People with severe mental illness (SMI) die 10-20 years earlier than people without SMI (referred to as the mortality gap), often because they do not receive the care they need. UCLPartners-Primrose (also known as UCLP-Primrose) transforms care for people with SMI. It combines:
- early, proactive identification of patients who are at risk of cardiovascular disease, with
- evidence-based interventions to change and sustain improvements to both patients’ physical and mental health.
Read on to discover the history and context of UCLP-Primrose, as well as some of its expected outcomes.
Why was UCLPartners-Primrose developed?
People living with severe mental illnesses (SMI), such as bipolar affective disorder or schizophrenia, face one of the biggest health inequality gaps in England. Much of the early mortality in this population is caused by common risk factors such as high blood pressure, high cholesterol, and smoking that leads to heart attack, stroke, respiratory disease, and cancer. With more than 40% of adults with SMI smoking, smoking is the largest avoidable cause of premature death. These risk factors are high impact but also highly modifiable. For example, treatments to lower blood pressure or cholesterol or help to stop smoking substantially reduce the risk of developing and dying from conditions, particularly those related to cardiovascular disease (CVD), which are diseases related to the heart and blood vessels.
Over the last 30 years UK policy has developed around CVD screening and prescription for people with SMI treated in primary care, such as the introduction of Quality and Outcomes Framework (QOF) in 2004 which included the incentivisation of an annual health review for people with SMI, guidelines for the management of bipolar disorder and schizophrenia published in 2006 and 2009, and the introduction of specific indicators to be screened in patients with SMI related to CVD (e.g., BMI and lipid levels) in the 2011 update to QOF.
Despite the recognised link between SMI and CVD, and policy developments to directly target this, early identification and importantly effective treatment of physical health problems in this population remains poor and the mortality gap for patients with SMI continues to be a concern.
The history of UCLP-Primrose
- Primrose
In 2012, to take steps towards reducing the recognised morality gap for patients with SMI, a team of researchers at UCL hosted 14 focus groups with patients, healthcare staff, and carers which asked what support should look like for people with SMI at risk of CVD. Informed by this, the researchers worked with patients, behavioural change experts, and healthcare staff to develop a new intervention for patients with SMI when CVD risks were identified in their annual physical health check.
The result was an integrated (bringing mental health and physical health together), primary care (based in GP practices, delivered by nurses) service (an intervention to reduce cardiovascular disease delivered to patients with severe mental illness) called Primrose (PRedIction and Management of Cardiovascular Risk in peOple with SEvere mental illness).
To test how effective this new intervention was, from 2014 researchers compared Primrose to the care patients would normally get when they had high CVD risk and SMI through a national randomised control trial across 76 GP practices in England. The headline findings published in 2019 were that people saw the need for Primrose, patients who were supported through Primrose were less likely to be admitted to inpatient hospital care, and Primrose was estimated to save the NHS £895 per patient per year through mental health costs compared to usual care.
- Primrose-A
Responding to findings from the Primrose trial, new research studies, and shifts in policy, researchers and clinicians adapted Primrose with the additional aim of further improving patient outcomes (becoming Primrose-Adapted or Primrose-A). The updates included adding in checks to make sure patients were prescribed and took statins if they needed them and changes to the delivery plan to increase the capacity in primary care, such as training different members of staff to make it more available and adding peer coach support (peer coaches are people with lived experience of mental health problems who could deliver sessions focused on different aspects of recovery). Primrose-A was rolled out in the London borough of Camden in 2019, with delivery being evaluated through the COVID-19 pandemic (this led to further adaptions with sessions being delivered online instead of face-to-face).
- UCLP-Primrose
Just a few years later, in 2021, the social and health landscape had changed to such a degree that further adaptions needed to be made to the Primrose-A model. In response to the increased burden on primary care, exacerbated by Covid-19 and the ongoing transformation within the NHS to integrated care systems (delayed due to NHS Trusts needing to create COVID-19 recovery plans), Primrose-A needed to be able to prioritise patients based on their clinical risk to ensure that those in most need would be seen first.
To do this, Primrose-A was combined with the UCLPartners Proactive Care Framework.
The UCLPartners Proactive Care Frameworks are a novel approach to managing long term conditions in primary care. The frameworks use stratification to identify patients who need priority management, and deploy the wider primary care workforce to provide structured support for patient education, self-management and behaviour change.
The combination of risk stratification, a clear care pathway with wraparound support including peer coaching, and interventions for identified CVD risk for patients with SMI is known as UCLPartners-Primrose (which is the combination of the ‘UCLPartners Proactive-Care Framework’ with Primrose-A, shortened to UCLP-Primrose).
