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Report: Evaluation of the physical health checks programme for people with severe mental illness in south east London
Background
In England, people with severe mental illness have a life expectancy 15-20 years shorter relative to the general population, largely due to preventable physical illnesses. The NHS has a national target for at least 60 per cent of people with severe mental illness to receive a full annual physical health check by March 2025.
The Health Innovation Network (HIN) South London's Mental Health team worked in partnership with the South London Partnership, Oxleas NHS Foundation Trust and South London and Maudsley NHS Foundation Trust, to improve data sharing and increase the number of completed physical health checks for people living with a severe mental illness in south east London.
To do this, mental health nurses from Oxleas NHS Foundation Trust and South London and Maudsley NHS Foundation Trust were mobilised into primary care to enhance patient support and help practices meet physical health check targets. The programme was delivered from November 2022 to March 2025.
In its final year, the project expanded its focus to:
- Raise awareness of physical health checks among healthcare professionals and patients, by working with voluntary sector partners to deliver targeted activities; and
- Identify digital solutions by carrying out a horizon scan and market review to identify tools that could help address operational challenges.
The HIN's Insights team was then commissioned to deliver an independent mixed-methods evaluation of the programme.
Key findings
Reach
The programme engaged 31 GP practices and one primary care network across south east London, reviewing 2,684 patient records. Among the 1,540 patients with available programme data, the average number of completed physical health check elements increased by 0.5 to 1.2.
Implementation
Delivery was delayed by early information governance and recruitment issues, and later affected by staff sickness, turnover, ongoing recruitment and major external events such as GP collective action and the Synnovis cyberattack.
Impact and wider learnings
Despite these challenges, the programme delivered meaningful benefits.
- Nurses reported improved support for patients who were disengaged from primary care or community mental health services, enabling more holistic care.
- The model strengthened collaboration across primary, secondary and voluntary sectors and supported the professional development of the mental health nursing workforce.
- The work highlighted opportunities for more sustainable approaches to physical health checks, including primary care-led outreach and exploring an expanded role for mental health practitioners.
Key recommendations
Learning from programme delivery
- Engage primary care early: Early involvement helps address engagement challenges and align expectations.
- Coordinate and streamline information governance: A shared approach across partners can reduce delays and ensure issues are resolved before delivery.
- Prioritise patients: Future delivery should focus more on people who are significantly disengaged and less on those who have already completed checks.
Increasing targeting and uptake of physical health checks
- Expand Point of Care Testing for lipids: Reducing the need for multiple appointments could increase completion of lipid checks, which were among the least completed elements. Wider rollout of Point of Care Testing could streamline this process, reduce patient burden and improve completion rates.
- Advance primary care strategies: Improving physical health check delivery requires strong oversight of severe mental illness registers and a more consistent approach to annual monitoring.
- Extended outreach through system collaboration: There needs to be a continued movement towards integrating physical health in mental health. System-wide efforts should focus on working with voluntary sector partners to raise awareness of physical health checks, delivering community education on the physical health risks faced by people with a severe mental illness, conducting targeted outreach to engage disengaged groups, and continuing to promote awareness among healthcare professionals to reduce barriers to attendance.
Supporting system development
Opportunities to invest in data infrastructure and scale innovative tools included:
- Promoting the use of the London Care Record to reduce duplication, and improve data accuracy, and enhance patient experience.
- Prioritising the integration between primary and secondary care systems, using platforms such as OneLondon to support real-time access to patient information.
Read the evaluation
Learn more about the evaluation approaches, implementation insights, and project learnings.
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