Severe mental illness (SMI) physical health checks procedure

1 Aim

The aim of this standard operating procedure (SOP) is to ensure that the physical health of patients receiving care from trust primary and community mental health services is assessed, and they receive monitoring and interventions as appropriate, as required, relating to their physical health state. All colleagues working in community mental health services should have a full understanding of the processes and procedures to follow for physical health checks, to improve the health and wellbeing of patients held on the severe mental illness (SMI) register through prevention and improving health inequalities.

There is clear evidence that people living with severe mental illness often experience poor physical health and undiagnosed or untreated physical health conditions. Their life expectancy is 15 to 20 years shorter than for the general population and this disparity is largely due to preventable physical illnesses. With improvements in identification and treatment of physical health, the mortality gap can be reduced.

2 Scope

This procedure applies to all patients, who are on or new to the severe mental illness register and who are receiving care from mental health services within the trust.

3 Link to overarching policy

This standard operating procedure is overarched by the following policies, which can be found on the trust policy section:

4 Patient criteria

Severe mental illness (SMI) is defined as someone over the age of 18 who has (or had within the past year) a diagnosable mental, behavioural, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.

Patients for the severe mental illness register service are accepted where they meet the NHS England severe mental illness criteria that is aligned to:

patients with severe mental illness who are not in contact with secondary mental health services, including both:
- those whose care has always been solely in primary care
- those who have been discharged from secondary care back to primary care
patients with severe mental illness who have been in contact with secondary care mental health teams (with shared care arrangements in place) for more than 12 months and, or whose condition has stabilised

Severe mental illness codes associated with diagnosis and for reflective capture in the severe mental illness diagnostic list (appendix A).

In some circumstances, for example first episode psychosis it may not be appropriate to add the patient to the severe mental illness register as this is a first occurrence of a suspected psychotic disorder.  The Early Intervention in Psychosis team works with diagnostic uncertainty and aims to support the recovery and prevent long-term disability (see appendix B).

Should have medication reviews and their physical health monitored in line with summary of product characteristics (SmPC) and, or British National Formulary guidelines on:

antipsychotics (includes those prescribed antipsychotics without a mental health diagnosis, such as people with a learning disability whose behaviour challenges; see National Institute for Health and Care Excellence (NICE) guideline 11 (NG11)
lithium
sodium valproate (valproate should not be prescribed to new male patients and all female patients aged under 55 years, unless other treatments are ineffective or not tolerated) see valproate and risk of abnormal pregnancy outcomes (staff access only) for full guidance

4.1 Role of secondary care

It is important that when secondary care services initiate a person on any mental health medication, that they notify the general practice the patient is registered with promptly and in writing. This includes early intervention in psychosis (EIP) services, which may prescribe antipsychotics to patients. This communication is needed irrespective of whether ongoing prescribing is to be managed in secondary or primary care. Secondary care also needs to inform primary care of a new diagnosis, or in the case of early intervention in psychosis, a first episode of psychosis, so that the individual can be added as appropriate to the severe mental illness register and thus be invited for physical health checks by the appropriate service.

In Rotherham the current protocol states that Primary care teams are responsible for carrying out annual physical health assessments and follow-up care for:

patients with severe mental illness who are not in contact with secondary mental health services, including both:
- those whose care has always been solely in primary care
- those who have been discharged from secondary care back to primary care
- patients with severe mental illness who have been in contact with secondary care mental health teams (with shared care arrangements in place) for more than 12 months and, or whose condition has stabilised
Secondary care teams are responsible for carrying out annual physical health assessments and follow-up care for:
- patients with severe mental illness under care of mental health team for less than 12 months and, or whose condition has not yet stabilised
- inpatients

To note, patient preference will be honoured, if the patient opts for their GP to do the physical health check, this will be supported by offering support to access or arranging this if required.

4.2 Identifying a patient who is not appropriate for the severe mental illness registers

If you identify that a patient is not appropriate for the severe mental illness quality and outcomes framework (QOF) register, please discuss within your clinical team (or wellbeing service) about coding them correctly and removing them from the severe mental illness register, this can only be done by writing to the GP who can formally remove the patient. See letter template at appendix C.

