Title: Meeting the physical health care needs of people with serious mental illness in primary care
Funder: Department of Health and Social Care

Abstract: Background People with serious mental illness (SMI) have increased levels of physical ill health and die 15-20 years prematurely. This morbidity-mortality gap is largely due to a range of factors associated with SMI such as unhealthy lifestyle patterns, adverse effects of medication and unmet physical health care need. Since the Quality and Outcomes Framework (QOF) was introduced in 2004, general practices in England have been incentivised to conduct physical health checks on patients with SMI to identify unmet need and undertake health promotion. However, in 2014 all indicators rewarding physical health checks on people with SMI were retired with the exception of blood pressure. This provides a natural experiment to investigate the effect of the QOF on the quality of physical health care provided to people with SMI. Until recently, most quantitative studies of the effect of the QOF on patient care have focused on other long term conditions leaving an SMI/QOF evidence gap. Some qualitative studies have explored provider views of the QOF but there is scant evidence of patient perceptions of the care they receive. Research is needed to evaluate the effect of the QOF on the quality of physical health care provided to people with SMI; and to explore how to better meet their needs. Objectives 1) To explore the views and experiences of patients with SMI on their utilisation of physical and preventative health care in general practice; to identify barriers and facilitators to access and quality of care. 2) To explore provider views on the current provision of physical and preventative health care in general practice; and the effect of physical' QOF indicators for people with SMI on their quality of care. 3) To examine, using routine data, the effect of the QOF incentives on clinical behaviour in relation to annual physical checks for people with SMI. 4) To identify any inequalities in physical health care management between patients with and without SMI.5) To integrate findings and describe potential pathways for intervention to improve access to, and quality of, physical healthcare for those with SMI. Plan of investigation A mixed methods research approach will be used to examine the unmet physical health care need of people with SMI. The strength of mixed methods research is that the use of both qualitative and quantitative approaches in combination provides a better understanding and a more complete view of research problems than either approach alone. Integration and synthesis of the interlinked strands of research will provide more useful evidence, of particular value to policy makers and practitioner audiences. Part One Qualitative workstream 1) Focus groups with people who have SMI to explore their experiences of care and health promotion in general practice. 2) Semi-structured interviews with primary care clinicians and nurses to explore views on providing preventative health care to people with SMI, and more specifically, on the effect of the QOF on the quality of care. Part Two Quantitative workstream 3) Examination of a large routinely collected clinical primary care dataset to measure the effect of the retirement of QOF indicators on activity and health outcomes for people with SMI. 4) Estimation of differences in the management of physical health conditions such as high blood pressure between people with SMI and those without to identify inequalities.Synthesis of findings: 5) Integrating patient and clinician qualitative findings with the quantitative findings will produce a deeper understanding of the barriers and facilitators of meeting the physical health care needs of people with SMI. This process will likely reveal unanticipated interactions, providing rich evidence to inform policy recommendations on how to reduce the morbidity-mortality gap.

Lay abstract: Aim of the research At present, people with serious mental illnesses such as schizophrenia and bipolar disorder have worse access to health care for their physical conditions than the general population. They are also less likely to receive health advice/promotion that could prevent the onset of future physical illness. The aim of this research is to produce evidence about how we can better meet the physical health care needs of people with serious mental illness. Aim: To produce evidence on improving the quality of care in general practice for people with serious mental illness. Intended impact: To improve the physical health of people with serious mental illness, so they can live longer, healthier lives. Background to the research Research into the physical health care needs of people with serious mental illness is lacking. In the UK approximately 300,000 people have schizophrenia or bipolar disorder, the main types of serious mental illness, and on average they die 15-20 years earlier than people without such a condition. Death is usually due to a preventable physical disease, and the increased likelihood of premature death is a major injustice. Research is urgently needed to explore what people who have a serious mental illness think about the physical health care they receive, and to examine the effect policies aimed at reducing the inequality had on the quality of care provided. Design and methodsA number of different methods will be used to address this research problem. First, group discussions (focus groups) will explore the experiences of people who have a serious mental illness about their access to physical health care and their views on the quality of care they receive. Second, GPs and practice nurses will be interviewed to explore their views of providing care and promoting the physical health of people with a serious mental illness. Third, information from patient records will be used to assess whether or not changes to national policy including programmes to improve quality of care improved treatment and health outcomes for people with serious mental illness. Differences in how physical health care and health advice/promotion are delivered to people with a serious mental illness, compared to people without, will also be examined. Finally, I will combine findings from the different strands of this research. This is likely to provide a deeper understanding of the problem. Patient and public involvement Patient and public involvement has been at the heart of this research application. Two collaborators were involved throughout the process. KO, a service user, supported this proposal by talking to me about her own experiences and the difficulties she encounters trying to meet her physical health care needs. She also read the research plan and provided feedback on the language and content used. DS cares for a daughter who has schizophrenia and has developed expertise on this topic. This enabled him to make a valuable contribution to this application and to provide ongoing advice and support. Patient and public involvement will take place throughout the entire research process from the design of materials to the sharing of results. The two people involved in the application have both agreed to continue their collaboration: KO will adopt a more active role as a user researcher, and she will be supported with relevant training. She will contribute to the interview/focus group part of the research and will attend regular meetings with my supervisory team to discuss findings.My fellowship will also be informed by consultation with two additional individuals who either have a serious mental illness or who care for a family member who has one. They will join my thesis advisory panel, which meets twice a year to comment on study materials and advise on the development of the research process. My planned public patient involvement will provide different viewpoints and perspectives to those from my academic advisors. This will ensure that my research is continuously informed by user experience and remains focused on providing evidence that will benefit people with serious mental illness. Dissemination Findings will be disseminated to a wide range of audiences through publication and oral presentations. I will target service user literature, specialist academic and clinical journals as well as the general media. My public patient involvement collaborators will advise on effective strategies to reach intended audiences. Additionally, KO will co-present findings with me to a variety of audiences, including to service users, academics and health professionals.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH