Case Study: Whole Practice Approach

Aim and rationale: The aim of this GP practice approach was to give people with severe mental illness the best care they can have and get to know their population with SMI. They wanted to make relationships with people with SMI and not just tick boxes. They felt this was possible as the SMI population in their practice is small (90 out of 10,000 patients).

Preparation and organisation: After finding out about the SMI project from ICN in October 2022, the practice staff agreed that this was worthy of their time. They set up a team to organise the delivery of physical health checks for people with SMI consisting of the practice manager (PM), a care coordinator (CC), and a GP. They had support from the rest of the partners and team to take this on. The CC attended the online WORTH course for administrators. The GP attended the WORTH face-to-face training for healthcare professionals and has watched all the available films and videos. Patients with SMI are invited to see a healthcare assistant or nurse prior to their health check for routine measurements and blood test, meaning that the GP has this information at the health check appointment. The PM sets up regular clinics for the GP to carry out the health checks. In the first year the appointments were 45 min long but were reduced to 30 min in the second year; less time was needed as the relationships with patients had been built. People living in care homes are visited there. The CC books the health check appointments for people with SMI. Once a month the team meet for a morning or afternoon to discuss some of the patients with SMI and check the SMI register. Individual tasks regarding patients are dealt with daily as needed.

The health check The CC is present at the health check. He records the action plan. The GP performs a full physical examination and acts upon any findings as appropriate. Any measures or blood tests missed are performed. She also provides suitable lifestyle advice and makes referrals as necessary (e.g., weight management and stop smoking groups, opticians, and dentist).

Following the health check The CC sends a letter to the patient advising them of what was discussed in the health check. He then rings the patient to discuss the action plan and support them with any behaviour change identified. The GP sees patients again when she has introduced or changed a medication, and when a clinical issue is identified during the check.

Overcoming challenges: Some people with SMI have not responded to the invitation for a health check. The CC rings them to encourage them to come. On one occasion a patient has walked out of a consultation but did return for another appointment, which went well. The focus has been on building trust with this group. The team feel that the remuneration provided by ICN does not cover the cost of providing the service they are giving.

Outcomes: Outcomes have been positive: Patients have got to know the GP and CC. They appear more open and relaxed when attending. Several safeguarding issues have been identified and dealt with. Concerning symptoms have resulted in 2 week wait referrals being made. Other medical conditions have been identified, for example, a person with aortic stenosis whose family were also screened. Cardiovascular risks factors have been identified and treated as appropriate. The team delivering this care feel proud and satisfied in what they are doing.

Recommendations to others: Providing this service needs to be a team effort. A care coordinator is necessary, and the rest of the practice team need to be supportive. Adequate time needs to be given to carry out the health check in order to perform all the required activities.