GPs in Brighton have set up a pioneering local enhanced service (LES) to manage patients with serious mental illness in primary care. Dr Becky Jarvis explains how it works
The serious mental illness LES – SMI LES for short – grew out of a national change in approach to patients with serious mental illness several years ago. The new approach suggested that patients with serious mental illness who are stabilised needn't stay within mental health services, but could receive improved holistic and less stigmatised treatment within primary care instead.
There is a group of patients who traditionally stay long-term within mental health services. But like patients with physical illnesses such as diabetes, who are no longer seen in hospital for routine care, we felt the same was possible for patients with serious mental health problems.
For primary care to safely accept patients, GPs and practice nurses would need training, practices would need to establish enhanced recall systems and patients would need to be supported by community psychiatric nurses linked to practices in the initial phase.
We met with secondary care clinicians to try and understand their situation a bit better.
We already knew that GPs and practice nurses needed training and patients needed support as they stepped down towards being looked after within GMS.
To pull that together, we came up with SMI LES towards the end of last year. GPs have worked closely with Sussex Partnership to develop the pathway, in particular with practice development nurse Zo Payne. The first wave of 13 practices started the LES in December 2010 and we're now onto the second wave – a further six practices – that are starting currently.
The LES funds participating practices to manage care of patients with serious mental illness discharged from the recovery services at the trust.
Practices' responsibilities include prescribing, monitoring and administering medication, regular comprehensive
reviews, proactive follow-up and comprehensive risk assessment and collaborative care planning.
Patients move from intensive levels of care to GMS in a stepped-down approach.
Participating practices have access to a qualified mental health liaison nurse to support both patients and practices.
The recovery services only discharge eligible patients to practices that are participating in the LES. The agreed patient capacity for each practice is negotiated with a clinical steering group according to projected and actual numbers of patients at each tier of service.
Participating practices have to:
• achieve QOF indicator MH8 (SMI register) and an 85% score for QOF indicator MH9 (annual review including health promotion) for 2009/10 (or QOF year previous to start) – in the second year of the scheme, 60% achievement for MH6 (comprehensive care plan agreed) in the previous QOF year is also required
• nominate a lead GP and lead practice nurse for the LES
• commit to attending three half-day initial training sessions and ongoing updates
• participate in audit as required
• work to agreed clinical protocols and guidelines
• attend at least two of the three annual SMI LES clinical network evening meetings – at least one by each clinical lead (GP and practice nurse).
We've had two of these meetings so far and will have another in October.
Under the terms of the LES, patients have to be local residents aged 18 and over. They are considered on a case-by-case basis, and some of their original diagnoses include schizophrenia, bipolar affective disorder and personality disorder.
The LES includes patients requiring lithium prescribing or depot injections in primary care following agreed protocols. Patients requiring clozapine prescribing may be considered during the second year.
Patients can decline a referral to the SMI LES without prejudice to ongoing or future treatment.
The LES has two levels.
Patients are considered for level one if they are currently stable, require either depot injections or lithium monitoring to NICE standards, and do not require intensive monitoring over and above general medical services and the QOF.
For level two of the LES, patients must currently be under the care of or recently discharged from Brighton & Hove recovery services.
They should be managing well within stable accommodation and able to meet their own basic living needs, require minimal assistance with medication concordance and be stable on medication, but require regular review and monitoring because of risk of potential relapse.
Patients should also be prepared to participate in regular health and medication checks in primary care when prompted to do so. They should have sustained their progress with less frequent support from the recovery service, and not need specialist recovery interventions and treatments.
They must be prepared to receive the support of primary care services and have an identified relapse management plan included in their discharge care plan.
Practices receive an initial training grant of £750 for practice backfill, plus an annual retainer of £750. To earn the first-year, level-one payment of £128, patients on lithium have to have a blood test every three months rather than every four months as per the QOF and have an annual review against a template.
Patients requiring depot antipsychotic injections just need an annual check against a template and a six-monthly side-effects review.
For level two, patients receiving enhanced care have a six-monthly review by dedicated LES community psychiatric nurses (CPNs) together with the GP against a template, as well as the annual physical. Practices are again paid £128 per patient per year for these.
There are two community psychiatric nurses funded by the LES and employed by Sussex Partnership, and each has a maximum caseload of 45 patients. There are 57 patients on the scheme at the moment, and the CPNs see the level-two patients at least once every 12 weeks.
The default for patients of practices not involved in the LES is that they stay in recovery services until they are fit to discharge to GMS.
The LES has resulted in no loss of income for Sussex Partnership, as it continues to have a block contract.
With the second wave starting, we're getting towards 40% of practices signed up now. Because the LES is voluntary, I'm sure there will be some practices that won't want to sign up.
We'll have our next review of the LES later this month, but so far informal feedback from primary care staff who've been trained, recovery consultants, community psychiatric nurses, GPs and patients in my practice has been positive.
The emerging clinical commissioning group (CCG) is fully engaged in this, and so is our LMC. To make a service like this work, I think it's important to have strong links between primary and secondary care and commissioners.
As a CCG, we are trying to work hand in hand with our clinical colleagues and there is real optimism that we can change things together. As far as I know, nowhere else has done this and we're getting plenty of interest from other areas who are looking at us and what we've achieved.
Dr Becky Jarvis is joint clinical lead for mental health in Brighton & Hove and a GP at the St Peter's Medical Centre in Brighton
The LES in action
A man in his 50s with a diagnosis of bipolar affective disorder was attending the lithium clinic for regular blood tests. He had no other contact with mental health services, worked part time and was in a stable relationship. His last admission was in 1990. As well as his mental health problems he had a diagnosis of type 2 diabetes. He was frustrated by the lack of co-ordination between primary and secondary care regarding blood tests, as he frequently had to have his lithium tested within days or weeks of a diabetes check. He disliked having to go to a centre with other patients with serious mental illness , and felt that this stigmatised him. After completing the SMI LES training, the GP and practice nurse felt confident in taking over lithium prescribing and instituted a computerised call and recall system to ensure that the patient had lithium levels checked every 12 weeks. The bloods and physical review were co-ordinated with the patient's diabetes checks, and the patient has benefited from a newly co-ordinated and holistic care plan for his physical and mental health.
A woman in her 40s with schizophrenia and personality disorder had been under long-term follow-up from psychiatry. A previous attempt to discharge her before the LES was introduced to primary care had resulted in numerous presentations to her GP practice and A&E, and referral back to mental health services. The patient was transferred to the LES in April 2011 when taking aripiprazole 30mg and duloxetine 90mg. She met the community psychiatric nurse (CPN) and has worked with him to develop a Wellness Recovery Action Plan. She has been referred to a exercise scheme after a physical check according to the template and her contraceptive needs reviewed as a previously unidentified need. Since being referred onto the LES, she has had one attendance at A&E with mental health problems and nine GP attendances (physical and mental health problems) – compared with 10 attendances and 25 attendances, respectively, in the previous six months. The patient has seen the CPN on a regular basis and has benefited from a clear care plan and consistent advice.