New model of working, developed with MMHSCT, equals better use of GP time and resources

The introduction of a Community Physical Health Coordinator (CPHC) has physical health benefits for people with mental illness – and results in more co-ordinated working between GPs, Care Coordinators and other teams.

CLAHRC Greater Manchester has been working in collaboration with Manchester Mental Health and Social Care Trust (MMHSCT) on a new model of working to improve the physical health of people with mental illness.

The model involves a number of different facets, the most notable being the introduction of a CPHC within Community Mental Health Teams (CMHTs). The CPHC’s role is to liaise, discuss and coordinate the physical health management of people under the care of the CMHT. They do this with GPs via multi-disciplinary team (MDT) meetings.

So far, the new model has produced some excellent outcomes. These are typified by George* and Jim’s* stories.

George is overweight, has high cholesterol and a family history of cardiovascular disease. He is an extremely heavy smoker and suffers from stress in relation to managing his children, as well as psychotic depression. Before the introduction of a CPHC, he was only semi-compliant with taking his medication and was not up-to-date with his physical health checks. He was also notorious for missing appointments.

Information passed on by David*, George’s CPHC, led George’s Care Coordinator to prompt George to attend surgery. David also informed George’s GP that his Care Coordinator was concerned about his behaviour; this in turn led to the GP identifying that George had relapse symptoms and needed closer monitoring from the mental health service, resulting in the prescription of anti-psychotic medication. George is now also up-to-date with his physical health checks and attends appointments.

Jim, on the other hand, regularly visited his GP and contacted his Care Coordinator on an almost daily basis. He complains of discomfort in his legs, suffers from osteoarthritis and is diabetic. Jim is overweight, has poor mobility and is in a lot of pain. He has a number of mental health problems and at times struggles to cope. Before the introduction of a CPHC, Jim’s Care Coordinator felt “stuck” with his progress.

Greg*, Jim’s CPHC, was able to give Jim’s GP the information needed to make progress with Jim’s health. Before Greg became involved with Jim’s care, his GP wasn’t aware of some of Jim’s health issues. It also became clear that Jim struggled with weight control and, through the use of MDTs, Jim’s GP liaised with the diabetes clinic so that they could assist with getting Jim’s weight under control and help provide Jim with lifestyle advice. Jim’s GP was also able to start him on a new type of insulin for diabetes. The coordination of Jim’s care through the CPHC has been extremely successful: Jim has been compliant with his new regime and his Care Coordinator has reported no problems.

The excellent results of this work have led MMHSCT to roll-out the new model to every CMHT across the Trust, spanning to North, Central and South Manchester Clinical Commissioning Groups. To find out more, please contact Michael Spence, CLAHRC Greater Manchester Programme Manager, or read the full evaluation report of the pilot project, including a section on the key ingredients required for spreading the model, along with a more practical CPHC and MDT guidance document.

*Names have been changed to protect anonymity.