Lethal discrimination - Rethink Mental Illness · 2 Rethink Mental Illness.Lethal discrimination. Foreword The fact that people with serious mental illness die an average of 20 years

Rethink Mental Illness. Lethal discrimination. 1

Lethal discrimination

Why people with mental illness are dying needlessly and what needs to change.

September 2013

2 Rethink Mental Illness. Lethal discrimination.

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 5Obesity 6Accessingphysicalhealthcare 7Poorphysicalhealthmonitoring 8ActionsfortheNHS 8ActionsforGovernment 9

Change is possible 11

How Rethink Mental Illness is tackling this 13

Conclusion 14

Acknowledgments

WewouldliketoofferourthankstocolleaguesfromboththeRoyalCollegeofPsychiatristsandRoyalCollegeofPhysiciansfortheirreports‘Wholepersoncare:fromrhetorictoreality:Achievingparitybetweenmentalandphysicalhealth’and‘SmokingandMentalHealth’.Thispaperhasdrawnontheirworkandwewouldliketoacknowledgethis.


One in three of the 100,000 ‘avoidable deaths’ every year have a mental illness, but this issue is virtually ignored across Government.1

This report examines how people with mental illness are being let down and lays out recommendations for change.

Summary

OUR KEY RECOMMENDATIONS

• Peoplewithmentalillnessshouldbeofferedtailoredsupporttoquitsmoking.

• Patientsshouldbetoldabouttheside-effectsofantipsychoticmedicationsotheycanlookoutforwarningsigns,andGPsshouldmonitortheirphysicalhealthclosely.

• Allmentalhealthprofessionalsshouldreceivebasicphysicalhealthtrainingaspartoftheirmandatorytraining.

• Commissionersandserviceprovidersneedtobeclearabouttherespectiveresponsibilitiesofprimaryandsecondarycareservicesformonitoringandmanagingthephysicalhealthofpeoplewithmentalhealthproblems.

OUR KEY FINDINGS

• Peoplewithseriousmentalillnesseslikeschizophreniadie,onaverage,20yearsearlierthantherestofthepopulation.

• Morethan40%ofalltobaccoissmokedbypeoplewithmentalillness,buttheyarelesslikelytobegivensupporttoquit.

• Fewerthan30%ofpeoplewithschizophreniaarebeinggivenabasicannualphysicalhealthcheck.

• Peoplegainanaverageof13lbsinthefirsttwomonthsoftakingantipsychoticmedicationandthiscontinuesoverthefirstyear.Despitethis,insomeareas70%ofpeopleinthisgrouparenothavingtheirweightmonitored.

• Manyhealthprofessionalsarefailingtotakepeoplewithmentalillnessseriouslywhentheyraiseconcernsabouttheirphysicalhealth.

1. ThisfigurehasbeenderivedusingdatafromtheHealthSurveyforEngland,MentalHealthMinimumDataSetandRussTC,StamatakisE,HamerM,StarrJM,KivimakiMandBattyGD(2012),Associationbetweenpsychologicaldistressandmortality:anindividualparticipantpooledanalysisoftheHealthSurveyforEnglandprospectivecohortstudies.BMJ345:e4933.


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.

Imagineforamomentthatthischillingstatisticappliedtoanyothergroupofpeople,suchasresidentsofaparticulartown.Therewouldbepublicoutcry.Questionswouldbeaskedaboutwhythesepeoplearebeingsobadlyletdownbyhealthservicesandpoliticianswouldcallfortargetedsupport.Butthissimplyisn’thappeningforpeoplewithmentalillness.

Thefactsarestarkandshocking.Oneinthreeofthe100,000peoplewhodieavoidablyeachyearhaveamentalillness.Weknowthatpeoplewithmentalillnessarethreetimesmorelikelytodevelopdiabetesandtwiceaslikelytodiefromheartdisease.Morethan40%ofalltobaccoissmokedbypeoplewithmentalhealthproblems.

Despitetheindisputableevidencethatpeoplewithmentalillnessareoneofthemostat-riskgroupsinoursocietywhenitcomestoavoidabledeaths,theGovernmentisfailingtotakefirmaction.

TheHealthSecretaryJeremyHuntwantstoreducethe100,000avoidabledeathsperyearinEnglandbyathird.Yethisrecent‘calltoaction’onaddressingavoidableprematuremortalitybarelytouchesonthephysicalhealthofpeoplewithmentalillness,althoughitdoesacknowledgethe‘shamefulinequality’ofoutcomesrelatedtosmoking.

Whensuchstarkevidencehasbeenpresentedforotherconditions,suchasdiabetes,actionhasfollowed.Thesameisnottrueformentalhealth.Failuretoaddressthisissueamountstolethaldiscriminationwhichiscostinglives.WeurgetheSecretaryofStateforHealthtoactnowandpublishanavoidabledeathsstrategythatwillchangethis.

