The following section provides information about each of the different components involved in UCLP-Primrose, and why each part is so important for transforming healthcare for people with SMI.
The search and stratification tool
What: The UCLP-Primrose search tool, built for EMIS and SystmOne, identifies and stratifies all patients with SMI into priority groups based on recorded evidence of factors that contribute to cardiovascular disease risk, such as high blood pressure and cholesterol. Patients who have not had a blood pressure check in the last 18 months (as a proxy for a health check) are also identified.
Why: This tool allows practices to prioritise patients for their invitation to a health check, so that those most in need of care receive it as soon as possible, and those who have not been seen in the last 18months (usually 30-40% of patients with SMI) are flagged as potentially needing additional action to engage.
How: You can find the search and stratification introduction document here. Download the SMI search and stratification tool.
The mental health desktop review and outreach
What: A mental health professional (usually a nurse) will draw from the patient’s electronic patient records to identify any additional needs or adjustments the person might require to support them to engage. They will also organise early, proactive outreach to those who do not respond to invites, usually in the form of home visits.
Why: 30-40% of patients will not respond to their invite for a health check. However, such patients have a high likelihood of being at risk of cardiometabolic disease and will need access to life-saving interventions. Research shows us that despite national initiatives to improve physical health screening for patients with SMI, the physical health of this population remains poor. In most cases, a ‘business as usual’ approach cannot be taken, and more flexible, proactive care must be opted for. Home visits are often the only way to reach such patients.
How: Many GP practices now have mental health professionals as part of their core teams, or have used the Additional Roles Reimbursement Scheme (ARRS) funded posts to deliver this part of the pathway. You may want to consider who could also support with outreach – such as peer workers, occupational therapists, or finding out information from the secondary care team. View our mental health review guide.
The physical health check
What: The physical health check involves measuring things like weight, height, and blood pressure; doing some blood tests and reviewing medication; and talking with patients about their health and how they could improve it. For patients with SMI, the physical health check should be completed annually.
Why: In line with NICE guidance , the annual health check is to assess the overall health of a patient with SMI, to offer better physical care including paying attention to the risk factors of cardiovascular disease. Research shows people with SMI die 15-20 years earlier, and are 3x more likely to die from cardiovascular disease than people without SMI. Performing the health check provides the opportunity to prevent cardiovascular disease risks getting any worse and ideally reducing these by supporting patients to improve their health. “Don’t just screen, intervene”.
How: Continue with your existing health check programme. View the physical health check manual.
The clinical review
What: Patients will also see a clinician (such as a GP, pharmacist, or nurse) for a clinical review. The clinician will review the patient’s clinical conditions and where needed, optimise medication to manage the high impact risk factors such as blood pressure, cholesterol, and diabetes.
Why: The clinical review provides the opportunity to identify and intervene. There is a clear line of evidence from reducing blood pressure and cholesterol to reducing risk of heart disease, stroke and death, so we need to ensure that people with SMI receive these interventions when needed. Particularly relevant is the optimisation of medication. Use of statins should be discussed with patients and where needed prescribed. Statins have been shown as effective for people with SMI, and in some age groups statins are less likely to be prescribed to patients with severe mental illness.
How: Staff offering the physical health check will need to know under what circumstances and how to make an appointment for a clinical review. The clinical review appointment will be made during or after the health check appointment depending on when risk factors are identified.
Intensive behaviour change appointments
What: Some patients will require more intensive support to make changes to their physical health. For this, we recommend ‘intensive behaviour change’ sessions (‘Primrose’ – developed using the evidence base, focus groups, a Lived Experience Advisory Panel, and the behaviour change wheel) offered regularly over approximately 8 sessions.
Why: Primrose was evaluated in a cluster randomised trial across GP surgeries in England, with findings suggesting that Primrose could modify cardiovascular disease risk in patients with SMI. Delivery of Primrose was estimated to save the NHS £895 per patient per year compared to screening and feedback on cardiovascular disease risk (standard care) through reducing psychiatric inpatient costs, adverse events, and hospital admissions.
How: These sessions can be provided by any suitably trained person (see our training manual, training playlist, and lesson plan for in-person training on our training resources page).
Peer support
What: Peer coach appointments are a key element in the UCLP-Primrose pathway as these appointments are less structured, giving space for the patient to really feel heard and to lead in their own health journey. Peer coaches can facilitate the patient in determining the help they need, whether that be for their physical health, mental health, or a broader social need.
Why: A randomised control trial showed that peer-delivered self-management has been found to reduce readmission to acute care once a patient has been discharged from a mental health crisis team. Research has also found that social support encourages health behaviours, and can improve appointment attendance and medication adherence for patients with SMI at risk of cardiovascular disease. In research exploring the acceptability and experiences with Primrose-A, peer coaches were found to further augment the holistic, integrated approach to mental and physical health improvement and prevention through providing support where patients could feel connected during their care.
How: In the developed model of Primrose, (Primrose Adapted or Primrose-A), peer coaches provided four one-hour appointments over a six-month period. These appointments are flexible and should be tailored to the patient and their preferences. View the peer coaching manual.