The programme

Through this programme we will work with members in primary care to improve the physical health of people with serious mental illness (SMI) through the early detection of cardiovascular disease risks.
A team from Bradford District Care Foundation Trust (BDCFT) has designed, piloted and implemented a short, electronic physical health assessment template to be used in primary care to support annual health checks for patients with severe mental illness.
Using BDCFTs model, which has achieved national recognition in this area of care we will support the roll-out of the programme in three pilot CCGs across the region.
We will also work with partners to complete a detailed cost-effectiveness analysis of physical health programmes in mental health settings, sharing the findings with local, regional and national stakeholders to improve patient outcomes.


People with serious mental health problems are at a significantly higher risk of developing preventable chronic conditions such as diabetes and cardiovascular disease.

Cardiovascular disease rates are between two and three times higher than in the general population and it is the most common cause of death in people with a serious mental health problem.

Untreated physical illness in people with mental health problems places a major burden on health systems by increasing use of unplanned and urgent health care.

The programme directly supports the Parity of Esteem agenda.

How are we helping?

We are supporting roll out of the Bradford model across the region, offering specific support for three member CCGs as part of a pilot programme, but providing further guidance and shared learning beyond the initial cohort. Take a look at our short film to find out more about the programme and roll out.
As part of this programme:

  • Primary care staff are appropriately trained in how to use the Bradford Physical Health Assessment template and complete physical health assessments for patients in primary care, resulting in more appropriate, timely interventions.
  • These interventions are then tracked in-patient records including cardiovascular QRISK scores.
  • We are supporting organisations to adopt, adapt and implement local approaches that will reduce variation in the quality of annual health checks and increase the number of people with SMI who receive an annual health check.
  • We are funding health economics expertise to review the evidence of impact for implementing models of care that aim to improve the physical healthcare of people with SMI

Our Impact to date

The NHS spends £10bn per year managing the effects of mental health on other long-term chronic conditions – that’s equivalent to £47m per CCG per year. There are wider economic impacts related to social care and unemployment.
During 15/16, Yorkshire & Humber AHSN implemented an initiative that aimed to improve the physical health of people with serious mental health issues in a secondary care setting. The Bradford physical health assessment template was uploaded into patient electronic records in a number of secondary care hospitals in Yorkshire and the Humber. Training has been given to help and encourage provision of good physical health care services for patients with serious mental illness. This year’s programme, targeting primary care settings, will link to secondary care to ensure a consistent, high-quality service at every level.

Next Steps

As we continue to support the roll-out of the programme, we will support:

  • Support national roll out of the Bradford physical health assessment tool by supporting national providers of IT software for primary care including Systm1 and EMIS web
  • The development of a 45 minute e-learning module for primary care staff
  • The recruitment of regional clinical and GP champions to support the adoption of the programme
  • Increased detection of cardiovascular disease risk in patients with serious mental illness
  • Reduced unplanned hospital admissions through earlier prevention and prevention of emergency situations
  • Increased life expectancy of people with serious mental illness
  • Significant system savings – it is estimated that £1 in every £8 spent on long-term conditions is linked to poor mental health, equating to £8 – 13 billion of NHS spending each year.