AyearagotheNHSmandatesetaneedtoachievechangeinthisarea.Howprogresstowardsthiswillbemeasured,whenitwillbedeliveredandhowitwillbefundedhasyettobedefined.IfthisisaGovernmentpriority,whyarewestillwaiting?

Somesaythisissueissimply‘toodifficult’totackle,butinrealitytherearesimple,cost-effectivesolutionsdetailedinthisreport,whichcouldsavethousandsoflives.TheyaresmallthingslikeofferingtargetedsupporttogiveupsmokingandensuringGPscarryoutbasicphysicalhealthchecksonpatientswithmentalillnessandactontheresults.

Weknowwhattheproblemisandweknowwhatthesolutionis.AllweneednowisfortheGovernment,localauthorities,clinicalcommissioninggroups,healthandwellbeingboards,serviceprovidersandindividualclinicianstofacethisissueheadonandtakeactionwhichwillsavethousandsofpeoplewithmentalillnessfromdyingtoosoon.

Professor Sue Bailey PresidentoftheRoyalCollegeofPsychiatrists


The problem

Thereisextensiveevidencethatpeoplewithseriousmentalillnesses,suchasschizophrenia,areatriskofdyingonaverage20yearsprematurely.2,3Comparedwiththegeneralpopulation,theyhave:

• 2timestheriskofdiabetes.4

• 2-3timestheriskofhypertension.

• 3timestheriskofdyingfromcoronaryheartdisease.5

• 10-foldincreaseindeathsfromrespiratorydiseaseforpeoplewithschizophrenia.6

• 4.1timestheoverallriskofdyingprematurely(thanthegeneralpopulationagedunder50).

Manyoftheprematuredeathsofpeoplewithseriousmentalillnessaretheresultofpoormedicalcarethatfailstomonitorriskfactorssuchassmokingandobesity.Theyareavoidable.Yetdespitethesepooroutcomes,theNHSisnotprovidingthecarepatientsneedtostaywell.

Forexample,NICEguidelinesstatethateveryonewithschizophreniashouldhaveannualphysicalhealthchecks.YettherecentNationalAuditofSchizophreniafoundthatjust29%ofpeoplearereceivingthis.7Evenverycheapandbasiccareisnotbeingprovided,suchasweighingpeopleandtakingtheirbloodpressure.

Just56%ofpeoplewithschizophreniaareweighedbyhealthprofessionals,withsomeNHSTrustsweighingjust30%ofpatients.8Weoftenhearthatpsychiatricwardsdon’tevenhavescales.It’sabouttimetheydid.

Furthermore,evenwhenhealthchecksareprovidedandproblemsarediscovered,thisdoesnotalwaysresultinaction.TheAuditfoundthatwhenpatientswerefoundtohavehighbloodpressure,just25%ofthemwerethentreated.

The‘inversecarelaw’iswellknown,where“the availability of good medical care tends to vary inversely with the need for it in the population served”.9Nowhereisthismoreevidentthaninthetreatmentofthephysicalhealthneedsofpeopleaffectedbymentalillness.Whensuchbasiccareisdenied,itisnotbecauseoflackoffundingorNHSreorganisations.Itisbecausethephysicalhealthofthesepatientsisnotdeemedimportant.Thissystemicdiscriminationiscausingthousandsofpeopletodietoosoon–changeislongoverdue.

2. NewmanSC,BlandRC.,1991.Mortalityinacohortofpatientswithschizophrenia:arecordlinkagestudy.Can J Psychiatry36,pp239–45.

3. BrownS,KimM,MitchellCandInskipH.,2010.Twenty-fiveyearmortalityofacommunitycohortwithschizophrenia.British Journal of Psychiatry196pp116–121;ParksJ,SvendsenD,SingerPetal.,2006.MorbidityandMortalityinPeoplewithSeriousMentalIllness.13thtechnicalreport.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,dietaryhabitsandcoronaryheartdiseaseriskfactorknowledgeamongstpeoplewithseverementalillness:acrosssectionalcomparativestudyinprimarycare.Social Psychiatry Psychiatric Epidemiologypp787-93.

6. Mentalhealthandsmoking:apositionstatement(2008),FacultyofPublicHealth.

7. RoyalCollegeofPsychiatrists,2012. Report of the National Audit of Schizophrenia (NAS) 2012.London:HealthcareQualityImprovementPartnership.

8. RoyalCollegeofPsychiatrists,2012.Report of the National Audit of Schizophrenia (NAS) 2012. London:HealthcareQualityImprovementPartnership.

