your breath whilst the nursetakes the measurement

• They will tell you what the results areand record this on a chart

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If you fall into the at risk category andwould like help to reduce your weightand waist size, then we can talk to youabout this as part of your care plan.




Urine tests

Why do we do this?We can tell lots of helpful things bychecking urine, such as if you have aninfection, are at risk of diabetes or ifyou are dehydrated.

Sometimes we may ask to test your urinefor illegal drugs, such as cannabis. We dothis as part of an agreed care plan and

we will always ask your permission rst.

What happens?A nurse will give you a small plasticbottle or container to urinate into. Wetest your urine using a dipstick, a smallstrip of plastic to test different parts ofyour urine. This takes about 30 seconds.

What do the results mean?This can check if you have sugar in your

urine, which can tell us if you are at riskof diabetes; if it has protein in it, whichcan alert you if you have a problem withyour kidneys; or if you have bacteriain it, which can be a sign of infection.Sometimes we may want to send off asample for further testing to help usplan any treatment.

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Sugar levelsWhy do we do this?Sugar levels in our body uctuatedepending on what we eat and drink

and how active we are. They can alsobe affected by some medicines and howstressed we feel. High levels of sugar inthe blood can happen if we have toomuch food and there is not enoughinsulin in the body to balance bloodsugar. This can make us feel tired andnauseous. Low blood sugar can happenif we have not eaten enough or there istoo much insulin in the body to balance

blood sugar and can cause shaking, afast heartbeat, sweating, tiredness andirritability. Changes in blood sugar may bea sign of diabetes. Over a long period oftime high sugar levels can damage bloodvessels and can lead to heart disease.

What happens?• A glucose test strip is inserted into

a glucose monitor

• The tip of one of your ngers is cleaned

• Your nger is pricked using a sterilelancet and a drop of blood squeezedonto the test strip

• The glucose monitor reads the test strip• You are given some cotton wool to

clean your nger

• The nurse will tell you the result andrecord it on a chart

What do the results mean?There are differing opinions about theideal blood sugar range, so it is best todiscuss this with your nurse or doctor. Forthe majority of healthy people a normalblood sugar level is around four to sixmmol/L. This depends on the time of daythe test is done. Blood sugar will usually

be lowest in the morning and be higherafter meals. If your results are consistentlylow or high, the doctor will talk to youabout treatment options with you, such asfurther blood tests to nd out the causeand changes to your lifestyle.

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Why do we do this?The body needs to balance its uid intakewith uid loss. Often when our mentalhealth deteriorates, we neglect whatwe eat and drink. We may eat and drinktoo much or not enough and can easilybecome dehydrated and malnourished.

Dehydration happens when the bodyhas less water than it needs to functionproperly. Signs of dehydration include:

• dry mouth• feeling thirsty• headache• feeling tired• urine darker than usual

• passing less urine than usual• feeling dizzy and lightheaded• feeling confused• low blood pressure• fast, weak pulse• cold hands and feet

Consequences of ongoing dehydrationcan cause constipation. It can also leadto problems with the kidneys, muscles,liver and circulation.

What happens?In the rst few days of your stay, we

will make a note of what and when youare eating, how much you are drinkingand when you go to the toilet. We willalso ask you if you have any problemswith eating food such as swallowingand chewing.

What do the results mean?We will be able to tell if you may bedehydrated and help you improve

your uid intake. If you are havingany problems with chewing orswallowing food, we can discuss theadditional support you may like.

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Eating and drinking

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Why do we do this?Looking after the health of our skinis important to our overall wellbeing.Some medical conditions can lead toskin problems, such as dry skin or fungalinfections. Having problems movingaround may also make it difcult tocare for ourselves and affect our skinfrom too much pressure and reducedblood ow in a particular area.

When our mental health gets worse, itis not unusual to overlook simple thingssuch as washing or bathing and takingcare of our hygiene as we normallywould. Looking after our hair, nails andteeth can be easily forgotten about.Washing clothes may even becomedifcult. Alternatively, we may becometoo preoccupied with our hygiene andwash ourselves too much. Over a periodof time, this may lead to problems suchas rashes, skin, nail or dental infections.Paying attention to our hygiene not onlyprevents problems from developing, italso helps us feel good about ourselves.

What happens?We will ask you if you have any problemswith caring for your hygiene. If you raiseany concerns or we see any problems, wewill ask you what help you would like.We can provide you with toiletriesduring your stay and assist you with anyhygiene needs. We can also help you withwashing your clothes. If you are at risk ofdeveloping skin problems (e.g. if you havediabetes), we will check your skin, nailsand feet during your physical checks.Skin problems may need treatment withcreams or dressings and regular check ups.

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Skin care and personal hygiene

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Blood testsWhy do we do this?Blood tests are one of the most commontype of medical tests and can tell usabout the general state of your health,e.g. if you are anaemic or have aninfection, and how well your heart,liver and kidneys are working. Bloodtests can also help nd problems early,

when treatments or lifestyle changesmay work best.

