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Organisation forms an alliance to standardise healthcare for patients with serious mental illness, achieving the highest coverage of physical health checks in England

HSJ Awards 2019/ Community or Primary Care Service Redesign - London and the SouthHSJ Awards 2019/ Mental Health Innovation of the Year HSJ Awards 2019/ Primary Care Innovation of the Year
Winner- Mental Health Innovation of the Year   Highly Commended- Primary Care Innovation of the Year/Community or Primary Care Service Redesign - London and the South


    • Ranked 5th highest for Serious Mental Illness (SMI) incidences, out of the 211 CCGs in England
    • Uneven coverage of health checks across GP practices and irregularity in patietns attending care services
    • Create a seamless pathway between primary/secondary care to avoid duplication in treatment and reach 70% of the patient coverage


    • Formed the Primary Care Mental Health Alliance to bring together various stakeholders for delivering and overseeing physical health checks
    • Underpinned services through use of dashboard and practice visits, providing analysis of checks, follow-ups and outcomes
    • Executed joint psychiatrist-GP medication reviews, home visits for hard-to-reach patients and re-designed
    • recovery care plans


    • Achieved 71.2 % SMI physical health checks – the highest coverage in England
    • Resulted in planned medication reduction for 101 patients and 105 patients came off antipsychotics completely
    • Improved mental wellbeing of patients and enhanced access for residents within the community
    • Reduced duplication by standardising primary and secondary health check systems


The Primary Care Mental Health Alliance brings together the GP Confederation (GP practices), ELFT (secondary care mental health), the CEG (healthcare informatics), Core Sports (diet/exercise) and the CCG (commissioning), to deliver and oversee physical health checks and follow up interventions for people with Serious Mental Illness (SMI).

The Alliance structure has enabled us to redesign the use of people and data systems from different organisations to create a seamless pathway between primary and secondary care settings for SMI physical health checks and follow up interventions. This has led to a greater ability to reach the patients, some of whom do not visit their GP regularly, are in residential accommodation or are housebound. Services are underpinned by a sophisticated dashboard and practice visits, which provide an analysis of checks, follow-ups and outcomes.

The dashboard has evened out practice performance and led to important innovations such as joint GP-Psychiatrist reviews, which have reduced medication use. Service users have welcomed the integration of mental health physical health provision and the offer of a choice of settings. City and Hackney CCG has the 5th highest SMI incidence out of the 211 CCGs England.

Despite this challenge City and Hackney achieved the highest SMI physical health check coverage in England (2018-19 - see National Benchmarking attachment).


City and Hackney has the 5th highest SMI prevalence in England and the cohort have far poorer physical healthcare. Health check coverage was very uneven across GP practices and a significant number of SMI patients did not attend practices regularly.

Because of this, a unique vision of delivering SMI physical health checks as a partnership between primary care, secondary care, healthcare analytics and a VSO emerged with the target of reaching 70% coverage of the patient cohort.

This was tested, by patient flow modelling, showing 50% of the SMI population pass through secondary care p.a.(NHSE Workshop attachment). Patient groups highlighted the need to improve physical healthcare in secondary care mental health and to avoid duplicate questions asked by different organisations. This led to a re-design of the existing model, which separated primary care and secondary care.

The re-design had the following features:

  • Integrated multi-organisational delivery through an Alliance
  • Secondary care HCAs delivering health checks alongside primary care HCAs working across secondary/primary care boundary
  • Secondary care checks standardised with primary care, reducing duplication
  • All data entered on primary care’s EMIS system
  • MH Liaison worker to help practices analyse dashboard findings
  • Psychiatrist-GP joint medication reviews
  • Home visits for hard to reach
  • Outcome payments
  • Service user co-led follow-up interventions
  • Service user co-designed, co-produced recovery care plans.
  • Tableau dashboard, which tested the efficacy of the above.