4.3 People in remission

If a patient is presenting in remission (5 years with no antipsychotic medication and no contact with secondary mental health services or acute admissions), they will remain on the severe mental illness register in case they relapse, but they should not be invited for an annual physical health check. A remission code (under the “SNOMED” cluster “MHREM_COD”) should only be applied if the patient has had none of the following for at least 5 years:

record of antipsychotic or mood stabiliser medication
mental health inpatient episode
secondary or community care mental health follow-up

Please note the above definition of remission is for guidance and clinical discretion should be applied. A small group of patients may not have any of the above, are seen solely in primary care, are still unwell and should not be coded as in remission.

Once a patient has been identified as in remission, a letter (appendix D) should be sent to the GP requesting they be removed from the severe mental illness register and code added on trust SystmOne to remove from the register and caseload.

If after reviewing the patient record a clinician considers that someone is incorrectly on the severe mental illness register (for example, due to an incorrect diagnosis), they can apply a code of “unsuitable” and record the reason for this.

5 Procedure

Joint working and good communication between all colleagues workings with patients with severe mental illness is essential. Most people with severe mental illness or who are receiving care, should have an annual physical health check conducted in primary care by GPs, practice nurses or other primary care staff where possible. For some patients receiving care from trust community mental health teams, it may be more appropriate for the review to be completed by the trust Community Wellbeing team, Severe Mental Illness team or Community Mental Health team. Nevertheless, community teams have a responsibility to:

encourage and support patients to take up the offer of an annual physical health review
check that the review has happened and ensure that the details of the review are recorded in the patients care record on SystmOne
share information about physical health reviews completed by trust staff with the GP
document plans to improve physical health following reviews in primary or secondary care in the patients care plan
encourage and support patients to access services to improve their physical health, with the help of voluntary community social enterprise colleagues

Many people living with severe mental illness may be unaware they should be receiving an annual physical health check and why it is important. They may also be unaware they are on an “severe mental illness register” and what this means. You can support someone to access their health check by asking them if they have attended a health check before, if they have received an invitation from the GP surgery, or by encouraging them to take up the offer, or support them to call the GP surgery for an appointment.

When booking a patient into the service, the health check status should be checked and this should be booked, as appropriate, for when it is due.

If the assessment has been documented by another prior to the patient being taken on by your team it does not need to be repeated until it is due.

Point of care device machines will be available to all care groups to support the delivery of the blood test elements of the severe mental illness physical health check. The use of these devices does not replace a blood test but is intended as an additional option for completing the blood test, if clinically appropriate.

The manufacturer of the devices will provide full, face to face training to representatives from each care group, who will then train their teams on the use of the equipment.

5.1 Physical health check

The care coordinator or key worker is responsible for arranging the review of an annual severe mental illness health check on behalf of the patient, or alternatively with an appropriate staff member who is trained and supported to undertake the annual health check in full as a minimum 4 weeks post being newly added to the severe mental illness register, three months recall prior to annual 12 month data or as an inpatient admission within the first 1 to 7 days of admission.

On the day of the appointment make sure you have the physical health check template ready to complete as you talk to the patient. Guidance is available at physical health checks guide (staff access only).

The physical health check template should be completed as part of the physical health check and will support practices in obtaining all elements required to achieve an annual health check.

The six core physical heath assessments are:

weight, waist circumference and body mass index
blood pressure and pulse
blood lipids including cholesterol
blood glucose and haemoglobin A1c (HbA1c)
alcohol consumption
smoking status

In order to meet the national reporting requirements, it is critical that the annual health check is completed including the care plan and care plan review boxes within the template.

In advance of the physical health check appointment, the “patient physical health and well-being questionnaire” can be shared with the patient via the communication annex on SystmOne.

In circumstances where the appropriate bloods cannot be obtained local relevant steps will be taken to support the checks to be completed, this could include accessing other phlebotomy services, that is via general hospitals, district nursing services (if patient is housebound) or use of point of care machines.

5.2 Recording the physical health check

Physical health checks must be documented in the patients’ electronic patient record (EPR) using the physical health check template. A care plan goal related to physical health covering arrangements for physical health reviews and any treatment or support required after the reviews must be documented in the care plan.