These are examples of the tests wetake blood for:

Full blood count (FBC): This can helpidentify if you have anaemia and ifyou have enough white blood cells,which help ght infection.

Electrolytes: We check the levels of some

minerals in the blood such as sodium andpotassium. Dehydration, vomiting anddiarrhoea, or uncontrolled diabetes canaffect electrolytes. These results can giveus an idea if your heart and kidneys areworking well and the effects of somemedicines, such as blood pressure tablets.

Liver function test (LFT): We need tocheck how healthy your liver is as most

of the medicines we prescribe for youare broken down by the liver.

Glucose test: This can tell us how muchsugar is in the blood. High levels of sugarcan be a sign of diabetes. This test is themost accurate if blood is taken about eighthours after eating. If this is too difcultthere are similar tests we can do that donot require you to stop eating.

Thyroid function test (TFT): This cantell us if your thyroid gland is workingproperly. An overactive thyroid can causenervousness, anxiety and weight losswhereas an underactive thyroid can causedepression, tiredness and weight gain.

Cholesterol test: This checks the fats

in your blood to make sure they are in ahealthy range. This test is more accurateif you don’t eat anything for about eighthours before your blood is taken.

Blood born viruses (hepatitis B andC and HIV): Hepatitis (inammation ofthe liver) and HIV, is more common insouth London compared to other partsof the country. Similar to local GPs and

A&E departments, SLaM routinely offerblood tests to test for these conditions. Ifdetected early, these conditions respondwell to treatment and the earlier youknow about these conditions, the moresuccessful treatment will be.

If you do not wish to have these testsplease tell your doctor.

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What happens?

• A tight band (tourniquet) is usuallyput around your upper arm totemporarily slow down the ow ofblood out of the arm to make iteasier to take the sample

• A sample of blood is taken from theinside of the elbow or wrist, this iswhere the veins are close to the surface

• A needle attached to a syringe or a

special blood collecting tube is gentlypushed into the vein

• You may feel a slight pricking sensationas the needle goes in, but it should notbe painful

• We usually test for a few things at thesame time, so more than one tubemight be attached to the needlebefore it’s taken out of your arm

• When the sample has been taken,

the needle will be removed andthrown away

• Pressure is applied to the tiny break inthe skin for a few minutes using acotton-wool pad to stop the bleeding

• The sample is sent to a differenthospital to be tested, so it may take afew days before we know the results

If you do not like needles, tell the personwho is taking the sample so they canmake you more comfortable.

What do the results mean?

Many medical problems cannot bediagnosed with blood tests alone.However, blood tests can help you andyour doctor learn more about yourhealth. Your doctor will discuss yourresults with you. Your doctor will talkabout your results with you and if they’reoutside the normal range you can talkabout what to do next.




If you are prescribed certain medicines,it is helpful to know how much of themedicine is in your blood. This can guideus about the daily amount of medicationthat is best for you and make sure you

are not getting too much or too little.

Many research studies suggest thatclozapine is the most effective medicinefor treating psychotic experiences.However, it can cause the levels of whiteblood cells to drop. The white cells in theblood are made up from lots of differenttypes of cells and are important for thebody’s immune system and for ghtingany signs of infection. Sometimes

clozapine and to a lesser extent all theother types of antipsychotic medicinescan cause a reduction in white cells andmake people more vulnerable to ghtinginfections. People who are prescribedclozapine have their blood monitoredvery closely - weekly when it is rst

prescribed and eventually monthly.The risk of harming the white cellsreduces the longer the medicine istaken. However, the risk never entirelygoes away, which is why all the timesomeone is prescribed clozapine,blood tests will be needed. Symptoms of a very low white cell

count can include fever, chills andinfections, such as recurrent bacterialthroat or skin infections, and constantbody aches and pain. This condition isvery rare and constant monitoring isa good way of preventing any seriousconditions and means the drug canbe altered or stopped.

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Blood levelso prescribed

medication

Blood tests orpeople takingclozapine



As part of any admission to a hospital,whether it is to a mental health unitor a general hospital ward, a doctorwill want to carry out a routineexamination. For example:

• They will want to check yourabdomen by gently feeling your

stomach, liver and kidneys to seeif they feel tender or swollen

• They will also check your strength,coordination, reexes and howyou respond to light and touch

• They will examine your joints andmuscles to see if there is anystiffness or pain

Physical health as well as mental healthproblems can get in the way of having agood night’s sleep. During your time inhospital, the staff will monitor how wellyou sleep. They will take note if you sleep

during the day. The night staff also needto monitor how well you sleep at night.They should check on you at least onceevery hour and make a note of it. Theydo this to make sure you are safe and

also because your doctor and team needto know what your quality of sleep is likeas they may need to alter your treatment.As long as everything is ne, they won’tdisturb you when you’re asleep.

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What otherchecks can I

expect?