  • Pre-implementation coverage (6 NHSE checks): 31%. After 12 months: 71.2 % (highest in England, National Benchmarking attachment)
  • Dashboard revealed 800 patients on anti-psychotic medication but without a psychotic diagnosis and not on the SMI register. These patients had physical health check coverage of just 15%. After 12 months coverage: 74%
  • Practice visits revealed many people on anti-psychotics in primary care had not had their medication properly reviewed for many years. A system of joint GP-Psychiatrist medication reviews was initiated. Results: 101 patients had a planned medication reduction and 105 patients had a plan to come off antipsychotics completely.
  • Patient testimonies reveal focusing on physical health improved mental wellbeing, particularly dietary advice. Many patients preferred the non-clinical settings offered. Patients also valued exercise with people with similar experiences, co-led by service users (Testimonials attachment).
  • Visits to homes and residential settings allowed many patients to be reached for the first time
  • A patient, who would not attend the GP was reached, whose blood test revealed lithium toxicity and an urgent need to change medication.
  • 113 p.a. on SMI register engaged in Core Sports - all reported increases in exercises levels and mental wellbeing.
  • 3% p.a. fall in no. smokers.

Cost: £150K for 100%+ increase in coverage. Cost per health check has fallen due to greater efficiencies in terms of reducing duplication between primary and secondary care and because the new HCAs operate from fewer locations.


City and Hackney CCG has shared the model across NEL STP through the STP primary care delivery group. As a result all CCGs now use the CEG to provide a primary care-based dashboard and some CCGs have adopted the use of outcome payments for population-based coverage and practice visits. Since these measures were adopted, coverage in Waltham Forest has risen by 32% and by 16% in Redbridge.

City and Hackney has presented the model at the NHSE SMI Workshop (2018 – NHSE workshop attachment), the NHS Expo and at the Surrey GP Master-class (2018). City and Hackney is currently cited in the 2019 NHSE SMI Physical Health Check guidance as an example of good practice. Furthermore, the NHSE guidance has now been changed support a fluid pathway between secondary and primary care in line with the City and Hackney model.

Research on City and Hackney’s Primary Care Alliance model was undertaken and disseminated by Healthy London Partnership and UCL. There now is much interest in the use of secondary care HCAs and in an alliance model from other CCGs. The healthcare alliance structure we adopted is replicated for other health areas in City and Hackney.


Service user feedback demonstrates that the patient experience has been improved by:

  • A choice of settings beyond GP practices: including home visits ‘so glad there is a service like this at the DW Centre’. ‘I prefer the clinic than the long queues at the GP’
  • Offering follow-up interventions with people facing similar issues: ‘Core Sport.. made me realise I am not alone in my recovery.’
  • Bringing mental health and physical health approaches together: ‘(I) changed my mindset about diet and exercise…I got the support to face my biggest fears’(Testimonials attachment).
  • Staff feedback demonstrates that staff benefitted from:
  • The HCA’s bringing new skills‘‘ The HCA has transformed the experience of patients attending the Recovery Team. There has been consistent expressions of gratitude about patients having on-site physical health checks.’ Dr Mears
  • HCAs creating ‘is a safer, quicker pathway’ (Testimonials attachment).

The model increased capacity by 2 WTE secondary care HCAs; 0.5 WTE liaison worker. Practices received £60K in outcome payments covering extra time. Efficiency and VFM was produced by standardising primary and secondary health check systems thereby reducing duplication. Also, secondary healthcare HCAs are able to see high numbers of patients in a few locations.


The Alliance provides a forum where different organisations and groups can discuss problems and find solutions through partnership working, which cut across organisational boundaries, e.g. the GP Confederation facilitating data sharing between 42 GP practices and secondary care. Innovation is further supported by members attending seminars, conferences, best practice visits.

Team working has also been strengthened by creating a dashboard, which is not simply used to measure performance but which is also an investigative tool within an Action Learning Cycle e.g. the dashboard highlighted the lack of medication reviews (NHSE workshop attachment). This led to innovations in partnership working such as joint GP-psychiatrist reviews, which are then further refined through the dashboard.

The engagement of service users in a culture of co-production has been central to the re-design. For example, service user criticisms of mainstream exercise programmes led to the development of the coproduced, co-led programme by Core Sports. The Recovery Care plans were co-designed with service users and have been extensively reviewed by service users as part of an on-going process of refinement.

The Alliance has also supported partnership working by authorising a sharing of skills and staff across organisations e.g. primary care staff, co-supervising, secondary care HCAs.