Walking down a busy road in south London, you can't help but notice a psychiatric hospital on one side and a general hospital on the other. The road between is full of traffic and hard to cross, and perhaps this reflects the fragmentation in patient care that too many people living with severe mental illness (SMI) are facing.
Dulcie Wood is addressing this challenge head-on by bringing registered general nursing staff from local acute trusts into South London and Maudsley NHS Foundation Trust’s inpatient wards.
As the trust’s matron for physical health care, Dulcie identified that bringing in this expertise is a great way to improve quality physical health care among people living with SMI.
Physical health challenges in the SMI population
People living with SMI typically die younger than the general population, by up to 20 years, often due to preventable physical health causes.
They often have multiple physical health co-morbidities, traditionally considered out of scope for mental health nurses. Long-term conditions, such as cardiovascular disease, are common in this demographic due to factors like antipsychotic-induced weight gain, increased rates of smoking, and high levels of socio-economic deprivation leading to poorer health outcomes.
Physical health conditions – for instance diabetes and hypertension – may have been poorly managed in the community, often due to psychiatric symptoms, digital exclusion and mainstream services not always being designed to meet the specific needs of people living with SMI.
For 12 months, Dulcie led a pilot project focused around improving physical health outcomes for mental health inpatients at South London and Maudsley NHS Foundation Trust.
The pilot was successful and has now become part of the trust’s mainstream services. Here, she tells us how she achieved this, and the meaningful change it has brought to where she works.
Bringing mental and physical health nurses together
When Dulcie started her role in 2022, she covered the trust’s four hospitals as well as community mental health teams across south London. It became obvious to Dulcie that much more support was needed to meet a large patient population’s complex physical health needs.
A successful funding bid to improve physical health outcomes for adult inpatients with SMI gave Dulcie an opportunity to lead a pilot project in this area. The pilot, called Inpatient Physical Health Team, aimed to support and upskill mental health nurses, providing them with confidence and competence to provide physical health care alongside mental health care.
After 18 months the team have gone a long way to achieve their aims by bringing general nurses and their skillsets directly into the mental health wards for everyone there to learn from.
- Read next: Empowering mental health nurses
To begin, Dulcie supported nursing colleagues from across the trust to complete a comprehensive review of physical health-related Datix incidents. They then completed a training needs analysis, staff consultations, and patient and carer feedback.
She soon found the best approach was bite-sized training, where the team worked flexibly to deliver sessions at times that fit with the busy ward environment. The team also supported nurses and the wider multidisciplinary team to write physical health care plans using a “what good looks like” model, which has benefited staff and patients alike.
Dulcie’s team can also support inpatient multidisciplinary teams to link patients back to primary care and community nursing teams, so their physical health needs can be managed when they’re discharged from hospital. This advocacy has been invaluable.
“The mind and body are intrinsically connected; however, we still often separate them when it comes to where care is delivered,” explains Dulcie. “We aim to find a solution by bringing the clinical expertise of acute general nursing directly to our inpatient wards.”
Dulcie, who is also a clinical academic research fellow at King’s College London’s Institute of Psychiatry, Psychology and Neuroscience, has faced challenges along the way. These include protected time for learning – because of the uncertain, often vulnerable nature of acute psychiatric wards – as well as in providing care to people experiencing psychosis who may refuse physical health care due to paranoia or delusions.
We can have an impact on how people living with SMI seek physical health care in future
“It’s a culture shift in the direction of shared responsibility and where multidisciplinary team (MDT) working shines,” she continues. “The Inpatient Physical Health Team are now key members of the inpatient MDT, contributing to clinical handovers, ward rounds and discharge planning.
“We’re trained to work with patients who may decline mental health support, and we have the skills to build rapport with patients, in the hope they will work with us towards recovery. The concept is the same with physical health care.
“Patience, flexibility, listening and understanding experiences are key – we often hear about traumatic experiences when seeking help for physical health problems, related to diagnostic overshadowing and not feeling seen in mainstream services. This is the benefit of having skills in both mental and physical health care – patients find it reassuring to be cared for by someone they know has the right training.”
Looking ahead
Now, lots of patients self-refer to the Inpatient Physical Health Team. Many patients living with SMI have struggled to access physical health care in the community, so when they’re admitted to hospital, Dulcie’s team aspires to fill any gaps experienced elsewhere.
“When patients ask for help, our actions in that moment can have an impact on how they seek help in future. Patients have shared that they really appreciate being able to get all their health needs met in one place, by a team that understands the specific needs of people with SMI,” reflects Dulcie.
The future focus is on improving the quality of physical health care at South London and Maudsley NHS Foundation Trust. For example, supporting inpatient nursing staff to fully utilise digital platforms to improve physical health care.
The team are currently working with Guy’s and St Thomas’ NHS Foundation Trust’s Sexual and Reproductive Health Services to gain a diploma from the College of Sexual and Reproductive Health, to provide further expertise around contraception and STI testing.
Amber O'Brien, RCN Professional Lead for Mental Health, said: “The fantastic work Dulcie is leading showcases the importance of a nurse-led approach in improving the physical health of this demographic. Mental health nurses spend the most time with patients and the trust they build means they can make physical health care and health promotion part of routine practice.
“Small, sustained changes at ward level scale up to better detection, earlier treatment, and fewer preventable deaths. It would be fantastic to see greater investment in nursing leadership roles like Dulcie’s in the promotion of physical health within mental health services.”
“When nurses are empowered to work across these boundaries, care becomes more coordinated, compassionate and effective for those with the most complex needs,” adds Callum Metcalfe-O’Shea, RCN Professional Lead for Long Term Conditions.
Dulcie, who also has a keen interest in tackling health inequalities, hopes bigger-scale projects go on to better reflect the realities of people with SMI. She wants other health care trusts to follow their example.
Her top pieces of advice are:
- to understand trauma-informed care when people living with SMI refuse physical health care interventions
- to take time to listen to their experiences
- to embrace opportunities to learn something new or out of your comfort zone.
"By doing this, we can make a genuine difference in peoples' lives," Dulcie concludes.
Find out more
- How you can join the RCN Mental Health Forum.
- Learn about the RCN Nursing Practice Academy’s psychosocial interventions programme.
- Protecting your own mental health as a nurse.