We also want toknow how well

you sleep




The results of any health checksand blood tests are recordedin your medical records. Thesewill be both in paper form andcomputerised form. We will let

your GP know about the resultswhen you are discharged so thatwe and your other healthcareproviders can give you thebest possible care. For moreinformation, please ask for theTrust information leaets ‘Use ofpersonal information: your rights’and our leaet on condentiality.

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Who is this

inormationshared with?



The care programme approach (CPA) isa way of making sure you get the bestsupport and care for your recovery. Itincludes an assessment and care plan ofboth your mental and physical health.

Your care plan is a joint writtenagreement of the care you can expect.It should include relevant informationabout what physical health care willhelp you, the frequency and type ofphysical health checks available and whois responsible for providing each part ofyour care. Following your discharge fromhospital, at each CPA review, it is helpfulto discuss your progress for both yourmental and physical health.

There are lots of things you and yourmental health team can do to worktogether to support your physicalwellbeing during your inpatient stay.All hospital sites have informationavailable about their range of healthand wellbeing activities, such ashow to access the hospital gym,swimming or yoga classes. It may alsobe helpful if you work with otherhealth professionals during your staysuch as a dietician, exercise trainer,stop smoking specialist or chiropodist.

Taking control of what we eat, howactive we are and stopping smokinghave all been linked with bettermental health.

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How does

my physicalhealthcare fitinto the careprogrammeapproach?

What else can I

do to support mywellbeing whilstin hospital?



If I am a smoker, what support will Iget whilst I am in hospital?

We can support you to temporarily or permanentlystop smoking whilst you are in hospital.

• We will look at your smoking behaviourand how dependent you are on nicotine

• We will work with you to understand whyyou are addicted to cigarettes and how theyt into your life

• We will help with tobacco withdrawal

symptoms by providing you with nicotinereplacement therapy (NRT) throughout your stay

• We will explain how NRT works and howto get the best out of it

• We will also provide emotional andpsychological support to help with the cravings

• We will regularly check the effects of reducing/ stopping smoking on your mental healthand medication levels

• When you are discharged, we will link youup with a stop smoking specialist in yourlocal community

There are many positive reasons why stoppingsmoking is good for your overall wellbeing.

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When people are recovering, theirappetite often improves. Also, someof the medicines we prescribe maymake you feel more hungry and thirsty.

We will work with you to make surethat you still enjoy food whilst tryingto stop you gaining any more weight.For a diet to be considered healthy, weneed to balance the amount of foodwe eat with how active we are, andalso eat a range of foods. Men needaround 2,500 calories a day to keeptheir weight stable whereas womenneed around 2,000. However, peopleneed fewer calories than this if theyare not very active and spend most oftheir day sitting down.

The latest guidelines from theDepartment of Health suggest weshould do at least two hours and 30minutes of moderately intense activityeach week. This means being active

enough to get slightly warmer, out

of breath but still be able to talk.They also suggest we do some musclestrengthening activities at least twicea week.

Every ward has access to an exercisetrainer. These are valuable membersof the team who can assess yourcurrent level of tness and work outan individual exercise programme tosuit your tness needs and condence.

More information on diet andexercise can be found in this booklet.You can also nd more informationon the ward.

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Diet andexerciseduring yourhospital stay



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Lookingafer your

physicalhealth athome

39

Looking afer your physical health at home



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What physicalhealth checks can

I expect when Iam at home?

People with specic mental health andphysical health conditions are invited toattend their GP practice every year.

During these appointments you arelikely to be asked:

• if you smoke and how much: if youare a smoker, you will be offeredsupport to stop

• if you drink and how much: if youdrink too much, you will be offeredsupport to cut down

• if you are a woman aged between25- 65 they will check if you have

attended for cervical screening inthe previous ve years

Your GP or practice nurse willalso monitor:

• your blood pressure• body mass index (BMI)• take blood to check sugar and

cholesterol levels

For people without mental healthconditions, GP practices have recentlyintroduced ‘NHS checks’ for all theirpatients aged between 40 and 74.These ve yearly checks aim to identifypeople at risk of preventable conditionssuch as heart disease, stroke, diabetes,kidney disease and dementia.

If you are invited to attend to see yourGP; it will be helpful to your overallwellbeing to attend. You can takealong a family member, friend oradvocate to support you.



The answer to this is quite simple.People with a mental health conditionexperience exactly the same physicalhealth problems as everybody elsesuch as heart disease, diabetes, cancerand respiratory diseases. People with

a mental health condition oftenexperience some physical healthproblems more frequently and insome cases more severely.

Most physical health conditions arepreventable. Poor physical health is notinevitable. Being fully aware of potentialproblems gives you a true choice in

whether or not to take on board theinformation and act to change things.

There are a number of things that increaseor lower your chances of getting heartdisease, diabetes, cancer and respiratorydisease. Some risk factors cannot bechanged, for example the older you getthe more at risk you are and if one of

your parents has heart disease you willbe more at risk.