9. HartJT,.1971Theinversecarelaw.LancetFeb27;1(7696)pp405-12.


Recent policy developments

ThisGovernmenthasmadeapromiseintheNHSMandatetotransformtheNHSsothatmentalandphysicalhealtharetreatedequally,andtheNHSOutcomesFrameworkincludesanindicatortoreducetheunder-75excessmortalityrateinadultswithseriousmentalillness.However,howprogresstowardsthiswillbemeasured,whenitwillbedeliveredandhowitwillbefundedhasyettobedefined.YetwhentheHealthSecretarypublishedhis‘calltoaction’toreduceavoidableprematuremortality,10hebarelymentionedthewidelyacknowledgedissuesaboutprematuremortalityinmentalhealth.

Hestatedthattwothirds(around103,000)ofthedeathsamongtheunder75sareavoidable.Asaroundathirdofthosedeathsarepeoplewithmental

healthproblems,weknowthattheHealthSecretarywillfinditmuchhardertoreduceprematuremortalityifhedoesnotaddresstheneedsofthisgroup.

TheGovernment’spromisestotackleavoidabledeathsandimprovementalhealthcarehavebeenwelcomed.WhiletheNHSMandatedemandsimprovementsinthisarea,theNHSOutcomesFrameworkonlymeasuresratesofmortality,notcausesofdeathorco-morbidities.

NHSrecordstelluswhenpeoplehavedied,butdoverylittletohighlightat-riskgroupsandensuretheyareofferedtargetedsupport.Moremustbedone–urgently–toprioritiseinterventionsthatareknowntowork,andwhichcanpreventtheonsetofthepoorphysicalhealthassociatedwithmentalillness.

10. DepartmentofHealth,2013.Living Well for Longer: A call to action to reduce avoidable premature mortality.


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

PeoplewithmentalhealthproblemsconsumealmosthalfofalltobaccoinEngland(42%),11andare70%morelikelytosmokethanapersonwithoutmentalhealthproblems.12Inmentalhealthunits,itisestimatedthat70%ofpatientssmoke,with50%describedasheavysmokers.13

Theyalsohaveincreasedlevelsofnicotinedependencyandareatevengreaterriskofsmoking-relatedharm.14Despitethis,onlyaminorityofpeoplewithamentalillnessreceiveeffectivesmokingcessationinterventions.15

Peopleaffectedbymentalhealthproblemshavethesamedesiretoquitaseveryoneelse.However,theirsmokingratehasbarelychangedinthelast20years,whiletherateinthegeneralpopulationhasfallendramaticallyfrom45%in1974to20%in2010.16

Thereareanumberofbarrierstopeoplewithmentalillnessaccessingsmokingcessation,includingstaffattitudesandinflexibleservicetargets.In2012,TheSchizophreniaCommissionheardevidencethatsomehealthprofessionalsdonothelppatientsgiveupsmokingbecausetheybelieveitisthe‘lastpleasuretheyhave’.17Webelievethisattitudeisunacceptableandiscostinglives.

Similarlyweareconcernedthatsomeserviceshavesuchrigidperformancetargetsthatthereisnoincentiveforthemtosupportsomeoneaffectedbymentalillness,whomighttakelongertoquit.Performancetargetsshouldbedesignedsothatservicesareencouragedtosupportthepeoplewhostrugglehardest.Addressingthesebarriersandofferingtargetedsupportshouldbeapriority.

Itisessentialthatsmokingcessationservicescheckthementalhealthstatusoftheirclients,asevidencesuggeststhatthisisnotbeingroutinelyundertaken.18Alongsidethis,allsmokingcessationstaffneedtohavementalhealthtrainingtoensuretheyoffertheappropriatelevelofsupport.

Targetedsupportwouldsavemoneyaswellaslives.£720m19isspentannuallytreatingsmoking-relatedillnessesinpeopleaffectedbymentalhealthproblemsthroughhospitaladmission,GPconsultationsandprescriptions.ProvidingsmokingcessationsupportforthisgroupisoneofthemostcosteffectiveinterventionsintheNHS.20TheRoyalCollegeofPhysiciansandRoyalCollegeofPsychiatrist’sreport,SmokingandMentalHealth,recommendsthatbecausesmokerswithamentalillnessareusuallymoreheavilyaddictedtonicotine,theyshouldbeprescribednicotinereplacementtherapyproductstosupportattemptstostopsmoking.

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,asreferencedinMentalHealthNetwork,NHSConfederation(2013),‘SmokingandMentalHealthbriefing’,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:AsurveyofNHSstopsmokingservices.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.