All information must be discussed with the patient. Advice on actions required should be given, and a care plan should be discussed and agreed with the patient and documented on the care plan. Actions required may include advice or referral for specialist support related to smoking, alcohol, or substance misuse, improving diet and increasing activity. Patients may require signposting to their GP or referral directly to a specialist service.

The severe mental illness physical health check planner and can be used to share the information with the patient (appendix E).

5.3 Additional checks

As part of the annual health check, although not expected, it is good practice to review the patient flu (if eligible) and Covid vaccination status and encourage uptake.

All follow-up support should form part of personalised care and support planning and the requirement to ensure the care plan and care plan review boxes are ticked within the template as part of the full severe mental illness annual health check delivery.

6 Monitoring

Support should not end with the physical health check but continue by supporting people living with severe mental illness to access follow-up interventions that are tailored to their needs. This may include support via peer support workers. All follow-up support should form part of personalised care planning in line with shared decision-making. Follow up may include onward referrals and, or signposting opportunities to community, primary or secondary care services.

People offered a severe mental illness annual physical health check may have a history of trauma. It is vital that delivery of the checks and follow-up care is trauma informed and considers how someone’s mental health may impact on how they experience their physical health, the health check and ability to make lifestyle changes. Reasonable adjustments should be made to assist people to access severe mental illness annual physical health checks and follow-up interventions as appropriate.

7 Recording the completion of an annual health check

Please refer to the physical health checks guide (staff access only) to ensure that all required fields are completed on the template. Accurate data allows healthcare professionals to provide better, more targeted advice and interventions.

See physical health guidance and videos (staff access only).

Making every contact count (MECC) encourages conversations based on behaviour change methodologies (ranging from brief advice to more advanced behaviour change techniques). It is about making the best of every appropriate opportunity to raise the issue of healthy lifestyle, for example, smoking cessation, healthy eating, and physical activity

As part of the Data Saves Strategy following the guidance will avoid patients repeatedly sharing the same information or have unnecessary tests carried out.

SystmOne’s recall functionality allows you to set a marker on a patient’s record to act as a reminder that the patient needs to be reviewed within the mandated 12-month period. Recall reports allow you to generate a report which lists patients who have recalls and has the functionality of sending bulk letters to the patients listed in a Recall report (staff access only).

Compliance will be monitored monthly using RePortal reports 638 and 642; this information will be used for reporting against the agreed trust target and to also ensure data correctness, reliability and identify any anomalies. Issues are escalated to the appropriate clinical or corporate service, if risk critical this must be logged on the trust risk register with a supporting action plan.

8 Triage and management of patients

We would encourage all care groups to introduce self-bookings for those on the severe mental illness register, providing opportunity for a patient to log in and book their own annual health check at the point they are recalled (usually three months pre due date from previous check). New or existing patients should be added to a monthly recall list and when invited for their check, the booking team should send the following information:

Information leaflet explaining what to expect from the annual health check
new health check planner
advise on what to do if the patient wants to discuss the annual health check in advance of booking an appointment

Invitations to book the health check should be requested each month reinvited back every month for the three months leading up to the due date of the 12-month review until the appointment is booked. If the patient declines the invitation to their annual health check this must be recorded clearly on SystmOne.

8.1 Management of cancelled appointments

In the event of an appointment needing to be cancelled by the service, the patient should be contacted immediately and offered the next available appointment. The reason for the cancellation should be documented on SystmOne.

8.2 Management of did not attend (DNA) appointments

The service should ensure that different opportunities are offered to ensure equity across all localities and to encourage attendance, such as:

use of different means of communication and liaison with the care co-ordinator (if they are under the care of community mental health team)
offer of different venues or home in combination with the above

8.2.1 Did not attend (DNA) process

8.2.1.1 Appointment reminders

Appointment letter sent for severe mental illness physical health check at local GP surgery, or home visit or base if more convenient, closest to recall date.
Designated person, Mind, or alternative voluntary, community, and social enterprise (VCSE) to contact patient by phone 1 week prior to appointment to check if attending or any support needed.
1 to 2 days before appointment reminder text sent by designated person, Mind, alternative voluntary, community, and social enterprise.