What are our aspirations for UCLP-Primrose?
Ultimately, the goal is for UCLP-Primrose to transform the care for people with SMI, so that this population no longer faces one of the biggest health inequality gaps in England. In the long run, this will be seen in a reduction of the mortality gap. In the short term, we will be looking for evidence of transformation in the following ways:
- Improved uptake of SMI annual health check and completeness (e.g. does use of UCLP-Primrose increase numbers of patients having all parts of the health check measures as well as ensuring reach to patients who had not engaged previously)
- Clinical measures e.g. how many people get put onto a statin, how many people have their blood pressure optimised
- Recording the number of people in priority groups 1 and 2 each year, measured on years 1,3 and 5 (we would expect the numbers in priority groups 1 and 2 to fall each year)
- Improved ‘Did Not Attend’ rates for health check appointments
- Outcomes on Long Term Conditions management e.g. diabetes or hypertension
- DIALOG+ (e.g. changes in satisfaction score for physical health)
Our successes so far
Case-study: Helen
“I am delighted to tell you about my recent experience of UCLP-Primrose as it was very positive for both my mental and physical health.
In the time of covid and post lockdowns I was quite flat like a lot of other people, watching a lot of TV and going out only a little… I thought this was enough to sustain me, until I started UCLP-Primrose.
I started UCLP-Primrose at my doctor’s surgery from January 2022 until September 2022, meeting the nurse on several occasions. She made it clear that UCLP-Primrose would be a holistic approach for both mind and body. Using My Health Plan I embarked upon a series of achievable goals slowly at first e.g. walking more, my motivation improving over time with her encouragement. She also encouraged me to develop more structure to my days and weeks and to socialise with more people as I was quite isolated.
The UCLP-Primrose team have encouraged me to seek out wider options for myself and taught me that with a little effort and planning I can lead a more fulfilling and healthier life and look forward to the future.
My nurse also gently got me to look at my diet and kept an eye on my weight, encouraging me to eat more fruit, fibre and vegetables. During lockdown I had ordered ready meals (high in fat) online from the supermarket and pizza and ice cream take-aways. The gym felt anonymous so I didn’t use my membership. No wonder I was gaining weight. She encouraged me to go to Slimming World starting in May 2022. My starting weight was 11 stone 5lb, when I left Slimming World in December 2022 I was 10 stone 1lb. I am just under 10 stone today and hope to lose a further stone gradually by myself this year, my ultimate aim is to have a BMI of 24 (around 8 ½ stone). I feel fitter, lighter and slimmer as a result.
We also did a series of physical checks. Some blood tests showed I had raised fats and a liver problem. I was sent for an ultrasound by my GP and discovered I had a fatty liver and gallstones which I had been unaware of. My latest blood tests in October 2022 were satisfactory and show liver result stable.
My mental health history and medication was also reviewed, including the side effects of Sodium Valproate. This can affect the liver, and cause sluggishness, tiredness and weight gain. We spoke to a psychiatrist about my mental state and he reviewed my medication advising a reduction in Sodium Valproate initially from 500mg down to 400m then down to 300mg. I gradually came off Sodium Valproate altogether. As a result I feel more alert and have more energy and need less sleep. I remain on Fluoxetine, Aripiprazole and continue to take statins.
I met my Peer Coach in June 2022 for the first of a series of four hourly meetings with the initial aim of linking up with some community services. She gave me details of organisations, running, walks, those for over 60s, mental health organisations, and community centres. She also encouraged me to get a smartphone which I have just done to organise life better and make connections. She asked me to list what I enjoyed doing and gave suggestions of easy low cost or free activities which would introduce me to new people and communities. I joined a very inclusive community centre and took up Tai Chi as a result. I also joined their fortnightly walking group and have gone to places and parks I have never visited before. I have made many new friends there and hope to attend their Pilates class. We held our last peer coaching meeting in February 2023.
The UCLP-Primrose team have encouraged me to seek out wider options for myself and taught me that with a little effort and planning I can lead a more fulfilling and healthier life and look forward to the future. I want to thank the whole UCLP-Primrose and Core Team for this opportunity to get involved. The holistic approach has been of great benefit to me. I plan my days now and am more active physically and mentally. I have more of a sense of purpose and confidence having received great care, support information and input. I will definitely encourage others to pursue the programme.”
Supporting resources
- For more information about implementing UCLP-Primrose, see our ‘Information for Implementors’ page.
- For more information about training, see our Training and Resources’ page.