Meeting the physical health needs of people with serious mental illness in primary care

Background: People with serious mental illness (SMI) die 15-20 years earlier than the general population, principally from cardiovascular and respiratory disease. Under-recognition and under-treatment of the physical health needs of people with SMI is one of the biggest health inequalities in England. Despite growing policy attention, evidence suggests the mortality gap between people with and without SMI is widening. This thesis aimed to enhance understanding about factors affecting the quality of primary care for people with SMI. Methods Mixed methods. Qualitative: thematic analysis of semi-structured interviews provided new insights from patients and practitioners on the quality of primary care. Quantitative: a difference-in-differences approach used to estimate the effect of removal of financial incentives on the proportion of patients who had physical health checks (blood pressure/BMI/cholesterol/glucose) recorded in primary care. Using a process of triangulation, findings from contrasting paradigms were synthesised. Results Qualitative study: quality of care for people with SMI is inadequate. Patient and practitioner aspirations for continuity and patient-centred care, increasingly undermined by new models of care delivery; Quality and Outcomes Framework (QOF) regarded as having been detrimental by prioritising a biomedical box ticking agenda in favour of holistic care; and a breakdown in communication between primary care and mental health services further eroded quality of care. Quantitative study: each difference-in-differences estimate for indicators where financial incentives were removed, compared with blood pressure which remained incentivised, indicated a significant decrease (p<0.01) in the proportion of patients with health checks recorded: BMI (-14.6%), cholesterol (-9.8%) and glucose (-8.8%). Conclusion: Despite growing interest in addressing the mortality gap, policy has focused on a biomedical approach in attempts to extend life expectancy, at the expense of addressing what matters to patients: being able to enhance their daily functioning and quality of life, to enable them to live better with their condition.