Severe mental illness and physical health project results in joined-up care for Neha

Neha*, a 46 year old woman from South Asia, has been involved with mental health services in Greater Manchester since 2008. She has a diagnosis of Paranoid Schizophrenia and has worked with Crisis Resolution Home Treatment Teams on several occasions. She has also worked with the Community Mental Health Team twice but, prior to becoming involved in the CLAHRC for Greater Manchester severe mental illness and physical health project, had a history of poor engagement and non-compliance with medication. Neha speaks some English but generally requires an interpreter; she has never learnt to read or write in her native language or English.

Neha lives with her husband and 7 children. She is significantly overweight and has diabetes, which is poorly controlled. She has a limited understanding of her health needs, tends to prioritise looking after her family over herself, is reluctant to engage with health services and, as a result, requires a proactive approach from services.

Linda*, a Care Co-ordinator, became involved with Neha in August 2012. Linda’s work mainly focused on providing information to Neha about her illness to allow her to manage it appropriately, and to improve her understanding of the importance of medication compliance and attending outpatient appointments. Linda also tried to focus on Neha’s physical health (i.e. compliance with treatment for diabetes, healthy eating, weight management and attending appointments).

There were several barriers to this work. Neha was often not at home at the times Linda arranged to visit, and her English was so limited that Linda was required to use an interpreter, which makes communication and easy conversation more difficult. Neha was always busy looking after her family and could be preoccupied with domestic tasks; her husband was usually at work and her older children were at college when Linda visited, so it was difficult for her to establish what support they provided.

Linda liaised with Sarah*, the Manchester Mental Health and Social Care Trust Community Physical Health Co-ordinator (seconded to the CLAHRC for Greater Manchester), who in turn liaised with staff at Neha’s GP practice, allowing Linda to better co-ordinate her care in relation to her physical health. Sarah sent frequent emails to Linda asking whether she had concerns she wanted to raise at the regular multidisciplinary team meeting held within the GP practice. Sarah subsequently provided feedback and action points via follow-up emails and face-to-face conversations. If Linda had any queries, Sarah was able to liaise with the relevant health professional on her behalf which was extremely helpful and saved time.

Overall, Sarah’s support allowed Linda to increase her awareness of the physical health needs of the service users she worked with and Linda felt she was able to provide better support to Neha as a result. Specifically, because GP staff highlighted Neha’s historical poor attendance, Linda was able to monitor Neha’s appointments with the Practice Nurse and support her to attend. This allowed the Practice Nurse to carry out several tests, including blood tests and BMI, and Neha’s diabetes medication has been changed as a result. Neha has also been referred to the dietician as it was noted that her weight had increased over the past year.

It became apparent that even with support to attend GP appointments, Neha lacked understanding of her physical health needs and their possible implications. She continued to miss appointments unless Linda supported her to attend, which was not always possible. To find a solution to this problem, Sarah co-ordinated a referral to the Supporting Health Nurses who offered Neha further support at home.

Without the CLAHRC for Greater Manchester severe mental illness and physical health project, Neha may have continued to miss appointments, potentially causing her mental and physical health to deteriorate.

*Names have been changed to protect confidentiality