However, the good news is there any manythings we can take control of, such as:

• stopping smoking• reducing cholesterol• maintaining a healthy weight• controlling blood pressure

• controlling blood sugar• attending health screening checks• maintaining good dental health• avoiding drinking too much alcohol• avoiding illegal drugs• practising safe sex• managing your medication

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What physicalhealth problems

might I be atrisk of?

What positiveaction can I take

to improve myhealth?




Why does it matter?

• Smoking is the main cause ofpreventable death and disease in theUK and throughout the world. Abouthalf of all smokers will die too soon,losing on average about 10 years of life

• If you are a smoker, you are not onlymore likely to have poor physicalhealth but also poorer mental healththan someone who does not smoke

• Adults with mental health problems,including those who misuse alcohol ordrugs smoke up to four times morethan people who don’t have a mentalillness. This is one of the main reasonswhy people with a mental illness tendto die younger than people who arementally well

• Tobacco smoke contains around 7000chemicals, including 60 poisonous onesthat are known to cause cancer

• Even if you are not a smoker, breathingin second-hand smoke increases yourchances of getting lung disease andheart disease by up to 60%

• People with a mental illness whosmoke have more severe mental healthsymptoms and need higher doses ofantipsychotic medication

• The tar in tobacco smoke speeds upthe metabolism of some antipsychotic

medication (chlorpromazine,clozapine, olanzapine, uphenazine,haloperidol and zucopenthixol)and some antidepressants andbenzodiazepines (e.g. amitriptylineand diazepam)

• This means that smokers often needhigher doses of medicines comparedto non-smokers to have a similarclinical effect. This is becausethese medicines do not stay in the bodylong enough to work efciently

• When people cut down or stop smokingthey need to have the dosage oftheir medication closely monitoredand possibly reduced. This is becausethe tar from the smoke is no longerin your system to speed up themetabolism of the medicines

42

Taking controlo smoking

Smoking andmental healthmedicines



Smokers, carers and mental healthclinicians sometimes believe smokinghelps them feel less stressed, improvesmood and reduces anxiety. The realityis - smoking simply medicates the effectsof nicotine withdrawal that occur several

times throughout the day. The nicotinefrom a cigarette does not stay in thebody for very long and as nicotine levelsstart to drop you start to have withdrawalsymptoms, such as nicotine craving,irritability, anxiety, restlessness, low moodand poor concentration.

To prevent these awful feelings, theeasiest and quickest thing to do ishave another cigarette

Research shows that current smokershave the highest levels of stress, anxiety

and depression compared to ex-smokersand people who have never smoked.Once people have managed to quit forabout four weeks, their stress andanxiety levels actually reduce.

43

The mythof smoking

cigarettesto help withstress




44

Stopping smoking is one of the best thingsyou can do to improve your overall health.However, many smokers (with or without a

mental health problem) struggle to give up,or manage to give up and then go back tosmoking. It’s easier to take control of yoursmoking if you have support. Getting supportfrom an NHS stop smoking service greatlyincreases the chance of successfully stoppingcompared with having no support.

What help isavailable i Iwant to stopsmoking?

Local NHS Stop Smoking Services

Croydon: Lennard Rd.Freephone 0800 0198570

Lambeth: Sanscroft St, Kennington.Freephone: 0800 8563409

Lewisham: Waldron Health Centre,Amersham Vale, New Cross.Freephone: 0800 0828388

Southwark: Clinical Treatment Centre,Maudsley Hospital.Freephone: 0800 1696002



Why does it matter? Cholesterol is a type of fat. The bodyneeds cholesterol to help make certainvitamins and hormones and can makeenough cholesterol of its own. We alsoget extra cholesterol from some of thefoods we eat.

Too much cholesterol can lead to seriousproblems like heart disease. A highintake of animal fats such as meat,eggs and cheese are the main cause of

excess cholesterol. It’s not just eating toomuch fat that causes high cholesterol;smoking contributes to it, as does havinghigh blood pressure, diabetes or anunderactive thyroid.

If you are on antipsychotic medication,you will need to have a blood test aboutthree months after starting treatmentand then at least every year to check yourcholesterol levels. This is because somemedicines may increase cholesterol levels.

To take control of your cholesterol,you may want to consider…

• Eating a healthy diet

• Regular exercise

• Stopping smoking

There are also medications calledstatins that can be prescribed by yourGP if your cholesterol is not reducedfrom diet and exercise alone.

It might be helpful to keep a recordof your cholesterol levels and whenyour next test is due in the healthcheck results tracker in the back ofthis booklet.

46

Takingcontrol ocholesterol



Why does this matter?Diabetes is a condition that often goesundiagnosed for many years. Thisdelay can mean you’re more at risk of

problems with your eyes and damage toyour kidneys and nervous system. Thesymptoms of diabetes can be inuencedby a family history of diabetes, smoking,physical inactivity, poor diet and theeffects of some medicines.

To take control of your blood sugarlevels, you may want to consider…That glucose (sugar) monitoring is not

only necessary for people with diabetes.If you do have diabetes you will needto monitor your levels at least twice aday using test strips that you can get onprescription from your GP. However, ifyou are taking an antipsychotic medicine

you should have your blood tested threemonths after you are prescribed themedicine and every six–12 months afterthat to assess your sugar levels.

