Rethink Mental Illness - Lethal Discrimination

7/27/2019 Rethink Mental Illness - Lethal Discrimination

http://slidepdf.com/reader/full/rethink-mental-illness-lethal-discrimination 1/17Rethink Mental Illness. Lethal discrimination. 1

Lethal

discrimination

W hy p e op l e w i t h me nt al i l l ne ss ar e d y i ng

ne e d l e ssl y and w hat ne e d s t o c hange .

September 2013


http://slidepdf.com/reader/full/rethink-mental-illness-lethal-discrimination 2/172 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 5

Obesity 6

Accessingphysicalhealthcare 7

Poorphysicalhealthmonitoring 8

ActionsfortheNHS 8

ActionsforGovernment 9

Change is possible 11

How Rethink Mental Illness is tackling this 13

Conclusion 14

Acknowledgments

WewouldliketoofferourthankstocolleaguesfromboththeRoyal

CollegeofPsychiatristsandRoyalCollegeofPhysiciansfortheirreports‘Wholepersoncare:fromrhetorictoreality:Achievingparitybetween

mentalandphysicalhealth’and‘SmokingandMentalHealth’.Thispaper

hasdrawnontheirworkandwewouldliketoacknowledgethis.


http://slidepdf.com/reader/full/rethink-mental-illness-lethal-discrimination 3/17



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.

Imagineforamomentthatthischillingstatistic

appliedtoanyothergroupofpeople,suchas

residentsofaparticulartown.Therewouldbe

publicoutcry.Questionswouldbeaskedaboutwhy

thesepeoplearebeingsobadlyletdownbyhealth

servicesandpoliticianswouldcallfortargeted

support.Butthissimplyisn’thappeningforpeople

withmentalillness.

Thefactsarestarkandshocking.Oneinthreeofthe100,000peoplewhodieavoidablyeachyearhave

amentalillness.Weknowthatpeoplewithmental

illnessarethreetimesmorelikelytodevelopdiabetes

andtwiceaslikelytodiefromheartdisease.More

than40%ofalltobaccoissmokedbypeoplewith

mentalhealthproblems.

Despitetheindisputableevidencethatpeoplewith

mentalillnessareoneofthemostat-riskgroupsin

oursocietywhenitcomestoavoidabledeaths,theGovernmentisfailingtotakermaction.

TheHealthSecretaryJeremyHuntwantstoreduce

the100,000avoidabledeathsperyearinEnglandby

athird.Yethisrecent‘calltoaction’onaddressing

avoidableprematuremortalitybarelytouchesonthe

physicalhealthofpeoplewithmentalillness,although

itdoesacknowledgethe‘shamefulinequality’of

outcomesrelatedtosmoking.

Whensuchstarkevidencehasbeenpresentedforotherconditions,suchasdiabetes,actionhas

followed.Thesameisnottrueformentalhealth.

Failuretoaddressthisissueamountstolethal

discriminationwhichiscostinglives.Weurgethe

SecretaryofStateforHealthtoactnowandpublish

anavoidabledeathsstrategythatwillchangethis.

AyearagotheNHSmandatesetaneedtoachieve

changeinthisarea.Howprogresstowardsthiswillbe

measured,whenitwillbedeliveredandhowitwillbe

fundedhasyettobedened.IfthisisaGovernment

priority,whyarewestillwaiting?

Somesaythisissueissimply‘toodifcult’totackle,

butinrealitytherearesimple,cost-effectivesolutions

detailedinthisreport,whichcouldsavethousands

oflives.TheyaresmallthingslikeofferingtargetedsupporttogiveupsmokingandensuringGPscarry

outbasicphysicalhealthchecksonpatientswith

mentalillnessandactontheresults.

Weknowwhattheproblemisandweknowwhatthe

solutionis.AllweneednowisfortheGovernment,

localauthorities,clinicalcommissioninggroups,

healthandwellbeingboards,serviceprovidersand

individualclinicianstofacethisissueheadonand

takeactionwhichwillsavethousandsofpeoplewithmentalillnessfromdyingtoosoon.

Professor Sue Bailey

PresidentoftheRoyalCollegeofPsychiatrists



The problem

Thereisextensiveevidencethatpeoplewithserious

mentalillnesses,suchasschizophrenia,areatrisk

ofdyingonaverage20yearsprematurely.2,3

Comparedwiththegeneralpopulation,theyhave:

• 2timestheriskofdiabetes.4

• 2-3timestheriskofhypertension.

