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EV0368

Double jeopardy in severe mental illness care: physical health monitoring in patients without a mental health care plan at a general practice in England

DOUBLE JEOPARDY IN SEVERE MENTAL ILLNESS CARE: PHYSICAL HEALTH MONITORING IN PATIENTS WITHOUT A MENTAL HEALTH CARE PLAN IN A SINGLE UK GENERAL PRACTICE

Among patients with severe mental illness who had no coded mental health care plan, the rate of complete documentation of annual Core 6 physical health monitoring was approximately 15%, far below the local standard (≥ 70%).

The study aimed to assess the completeness of documentation of annual Core 6 physical health monitoring in patients with severe mental illness (SMI) who had no coded mental health care plan, and to identify remediable causes of incomplete monitoring. A retrospective clinical audit was conducted using EMIS electronic health records at an anonymised general practice in England; the audit window ran from 24 February 2025 to 24 February 2026. Of the 181 patients on the SMI register, 107 (59%) had no coded mental health care plan within the preceding 12 months, and the records of 50 randomly selected patients from this group were reviewed; the Core 6 components were smoking status, alcohol consumption, body mass index (BMI), blood pressure, HbA1c or blood glucose, and lipid profile. The full completion rate, defined as all six components being coded, was approximately 15%, while the local standard was defined as ≥ 70% for full completion or a documented appropriate exception. Monitoring was partial rather than complete for most patients; smoking status was the most consistently recorded component, whereas alcohol status, BMI, HbA1c and lipid profile were frequently missing, and the subgroup with no data included patients receiving secondary care whose results had not been coded in structured EMIS fields. A structured root cause classification highlighted four areas: fragmented workflows (blood tests, measurements and lifestyle assessments spread across separate appointments), uncertainty over clinical priorities and boundaries of responsibility, data delays and gaps in shared care (secondary care results remaining in letters or PDFs), and barriers to patient engagement (non-attendance, inability to contact patients, needle phobia and informed refusal). Recommendations included a one-stop SMI clinic, routine entry of secondary care results into structured fields, an EMIS alert displaying outstanding investigations when an eligible patient attends, and explicit exception coding; a repeat audit 12 months after implementation aims to increase full completion to above 50% and halve the subgroup with no data. In conclusion, SMI patients without a coded care plan are also being overlooked in physical health monitoring, and improvements in coordination and coding may increase recognition of risk in this group.

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