It is important that you and your carerswatch out for the early signs andsymptoms of diabetes. These can includepassing urine more often than usual,especially at night, feeling thirstier thanusual, extreme tiredness, losing weightwithout trying, blurred vision, and slowhealing of cuts and wounds.

Report any of these symptoms to yourGP or care coordinator. Again, as withall areas of health, diet, exercise andstopping smoking will improve glucosecontrol. Every GP practice will have anurse who specialises in the prevention

and management of diabetes. Theycan be a great source of support andinformation so make sure you see themif you need to.

47

Taking control ofblood sugar




Why does it matter? Being a healthy weight will help control

your blood pressure and blood sugarlevels, and helps reduce the risk of heartdisease and diabetes. It is not unusual forweight to rapidly increase when you rststart taking some medicines.

To take control of your weight, youmay want to consider...

• That maintaining a healthy weight

involves balancing the calories fromthe food and drink we eat with theamount of calories we burn throughbeing active

• To lose weight in a healthy way weneed to use up more calories than weeat, such as by being more active

• Losing weight slowly and steadily ismuch healthier than going on a crashdiet. Skipping meals is not a helpfulway to lose weight either – it onlymakes snacking on cakes, biscuits andsweets more tempting. Planningmeals a day or two in advance insteadof making decisions on a moment tomoment basis gives you more controlover what you eat

• Eating healthily: the currentrecommendation from the Departmentof Health is that our diet should mostlybe made up of fruit, vegetables andstarchy foods such as wholegrainrice and pasta or potatoes. The restshould consist of proteins such asmeat, sh or beans as well as a smallamount of dairy (e.g. milk, eggs and

cheese). Foods that contain sugar andfat, such as cakes and biscuits, shouldonly make up a very small amountof our diet

• Sometimes people are not sure whereto start with healthy eating and mayneed a bit of guidance. There willbe professionals in your mental health

team, such as occupational therapistsand dieticians who are a good sourceof information and practical advice

• Getting enough exercise: A number ofstudies have demonstrated the positivebenets of exercise on both physicaland mental health. To stay healthy orto improve health we need to do twotypes of physical activity each week:

aerobic and muscle strengtheningactivity for about two hours and30 minutes

• Aerobic activities improvecardiovascular health and include briskwalking, cycling, jogging, swimmingand dancing, anything that gets yourheart rate up and gets you out ofbreath

• Muscle-strengthening exercisesimprove balance, muscle tone andbone health, increase the rate atwhich the body burns calories and canbe achieved by climbing stairs, carryingshopping, walking uphill, gardening,yoga or t’ai chi

48

Taking

control oweight



• We need to be creative about howwe can incorporate exercise into ourdaily routine without much effortor disruption – for example, exercisingfor two 10-minute slots each daymight be initially more achievablethan half an hour at a time on ve

days of the week. Your mentalhealth team and GP practice canoften help you get discountedmembership rates at your local gym orprovide you with information aboutlocal exercise/wellbeing classes

49




Why does it matter? When your heart beats, it pumps bloodround your body, and as the bloodmoves, it pushes against the sides ofthe blood vessels. The strength of thispushing is your blood pressure. If yourblood pressure is too high for a longperiod of time, it puts extra strain onthe heart and this may lead to a heartattack and stroke.

To take control of your bloodpressure, you may want to consider:

That lifestyle changes will lower your

blood pressure:

• eating more fruit and vegetables

• maintaining a healthy weight

• getting physically active

• stopping smoking

• eating less salt

If you are diagnosed with high bloodpressure, there is much you can do tolower it. The more you can reduce your

blood pressure, the lower your risk ofa heart attack or stroke will be. Highblood pressure is diagnosed if readingson a number of separate occasionsconsistently show your blood pressureis 140/90 mmHg or higher.

Medication for high blood pressureMedication to lower blood pressure isrecommended for people who havepersistent blood pressure readings over140/90 mmHg. People with diabeteswill be offered treatment if theyhave persistent blood pressure over130/85 mmHg. Just as with any othermedication, this needs to be takenconsistently for as long as it is prescribed,with regular blood pressure check ups.Machines that can be used at home can

be bought at your local pharmacy andare a useful way of keeping a check onyour day to day health.

It might be helpful to keep a record ofyour blood pressure in the health checkresults tracker in the back of this booklet.

50

Taking

controlo bloodpressure



Why does it matter? We are all at risk of cancer. There are anumber of cancer screening programmeswhich anyone can use. However, theuptake of cancer screening services isgenerally poor by people with mentalhealth conditions. Early detection ofcancer improves our chances of beating it.

