The Being Equally Well national policy roadmap: providing better physical health care and supporting longer lives for people living with serious mental illness

We have the knowledge and tools required to end the systemic neglect that contributes to the shorter life expectancy of people with serious mental illness

There is a stark divide of up to 23 years between the life expectancy of people living with serious mental illness, and that of their age peers in the population. More than 400 000 Australian people live with serious mental illness. ¹ Their life expectancy is 50–59 years. ² Between 80% and 95% of the causes of early death relate to physical illnesses such as cardiovascular disease, cancer, respiratory illnesses, and diabetes. ² , ³

This has been recognised as a national priority. In 2017, the Fifth National Mental Health and Suicide Prevention Plan, ⁴ agreed to by all health ministers, acknowledged that the quality of life and recovery of people with mental illness is impeded by serious physical illness. The Plan acknowledged that these outcomes are often “system driven, with unnecessary barriers within health services and unclear delineation between professional roles hindering a consumer’s ability to get the care they need”. ⁴

The National Preventive Health Strategy 2021–2030⁵ also includes a commitment to improving the preventive health care of people with serious mental illness. There are a range of initiatives in some state and territory mental health services and in some Primary Health Networks (PHNs) that are endeavouring to put these aims into effect. These are pockets of innovative work, but there is no universal or national approach or model, and the pockets of work are not consistent with each other.

Good work has not been enough

There is a lack of structured support for frontline staff and consumers to enable reductions in premature mortality from physical disease.

The Being Equally Well project aimed to create a strong, evidence‐ and consensus‐based suite of recommendations for health service and system improvements to enable consistent and effective health care improvements for all who live with serious mental illness. ⁶ Being Equally Well is an innovative joint venture between actors in primary care, chronic diseases, population health, mental health, and consumers and carers to develop implementable clinical service and system improvements. The project has been led by the Mitchell Institute at Victoria University, with the Australian Health Policy Collaboration, a national network of chronic disease and population health experts, and Equally Well Australia, a network of over 90 organisations working collectively to make the physical health of people living with mental illness a priority throughout the health system. The results are a suite of recommendations in the Being Equally Well national policy roadmap, ⁶ launched in August 2021 by the then Australian Government Minister for Health, the Hon. Greg Hunt. ⁷

A clinical microsystems approach was chosen for the project because clinical microsystems are the teams at the frontlines of care. General practices and mental health teams are clinical microsystems. It is at the frontline and only at the frontline that improvements in health outcomes are made. ⁸ At the macro system level are the federal and state governments and agencies. The meso system level includes acute health services and PHNs. The Being Equally Well project focused on quality across and within these system levels. The meso and macro systems can facilitate outcomes produced by the clinical microsystems. We chose this approach because most previous and current policies have meant little to people at the frontlines of care where consumers and their families meet the system. Consequently, little has changed. In Being Equally Well, frontline clinicians and consumers have designed changes which will lead to improvements in physical health.

An expert group of consumers and carers worked collaboratively with clinical system level and quality improvement working groups. They identified barriers and frustrations they had experienced, and developed a suite of measures of success from the consumer perspective. These comprise five domains for success: improved physical health; management of medication impact; relationships with health professionals; system navigation, support/equity of access and care quality; and peer support. Each of these has three indicators. ⁶ This framework provides a valuable checklist for health services, practitioners and policymakers as they engage with the roadmap recommendations. ⁹

Primary care and shared care are crucial

General practice will need additional resources and enhanced capability practice‐based registers and recall systems for people with serious mental illness. These will enable general practitioners to actively engage and support people to participate in screening and monitoring investigations and health checks — focused particularly on regular assessment and management of cardiovascular risk, blood pressure, cholesterol levels and smoking — and to promote participation in regular cancer screening programs.

At the heart of our recommendations is a system for learning and improvement at every level from general practices and mental health services to the national level (Box). ⁶ This will occur through monitoring and feedback in a similar way to the Australian Primary Care Collaboratives from 2004 to 2014, which covered nearly one‐third of general practices. ⁹

Box 1. Organisational chart for improved physical health outcomes among people with serious mental illness.

