There is a growing international network of people leading QI work in mental health settings. Led by the East London NHS Foundation Trust and the Scottish Patient Safety Programme (part of Healthcare Improvement Scotland), they meet twice a year (at the IHI National Forum and the International Forum on Quality and Safety), with virtual collaboration in between. IHI spoke to network participants Daniel Fung, Chairman Medical Board at the Institute of Mental Health, Singapore; James Innes, Associate Director of Quality Improvement, East London NHS Foundation Trust; and Johnathan MacLennan, Improvement Advisor at Healthcare Improvement Scotland, Lead for the Scottish Patient Safety Programme in Mental Health, to learn about their efforts to better connect physical care with mental health.
Why is it so important to connect mental and physical health care?
Johnathan MacLennan (JM): Premature mortality in people with serious mental health issues is a huge problem. There are people losing 10 to 25 years of their lives. It’s unacceptable. If we were talking about Hospital Standardized Mortality Ratios (HSMRs), people would be all over it. We need to place equal value on both mental health and physical health. That’s why we came together to raise the profile of these issues, share learning, and get ideas and grow a global network to do something about it.
Daniel Fung (DF): It’s important for the mental health system to determine the reasons for this life expectancy gap and do something systematically to address them.
What are some of the challenges to bridging the gap?
James Innes (JI): Sometimes our support systems (electronic record systems, notes systems, or physical monitoring systems) aren’t set up to help us work on improving physical health. In England, many of our systems are set up to help us achieve performance targets and appease our commissioners, rather than show us how we are doing over time. This means we don’t have many ways of looking at an overall physical health outcome to see whether things are getting better or worse.
The other big issue is that declining physical health can often be insidious. For example, when I prescribe a medicine that may induce weight gain, it may often take many months for that side effect to be realized. It is only when I see the patient in a clinic nine to ten months later that I see they’ve bloomed in weight. The missing cause-and-effect is the issue. Whereas with something like violence, we see it there and then. It’s tangible, I can measure it, and I can see if it’s reducing. It’s important that we become far more sensitive to declining physical health and do something about it as soon as we see signs of deterioration.
DF: I also think it’s difficult for a lot of mental health professionals to think of themselves as experts in physical health, but we are part of the health system. There is no reason why we shouldn’t be doing physical health, particularly when we know that when we refer patients to physical health services, as we traditionally do, they don’t always turn up for their appointments. We have a responsibility to look at the whole health of our patients.
JM: And that’s key. Some of the feedback from Support in Mind Scotland supports that. The Equally Fit Charter developed by their service users, family members, and carers looks at these issues from both a rights-based angle and a social angle.
What do people often misunderstand about the need to connect mental and physical health care?
JI: Sometimes people assume this is purely an issue for health care to sort out. It is far broader than that. The issue for [health care] is we only see people a fraction of a percent of their time.
JM: I was at a Scottish parliamentary reception for Equally Fit recently, and there was a gentleman there who was a service user. He said that the thing that benefited his physical health the most was someone reminding him, not telling him, but reminding him how to cook. He felt his outcomes were better because he got the practical and emotional support he needed.
Cooking is a basic life skill that enables people. He said [without that support], “[People will] go and sit and spend their money on fried food and eat rubbish.” And before you know it, you can have serious weight and health issues.
This is where people with quality improvement skills can help. It is one thing to start a walking class that runs for six weeks, but what happens at the end of that? Chances are you’re not going to sustain that without support.
JI: One example I am particularly proud of is called the Bridge Club QI project in our medium secure inpatient services at ELFT. It’s a QI project run by service users and staff and is about helping service users become more active whilst reducing their social isolation. They have been testing lots of change ideas including self-directed activities, like boxing and football. And they are seeing some pretty astonishing results with unprecedented levels of involvement in physical exercise. And the service users enjoy it.
JM: With positive outcomes comes funding. There’s a wonderful project near Inverness called Abriachan. It’s a walking group that started off with people who had long-term schizophrenia. Two years ago, they won the Mental Health Nurses Forum Award in Scotland. If health and social care put their money into charities and organizations like this, that would be a big boost. It’s not just a health care issue. You have to come at it from a number of different angles.
Would you describe the work of the larger mental health network to which you belong?
JM: It started off with a handful of us in a breakfast group at the 2014 International Forum. We kind of grabbed onto each other and said, “We are doing the same stuff here.” We have been talking now for three years. Pedro [Delgado, IHI Executive Director] described us as “the most organic and sharing group he had ever seen.”
Our session at the International Forum was a good case example of this. A few emails, tweets, and texts went out, and before you know it we had a room of 150 people talking about the same subjects. We had a meeting of 75 people from as far away as Brazil and Scotland and London and Singapore. It’s an informal network. There are no agendas other than we are all involved in quality improvement and mental health and we all want to improve outcomes for people.
DF: I hope we can bring in more participants from new parts of the world. We need more people from Africa and Asia.
JM: Also at the core of all our thoughts and thinking is making sure that more service users are involved in this group.
JI: I think QI knows no boundaries, and that’s what I love about it. We’ve all got so much to share and learn from each other about what’s worked and hasn’t worked. The more of us there are who are willing to share, the more we can accelerate and work to improve global mental health together.
Note: This conversation was edited for length and clarity.
Editor’s Note: Are you interested in joining the conversation? Use the hashtag #MHImprove on Twitter and contact Dr. Amar Shah at Amar.Shah@elft.nhs.uk of the East London NHS Foundation Trust to join this global network leading QI work in mental health settings. If you’re active on Twitter, look for the #MHimprove hashtag or follow @DrAmarShah, @jonnybaldy, @JInnesMPharm, and @danielssfung.
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