• 3timestheriskofdyingfromcoronary

heartdisease.5

• 10-foldincreaseindeathsfromrespiratorydisease

forpeoplewithschizophrenia.6

• 4.1timestheoverallriskofdyingprematurely

(thanthegeneralpopulationagedunder50).

Manyoftheprematuredeathsofpeoplewithserious

mentalillnessaretheresultofpoormedicalcare

thatfailstomonitorriskfactorssuchassmokingand

obesity.Theyareavoidable.Yetdespitethesepoor

outcomes,theNHSisnotprovidingthecarepatients

needtostaywell.

Forexample,NICEguidelinesstatethateveryonewith

schizophreniashouldhaveannualphysicalhealth

checks.YettherecentNationalAuditofSchizophrenia

foundthatjust29%ofpeoplearereceivingthis. 7Even

verycheapandbasiccareisnotbeingprovided,such

asweighingpeopleandtakingtheirbloodpressure.

Just56%ofpeoplewithschizophreniaareweighed

byhealthprofessionals,withsomeNHSTrusts

weighingjust30%ofpatients.8Weoftenhearthat

psychiatricwardsdon’tevenhavescales.It’sabout

timetheydid.

Furthermore,evenwhenhealthchecksareprovided

andproblemsarediscovered,thisdoesnotalways

resultinaction.TheAuditfoundthatwhenpatients

werefoundtohavehighbloodpressure,just25%of

themwerethentreated.

The‘inversecarelaw’iswellknown,where“ the

availability of good medical care tends to vary

inversely with the need for it in the population

served ”.9Nowhereisthismoreevidentthaninthetreatmentofthephysicalhealthneedsofpeople

affectedbymentalillness.

Whensuchbasiccareisdenied,itisnotbecause

oflackoffundingorNHSreorganisations.Itis

becausethephysicalhealthofthesepatientsisnot

deemedimportant.Thissystemicdiscrimination

iscausingthousandsofpeopletodietoosoon–

changeislongoverdue.

2. NewmanSC,BlandRC.,1991.Mortalityinacohortofpatientswithschizophrenia:arecordlinkagestudy.Can J Psychiatry 36,pp239–45.

3. BrownS,KimM,MitchellCandInskipH.,2010.Twenty-veyearmortalityofacommunitycohortwithschizophrenia.British Journal of

Psychiatry 196pp116–121;ParksJ,SvendsenD,SingerPetal.,2006.MorbidityandMortalityinPeoplewithSeriousMentalIllness.13th

technicalreport.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,dietaryhabitsandcoronaryheartdiseaseriskfactorknowledgeamongstpeoplewithseveremental

illness:acrosssectionalcomparativestudyinprimarycare.Social Psychiatry Psychiatric Epidemiology pp787-93.

6. Mentalhealthandsmoking:apositionstatement(2008),FacultyofPublicHealth.

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

ImprovementPartnership.

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

ImprovementPartnership.

9. HartJT,.1971Theinversecarelaw.Lancet Feb27;1(7696)pp405-12.



Recent policy developments

ThisGovernmenthasmadeapromiseinthe

NHSMandatetotransformtheNHSsothatmental

andphysicalhealtharetreatedequally,andthe

NHSOutcomesFrameworkincludesanindicator

toreducetheunder-75excessmortalityrateinadultswithseriousmentalillness.However,how

progresstowardsthiswillbemeasured,whenit

willbedeliveredandhowitwillbefundedhas

yettobedened.YetwhentheHealthSecretary

publishedhis‘calltoaction’toreduceavoidable

prematuremortality,10hebarelymentionedthewidely

acknowledgedissuesaboutprematuremortalityin

mentalhealth.

Hestatedthattwothirds(around103,000)ofthe

deathsamongtheunder75sareavoidable.Asaroundathirdofthosedeathsarepeoplewithmental

healthproblems,weknowthattheHealthSecretary

willnditmuchhardertoreduceprematuremortality

ifhedoesnotaddresstheneedsofthisgroup.

TheGovernment’spromisestotackleavoidabledeathsandimprovementalhealthcarehavebeen

welcomed.WhiletheNHSMandatedemands

improvementsinthisarea,theNHSOutcomes

Frameworkonlymeasuresratesofmortality,not

causesofdeathorco-morbidities.