Tailoredsupportisalsoimportantbecausemedications,suchasclozapine,areaffectedbynicotineintake.Medicationdosagesmaythereforeneedtochangeinparalleltosmokingcessation.However,NHSStopSmokingservicesdonotcurrentlyrecordwhethersomeoneisusingmedicationforamentalhealthcondition.Thisneedstoberecordedifprescribingcliniciansandsmokingcessationservicesaretoworktogethertodothissafely.Equally,GPrecordsshouldrecordthesmokingstatusofpeoplewithmentalillnesssothattheyareofferedtheappropriatesupporttogiveup.TheNHSQualityOutcomeFramework(QOF)andCommissioningforQualityandInnovation(CQUIN)paymentscouldbeusedmorewidelyandeffectivelytoincentivisehealthcareprofessionalstoprovidetargeted,effectivesupportforthisgroup.21

Obesity

Peoplewithaseriousmentalillnessareatmuchgreaterriskofobesity.Thisisbecausesomeofthemedicationstheyuseareassociatedwithweightgain.22Thishasrecentlybeendescribedasan‘epidemic within an epidemic’23asyoungpeoplewithemergingpsychosisarequicklygainingweightwhenusingmedication.Oftenthereissomuchfocusonmanagingtheirmentalillness,thatpeople’sphysicalhealthneedsareignored.

21. RoyalCollegeofPsychiatrists,‘Wholepersoncare:fromrhetorictoreality.Achievingparitybetweenmentalandphysicalhealth’,OccasionalpaperOP88,2013

22. McElroy,SL,2009.Obesityinpatientswithseverementalillness:overviewandmanagement, Journal of Clinical Psychiatry,70,Supplement3:12-21.

23. Bailey,Gerada,LesterandShiers,2012.Thecardiovascularhealthofyoungpeoplewithseverementalillness:addressinganepidemicwithinanepidemicThe Psychiatrist Online October(36)pp375-378.Availableat:www.rcpsych.ac.uk/quality/NAS/resources.

24. LesterH,ShiersDE,RafiI,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,peoplehavegainedsignificantweightandareatgreatriskofcardiovascularproblemsanddyingprematurely.Itisthereforeessentialthatphysicalhealthmonitoringisprioritisedattheonsetofillness.Mentalhealthprovidersshouldpromotetheuseofclinicaltoolstosupportthephysicalhealthneedsofpeoplewithmentalillnessonantipsychoticmedication,suchastheLesterUKAdaptation–PositiveCardiometabolicHealthResource.24

Giventhatmedicationplayssuchasignificantroleinweightgain,itisimportantthatpeoplearegivenaccessibleinformationaboutmedicationandpotentialside-effectsbeforemedicationisprescribed.Thiswouldallowpeopletobemoreawareoftherisksandwhattheyshouldbelookingoutfor,andhowtheirphysicalhealthwillbemonitoredalongsidetheirmentalhealth.Howeverthisiscurrentlynotthecase.ArecentCQCsurvey25ofcommunitymentalhealthservicesfoundthatonly44%ofpeoplefeltthesideeffectsofmedicationhadbeenfullyexplainedtothem.Ifpeoplearen’tequippedwiththeappropriateknowledge,theyandtheircarerscannotmakeinformeddecisionsabouttheircareandtreatment.Theyalsocannottakestepstomitigatetheside-effectsoftheirmedicationandphysicalhealthcomplicationscandevelop.

“ It’s so sad when one has cared for an 18-year-old at the time of their first psychotic illness and then one doesn’t recognise them when one meets them again five years later because they are 10Kg heavier. Psychiatrists need to take more responsibility for the physical health of their patients because some GPs and hospital physicians don’t like treating people with psychosis.”

ProfessorSirRobinMurray,ChairoftheSchizophreniaCommission


“My son was a fit 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 given haloperidol 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

Thereareanumberofbarriersforpeopleaffectedbymentalillnesswhenaccessingphysicalhealthcareandmonitoring.

AlthoughGPsareobligedtoofferpeoplecertainphysicalhealthchecksannuallyaspartoftheQualityOutcomesFramework(QOF),thisisnotaflawlesssystem.SomeofthetestsintheQOFareonlyofferedtopeopleover40yearsold,meaningtherecouldbesignificantdelaysinaddressingphysicalhealthconcernsifpeoplehavebeentakingantipsychoticmedicationsincetheir20s.

Practicescanalso‘exceptionreport’oromitpeoplefromtheirQOFresultsincertaincases.Exceptionreportingformentalhealthisparticularlyhighcomparedwithotherhealthconditions.In2011/12theexceptionreportingratewas11.8%,comparedto0.5%forcancer.26

ThesehighexceptionratesaresometimesputdowntoaperceivedreluctanceofpeoplewithmentalillnesstoengagewithGPs.However,peoplecanfinditverydifficulttoaccessGPsurgeries.Theymightbeanxiousaboutattendingormightstrugglewiththeearlymorningbookingsystembecauseofmedicationside-effects.GPpracticesneedtomakesurereasonableadjustmentsareinplacesothatpeoplearenotmissingoutoncrucialcare.

