Improving physical health monitoring

Primary Care | Secondary Care


A multi-disciplinary team in Yorkshire found that 10% of people with severe mental illness (SMI) were excluded from the SMI register in primary care and only 30% of those on the register had received an annual physical health check.

Who and where?

The project was led by Kate Dale of Bradford District Care NHS Foundation Trust  and involved professionals from Bradford and Airedale GP surgeries, Leeds and York Partnership NHS Foundation Trust and South Yorkshire and Bassetlaw Commissioning Support Unit.

More recently, Yorkshire and Humber Academic Health Science Network  and South West Yorkshire NHS Foundation Trust have been involved in work to evaluate, sustain and spread the change.


The team designed, piloted and implemented a short, electronic physical health template to be used in primary care to support annual health checks for patients with severe mental illness. The new physical health template was uploaded into patient electronic records. Training was given, firstly, in primary care to encourage good physical healthcare provision for patients with severe mental illness. This was then linked to secondary care to ensure a consistent, high quality service at every level.


To begin with, the team did not explicitly use quality improvement methods, but a Driver Diagram has been prepared to describe the project. Quality improvement methods, used to spread the change, included publishing the template on a national primary care patient record system and the development of an economic modelling tool to support local areas to develop business cases. The team used the Recognising and Assessing Medical Problems in Psychiatric Settings (RAMPPS) Programme to provide systematic training approach for mental health staff.

Our success

The new electronic template was adopted by 75% of practices in the project. Adoption of the template was associated with significantly higher rates of cardiovascular risk screening and detection of cardiovascular risk. Now 610 organisations and 59 CCG areas are using a version of the template and it has been used in more than 2,000 health checks.

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