NHSrecordstelluswhenpeoplehavedied,butdo

verylittletohighlightat-riskgroupsandensurethey

areofferedtargetedsupport.Moremustbedone–

urgently–toprioritiseinterventionsthatareknown

towork,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

Peoplewithmentalhealthproblemsconsume

almosthalfofalltobaccoinEngland(42%),11and

are70%morelikelytosmokethanapersonwithout

mentalhealthproblems.12Inmentalhealthunits,it

isestimatedthat70%ofpatientssmoke,with50%

describedasheavysmokers.13

Theyalsohaveincreasedlevelsofnicotine

dependencyandareatevengreaterriskofsmoking-

relatedharm.14Despitethis,onlyaminorityofpeople

withamentalillnessreceiveeffectivesmoking

cessationinterventions.15

Peopleaffectedbymentalhealthproblemshavethe

samedesiretoquitaseveryoneelse.However,their

smokingratehasbarelychangedinthelast20years,

whiletherateinthegeneralpopulationhasfallen

dramaticallyfrom45%in1974to20%in2010.16

Thereareanumberofbarrierstopeoplewithmental

illnessaccessingsmokingcessation,includingstaff

attitudesandinexibleservicetargets.In2012,The

SchizophreniaCommissionheardevidencethatsome

healthprofessionalsdonothelppatientsgiveup

smokingbecausetheybelieveitisthe‘lastpleasure

theyhave’.17Webelievethisattitudeisunacceptable

andiscostinglives.

Similarlyweareconcernedthatsomeservices

havesuchrigidperformancetargetsthatthereis

noincentiveforthemtosupportsomeoneaffected

bymentalillness,whomighttakelongertoquit.

Performancetargetsshouldbedesignedsothat

servicesareencouragedtosupportthepeoplewho

strugglehardest.Addressingthesebarriersand

offeringtargetedsupportshouldbeapriority.

Itisessentialthatsmokingcessationservicescheck

thementalhealthstatusoftheirclients,asevidence

suggeststhatthisisnotbeingroutinelyundertaken. 18

Alongsidethis,allsmokingcessationstaffneedto

havementalhealthtrainingtoensuretheyofferthe

appropriatelevelofsupport.

Targetedsupportwouldsavemoneyaswell

aslives.£720m19isspentannuallytreatingsmoking-

relatedillnessesinpeopleaffectedbymental

healthproblemsthroughhospitaladmission,GPconsultationsandprescriptions.Providingsmoking

cessationsupportforthisgroupisoneofthemost

costeffectiveinterventionsintheNHS. 20

TheRoyalCollegeofPhysiciansandRoyalCollegeof

Psychiatrist’sreport,SmokingandMental

Health,recommendsthatbecausesmokerswith

amentalillnessareusuallymoreheavilyaddicted

tonicotine,theyshouldbeprescribednicotine

replacementtherapyproductstosupportattemptsto

stopsmoking.

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,asreferencedinMental

HealthNetwork,NHSConfederation(2013),‘SmokingandMentalHealthbrieng’,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:AsurveyofNHSstopsmoking

services.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.



Tailoredsupportisalsoimportantbecause

medications,suchasclozapine,areaffected

bynicotineintake.Medicationdosagesmaythereforeneedtochangeinparalleltosmoking

cessation.However,NHSStopSmokingservices

donotcurrentlyrecordwhethersomeoneisusing

medicationforamentalhealthcondition.This

needstoberecordedifprescribingcliniciansand

smokingcessationservicesaretoworktogetherto

dothissafely.Equally,GPrecordsshouldrecordthe

smokingstatusofpeoplewithmentalillnesssothat

theyareofferedtheappropriatesupporttogiveup.

TheNHSQualityOutcomeFramework(QOF)and

CommissioningforQualityandInnovation(CQUIN)

paymentscouldbeusedmorewidelyandeffectively

toincentivisehealthcareprofessionalstoprovide

targeted,effectivesupportforthisgroup. 21

Obesity

Peoplewithaseriousmentalillnessareatmuch

greaterriskofobesity.Thisisbecausesomeofthe

medicationstheyuseareassociatedwithweightgain.22Thishasrecentlybeendescribedasan

‘epidemic within an epidemic’23asyoungpeoplewith

emergingpsychosisarequicklygainingweightwhen

usingmedication.Oftenthereissomuchfocuson

managingtheirmentalillness,thatpeople’sphysical

healthneedsareignored.

21. RoyalCollegeofPsychiatrists,‘Wholepersoncare:fromrhetorictoreality.Achievingparitybetweenmentalandphysicalhealth’,Occasional

paperOP88,2013

22. McElroy,SL,2009.Obesityinpatientswithseverementalillness:overviewandmanagement, Journal of Clinical Psychiatry ,70,

Supplement3:12-21.