You may want to consider…• Women between the ages of 25 and64 are eligible for a free cervicalscreening test every three to ve years

• The NHS breast screening programmeprovides free breast screening everythree years for all women aged 50 to 70

• The most recent screening programmeto be introduced in the UK is for bowelcancer. This offers screening everytwo years to all men and women aged60 to 69

When you become eligible for any cancerscreening, your GP will automaticallysend you a letter inviting you to attend

the GP practice or local hospital. It is veryimportant not to ignore these letters. Ifyou are uncertain or reluctant to attend,speak to your GP or mental healthteam, who will be able to give you someinformation and help in nding someoneto come with you to the appointment.

You can also keep a check on your ownhealth by self-examination. You can pickup a leaet from your GP surgery orcheck online about breast and testicularself-examination. These resourcesprovide simple instructions about whatto feel and look for and what to discusswith your GP.

51

Attending forhealth screeningcheck ups




Why does it matter? People with a serious mental illness havehigher rates of tooth decay and tooth losscompared to mentally healthy people. Poordental health is linked to diseases such asheart disease and stroke. Bacteria from ourmouths can enter the bloodstream frombleeding gums; once bacteria gets into thebloodstream, it can lead to clotting inside

blood vessels, increasing the risk of heartattacks and stroke.

You may want to consider that…A number of things cause poordental health, such as

• smoking (which causes the gums andbone to recede as well as tooth loss)

• poor diet (e.g. food and drink withhigh sugar content)

• excessive alcohol (which can erodethe enamel on the outside of theteeth, leading to decay)

• some medicines (which reduces theow of saliva in the mouth resultingin dry mouth)

• poor oral hygiene (e.g. forgettingto brush your teeth, not goingfor check ups)

52

Taking control o oral health



Why does it matter? People who have a mental illnessand drink alcohol excessively or useillicit drugs face a greater challengein maintaining their physical health.Alcohol often interferes with prescribedmedication. Short-term alcohol use canmake existing conditions such as heartdisease or depression worse. Long termalcohol use can result in heart andliver disease, as well as immune andgastrointestinal disorders. Drinking too

much over a long period of time can alsoincrease the risk of cancers of the mouth,throat, oesophagus, colon and breast.

Illegal drugs such as cannabis, cocaineand amphetamines make mentalhealth problems worse. They also

cause many physical health problems.Regularly smoking cannabis (or anydrug) affects the lungs and can lead

to lung disease. Many people smoketobacco and cannabis together, whichmay well increase the risk of developingrespiratory symptoms even further.Stimulants such as cocaine increase theheart rate and blood pressure, which inturn increases the oxygen demand onthe heart. This can lead to a heartattack and breathing problems.

To take control of substance use,you may want to consider…That mental health services have accessto specialist professionals whom they canput you in touch with if you would like

further support. There are also specialistaddiction services throughout SLaMthat can be a great source of support in

helping you to cut down your drinking.There are a number of things you can doyourself to take control of your drinking.Simply monitoring how many units ofalcohol you drink over the course of aweek can help you decide if you needto take further action.

The NHS recommends that men shoulddrink no more than three to four units a

day and women two to three units a day.On the next page, there is a tool tohelp you work out if your drinking maybe a potential problem.

53

Taking

control ofthe use ofsubstances

Alcohol Use DisordersIdentificationTest (Audit)(World Health

AUDIT SCORING SYSTEM YOURSCORE

0 1 2 3 4




SCORE

54

(World HealthOrganisation, 2001) How often do you have a drink containing alcohol? Never Monthly 2-4 times 2-3 times 4+ times

or less per month per week per week

How many units of alcohol do you drink on a typical day when youare drinking?

1-2 3-4 5-6 7-9 10+ How often have you had 6 or more units if female, or 8 or more ifmale, on a single occasion in the last year?

Never Less than Monthly Weekly Daily or monthly almost daily

How often during the last year have you found that you were notable to stop drinking once you had started?


How often during the last year have you failed to do what wasnormally expected from you because of your drinking?


How often during the last year have you needed an alcoholic drinkin the morning to get yourself going after a heavy drinking session?


How often during the last year have you had a feeling of guilt orremorse after drinking?


How often during the last year have you been unable to rememberwhat happened the night before because you had been drinking? Never Less than Monthly Weekly Daily or monthly almost daily

Have you or somebody else been injured as a result of your drinking? No Yes, but not in Yes, during the last year the last year

Has a relative or friend, doctor or other health worker beenconcerned about your drinking or suggested that you cut down?

No Yes, but not in Yes, during the last year the last year

This is one unitof alcohol…

…and each of these ismore than one unit

Half pint of regular beer,lager or cider

Pint of regular Beer/ Lager/Cider

Pint of PremiumBeer/Lager/Cider

Alcopop or can/bottleof Regular Lager

Can of PremiumLager or Strong Beer

Can of SuperStrength Lager

Glass of Wine(175ml)

Bottle of Wine

1 small glass of wine

1 single measure of spirits

1 small glass of sherry

1 single measureof aperitifs

Scoring: 0 – 7 - Lower risk: 8 – 15 - Increasing risk: 16 – 19 - Higher risk: 20+ Possible dependence



The scores can help you work out if youneed to speak to a health professionalabout your drinking. They are just arough guide; you also need to consider

your medical history as well as yourcurrent symptoms

Audit score What might this mean?

