We interviewed 31 patients with SMI (18 males and 13 females), aged between 28 and 67 years. The psychiatric diagnoses were schizophrenia (n = 15), bipolar affective disorder (n = 12) or schizoaffective disorder (n = 4) and the majority were unable to work due to long-term sickness or disability (n = 20). We also interviewed 35 health professionals (14 males and 21 females), aged between 24 and 57 years. Ten staff worked in primary care and 25 in CMHTs. They included community mental health nurses (n = 10), social workers (n = 7), occupational therapists (n = 1), psychiatrists (3 consultants, 2 registrars and 2 senior house officers) and GPs (n = 8) and practice nurses (n = 2).
Importance of targeted CHD screening
There was a consensus view that screening for CHD risk factors in people with SMI was an important priority for health service resources, for which a range of reasons were offered (see Table ). People with SMI and the professionals were aware of the high prevalence of risk factors for CHD. Professionals from all disciplines expressed concern that services neglect the physical health of people with SMI. Service users feared that their physical health needs often "fell through the net". Concerns about the adverse effects of atypical antipsychotic medication were repeatedly articulated by staff and users.
Views on the importance of CHD risk factor screening and obstacles to its success
I think it's very important because I think they [SMI] do have significant problems in this area, partly because of their lifestyle and partly because many of the drugs that they're taking, especially the people on antipsychotics ... atypical antipsychotics, you know, cause weight gain and problems with blood pressure, some of the antidepressants, so, you know ... the medication they're on predisposes them to risk factors for cardiac disease and diabetes and weight gain and dyslipidaemia ... and I don't think we're doing enough to adequately attend to those problems in this population (Consultant Psychiatrist 21).
I think it [check-ups] would be a great idea. I think actually ... not just a good idea, I think it's necessary. Because otherwise they [people with SMI] will just fall through the net ... when the only time they can get a medical check-up is when they have a psychotic episode and they're brought into hospital (Service User 17).
Many respondents expressed concerns that CHD prevention would be very difficult in people with SMI. The obstacles included low uptake rates, high current workload within the CMHT and poor communication between GPs and the CMHT (see Table ).
Some of our mental health reviews that we're expected to do ... getting people (with SMI) to actually turn up is very difficult (General Practitioner 3).
Motivation and ability of staff to deliver primary prevention of CHD in SMI
Professionals expressed various attitudes to incorporating CHD screening into their professional role. General practice staff stressed this was already a core component of their work and expected to take on this role in people with SMI. The UK primary care GMS contract requires practices to maintain an SMI register and provide an annual physical health review to clients with SMI. However, some primary care staff identified lack of experience with SMI and unfamiliarity with the CHD-related side effects of some antipsychotic medications as obstacles. One practice nurse stated that it was uncomfortable explaining that individuals had been invited for a physical check-up due to their inclusion on the practice SMI list.
I sort of felt a bit uncomfortable, because they came in and said, "I've got this letter" [about screening appointment] ... and so you sort of skirt around it because you don't want to say, "Oh, this is because you've got mental health problems and you don't come to screening" (Practice Nurse 04).
This unease about maintaining specific lists of people with SMI was repeated by several staff and service users who felt such lists or indeed special clinics were stigmatising or even "ghettoising". However some service users (and staff) voiced an opposing view, stating that special clinics for people with SMI gave them confidence that their mental health problems would be understood.
I think I would appreciate a separate service for mentally ill people, if I was going to my GP. Because I have a mental illness, I sometimes ask too many questions and I feel a bit sort of anxious about seeing the doctor whereas, if the GP knew that I was mentally ill, he'd be more patient with me if I was asking questions (Service User 10).
It would be stigmatising in a way, but I think these people are stigmatised anyway. And I think probably people would get lost in a more general clinic. That's just off the top of my head. I could give you some reasons for both [special vs. general clinics] ... but I think really, if we are going to take people's physical health more seriously, then I think probably to have dedicated services ... a dedicated clinic (Community Psychiatric Nurse 06).
Psychiatric staff rarely included formal assessment of CHD risk factors in their routine practice although some did discuss diet and exercise with patients. They expressed more diverse views on their role in performing this task than the primary care staff. Some viewed physical health care as an essential part of their work and emphasised the importance of an overall holistic approach to their patient's problems.
I think it's holistic. Like I said, it's the whole package, isn't it? You can't just ignore people's physical health and concentrate on their minds. I guess, as a social worker, we're trained to kind of see the whole package, rather than separate little conditions ... or physical health and mental health being split into two (Social Worker 02).
Other CMHT staff felt that physical health was the remit of primary care and that it would be an inappropriate use of their skills and time. They felt responsibility for screening would blur their professional roles. Moreover, they lacked the expertise and resources to provide an adequate primary prevention service for CHD.
I'm all for an holistic approach but ... if I was to speak truthfully ... I'm up to my limit really with mental health ... you know, so it is difficult to even think about some of these other issues because you've got so much else to focus on ... I mean, not just the mental health but the ... all the other stuff that at different levels ... you know, the social aspects of people's lives and their housing problems and their money problems and such-like (Community Psychiatric Nurse 06).
