Practice and system improvements for better physical health and longer lives for people living with serious mental illness

The Being Equally Well policy roadmap seeks to end the neglect of physical health for people living with serious mental illness

People living with serious mental illness die up to 20 years prematurely from chronic physical health conditions.1 Most of these early deaths are from preventable health conditions including cardiovascular disease, smoking‐related respiratory illness, diabetes, and cancer.2 Primary care is not organised to provide this group with screening for cardiometabolic risk factors.

Current policies addressing this disparity in Australia and comparable countries have been ineffective. They largely fail at the frontlines of care because they do not account for how frontline staff work. The Being Equally Well national policy roadmap proposes changes needed in both specialist mental health and primary health care and how to achieve these.3

The supplement accompanying this issue of the MJA comprises evidence reviews and discussion that fill gaps in knowledge about effective physical health care for people living with serious mental illness.

Clinical microsystems are the small teams where patients and their families meet the health care system. Here, the foundations of safety and quality in health care are built.4 We set up expert working groups to consider how each layer of the health system hinders or helps the clinical microsystem in providing equitable mental and physical health care to people with serious mental illness. The mesosystem (Primary Health Networks and acute mental health services) supports the clinical microsystem, while the macrosystem (federal and state governments) supports both the micro and meso systems.

Being Equally Well comprised five working groups. Four clinical groups looked at the three levels of the system and at system‐wide quality improvement. The fifth group — consumers and carers — charted the frustrations and health impacts of the barriers within and between each layer of the system and developed central measures of success. The groups worked iteratively over 6 months. Constant exchange of information was achieved through regular meetings of working group chairpersons. Group meeting recordings were thematically analysed to provide regular summaries to all groups.

Critical recommendations and evidence are summarised here and presented in detail in the supplement.

First, lack of coordination between primary, secondary and tertiary care services was a central issue. Collaboration by the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists to integrate their guidelines and develop shared care protocols is a critical recommendation.5

Second, consumers and carers identified as priorities the barriers of fragmented care and the complex difficulties navigating the health system, as well as the importance of support from community and peer groups. Investment in a workforce of nurse navigators is proposed to actively support consumers and to integrate the care they require from both primary and specialist mental health services. Expanded roles for community pharmacists would provide medication management to high needs individuals and facilitate shared care with allied health professionals.6 Development of peer worker roles is a high priority for consumers, as evidence indicates benefits of enhanced comprehensive care.7

Third, the health impacts of medications were a major concern, particularly the prevalence of metabolic syndrome. Although some countries use antidiabetic medication as a preventive therapy, this is not approved in Australia. The case for early use of antidiabetic medication is discussed in the supplement.8 Lessons from the use of clozapine are revealing. Despite the metabolic impacts, people receiving clozapine therapy have a longer life expectancy. Monitoring is mandatory, which may explain this result.9

Fourth, the benefits of nutrition interventions in improving the mental and physical health of people with serious mental illness were considered. Evidence indicates that they are particularly effective when led by dietitians.10

Finally, the lack of shared and consistent information between mental health and primary care services underlies inadequate service provision and exacerbates poor capacity to monitor and evaluate both health care and health outcomes. A systematic national approach to quality improvement is proposed by establishing a national clinical quality registry and an annual report to the Australian Council of Health Ministers.3

The outcomes and recommendations of the Being Equally Well project are set out in the national policy roadmap launched in August 2021.3 The Being Equally Well roadmap is a resource for primary care, mental health services, Primary Health Networks, and local hospital and health districts and networks. It is also a map for governments and health system administrators — without supporting system improvements, frontline health professionals cannot bring about sustainable change.

Similar enhancements in health care have successfully reduced deaths and disability from conditions such as stroke. Tailored shared care health services and support have been implemented to improve the physical and mental health care of cancer patients. People with serious mental illness need the same commitment and attention to reduce preventable deaths and serious physical illness.