0-7 This is okay, though it might

be helpful to read up on

alcohol and the possible

effects

8-15 You may just need simple

advice from your GP or

health professional about

how to avoid increasing

your alcohol use

Other simple things you might want totry if you’re thinking about cutting downyour drinking…

• alternating an alcohol drink with aglass of water so you stay hydrated

• drink a soft drink to quench yourthirst, rather than alcohol

• swap to a lower strength beer or wine

• only take a xed amount of money

out with you to buy alcohol or othersubstances

• educate yourself about the impact ofsubstances on your mind and body

• know what emotions and situationstrigger you to use substances

As well as services within SLaM, thereare a number of local voluntary andindependent services for people whowould like support with substance use.

What do thescores mean on

the AUDIT tool?




Why does it matter? There are many medicines (e.g.antipsychotics, antidepressants andtreatment for high blood pressure) thatcan make you feel like not having sex orreduce the pleasure you might get fromsex. A small number of medicines can

also cause problems such as painful,swollen breasts in both men andwomen and affect women’s periods.

Unprotected sex can lead to sexuallytransmitted diseases or diseases thatcan affect your immune system suchas HIV and hepatitis. It can also resultin pregnancy.

To take control of your sexualhealth, you may want to consider:that telling someone about yourconcerns will help your care team tochange your medication or help you getthe best support. People can feel a bitembarrassed talking about their sexual

health needs and end up never raisingthe issue. They are then left wonderingwhether some of the issues theyare experiencing are normal or area cause for concern. Don’t letembarrassment get in the way of thisimportant aspect of your health.

You can nd advice on sexual health

in a variety of places, such as your GP,sexual health clinics, family planning orcontraception clinics. There is a hugeamount of information you can accessonline that clearly and simply explainsall aspects of sexual health.

Considering contraceptionand safe sexThere are many different methods ofcontraception and every GP practice willhave a doctor or nurse who has specialtraining in this area who can discuss yourparticular needs or refer you to anotherprofessional. They can also advise aboutthe prevention of sexually transmitteddiseases and provide access to freecondoms. Sexual health clinics are avaluable source of support and can alsoprovide advice about any worries youmay have about any part of your sex life.

56

Taking control o

sexual health



Why does it matter? Taking medication is only one part ofstaying well, but it is an important part.

Medicines for mental health conditionsare usually part of a long term treatmentplan and work best if taken consistently.However, sometimes the side effectsof medication can get in the wayof taking them. All medicines haveunwanted side effects which may affectyour physical health, whether they areprescribed for the treatment of highblood pressure, for an infection or for

a mental health condition.

Sometimes it can be a delicate balancebetween getting relief from distressingsymptoms and avoiding side effects.Prevention, identifying side effects early,

and knowing how to manage themcan improve the experience of takingmedication.

What causes unwanted side effects?Medicines for the treatment of mentalhealth conditions work by increasing orreducing the effects of natural chemicals(neurotransmitters) in the brain. Thesenatural chemicals control various aspectsof behaviour, including mood andemotions, sleeping, alertness, eatingand interest in sex. Changing the amountof a natural chemical, (e.g. dopamineor serotonin) can be useful because itcan help reduce distressing experiences.However, although there have beenadvances in the design of new medicinesin the last 20 years, medicines forany health condition are still not thatsophisticated and also alter some ofthe natural chemicals we do not wantto change and this leads to unwanted

side effects.

Other reasons for sideeffects include…

• The dose may be too high or giventoo often

• The health of your stomach, liver andkidneys, e.g. if you are in poor physicalhealth, a drug may stay in the bodylonger than usual before it is excreted

• Taking two or more medicines atthe same time

Your prescriber or care coordinatorshould regularly review your medicationto see how well it is working for you andcheck if you have any side effects. Onthe next couple of pages we haveprovided a quick summary of everyday

medicines for mental health conditionsand their common side effects. Thesummary is adapted from the Maudsleyprescribing guidelines, written by leadingmedicines experts. We have also providedsome suggestions about how to dealwith side effects.

Everyone is different and some peoplemay be sensitive to a particular medicine

and have a side effect that is uncommonfor a particular drug, whereas otherpeople will be more resilient and mightavoid experiencing a common side effectassociated with a particular drug.