This diversity of this opinion was apparent across the professional disciplines, with some psychiatrists, nurses and social workers expressing a keen desire to include CHD screening in their work. Similarly there were professionals from all disciplines who were against conducting this work.
Views of primary versus secondary care service models
Most CMHT and primary care staff initially responded that screening would be best performed by primary care services. They described the benefits of a system that is already established to provide screening and relevant interventions for risk factors that are detected.
I don't see why they [SMI] should be treated in a different setting from other patients with the same condition, really. And I think that primary care would be the people who would know better than we would how to manage these things and then would be monitoring them in the longer-term. I think whoever is diagnosing them should really be managing the conditions as well (Consultant Psychiatrist 07).
Preference for a service for the primary prevention of CHD in secondary care services was mentioned more frequently by people with SMI, often because they felt more comfortable engaging with mental health staff.
Since it's geared towards mentally ill people, I think that it should be done, if possible, within the mental health service. I say that because, to me, I feel happier coming here to talk about my problem ... my mental health problems ... with a specialist, rather than going to a GP, who's fine but firstly they're not a specialist and secondly they haven't really got much time (Service User 14).
When staff was asked to consider the benefits and disadvantages of both models in turn, a more complex picture emerged. A variety of problems with the primary care model were forthcoming (see Table ). Poor uptake of screening, lack of engagement of SMI patients with GPs, poor communication of results from GPs to the CMHT and lack of knowledge among GPs regarding the relationship between antipsychotic medication and CHD risk were common concerns.
Primary care model for CHD risk factor screening in SMI: Advantages and disadvantages
This complexity was increasingly apparent when participants were asked to consider the pros and cons of a CMHT based model of screening (see Table ). Many people – who had initially stated that primary care was the best setting for primary prevention of CHD – began to identify disadvantages to the primary care model and advantages to the secondary care model which had not been immediately obvious. The benefits of the CMHT providing such a service included having access to users who rarely visit their GP and leaving the responsibility of early prevention of CHD in the hands of those who managed their antipsychotic medication.
Secondary care screening model: Advantages and disadvantages
Psychiatrists don't really often go below the neck ... in terms of the things they look out for and, if they're going to be handing out medicines, such as Risperidone or Olanzapine or Quetiapine, which of course make people fatter ... makes them diabetic ... then I think that's a responsibility they have to take – of being able to screen individuals for coronary heart disease and do something about it (General Practitioner 10).
The main disadvantages were being overworked and possibly unfamiliar with blood results and appropriate interventions such as anti-hypertensives, lipid lowering medication or diagnosis of diabetes and its management.
I think the risk would be that you're just filling in boxes and maybe they'd come to the clinic, someone would check their blood pressure, take the blood test, do the height and weight ... and you'd tick the boxes and say, "Right, we've done it" but then nothing really would be done about it. And I think it would be the next step about who would take the responsibility of saying, "Well, you've got high blood pressure" or "Your cholesterol is too high. We need to do something about it" ... and who then would go on to do that. What would happen? (Psychiatrist 23).
Shared care services or a service led by additional nursing staff
Having discussed the pros and cons of primary and secondary care screening, participants were asked to consider the best way forward. Several staff spontaneously suggested the need for improved collaboration between primary and secondary care services to ensure that screening was provided coherently and comprehensively.
I suppose we've been thinking a bit 'either-or' but, in a way, it's going to have to be 'both-and' because there's ... you know, two-thirds of mental health we don't see [in mental health services] anyway ... there are going to be some patients who don't make it to us and there are going to be some patients that we see who don't really make it to the GP. So, if you want to cover the entire spectrum, I think you need to do both (Psychiatrist 24).
However, there were still drawbacks to such models including issues about confusion of roles, who was actually taking responsibility for provision of the screening and for acting on any abnormal findings. Poor communication, especially from primary to secondary care, was again felt to be a major flaw in joint (or collaborative) working. Many participants agreed that one person should take overall responsibility to ensure adequate screening for risk factors of CHD – be it primary or secondary care – depending on patient, professional and local service characteristics. When a specialist nurse-led service was suggested to participants who had not raised it spontaneously, they usually endorsed it. The perceived benefits were its flexibility, greater accessibility for patients, clarity of roles and ensuring good liaison between primary and secondary care, irrespective of individual patient or staff preferences for delivery of screening (see Table ).
Views regarding a specialist nurse model for providing CHD screening in SMI
I think it's always good to have somebody whose kind of responsibility it is to make sure that things happen... I mean, if there was funding. That person wouldn't necessarily do it all but they would kind of have an overall responsibility for making sure that it, you know, happened and coming round to the practices and saying, "What are you doing?" and checking our records, or whatever, to find out (General Practitioner 01).
I think that [the specialist nurse model] would be best of all, because of its flexibility and because of the recognition that you really need to try and catch people in different settings. In fact, there probably isn't a one-size-fits-all scenario to offer this service really (Consultant Psychiatrist 25).
However, despite their enthusiasm, respondents were not optimistic about the likelihood of health service funding being available for this option.