23. Bailey,Gerada,LesterandShiers,2012.Thecardiovascularhealthofyoungpeoplewithseverementalillness:addressinganepidemicwithin

anepidemicThe Psychiatrist Online October(36)pp375-378.Availableat:www.rcpsych.ac.uk/quality/NAS/resources.

24. LesterH,ShiersDE,RaI,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,peoplehave

gainedsignicantweightandareatgreatriskof

cardiovascularproblemsanddyingprematurely.Itisthereforeessentialthatphysicalhealthmonitoring

isprioritisedattheonsetofillness.Mentalhealth

providersshouldpromotetheuseofclinicaltools

tosupportthephysicalhealthneedsofpeoplewith

mentalillnessonantipsychoticmedication,suchas

theLesterUKAdaptation–PositiveCardiometabolic

HealthResource.24

Giventhatmedicationplayssuchasignicant

roleinweightgain,itisimportantthatpeopleare

givenaccessibleinformationaboutmedicationand

potentialside-effectsbeforemedicationisprescribed.

Thiswouldallowpeopletobemoreawareofthe

risksandwhattheyshouldbelookingoutfor,and

howtheirphysicalhealthwillbemonitoredalongside

theirmentalhealth.Howeverthisiscurrentlynotthe

case.ArecentCQCsurvey 25ofcommunitymental

healthservicesfoundthatonly44%ofpeople

feltthesideeffectsofmedicationhadbeenfully

explainedtothem.Ifpeoplearen’tequippedwith

theappropriateknowledge,theyandtheircarerscannotmakeinformeddecisionsabouttheircareand

treatment.Theyalsocannottakestepstomitigatethe

side-effectsoftheirmedicationandphysicalhealth

complicationscandevelop.

“ It’s so sad when one has cared for an 18-year-old at the time of their rst psychotic illness and then one doesn’t recognise themwhen one meets them again ve years later because they are

10Kg heavier. Psychiatrists need to take more responsibility for thephysical health of their patients because some GPs and hospitalphysicians don’t like treating people with psychosis.”

ProfessorSirRobinMurray,ChairoftheSchizophreniaCommission



“My son was a t 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 givenhaloperidol 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

Thereareanumberofbarriersforpeopleaffectedby

mentalillnesswhenaccessingphysicalhealthcare

andmonitoring.

AlthoughGPsareobligedtoofferpeoplecertain

physicalhealthchecksannuallyaspartoftheQuality

OutcomesFramework(QOF),thisisnotaawless

system.SomeofthetestsintheQOFareonlyofferedtopeopleover40yearsold,meaningtherecould

besignicantdelaysinaddressingphysicalhealth

concernsifpeoplehavebeentakingantipsychotic

medicationsincetheir20s.

Practicescanalso‘exceptionreport’oromitpeople

fromtheirQOFresultsincertaincases.Exception

reportingformentalhealthisparticularlyhigh

comparedwithotherhealthconditions.In2011/12

theexceptionreportingratewas11.8%,comparedto0.5%forcancer.26

Thesehighexceptionratesaresometimesputdown

toaperceivedreluctanceofpeoplewithmental

illnesstoengagewithGPs.However,peoplecannd

itverydifculttoaccessGPsurgeries.Theymightbe

anxiousaboutattendingormightstrugglewiththe

earlymorningbookingsystembecauseofmedication

side-effects.GPpracticesneedtomakesure

reasonableadjustmentsareinplacesothatpeople

arenotmissingoutoncrucialcare.

Whenpeopledoaccesshealthservices,their

physicalhealthneedsareoftenignoredorseen

asamanifestationoftheirmentalhealthcondition,

ratherthanaseparatehealthissue.This‘diagnostic

overshadowing’iswelldocumented27andleadsto

physicalconditionsbeingundiagnosedanduntreated,

whichcanprovefatal.Concernsraisedbycarerscan

alsobeignored.

Thislethaldiscriminationhelpstoexplainwhypeople

withsevereandenduringmentalillnessappear

toaccesssignicantlylowerquantitiesofseveral

commonmedicationsforphysicalhealthconditions. 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.Achievingparitybetweenmentalandphysical

health’,OccasionalpaperOP88,2013,referringtoMitchellAJ,LordO,MaloneD.Differencesintheprescribingofmedicationforphysical

disordersinindividualswithv.withoutmentalillness:meta-analysis.Br J Psychiatry 2012;201:435–43.

“It seems that once you have a mental healthdiagnosis any physical symptoms you experienceare instantly assumed to be part of yourdiagnosis. Once that assumption is made it isdicult to get anyone to attempt to disprove it.”