Whenpeopledoaccesshealthservices,theirphysicalhealthneedsareoftenignoredorseenasamanifestationoftheirmentalhealthcondition,ratherthanaseparatehealthissue.This‘diagnosticovershadowing’iswelldocumented27andleadstophysicalconditionsbeingundiagnosedanduntreated,whichcanprovefatal.Concernsraisedbycarerscanalsobeignored.

Thislethaldiscriminationhelpstoexplainwhypeoplewithsevereandenduringmentalillnessappeartoaccesssignificantlylowerquantitiesofseveralcommonmedicationsforphysicalhealthconditions.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.Achievingparitybetweenmentalandphysicalhealth’,OccasionalpaperOP88,2013,referringtoMitchellAJ,LordO,MaloneD.Differencesintheprescribingofmedicationforphysicaldisordersinindividualswithv.withoutmentalillness:meta-analysis. Br J Psychiatry 2012;201:435–43.

“It seems that once you have a mental health diagnosis any physical symptoms you experience are instantly assumed to be part of your diagnosis. Once that assumption is made it is difficult to get anyone to attempt to disprove it.”

AnonymousRethinkMentalIllnessmember


Poor physical health monitoring

Peoplewithseriousmentalillnessneedcomprehensivephysicalhealthmonitoringatleastonceayeartohelpwithriskfactors,suchasweightgainassociatedwithantipsychoticmedication.However,therecentNationalAuditofSchizophrenia(NAS)revealedthat,onaverage,only29%ofpeoplehadreceivedafullcheckofBodyMassIndex(BMI),smoking,bloodpressure,bloodglucoseandlipidsintheprevious12months.InsomeTrusts,thisnumberwasbelow15%.Wewouldliketoseemoretraininginphysicalhealthcareandhealthpromotionforallmentalhealthpractitioners.Mentalhealthnursesshouldbeabletoprovidebasicphysicalhealthcareandprogressionthroughtrainingshoulddependuponthis.

Thislargevariationinresultsshowsthatthereisaninconsistentapproachacrossthecountryandthatphysicalhealthisnotbeingproperlyprioritised.Certainaspectsofphysicalhealthcare,includingweightorBMI,wereonlycheckedinaroundhalfofcases,withsomeNHSTrustsweighingjust30%ofpatients.29Thisisparticularlyworryinggiventhelinkbetweenmedication,weightgainandhealthproblems,suchasheartdisease.Evenwhereproblemsareidentified,actionisoftennottakentoaddressthese.TheNationalAuditofSchizophreniashowedthatonlyoneinfivepeoplewithraisedlipidlevelsandoneinfourpeoplewithhighbloodpressurewereofferedthenecessaryintervention.

RethinkMentalIllnesshasbeenholdingsummitsacrossEnglandtodiscusstheseissueswithhundredsofpeopleaffectedbymentalillnessandwithhealthprofessionals.Againandagain,wehaveheardthatthephysicalhealthcareofpeopleaffectedbymentalillnessisfallingthroughthegapsbetweenGPservicesandsecondarymentalhealthcare.Itisoftenunclear,bothtoprofessionalsandpeopleaffectedbymentalillness,whoisresponsibleforcoordinatingthissupport.Asaresult,nosupportisoffered.Thisresponsibilityneedstobeclarifiedsothatpeople’sphysicalhealthisn’toverlooked.ToolsliketheIntegratedPhysicalHealthPathwaycouldsupportprofessionalstoagreeprocesseslocallysochecksarenotmissed.30

ACTIONS FOR THE NHS

• Commissionersandserviceprovidersneedtobeclearabouttherespectiveresponsibilitiesofprimaryandsecondarycareservicesformonitoringandmanagingthephysicalhealthofpeoplewithmentalhealthproblems.

• Everyonebeingprescribedantipsychoticmedicationshouldbegivenclearandaccessibleinformationabouttherisksandbenefitssotheycanmakeaninformedchoiceaboutmedication.Physicalhealthmonitoringshouldstartfromtheverybeginningoftreatmentwithidentifiedhealthneedsquicklyactedupon.

• EachCCGandmentalhealthprovidershouldworkwiththelocalDirectorofPublicHealthtoensurethattargetedsmokingcessationservicesandsupportarebothavailableandpromotedtosmokerswithschizophreniaandpsychosis.

• Allsmokingcessationservicesmustcheckthementalhealthstatusoftheirclients.Theirstaffneedtohavementalhealthtrainingtoensuretheyoffertheappropriatelevelofsupport.Theyshouldalsorecordwhethersomeoneistakingmentalhealthmedication,toensuredosagesarechangedasnecessary.

• Allmentalhealthprofessionalsshouldreceivebasicphysicalhealthtrainingaspartoftheirmandatorytraining.Mentalhealthnursesshouldbetrainedtocarryoutsimplephysicalhealthchecks.