ABS = Australian Bureau of Statistics; AHPRA = Australian Health Practitioners Regulation Agency; AIHW = Australian institute of Health and Welfare; BEW = Being Equally Well; CQR = Clinical Quality Registry; GP = general practitioner; MBS = Medical Benefits Scheme; PBS = Pharmaceutical Benefits Scheme.

Data on risk factor management from practice registers would be fed into a National Mental Health Clinical Quality Register, with results fed back to practices showing how they compared against national averages. PHNs would belong to a national collaborative to support practices to learn from each other. An annual report and quality improvement plan on the outcomes for physical health conditions would be prepared and reported to the Australian Health Council. These would ensure national supervision at the highest level. ⁹

Data sharing is contentious for GPs, but they were prepared to submit data to the Australian Primary Care Collaboratives. The central organisation hosting the National Mental Health Clinical Quality Register would need to be chosen with care. The prime candidate is the Australian Commission on Safety and Quality in Health Care.

A new workforce of clinical navigators would support practices, liaise with mental health and local preventive services, and ensure that all consumers have a general practice home. Shared care arrangements have long been in place for aspects of health care where specialists and GPs need to work closely together, and where patient and consumer engagement is recognised as essential to good health care and outcomes. Intercollegiate clinical guidelines to support shared care by GPs, psychiatrists and consumers working collaboratively are strongly recommended. Shared care protocols would support implementation of guidelines.

The articles published in this MJA supplement support these efforts in several ways. First, a multifaceted change management approach would support care providers in applying shared care protocols. ¹⁰ , ¹¹ Without supporting levers and incentives, nothing will happen. The impact on workload and the cost of more comprehensive care could be recognised through the introduction of bundled care payments, better electronic clinical records, and real‐time computer decision support.

Further, community pharmacists provide readily accessible health services, are underutilised, and could contribute more to better management of psychotropic drugs. There are also significant potential roles for other allied health professionals and services. ¹²

Finally, peer worker support for physical health care is strongly endorsed by consumers and carers. A systematic review of peer‐facilitated interventions for physical health outcomes in individuals with schizophrenia spectrum disorders has identified benefits to physical health and mental health outcomes. ¹³ However, there are structural barriers to implementation that need to be addressed.

Nutrition and medication impacts

Consumers and carers are concerned about the impact of antipsychotic medication on weight, leading to a systematic review and meta‐analysis of interventions with a nutrition component. A meta‐analysis published as part of this supplement found that dietitian‐delivered, individualised interventions might be an effective approach. ¹⁴ In addition, a review that considered the cardiometabolic effects of using antidiabetic medications in people with serious mental illness supports a recommendation that these drugs be made available through the Pharmaceutical Benefits Scheme. ¹⁵

A resource for clinicians, health services and governments

The Being Equally Well roadmap ⁶ is a resource for GPs, for other primary health care and mental health professionals and services, for PHNs, and for local hospital and health districts and networks. It is also a map for governments and health system administrators, as frontline health professionals cannot achieve sustainable change without system improvements to support them.

The roadmap details other system enhancements that are needed to support the frontline of care in doing more to improve the physical health of individuals. These include:

• funding for shared care service provision;

• removal of financial barriers for medication, such as gap payments for cardiovascular risk reduction medication including metformin, and for nicotine replacement therapy;

• Medical Research Future Fund support for research into health system design and delivery for people living with serious mental illness, including further clinical trials of peer worker impact on physical health; and

• development and dissemination of targeted education materials for all relevant health professions informed by the proposed shared care protocol and guidelines.

Being Equally Well has focused on improving the physical health care and life expectancy for people living with serious mental illness. This supplement fills gaps in our knowledge needed for policy formation. This knowledge is being integrated with the Being Equally Well roadmap through a series of roundtable meetings with stakeholders. The Being Equally Well roadmap and contributions from these roundtables will mean that policies to reduce preventable physical conditions among people with serious mental illness will be readily implementable.

It is hoped that this supplement will heighten awareness, at all levels of the health system and within government, of the recommended service and policy enhancements. Full implementation of these recommendations will end the systemic neglect that contributes to the shorter life expectancy of people with serious mental illness.

Open access

Open access publishing facilitated by Victoria University, as part of the Wiley ‐ Victoria University agreement via the Council of Australian University Librarians.

Competing interests

No relevant disclosures.

Provenance

Commissioned; externally peer reviewed.