AnonymousRethinkMentalIllnessmember



Poor physical health monitoring

Peoplewithseriousmentalillnessneedcomprehensive

physicalhealthmonitoringatleastonceayeartohelp

withriskfactors,suchasweightgainassociatedwithantipsychoticmedication.However,therecentNational

AuditofSchizophrenia(NAS)revealedthat,onaverage,

only29%ofpeoplehadreceivedafullcheckofBody

MassIndex(BMI),smoking,bloodpressure,blood

glucoseandlipidsintheprevious12months.Insome

Trusts,thisnumberwasbelow15%.Wewouldliketo

seemoretraininginphysicalhealthcareandhealth

promotionforallmentalhealthpractitioners.Mental

healthnursesshouldbeabletoprovidebasicphysical

healthcareandprogressionthroughtrainingshould

dependuponthis.

Thislargevariationinresultsshowsthatthereisan

inconsistentapproachacrossthecountryandthat

physicalhealthisnotbeingproperlyprioritised.

Certainaspectsofphysicalhealthcare,including

weightorBMI,wereonlycheckedinaroundhalfof

cases,withsomeNHSTrustsweighingjust30%

ofpatients.29Thisisparticularlyworryinggiventhe

linkbetweenmedication,weightgainandhealth

problems,suchasheartdisease.Evenwhereproblemsareidentied,actionisoftennottakento

addressthese.TheNationalAuditofSchizophrenia

showedthatonlyoneinvepeoplewithraisedlipid

levelsandoneinfourpeoplewithhighbloodpressure

wereofferedthenecessaryintervention.

RethinkMentalIllnesshasbeenholdingsummits

acrossEnglandtodiscusstheseissueswithhundreds

ofpeopleaffectedbymentalillnessandwithhealth

professionals.Againandagain,wehaveheard

thatthephysicalhealthcareofpeopleaffectedbymentalillnessisfallingthroughthegapsbetweenGP

servicesandsecondarymentalhealthcare.Itisoften

unclear,bothtoprofessionalsandpeopleaffected

bymentalillness,whoisresponsibleforcoordinating

thissupport.Asaresult,nosupportisoffered.This

responsibilityneedstobeclariedsothatpeople’s

physicalhealthisn’toverlooked.Toolslikethe

IntegratedPhysicalHealthPathwaycouldsupport

professionalstoagreeprocesseslocallysochecks

arenotmissed.30

ACTIONS FOR THE NHS

• Commissionersandserviceproviders

needtobeclearabouttherespective

responsibilitiesofprimaryandsecondary

careservicesformonitoringandmanaging

thephysicalhealthofpeoplewithmental

healthproblems.

• Everyonebeingprescribedantipsychotic

medicationshouldbegivenclearand

accessibleinformationabouttherisksand

benetssotheycanmakeaninformed

choiceaboutmedication.Physicalhealth

monitoringshouldstartfromthevery

beginningoftreatmentwithidentiedhealth

needsquicklyactedupon.

• EachCCGandmentalhealthprovider

shouldworkwiththelocalDirectorofPublic

Healthtoensurethattargetedsmoking

cessationservicesandsupportareboth

availableandpromotedtosmokerswith

schizophreniaandpsychosis.

• Allsmokingcessationservicesmustcheck

thementalhealthstatusoftheirclients.

Theirstaffneedtohavementalhealth

trainingtoensuretheyoffertheappropriatelevelofsupport.Theyshouldalsorecord

whethersomeoneistakingmentalhealth

medication,toensuredosagesarechanged

asnecessary.

• Allmentalhealthprofessionalsshould

receivebasicphysicalhealthtrainingaspart

oftheirmandatorytraining.Mentalhealth

nursesshouldbetrainedtocarryoutsimple

physicalhealthchecks.

• RatesofpeopleaccessinginterventionsincludedintheQualityandOutcomes

Framework(QOF)tobeinlinewithpredicted

prevalenceoftheillness.

Evidencealsoshowsthatpracticenursesconsulted

withpeopleaffectedbymentalillnessonlyoncea

year,comparedwiththegeneralpracticepopulation

rateofalmosttwiceayear.31Practicenurseshavea

crucialroletoplayinhealthpromotionandpreventionand,giventhehigherriskofarangeofphysicalhealth

problems,thisisamatterofconcern.



ACTIONS FOR GOVERNMENT

TheGovernmentsaysmentalhealthisoneofitstoppriorities,butthishasnottranslatedintoaction

ontheground.

TheDepartmentofHealthandPublicHealthEnglandneedto:

• PrioritisetheneedsofpeopleaffectedbymentalillnessintheHealthSecretary’sforthcoming

strategyonprematuremortality.Asignicantproportionofavoidabledeathsarelinkedtomental

illhealth.Thismustberecognisedandactedupon.