• RatesofpeopleaccessinginterventionsincludedintheQualityandOutcomesFramework(QOF)tobeinlinewithpredictedprevalenceoftheillness.

Evidencealsoshowsthatpracticenursesconsultedwithpeopleaffectedbymentalillnessonlyonceayear,comparedwiththegeneralpracticepopulationrateofalmosttwiceayear.31Practicenurseshaveacrucialroletoplayinhealthpromotionandpreventionand,giventhehigherriskofarangeofphysicalhealthproblems,thisisamatterofconcern.


ACTIONS FOR GOVERNMENT

TheGovernmentsaysmentalhealthisoneofitstoppriorities,butthishasnottranslatedintoactionontheground.

TheDepartmentofHealthandPublicHealthEnglandneedto:

• PrioritisetheneedsofpeopleaffectedbymentalillnessintheHealthSecretary’sforthcomingstrategyonprematuremortality.Asignificantproportionofavoidabledeathsarelinkedtomentalillhealth.Thismustberecognisedandactedupon.

• HoldNHSEnglandtoaccountfordeliveringprogressonreducingtheprematuremortalityofpeoplewithmentalillnessinlinewiththeNHSOutcomesFrameworkandthecommitmentintheNHSMandate.Definetheprogresstobemade,howlongitwilltakeandhowitwillbemeasured.

• Takeactiontoensurethateverysmokeraffectedbymentalillnessisofferedtailored‘quitsmoking’supportandinterventionsinlinewithNICEguidance.

• AmendNHSandCCGoutcomesindicatorstomeasureaccesstoproveninterventions,notjustphysicalhealthchecksandratesofdeath(e.g.proportionofpeoplewithmentalillnessaccessingsmokingcessationservices,proportionofeligibleindividualsaccessingEarlyInterventionforPsychosisservices).

• AmendtheQualityOutcomesFramework(QOF)toensurethatphysicalhealthscreeningisavailableforpeopleassoonastheytakecertainmedications,notjustattheageof40.

• NHSEnglandandCCGsshouldconsideranannualmortalityreviewbeingincludedaspartoftheircontractformentalhealthtrusts.CommittosustainingtheNationalAuditofSchizophreniaforaminimumofafurtherfiveyearstomonitorimpact,andextendtheremitoftheaudittoincludeallinpatientsettings.

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.TheroleofprimarycareinserviceprovisionforpeoplewithseverementalillnessintheUnitedKingdom.PLoS One (7).


Case study: Tracey Butler (39), Hampshire


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.

“Ihaveschizoaffectivedisorderandborderlinepersonalitydisorder,andwasfirstprescribedantipsychoticsinmyearlytwenties.AfterI’dbeentakingthemforaround18months,Istartedtonoticetheimpactitwashavingonmyphysicalhealth.Ifeltcompletelyexhaustedallthetime,thirstyanddehydratedandIconstantlyhadtoruntothetoilet.IwenttomyGPbecauseIwasconvincedsomethingwaswrong.Buthedismissedmyconcerns,hewouldn’tentertaintheideathattheremightbesomethingseriousgoingon.

Aboutayearpassedandthesymptomscontinuedtogetworse,beforeIwasfinallydiagnosedwithtype2diabetes.MydiabetesconsultanttoldmethatthesymptomsIhadgonetomyGPaboutwereclearearlysignsofthecondition.Healsosaidthatitwastheantipsychoticsthathadcausedmydiabetes.Seventeenyearslater,Istillhavetogoregularlytothediabetesconsultant.

WhenI’munwell,I’mnotgreatatlookingaftermyself.ItcanbequiteabigundertakingtogotoseemyGP,andIreallydoneedthemtotakemeseriously.Assoonasamedicalprofessionallooksatmyrecords,theysee‘borderlinepersonalitydisorder’flashinguponthescreenanditfeelsliketheystoplisteningtome.TheyjustthinkI’mneuroticorparanoid.

Therealsodoesn’tseemtobeanycommunicationbetweenmyGPandmypsychiatrist.Ithinkitwouldmakeabigdifferenceiftherewas.

Inmyexperience,GPsrarelyknowmuchaboutmentalillness.Onetime,myGPcalledmeafteraroutinebloodtest,sayingthatImighthaveatumourinmybrainbecausetherewasanunusuallyhighlevelofprolactininmyblood.ThissentmeintoastateofgreatdistressandIhadapanicattack.ButwhenIcalledmycommunitypsychiatricnurse,hetoldmetheprolactinlevelinmybloodwasprobablycausedbytheantipsychotics.Thatturnedouttobethecase–therewasnotumour,itwasjustaside-effectofmymedication.AgreatdealofworryandanxietycouldhavebeenavoidediftheGPhadknownmoreabouttheside-effectsofthemedicationIwason.”


