Annual physical health checks

The physical health inequalities faced by people with severe mental illness are not unavoidable.
Annual physical health checks were introduced to address these inequalities: as part of this, everyone on the SMI register is invited to an annual physical health check.
Physical health checks assess alcohol use, blood glucose levels, blood lipid levels, blood pressure, body mass index (BMI) and smoking status.

In NHS guidance on physical health checks, severe mental illness (SMI) is defined as a recorded diagnosis of bipolar affective disorder, schizophrenia or any long-term psychotic illness (NHS England, 2018b), although people in ‘remission’ are excluded from this register. This definition is used because of the cardiometabolic risks associated with antipsychotics; rather than implying that other mental health conditions are not ‘serious’ or ‘severe’, or do not have their own physical health risks (NHS England, 2018b).

What is the evidence base for annual physical health checks?

One large scale study found that annual physical checks for people with SMI are associated with a lower risk of attendance at Accident and Emergency services, hospital admission due to mental illness and lower overall healthcare costs (Jacobs et al., 2020).
Evidence shows that there are effective interventions which support people with severe mental illness to improve physical health, such as managing antipsychotic-induced weight gain (Álvarez-Jiménez et al., 2008). However, if people are not offered help and support after their health check, it is very unlikely that their physical health, and therefore morbidity and mortality rates, will improve (How to Improve the Physical Health of People with Severe Mental Illness, 2021).
This is the key emphasis of the cardiovascular intervention framework, the Lester Tool, the core principle of which is ‘don’t just screen – intervene’.

Local model for annual physical health checks

The Cambridgeshire and Peterborough ICS Health and Wellbeing Strategy set the target that 60% of people on the SMI register should receive annual physical health checks, as a key priority for tackling inequalities. This is in line with the NHS Long Term Plan (NHS England, 2018a). The local aim in 2023/24 is that at least 80% of people on the SMI register will receive their annual physical health check and be offered an additional 20-minute follow-up appointment where useful, to support them to access interventions to improve their physical health.

Since 2020, Specialist Health Care Assistants (SHACs) have offered to deliver SMI physical health checks to all patients in GP practices within Cambridgeshire and Peterborough. The Specialist Health Care Assistants:

Deliver 12-point annual physical health checks, including echocardiograms (ECGs) if needed, as well as flu and COVID-19 immunisations.
Provide 45-minute appointments for physical health checks, with an offer of 20 minute ‘follow-up’ appointments to support access to interventions as needed.
Provide physical health checks within a primary care setting and offer a home visit option if patients cannot attend their GP surgery for any reason.
Have strong pathways and links to voluntary sector and local authority resources, including digital resources.
Deliver medical monitoring of people with mild-to-moderate eating disorders.

By 2022/23, Specialist Health Care Assistants delivered 80% of all annual physical health checks in Cambridgeshire and Peterborough, with GP practices delivering the remaining 20% due to patient choice or circumstance.

Personalised Care Support Plans (PCSP) have been developed in collaboration with service users and the SUN (Service User Network) and were rolled out across the county in April 2023 to support the ambition of patients and healthcare truly taking a holistic approach to the patients’ needs.

How many people receive annual physical health checks?

Cambridgeshire and Peterborough was the highest performing area in the East of England in 2022/23, in terms of the proportion of people on the SMI register having their annual physical health check against the Long Term Plan target agreed with each ICB.
There has been a consistent increase in the uptake of physical health checks in Cambridgeshire and Peterborough from the start of 2021/22, with 63% of people on the SMI register receiving all six physical checks by the first quarter of 2023/24.

Figure 89: Proportion of people on the SMI register who have received all six physical health checks within the past 12 months in Cambridgeshire and Peterborough, 2019/20 – 2023/24. Data source: NHS England

The proportion of eligible people who have received different elements of the physical health checks varies. There is a consistently higher rate of blood pressure checks, and consistently lower rate of blood lipid and alcohol checks, although this gap is closing. For example, in the first quarter of 2023/24, the uptake of checks was (NHS England, 2018a):

75% for alcohol
79% for BMI
76% for blood glucose
72% for blood lipid
82% for blood pressure
78% for smoking

Figure 90: Proportion of people on the SMI register who have received physical health checks in Cambridgeshire and Peterborough within the past 12 months, 2019/20 – 2023/24. Data source: NHS England

How does physical health check uptake vary by general practice?