• HoldNHSEnglandtoaccountfordeliveringprogressonreducingtheprematuremortalityof

peoplewithmentalillnessinlinewiththeNHSOutcomesFrameworkandthecommitmentinthe

NHSMandate.Denetheprogresstobemade,howlongitwilltakeandhowitwillbemeasured.

• Takeactiontoensurethateverysmokeraffectedbymentalillnessisofferedtailored‘quit

smoking’supportandinterventionsinlinewithNICEguidance.

• AmendNHSandCCGoutcomesindicatorstomeasureaccesstoproveninterventions,notjust

physicalhealthchecksandratesofdeath(e.g.proportionofpeoplewithmentalillnessaccessing

smokingcessationservices,proportionofeligibleindividualsaccessingEarlyInterventionfor

Psychosisservices).

• AmendtheQualityOutcomesFramework(QOF)toensurethatphysicalhealthscreeningis

availableforpeopleassoonastheytakecertainmedications,notjustattheageof40.

• NHSEnglandandCCGsshouldconsideranannualmortalityreviewbeingincludedaspartof

theircontractformentalhealthtrusts.CommittosustainingtheNationalAuditofSchizophrenia

foraminimumofafurtherveyearstomonitorimpact,andextendtheremitoftheauditto

includeallinpatientsettings.

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.Theroleofprimarycareinserviceprovisionforpeoplewithseveremental

illnessintheUnitedKingdom.PLoS One (7).



Case study: Tracey Butler (39), Hampshire

0 Rethink Mental Illness. Lethal discrimination.

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.

“Ihaveschizoaffectivedisorderandborderline

personalitydisorder,andwasrstprescribed

antipsychoticsinmyearlytwenties.AfterI’dbeen

takingthemforaround18months,Istartedtonotice

theimpactitwashavingonmyphysicalhealth.I

feltcompletelyexhaustedallthetime,thirstyand

dehydratedandIconstantlyhadtoruntothetoilet.

IwenttomyGPbecauseIwasconvincedsomethingwaswrong.Buthedismissedmyconcerns,he

wouldn’tentertaintheideathattheremightbe

somethingseriousgoingon.

Aboutayearpassedandthesymptomscontinued

togetworse,beforeIwasnallydiagnosedwithtype

2diabetes.Mydiabetesconsultanttoldmethatthe

symptomsIhadgonetomyGPaboutwereclear

earlysignsofthecondition.Healsosaidthatitwas

theantipsychoticsthathadcausedmydiabetes.

Seventeenyearslater,Istillhavetogoregularlytothe

diabetesconsultant.

WhenI’munwell,I’mnotgreatatlookingaftermyself.

ItcanbequiteabigundertakingtogotoseemyGP,

andIreallydoneedthemtotakemeseriously.As

soonasamedicalprofessionallooksatmyrecords,

theysee‘borderlinepersonalitydisorder’ashingup

onthescreenanditfeelsliketheystoplisteningto

me.TheyjustthinkI’mneuroticorparanoid.

Therealsodoesn’tseemtobeanycommunication

betweenmyGPandmypsychiatrist.Ithinkitwould

makeabigdifferenceiftherewas.

Inmyexperience,GPsrarelyknowmuchabout

mentalillness.Onetime,myGPcalledmeaftera

routinebloodtest,sayingthatImighthaveatumour

inmybrainbecausetherewasanunusuallyhighlevelofprolactininmyblood.Thissentmeintoastateof

greatdistressandIhadapanicattack.ButwhenI

calledmycommunitypsychiatricnurse,hetoldme

theprolactinlevelinmybloodwasprobablycaused

bytheantipsychotics.Thatturnedouttobethecase

–therewasnotumour,itwasjustaside-effectofmy

medication.Agreatdealofworryandanxietycould

havebeenavoidediftheGPhadknownmoreabout

theside-effectsofthemedicationIwason.”



Change is possible

There is reluctance from some to tackle this problem, due to a belief that it’s

‘too difcult’. 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,holistic

approachtoimprovingphysicalhealthoutcomes.

BytriallingandadoptingthePhysicalHealthCheck

toolfromRethinkMentalIllnessandembedding

itacrosstheTrust,theyhavedrasticallyimproved

physicalhealthmonitoringandintervention.

TheTrustrstpilotedthePhysicalHealthCheckin

itsrecoveryteam.Theresultswerestartlingand

includedidentifyingundiagnosedhighblood

pressure,diabetesandcancer.TheTrustthen

decidedtoimplementtheCheckandsetitasa

serviceimprovementstandardacrossawiderrange

ofservices.