Change is possible

There is reluctance from some to tackle this problem, due to a belief that it’s ‘too difficult’. 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,holisticapproachtoimprovingphysicalhealthoutcomes.BytriallingandadoptingthePhysicalHealthChecktoolfromRethinkMentalIllnessandembeddingitacrosstheTrust,theyhavedrasticallyimprovedphysicalhealthmonitoringandintervention.

TheTrustfirstpilotedthePhysicalHealthCheckinitsrecoveryteam.Theresultswerestartlingandincludedidentifyingundiagnosedhighbloodpressure,diabetesandcancer.TheTrustthendecidedtoimplementtheCheckandsetitasaserviceimprovementstandardacrossawiderrangeofservices.

TheTrustthereforecommittedtoofferingeveryoneusingtheirmentalhealthservicesaPhysicalHealthCheck.Tosupportthis,theTrustofferedtraining,support,awarenessraisingactivitiesandinvolvedallstaff,notjustnurses.ItdevelopedformalguidanceontheCheckforsocialcarestaffandappointedlocalphysicalhealthleadsacrosstheTrust.

ThecompletedPhysicalHealthCheckisworkedintotheperson’scareplansothatbothphysicalhealthandmentalhealthneedscanbetreatedholistically.Whereissuesareidentified,Truststaffproactivelyensurethatthesearefollowedupandliaisewithprimarycarewherenecessary.StaffmembersattheTrusthavehighlightedtherolethePhysicalHealthCheckhasplayedinidentifyingserious,andpossiblyfatal,healthconditions.TheTrustcollecteddatafromthephysicalhealthchecksitundertookin2011/12and2012/13.Theseshoweda30%decreaseinpreviouslyunidentifiedhealthneedsinthelatestroundofchecks.ThissuggeststheTrustissuccessfullycatchingthingsearlyandtakingaction.

Lancashire’sfocusonphysicalhealthcontinuestogrow.FromApril2013,thePhysicalHealthCheckhasbeenincorporatedintotheTrust’selectronicrecords.Thisallowsforbetterrecordingofandreportingonphysicalhealthneedsandoutcomes.ThereisongoingworkandcommunicationwithGPsandotherprimarycareprofessionalsandtheTrustcontinuestodriveimprovementsinthephysicalhealthservicesitprovides.

Solent NHS Trust

SolentNHSTrustadultmentalhealthservicesareimprovingtheirmanagementofdiabeticpatientsanddevelopingcloselinkswiththediabetesclinicatthelocalhospitaltoimprovecare.Thisincludesintroducingthesamediabeticpathwayonadmissionasthegeneralhospital.Theunitisalsoarrangingforstafffromthediabetesclinictoauditthediabetescareitoffersonmentalhealthwards.

Thetrustisalsolookingatwhatfoodisofferedtopeopleonmentalhealthwards.Atrafficlightsystemoutliningthenutritionalcontentoffoodshasbeenintroducedsopeoplecanmakeinformedchoicesabouttheirmeals.Vendingmachinesarealsobeingstockedwithhealthieroptions.

ThisworkisfacilitatedbytheClinicalMatronforHealthandWellbeing,whohasbothRGNandRMNtraining.Bybeingabletotakemoreofateachingandadvisoryroleontheward,otherstafffeelbettersupportedtoaddressphysicalhealthconcernsandkeyworkingrelationshipscanbebuiltupwithotherservices.


Barnet, Enfield and Haringey: Early Intervention in Psychosis Service

Inthisservice,physicalhealthisgivenhighpriority.Ithasaclearprotocolaroundphysicalhealthmonitoringrightfromwhenpeoplefirstcometotheservice.InformationisinitiallyrequestedfromtheGPforthepreceding12monthsandtheserequestsareproactivelyfollowedup.IfsomeoneisnotregisteredwithaGPorrefusestoattendanappointment,thereareproceduresinplaceforensuringcrucialmonitoringandassessmentstilltakesplace.Oncetheseassessmentshavetakenplace,relevantinformationissharedwiththeappropriateparties.

Severalstaffwithintheservicehavecompletedaspecialistundergraduatetraining,focusingonpracticalskillsandtheresearchandknowledgeunderpinningidentifiedinterventions.Thereisalsoadedicatedstaffmemberwhohasresponsibilityforkeepingarecordofphysicalhealthmonitoringandanyoutstandingchecks.TheprogrammehasbeenwellreceivedbytheTrustandtherearehopesthatitmightbeadoptedbyotherteamsacrosstheTrust.

“The barriers to better physical health care for people with serious mental illness are related as much to communication and knowledge as the obstacles we are already aware of, i.e. diagnostic overshadowing, inflexible GP services, medication side effects and motivational problems. In respect of knowledge, there seems to be a consensus that mental health nurses lack both the training and the confidence to manage common physical health problems. However, we’re nearly there.... we know what the issues are, let’s work 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 Physical Health and Wellbeing Project

SheilaHardy,NurseConsultantandVisitingFellowattheUniversityofNorthamptonshire,hasdevelopedtrainingforpracticenursesandcarriedoutresearchonthephysicalhealthneedsofmentalhealthpatients.

