Physical Health - An Introduction

NICE Guidance – Schizophrenia Core interventions in the treatment and management of schizophrenia in primary and secondary care - Clinical Guideline 1 - December 2002 [61]

1.4.1 Primary care

Primary care professionals have an important part to play in the physical and mental health care of people with schizophrenia. They are best placed to monitor the physical health of people with schizophrenia and should do so regularly. Case registers will be an important means of doing so. In addition, primary care workers should monitor the mental health and treatment of their service users, work closely with secondary services and refer before crises arise wherever possible.

1.4.1.1 The organisation and development of practice case registers for people with schizophrenia is recommended as an essential step in monitoring the physical and mental health of people with schizophrenia in primary care.

1.4.1.2 GPs and other primary health workers should regularly monitor the physical health of people with schizophrenia registered with their practice. The frequency of checks will be a clinical decision made jointly between the service user and clinician. The agreed frequency should be recorded in the patient’s notes.

1.4.1.3 Physical health checks should pay particular attention to endocrine disorders, such as diabetes and hyperprolactinaemia, cardiovascular risk factors, such as blood pressure and lipids, side effects of medication, and lifestyle factors such as smoking. These must be recorded in the notes.

1.4.1.4 The decision to re-refer a service user from primary care to mental health services is a complex clinical judgment that should take account of the views of the service user and, where appropriate, carers. Issues of confidentiality should be respected when involving carers. Referral may be considered in a number of circumstances, but particular factors indicating referral include the following:

• where treatment adherence is a problem, referral is usually indicated
• a poor response to treatment would make referral a higher priority
• if co-morbid substance misuse is suspected, referral is indicated
• if the level of risk to self or others is increased, referral to secondary services is indicated
• when a person with schizophrenia first joins a GP practice list, referral to secondary services for assessment and care programming is indicated, subject to the full agreement of the service user.

1.4.2 Secondary services

Secondary services should undertake regular and full assessment of the mental and physical health of their service users, addressing all the issues relevant to a person’s quality of life and well-being. When a service user chooses not to receive physical care from his or her GP, this should be monitored by doctors in secondary care. Carers should be contacted routinely, subject to the agreement of the service user, and should be provided with a care plan.

The possible presence of co-morbid conditions, including substance and alcohol misuse or physical illness, or the existence of a forensic history, will necessitate the development of treatment and care plans outside the scope of this guideline. Nevertheless, full assessment of these issues should be included.

1.4.2.1 A full assessment of health and social care needs should be undertaken regularly, including assessment of accommodation and quality of life, the frequency of which should be based upon clinical need, and following discussion with the service user. The agreed frequency of assessment should be documented in the care plan. The higher physical morbidity and mortality of service users with schizophrenia should be considered in all assessments. Whilst this would normally be expected to be the role of primary care services, secondary care services should nevertheless monitor these matters where they believe a service user may have little regular contact with primary care.

1.4.2.2 Primary and secondary care services, in conjunction with the service user, should jointly identify which service will take responsibility for assessing and monitoring the physical health care needs of service users. This should be documented in both primary and secondary care notes/care plans and clearly recorded by care co-ordinators for those on the enhanced care programme approach (CPA).

1.4.2.3 Moreover, all non-professional carers who provide regular care for a person on CPA should have an assessment of their caring, physical and mental health needs, at a frequency agreed in conjunction with the carer and recorded in their own (carer) care plan.