TheTrustthereforecommittedtoofferingeveryone

usingtheirmentalhealthservicesaPhysicalHealth

Check.Tosupportthis,theTrustofferedtraining,support,awarenessraisingactivitiesandinvolvedall

staff,notjustnurses.Itdevelopedformalguidance

ontheCheckforsocialcarestaffandappointedlocal

physicalhealthleadsacrosstheTrust.

ThecompletedPhysicalHealthCheckisworkedinto

theperson’scareplansothatbothphysicalhealth

andmentalhealthneedscanbetreatedholistically.

Whereissuesareidentied,Truststaffproactively

ensurethatthesearefollowedupandliaisewith

primarycarewherenecessary.Staffmembersatthe

TrusthavehighlightedtherolethePhysicalHealth

Checkhasplayedinidentifyingserious,andpossibly

fatal,healthconditions.TheTrustcollecteddatafrom

thephysicalhealthchecksitundertookin2011/12and

2012/13.Theseshoweda30%decreaseinpreviously

unidentiedhealthneedsinthelatestroundof

checks.ThissuggeststheTrustissuccessfully

catchingthingsearlyandtakingaction.

Lancashire’sfocusonphysicalhealthcontinuesto

grow.FromApril2013,thePhysicalHealthCheck

hasbeenincorporatedintotheTrust’selectronic

records.Thisallowsforbetterrecordingofand

reportingonphysicalhealthneedsandoutcomes.

ThereisongoingworkandcommunicationwithGPs

andotherprimarycareprofessionalsandtheTrust

continuestodriveimprovementsinthephysical

healthservicesitprovides.

Solent NHS Trust

SolentNHSTrustadultmentalhealthservicesare

improvingtheirmanagementofdiabeticpatients

anddevelopingcloselinkswiththediabetesclinic

atthelocalhospitaltoimprovecare.Thisincludes

introducingthesamediabeticpathwayonadmission

asthegeneralhospital.Theunitisalsoarrangingfor

stafffromthediabetesclinictoauditthediabetescareitoffersonmentalhealthwards.

Thetrustisalsolookingatwhatfoodisofferedto

peopleonmentalhealthwards.Atrafclightsystem

outliningthenutritionalcontentoffoodshasbeen

introducedsopeoplecanmakeinformedchoices

abouttheirmeals.Vendingmachinesarealsobeing

stockedwithhealthieroptions.

ThisworkisfacilitatedbytheClinicalMatron

forHealthandWellbeing,whohasbothRGNand

RMNtraining.Bybeingabletotakemoreofa

teachingandadvisoryroleontheward,otherstaff

feelbettersupportedtoaddressphysicalhealth

concernsandkeyworkingrelationshipscanbebuilt

upwithotherservices.



Barnet, Eneld and Haringey:Early Intervention in Psychosis Service

Inthisservice,physicalhealthisgivenhighpriority.

Ithasaclearprotocolaroundphysicalhealthmonitoringrightfromwhenpeoplerstcometothe

service.InformationisinitiallyrequestedfromtheGP

forthepreceding12monthsandtheserequestsare

proactivelyfollowedup.Ifsomeoneisnotregistered

withaGPorrefusestoattendanappointment,

thereareproceduresinplaceforensuringcrucial

monitoringandassessmentstilltakesplace.Once

theseassessmentshavetakenplace,relevant

informationissharedwiththeappropriateparties.

Severalstaffwithintheservicehavecompleted

aspecialistundergraduatetraining,focusingon

practicalskillsandtheresearchandknowledge

underpinningidentiedinterventions.Thereisalso

adedicatedstaffmemberwhohasresponsibilityfor

keepingarecordofphysicalhealthmonitoringand

anyoutstandingchecks.Theprogrammehasbeen

wellreceivedbytheTrustandtherearehopesthatit

mightbeadoptedbyotherteamsacrosstheTrust.

“The barriers to better physical health care for people withserious mental illness are related as much to communication andknowledge as the obstacles we are already aware of, i.e. diagnosticovershadowing, inexible GP services, medication side eects andmotivational problems. In respect of knowledge, there seems tobe a consensus that mental health nurses lack both the trainingand the condence to manage common physical health problems.However, we’re nearly there.... we know what the issues are, let’swork 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 PhysicalHealth and Wellbeing Project

SheilaHardy,NurseConsultantand

VisitingFellowattheUniversityof

Northamptonshire,hasdevelopedtraining

forpracticenursesandcarriedoutresearch

onthephysicalhealthneedsofmental

healthpatients.