Shehasfoundthatcontrarytopopularbelief,patientswithseriousmentalillnesswillattendhealthchecks,andpropertraininginthisareaforpracticenursesincreasesthelevelofscreeningandlifestyleadvicegiven.

Thenecessaryguidanceandtoolsneededforsettingupanurse-ledclinicandcarryingoutahealthcheckforpeoplewithseriousmentalillnessareavailableonline(http://physicalsmi.webeden.co.uk/).Thisallowsnursestofollowbestpracticeguidanceeveniftheyhavenoaccesstoformaltraininginthisarea.


How Rethink Mental Illness is tackling this

FormanyyearstheseriouslyneglectedphysicalhealthneedsofpeoplewithmentalhealthproblemshasbeenapriorityforRethinkMentalIllness.Wehavebeenshoutingaboutthisshockinginequalityforaslongaswecanremember.Weknowthatchangeonlyhappenswhensolutionsareidentifiedalongwithnamingproblems.Inoureffortstoovercomethehurdlesthatpeoplefaceinaccessingappropriateandtimelyphysicalhealthcare,wehavespentthelastdecadeinpartnershipwithprofessionalbodiestotacklethisissueinpracticalways.Wedevelopedtoolstohelpprofessionalsassessandidentifykeyphysicalhealthconcerns.Wecreatedaccessibleonlinephysicalhealthresourcesandtraining,toraiseawarenessandbuildconfidencearoundsupportingpeople’sphysicalhealthneeds.Wewroteguidesforhealthpractitioners.WecreatedaPhysicalHealthChecktoolwhichenablesprofessionalsandpeopleaffectedbymentalillnesstodevelopplanstogethersothattheycanaddressanyunmetphysicalhealthneeds.Workingwithpeoplewithlivedexperience,weproducedguidestohelpindividualsgetsupportfortheirphysicalhealth.Wedevelopedtoolstohelppeoplespeakoutandcampaignforchange.Werunadviceandinformationservices.Wehelpasmanypeopleaswecomeintocontactwithandspendthelittleresourcewehavespreadingthewordabouttheimportanceofphysicalhealth.

Wewantthosewhocommissionanddeliverlocalservicestogetaninsightintothephysicalhealthissuesthatpeopleaffectedbymentalhealthexperiencesowefacilitatediscussionbetweencommissioners,professionalsandthoseaffected.Wecreateopportunitiesfordecisionmakersandpeopleaffectedbymentalillnesstoworktogethertodeveloppoliciesandpracticethatcanleadtoimprovementsintheirareas.Andwehavetirelesslypromotedthesetoolsandresourcestoanyoneandeveryoneweencounter.

Wehaverealisedmuchmoreisneeded.ToenablethesignificantchangethatisurgentlyrequiredintheNHSandbeyond,wehavethismonthlaunchedacountry-wideInnovationNetwork.Inpartnershipwithmentalhealthproviderorganisations,weareworkingtoembedexcellentphysicalhealthcareacrossthesystem.

ItistimefortheGovernmenttodoitspart.


Conclusion

Whiletherearesomepocketsofgoodpracticeinthesystem,mostpeoplewithmentalillnessarebeingbadlyletdownwhenitcomestotheirphysicalhealth.Thismeansmanythousandsofpeoplearedyingneedlesslyeveryyearandmanymoreareleftstrugglingwithlongtermconditionssuchasdiabetes.Manyfactorscontributetothisstateofaffairs,creatingoneofthebiggesthiddenhealthscandalsofourtime.

Bynotacting,theGovernmentandtheNHSareallowingsomeofthemostvulnerablepeopleinoursocietytobetreatedassecondclasscitizens.Wewouldneveracceptthisstateofaffairsforotherpatientgroups,andweshouldn’tacceptitforpeoplewithmentalillness.Weknowwhatthesolutionsareandtheyarenotcomplexorexpensive.Allweneednowisthepoliticalwill,atbothnationalandlocallevel,tomakechangehappen.


RegisteredinEnglandNumber1227970.RegisteredCharityNumber271028.RegisteredOffice89AlbertEmbankment,London,SE17TP.RethinkMentalIllnessistheoperatingnameofNationalSchizophreniaFellowship,acompanylimitedbyguarantee.©RethinkMentalIllness2013.

For more information on our wide range of physical health resources, please visit www.rethink.org/phc.

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Lethal discrimination - Rethink Mental Illness · 2 Rethink Mental Illness.Lethal discrimination. Foreword The fact that people with serious mental illness die an average of 20 years