8.2.1.2 First did not attend (DNA)

Did not attend (DNA) text sent to patient and clinician to attempt to contact by phone. If contactable by phone, clinician to discuss did not attend and importance of physical health check and to discuss attending appointment.
Task sent to admin to arrange at more suitable time or date as per conversation.
If no contact admin sends further appointment for GP if still available or at base, designated person, Mind, or alternative voluntary, community, and social enterprise to contact patient by phone 1 week prior to appointment to check if attending or any support needed.
1 to 2 days before appointment reminder text sent by designated person, Mind, or alternative voluntary, community, and social enterprise.

8.2.1.3 Second did not attend (DNA)

Phone call by clinician to discuss did not attend (DNA) and importance of physical health check.
Contact us letter sent with 2-week return.
If on receipt of appointment letter patient calls to decline appointment, task is sent to clinician to inform. They will either ring patient to confirm decline, or decline on situation depending on circumstances (and information provided).
If no contact made by patient, note patient declined on physical health check template and clinical judgement to be made as to appropriate recall date.

In the event of did not attend, the patient should be discussed at multi-disciplinary team so that safe prescribing can continue.

8.3 Management of declines

If there are no known or suspected significant risks, then the clinician must:

attempt to contact by the patient by phone as per process above
if there is still no contact then the assessor must notify the referrer and all other agencies involved with the patient including their GP, a joint plan of action must be agreed and recorded

Where appropriate consideration should be given to convening a Mental Health Act assessment.

Team should actively manage patient did not attends (DNAs) and declines and consider alternative ways to encourage uptake of annual physical health checks.

9 Management of patient risk and escalation

Where the patient identifies “at risk” and in need of a more urgent medical or psychological response, the patient should be signposted onto the appropriate service. This includes patients who are outside normal thresholds, for example, blood pressure check, where a patient has collapsed, or where a patient is deemed at risk of suicide.

All staff will offer re-assurance to the individual and seek the most appropriate support as follows:

dialling 999 for urgent medical assistance
contacting the patients registered General Practitioner (GP) to try and arrange an urgent appointment on behalf of the patient, where appropriate, the health professional should accompany the individual to the GP Practice and wait until the individual has been seen by the GP
contacting the relevant secondary care team
contacting the trust Crisis team in an urgent mental health crisis If the incident occurs during a consultation, the individual should not be left alone until it is deemed safe to do so, the event should be reported as an incident as per the trust serious incidents and significant events policy and procedure

10 Information governance and GP access

There are data sharing agreements in place between the trust and all other SystmOne organisations within Rotherham, Doncaster and North Lincolnshire, which ensures consistency and continuity of care, and enables data flow and avoiding duplication. A patient can still opt-out on an individual basis, either at trust level (sharing trust records) or at any other SystmOne organisation (for example, dissenting to other organisations viewing their GP record, for example).

The trust uses direct SystmOne to SystmOne sharing as we are on the same electronic patient record (EPR) system.

For EMIS (used in primary care in our geographical locations but not wider like SystmOne is), we use the supplier led interoperability Programme (SLIP) agreement. That is a sharing agreement between TPP and EMIS as suppliers, but it gives us EMIS record visibility. The EMIS record is limited, as it is only data items that are available through GP Connect, which is not the full patient record in its entirety, like it is for SystmOne.

In terms of access to data, as part of our strategic reporting extract (overnight download of electronic patient record data), we can include shared record items. This means we can access and use data that is not owned by us for business intelligence purposes (for example, severe mental illness physical health check data). That is only SystmOne data, as EMIS is not structured (it utilises a HTML view, meaning you can see data at a patient record level, but we cannot access the data or manipulate it in any way).

11 Appendices

Document control

Version: 1.
Unique reference number: 1110.
Approved by: clinical effectiveness meeting.
Date approved: 1 July 2025.
Name of originator or author: service manager.
Name of responsible individual: chief nursing officer.
Date issued: 1 September 2025.
Review date: 30 September 2028.
Target audience: all colleagues working within community mental health services.

Page last reviewed: September 24, 2025
Next review due: September 24, 2026

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