Shehasfoundthatcontrarytopopular

belief,patientswithseriousmentalillness

willattendhealthchecks,andproper

traininginthisareaforpracticenurses

increasesthelevelofscreeningandlifestyle

advicegiven.

Thenecessaryguidanceandtools

neededforsettingupanurse-ledclinicand

carryingoutahealthcheckforpeoplewith

seriousmentalillnessareavailableonline

(http://physicalsmi.webeden.co.uk/).This

allowsnursestofollowbestpractice

guidanceeveniftheyhavenoaccesstoformaltraininginthisarea.



How Rethink Mental Illness is tackling this

Formanyyearstheseriouslyneglectedphysical

healthneedsofpeoplewithmentalhealthproblems

hasbeenapriorityforRethinkMentalIllness.We

havebeenshoutingaboutthisshockinginequalityfor

aslongaswecanremember.Weknowthatchangeonlyhappenswhensolutionsareidentiedalong

withnamingproblems.Inoureffortstoovercomethe

hurdlesthatpeoplefaceinaccessingappropriate

andtimelyphysicalhealthcare,wehavespentthe

lastdecadeinpartnershipwithprofessionalbodiesto

tacklethisissueinpracticalways.

Wedevelopedtoolstohelpprofessionalsassessand

identifykeyphysicalhealthconcerns.Wecreated

accessibleonlinephysicalhealthresourcesand

training,toraiseawarenessandbuildcondencearoundsupportingpeople’sphysicalhealthneeds.

Wewroteguidesforhealthpractitioners.We

createdaPhysicalHealthChecktoolwhichenables

professionalsandpeopleaffectedbymentalillnessto

developplanstogethersothattheycanaddressany

unmetphysicalhealthneeds.

Workingwithpeoplewithlivedexperience,we

producedguidestohelpindividualsgetsupportfor

theirphysicalhealth.Wedevelopedtoolstohelp

peoplespeakoutandcampaignforchange.Werun

adviceandinformationservices.Wehelpasmany

peopleaswecomeintocontactwithandspendthe

littleresourcewehavespreadingthewordaboutthe

importanceofphysicalhealth.

Wewantthosewhocommissionanddeliverlocal

servicestogetaninsightintothephysicalhealth

issuesthatpeopleaffectedbymentalhealth

experiencesowefacilitatediscussionbetween

commissioners,professionalsandthoseaffected.Wecreateopportunitiesfordecisionmakersand

peopleaffectedbymentalillnesstoworktogether

todeveloppoliciesandpracticethatcanleadto

improvementsintheirareas.Andwehavetirelessly

promotedthesetoolsandresourcestoanyoneand

everyoneweencounter.

Wehaverealisedmuchmoreisneeded.Toenable

thesignicantchangethatisurgentlyrequiredinthe

NHSandbeyond,wehavethismonthlauncheda

country-wideInnovationNetwork.Inpartnershipwithmentalhealthproviderorganisations,weare

workingtoembedexcellentphysicalhealthcare

acrossthesystem.

ItistimefortheGovernmenttodoitspart.



Conclusion

Whiletherearesomepocketsofgoodpracticein

thesystem,mostpeoplewithmentalillnessare

beingbadlyletdownwhenitcomestotheirphysical

health.Thismeansmanythousandsofpeopleare

dyingneedlesslyeveryyearandmanymoreareleftstrugglingwithlongtermconditionssuchasdiabetes.

Manyfactorscontributetothisstateofaffairs,

creatingoneofthebiggesthiddenhealthscandals

ofourtime.

Bynotacting,theGovernmentandtheNHSare

allowingsomeofthemostvulnerablepeopleinour

societytobetreatedassecondclasscitizens.We

wouldneveracceptthisstateofaffairsforother

patientgroups,andweshouldn’tacceptitforpeoplewithmentalillness.Weknowwhatthesolutionsare

andtheyarenotcomplexorexpensive.Allweneed

nowisthepoliticalwill,atbothnationalandlocal

level,tomakechangehappen.


http://slidepdf.com/reader/full/rethink-mental-illness-lethal-discrimination 17/17

For more information on our wide rangeof physical health resources, please visit

www.rethink.org/phc.

Leading the way to a better

quality of life for everyone

affected by severe mental illness.

ForfurtherinformationonRethinkMentalIllness

[email protected]

facebook.com/rethinkcharity twitter.com/rethink_

www.rethink.org

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Rethink Mental Illness - Lethal Discrimination