57

Taking controlof medicationand physicalwellbeing

Physical health side effects and antipsychotic medicines




Adapted from Taylor et al (2012) The Maudsley Prescribing Guidelines in Psychiatry

58

very common: moderately common: uncommon: rare: uncommon to rare:

very common: moderately common: uncommon: rare: uncommon to rare:

Physical health side effects and antidepressant medicines

Physical health side effects and antipsychotic medicines

Drug Amisulpride Aripiprazole Clozapine Haloperidol Olanzapine Quetiapine Palperidone Risperidone

Tremor/stiffness

Weight gain

Constipation

Low blood pressure

Diabetes Sexual problems

Drug Amitriptyline Citalopram Fluoxetine Lofepramine Mirtazipine Paroxetine Sertraline Venlafaxine

Nausea/sickness Weight gain

Constipation

Low blood pressure

Sexual problems



MY HEALTH

CHECK RESULTS

60

Check Range date date date date date date

Weight

BMI 18.5 - 24.9 (ideal)

25 & over (take action)Waist size Men: less than 94cm (ideal)

94cm or above (take action)Women: less than 80cm (ideal) 80cm or above (take action)

Blood Pressure 120/80 mmHg (ideal) 140/90 mmHg (take action)

Pulse 60-100 beats a minute (ideal) More than 100 (take action)

Breathing 12-18 breaths a minute (ideal) < 12, > 20 (take action)

Last Done Next due

Annual health check

Dental check

Eye check

Flu immunisation



61

TAKING CONTROL

OF MY PHYSICAL

HEALTH

date date date date date date

Blood tests

Cholesterol

Glucose

Next due Next due

The following lifestyle choices are the main cause of heart disease, respiratoryproblems and diabetes. Poor physical health is not inevitable. There are lots of smallthings you can do to take control and improve your general wellbeing. Sometimes it ishelpful just to focus on trying to change one thing at a time. Once you have achieved

your goal this is likely to give you condence to try and change something else.



Description of Goal Action I will take My progressBehaviour

Taking control E.g How manyof my cigarettes Ismoking smoke a day

Taking control E.g How manyof my units I drink

drinking a day

Taking control How muchof my exercise I haveweight a day, what my

diet is like




Organisation Contact details Description

NHS Choices www.nhs.uk This is the UK’s leading website for health information. The site draws togetherknowledge and expert advice about wellbeing, health conditions, treatment and localservices. It is accessible in over 50 languages and has leaets, videos, interactive toolsand mobile apps to use

British Heart www.bhf.org.uk The British Heart Foundation (BHF) is the UK’s leading heart charity. It funds researchFoundation BHF, Greater London House, and pioneering treatment in heart disease. They provide free resources to download

180 Hampstead Road, or order such as booklets and DVDs on prevention, education and treatment, advice London NW1 7AW on healthy eating, exercise and smoking Tel: 0300 330 3311

Diabetes UK www.diabetes.org.uk The leading diabetes charity in the UK provides information and education about Macleod House, the prevention of diabetes as well as care and support for people with type

10 Parkway, London, 1 and 2 diabetes NW1 7AA Tel: 020 7424 1000

62

Useul resourcesThere are lots o local and national resources where you can find

additional inormation to support your wellbeing. Local inormationis available through your mental health team. Below are someexamples o national organisations that you may find helpul.



British Lung www.blf.org.uk The UK’s leading charity for lung diseases. It provides information and educationFoundation British Lung Foundation about lung conditions, a helpline and support groups

73-75 Goswell RoadLondon, EC1V 7ER

Tel: 03000 030 555 Cancer www.cancerresearchuk.org The UK’s leading cancer charity provides information and education about theResearch UK prevention and treatment of all types of cancer

Smokefree www.smokefree.nhs.uk NHS support for help with stopping smoking. Provides information, education andEngland NHS Stop smoking helpline: support to quit, DVDs, interactive tools and mobile apps

0800 022 4332 Rethink www.rethink.org One of the UK’s leading mental health charities, which has resources, checklists andMental Head Ofce,15th Floor information on improving physical health and wellbeing for people with a mental 89 Albert Embankment health condition London, SE1 7TP Tel: 0300 5000 927 Mental www.mentalhealth.org.uk One of the UK’s leading mental health charities, which has resources and informationHealth Colechurch House on improving physical health and wellbeing for people with a mental health conditionFoundation 1 London Bridge Walk London SE1 2SX Tel: 020 7803 1100 MIND www.mind.org.uk Another of the UK’s leading mental health charities, which has resources and 15-19 Broadway information on improving physical health and wellbeing for people with a Stratford mental health condition London E15 4BQ Tel: 020 8519 2122

63



Design: Bigfrankmedia.com

Published: January 2014Review date: January 2016

Acknowledgements

This booklet is the result o a collaboration betweenservice users and staff at SLaM and The Institute oPsychiatry, King’s College London. We would like to thankthe ollowing or their contribution: Debbie Robson,Alex Harwood, Annie Jordan, Jaqueline Best-Vassell,Natalie Warman, Fay Guest, Anne Middleton, RoslynByfield and the artists.

Art creditsFC: Sky Birds Ingrid Andrew, P3: For the trees 1 Sara Rivers,

P4: What the heart holds Ingrid Andrew, P11: Let the light inIngrid Andrew, P33: For the trees 2 Sara Rivers, P37: RousseauCalling Terence Wilde, P38: House Near Sancreed Elena Brebner,

P47: Spring Blossom with Interior John O’Donnell, P51: Help!Ingrid Andrew, BC: Untitled Nick Farey

slam physical healthcare

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