Closing the Gap Improvement Collaborative

Objectives and concerns

In 2018 community mental health teams from Oxford Health joined a national collaborative run by NHS Improvement to improve the quality of physical healthcare provision for patients with schizophrenia and psychosis.  These patients have increased rates of mortality, due to poor physical health, reduced quality of life and function and decreasing life expectancy. Many patients receive treatment in the form of antipsychotics which increase risk of cardiometabolic symptoms.

The quality improvement projects would use the Lester Tool to support the application of NICE (2009) guidance of annual physical health monitoring. Key areas of focus were smoking, lifestyle and life skills, BMI (weight), blood pressure, glucose regulation and blood lipids.


90% of patients on CPA on the AMHT caseload for at least a year in clusters 11, 12, 13, 16 & 17 will be offered a physical health check against the Lester Tool by 31st July 2019.

80% of patients on CPA and on the AMHT caseload for at least a year in clusters 11,12,13,16 & 17 will have received a physical health assessment on all aspects of the Lester Tool and relevant interventions offered by 31st July 2019

About this project

Together the teams set the aims for their projects and created a Driver Diagram to identify key areas that needed to be addressed. Mental health team doctors routinely asked GP’s to carry out the physical health checks, but many patients are reluctant to visit their GP or encounter barriers to accessing appointments. Physical health clinics were set up by the mental health teams, ran by nurses who had completed relevant training, however the clinic often had patients that would not attend so appointments were then made on a referral basis from patients’ CCs or doctors to prevent this.  Physical health equipment was identified as a being needed to achieve the project aim.  Culture was identified as a barrier of staff feeling that they were either not trained in physical health or did not see it as part of their role. As with any change the perception of extra burden was recognised as a potential barrier to be handed sensitively.

Next Steps

Please see attached poster for further information

Non-urgent advice: Further information

Local Project Leads

  • Louise Revell, Medicines Management Technician
  • Michelle Talbot
  • Tasmin Irving, Service Manager
  • Debbie Walton, Head of Service
  • Sarah Hill, Service Manager
  • Tracey Cooke, Quality & Clinical Standards Manager

QI Project Support

  • Hayley Trueman, Improvement Lead

Page last reviewed: 16 August, 2022