In the three years since the implementation of Specialist Health Care Assistants, there has been an increase in the uptake of annual physical health checks across the system.

Figure 91: Uptake of annual physical health checks across 89 general practices in Cambridgeshire and Peterborough, 2020/21 – 2022/23.

How many people receive physical health checks within mental health services?

There has been a sustained drive in CPFT to improve the percentage of inpatients that receive a physical health check within 24 hours of admission. The uptake of physical health checks does not show significant variation across ethnic groups or deprivation.

Figure 94: Proportion of inpatients who receive a physical health check in CPFT, April 2022 – October 2023.

Data from the National Clinical Audit of Psychosis (NCAP) report in 2022/23 suggested that 60% of people with first episode psychosis using CAMEO had a physical health review and relevant interventions in the last year. This may not reflect the true picture, as there have been issues with data access and recording.

What do people say about this service?

Feedback from people who received annual physical health checks from Specialist Health Care Assistants shows that almost everyone felt they were contacted about their appointment in a way that was right for them and that the staff listened to them. Feedback in 2022/23 (289 respondents) found that:

96% of people felt they were contacted about their appointment in a way that was right for them.
72% said they were given enough information about the appointment and why they had been invited before they attended their appointment.
93% of people felt that the Specialist Health Care Assistant listened to any concerns they may have had around their mental or physical wellbeing.
90% said the appointment met their expectations.

What are the outcomes of annual physical health checks?

In March 2023, there were 7,128 people on the SMI register, of whom 4,667 (65%) received a full physical health check within the past 12 months. Out of people who had received a health check, the following were given additional support through Specialist Health Care Assistants:

1,241 (27%) had their heart assessed using a 12 lead ECG.
1,135 (24%) were supported to access physical health services (such as cancer screening, cardiovascular risk assessment, dental care).
575 (12%) were supported to access health behaviour services (relating to smoking, weight or exercise).
378 (8%) attended a 20-minute follow-up appointment to explore health behaviour or physical health services that might benefit them.

Figure 92: Outcomes of annual physical health checks in Cambridgeshire and Peterborough, 2020/21 – 2022/23.

Referrals to smoking cessation services

Referrals to smoking cessation for people who received physical health checks from Specialist Health Care Assistants have been analysed, the links to interventions for the other risk factors (alcohol, blood glucose, blood lipid, blood pressure and BMI) are unknown.

In Cambridgeshire and Peterborough, at the end of year March 22/23, there were:

7,128 people on the SMI register.
1,977 people on the SMI register were recorded as smokers.
80 people who received an annual physical health check were referred for smoking cessation support (such as Healthy You or support within their general practice).

Figure 93: Breakdown of people on the SMI register by smoking status, Cambridgeshire and Peterborough ICS, end of year March 22/23

However, this data has several limitations:

It is likely to underestimate the number of people on the SMI register who were smoking at this time, because not everyone was asked about their smoking status.
It may underestimate the number of referrals to smoking cessation services, as it only includes referrals made by health care assistants within the Annual Physical Health Checks (APHC) team. Other healthcare professionals, such as GPs, may have also made referrals to these services.
It does not record whether people attended smoking cessation services or were successful in cutting out or reducing their smoking.

Models for improving physical health outcomes

One way of understanding and tackling inequalities in health is through the framework of inclusion health. NHS England states that ‘inclusion health groups… require an explicit, tangible focus in system efforts to reduce healthcare inequalities’ (NHS England, 2023a). People with severe mental illness can be considered as an inclusion health group, as they face substantial social and health inequalities. For example, some people with severe mental illness may face difficulties navigating the healthcare system or have experiences of being turned away from healthcare services.

NHS England sets out five key principles of inclusion health: committing to action; understanding people’s needs; developing workforce; delivering integrated and accessible services; and demonstrating impact and improvement through action (NHS England, 2023a).

Figure 95: Five principles of inclusion health. Image source: NHS England

Successful examples which have improved outcomes from physical health checks include optimising pathways between primary and secondary care and offering tailored follow up support. This approach was taken by another NHS Trust as it was found that a high proportion of people with severe mental illness were already attending appointments in secondary care (Trueland, 2020). Practical adjustments (such as offering appointments at a different time or access to a quiet waiting area) may also make it easier for people to attend appointments (How to Improve the Physical Health of People with Severe Mental Illness, 2021).

Additional resources

References

Full list of references is included at the end of this chapter.