“Don’t just screen, intervene” by Liam Loftus

The COVID-19 pandemic has shone a bright light on the seriousness of health inequalities within England, exacerbating the significant discrepancy between healthy life expectancy that is known to exist between the least and most deprived areas of England.  A national approach to reduce health inequalities and narrow the life expectancy inequality gap, has been developed by Dr Bola Owolabi and the Healthcare Inequalities Improvement Team at NHS England. This approach, known as ‘Core20PLUS5’, is to be implemented at both a national and system level. It defines target population cohorts – the ‘Core20PLUS’ and identifies ‘5’ focus clinical areas that require accelerated improvement as a priority due to their contribution to the life expectancy inequality gap. 

This is the second in a series of five blogs, written by clinical fellows on secondment at NHS England and NHS Improvement and Healthcare Quality Improvement Partnership (HQIP), explore the ‘5’ focus areas, the links between health inequalities and the invaluable contribution of leadership to narrowing the life expectancy inequality gap. The ‘5’ focus areas are cardiovascular disease, cancer, chronic respiratory disease, maternity and mental health.

In my personal life, I have seen first-hand the impact that severe mental illness (SMI) can have upon an individual. I have embraced the periods of stability and fulfilment that people with SMI experience, and I have comforted them during the times of anguish and distress. I’ve seen in my professional life too, how the challenges of living with SMI extend far beyond the impact upon mental health. Most notably, I’ve experienced how physical health issues are not only common, but are often overlooked; by patient, by clinician, and by the wider system.

There’s one fact in particular that continues to cause deep, personal sadness:

On average, a person with a diagnosis of SMI dies 15 to 20 years earlier than the general population. 

This sadness quickly becomes discomfort when I remember that this stark life expectancy gap is driven by physical conditions which are largely preventable; these include cardiovascular disease, respiratory disease, and infections. As leaders in healthcare, the responsibility for ensuring that this health injustice is tackled swiftly and directly sits on all of our shoulders.

Where should we start?

One key mechanism to confront this life expectancy gap is through the early detection of physical health conditions. The annual physical health check for people with SMI (which includes people diagnosed with schizophrenia, bipolar affective disorder, and other psychoses) aims to do just this. This check involves assessing and recording key physiological measurements (see below) to identify current and future health challenges, and is followed by a structured, supported discussion on how a person’s physical (and often mental) health may be improved.

The six key indicators measured during the SMI physical health check:

  • Alcohol intake
  • Blood glucose
  • Blood lipid profile
  • Blood pressure
  • BMI
  • Smoking status

Though the majority of these checks are delivered in primary care, it will take a concerted and collaborative effort across the whole system – from national policy-setters through to front-line clinicians – to ensure the benefits of these checks are realised. 

From national policy…

There is a renewed energy amongst many national organisations to increase the uptake of these checks. The NHS Long Term Plan, for example, sets out the ambition to increase the number of people with SMI who complete their annual physical health check to 390 000 per year by 2023/24 – currently, we stand at around 140 000. This aspiration is further emphasised in this year’s update to the Primary Care Network (PCN) service specifications, as well as in the recent NHS Core20PLUS5 initiative, both of which set out the aim to deliver a comprehensive physical health check for at least 60% of people with SMI. Financial support has also followed; as of April 2021, all six elements of the check are financially incentivised through the Quality Outcomes Framework.

…to the consulting room

Engagement closer to the patient, at the level of individual practices and PCNs, will also be pivotal in achieving success. Here, relatively simple measures – such as ensuring that computer system templates allow for easy recording of data, and ensuring that the staff involved are trained to comfortably deliver the checks – will be of great benefit. 

Of most significance, however, is the role clinicians and systems play in acting upon the measurements collected during the checks. Here, the “don’t just screen, intervene” mantra is critical. This involves doing the basics well; specifically, ensuring that any abnormalities identified are managed in accordance with NICE guidance, and through a shared decision making lens.

Adopting a system-wide approach

In order to truly make an impact, leaders will need to think differently. Working without walls across the health and social care system will be essential, and the FMLM System Leadership Standard of “seeking to understand and positively influence strategy and culture within and beyond their own organisation,” will be of utmost importance. The move towards the more collaborative Integrated Care System (ICS) model provides a timely opportunity to turn these words into action.

Cambridgeshire and Peterborough Clinical Commissioning Group have pioneered their own system-wide approach to this challenge, by training healthcare assistants specifically in delivering high-quality health checks. The HCAs are employed by GP Federations, and are linked to PCNs. They deliver the checks in the person’s regular GP practice, in a model that is cognisant of the pressure that primary care currently faces. Through using co-produced methods to invite people, and through establishing robust referral pathways into services such as weight management and smoking cessation, the expected impact this will have upon the health of people with SMI is both significant and tangible. 

Commissioners could also look to go further, too. Harnessing the learning from the recent COVID vaccination programme, systems may consider delivering these checks in alternative but familiar locations, such as local pharmacies and community centres.

ICSs now have the opportunity to tackle drivers of poor health that have traditionally sat beyond the remit of healthcare; most notably, the social determinants of health. Often, an SMI health check may reveal difficulties with housing, financial stability, or with finding meaningful employment. Social prescribing link workers, employed by PCNs, are now extremely well placed to make meaningful connections across the system, assisting people with SMI in receiving support from system partners such as the Local Authority, or from Voluntary, Community and Social Enterprise Organisations. The need to build close relationships between these organisations is also essential, and should be high on the priorities list for the recently-appointed PCN leads for tackling health inequalities.

Preventing the preventable

The challenge in this space is clear. But these challenges also present opportunities.

In the words of Dr Bola Owolabi, Director of Health Inequalities at NHS England and NHS Improvement, “a lot of their mortality is eminently preventable.” We, as leaders in healthcare, each have a role to play in preventing the preventable. In our professional lives, through each taking small but significant steps, and working collaboratively within and beyond our system, we can have a deep and meaningful impact upon each person with SMI that we care for. Together, we can narrow this life expectancy gap.

Dr Liam Loftus

Liam is a GP Trainee based in Cambridge. He is currently a National Medical Director’s Clinical Fellow, working with the Primary Care Team at NHS England and NHS Improvement. He developed a passion for clinical leadership through undertaking roles such as Junior Doctor Mess President at the Royal Liverpool Hospital, and Oxford Clinical School President, and through completing leadership qualifications with the University of Cambridge, Institute of Leadership and Management, and the NHS Leadership Academy. He has used these as a platform to lead projects in areas such as patient safety, workforce development, and service improvement, presenting his work both nationally and internationally. More recently, in his role as Leadership Fellow with Health Education East of England, he has co-led the development of The Leadership Ladder; a junior doctor-specific leadership development platform, which now forms the core offer for leadership development for all 5000 trainees in the East of England. As a future GP, Liam’s desire is not only to impact upon the patients who enter his consulting room, but also to take a step back, and consider how we can improve the health and wellbeing of all patients; locally, regionally, and nationally. In his current fellowship role with the National Primary Care Team, he is focussing specifically on his two key passions: the role that Primary Care plays in reducing health inequalities, and shaping the vision for the future of Primary Care.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

 

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