How Good a Doctor? Physical Health Care in a Forensic Setting. Dr. Alan Cohen FRCGP

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1 How Good a Doctor? Physical Health Care in a Forensic Setting Dr. Alan Cohen FRCGP Director of Primary Retired Care, West Grumpy London Old Git Mental Health Trust

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3 Take Diabetes More common in people with severe mental illness (SMI) One of the major causes of premature death in this group But no information on the quality of care provided to people with a SMI There is a National Diabetes Audit that could address this omission

4 The National Diabetes Audit Commissioned by HCIP and funded by NHSE, since 2004 Takes data from inpatient care, and primary care Addresses four specific questions Is everyone with diabetes diagnosed and recorded on a practice register? What percentage receive the 9 key interventions recommended by NICE? What percentage achieved the 7 treatment targets recommended by NICE? What are the acute and long term complication rates?

5 HbA1c (mmol/mol) Smoking 9 Key Interventions process measures BMI Blood Pressure (mmhg) Serum Cholesterol (mmol/l) Serum Creatinine Urine Albumen Foot Surveillance Retinal screening*

6 HbA1c <58 mmol/mol HbA1c <= 64 mmol/mol 7 Treatment Targets outcome measures HbA1c <= 75 mmol/mol Blood Pressure (Systolic) <150mmHg Blood Pressure (Systolic) <140 mmhg Blood Pressure <=140/80 Serum Cholesterol < 5mmol/l

7 West London Mental Health Trust Aim: to compare the standard of care delivered at Broadmoor and WLFS with the standards of the National Diabetic Audit Age Distribution at Broadmoor and at WLFS Broadmoor Male (%) Broadmoor Female (%) WLFS Male (%) WLFS Female (%)

8 Primary Care team GP Nurse practitioner Practice nurse, dietitian, health care assistant, physiotherapist Consultant diabetologist Primary Care IT system At each CPA Physical health examination Blood tests in line with NICE guidelines for both psychosis and diabetes ECG Review of previous physical health problems in the last six months

9 The Results - interventions Broadmoor 195 all male beds 30 (15.4%) have Type 2 diabetes 26 (86.7%) received 8 recommended interventions 29 (96.6%) received 5 recommended interventions 20 (66%) patients agreed to have retinopathy screening 0 patients were recorded as smokers WLFS 284 beds (61 female) 58 (20.4%) have Type 2 diabetes 48 (82.8%) received 8 recommended interventions 56 (96%) received 5 recommended interventions 36 (62%) patients agreed to have retinopathy screening 40 (68%) were recorded as smokers

10 The Results - outcomes Broadmoor Mean HbA1c was 63.9mmol/mol 14 (46.7%) achieved good control of diabetes 5 (16%) achieved the composite of good diabetic control, ideal blood pressure and ideal cholesterol Insulin needed in 8 (27%) of patients WLFS Mean HbA1c was 52.4mmol/mol 43 (74.1%) achieved good control of diabetes 27 (46.5%) achieved the composite of good diabetic control, ideal blood pressure and ideal cholesterol Insulin needed in 5 (8.6%) of patients

11 Differences between the units Mean HbA1c higher in Broadmoor (p = 0.05), And therefore overall worse control, and overall a smaller proportion achieve the composite score More likely to need insulin in Broadmoor (p = 0.05) Patients smoked at WLFS (68%) and none smoked at Broadmoor There was no statistical difference between any of the other treatment targets. Women at WLFS had a higher BMI than men at WLFS (p = 0.05)

12 Compared to National Data Comparisons are difficult because: It is a general population and not a specific population of people in the community with severe mental illness It is a population in the community and not a population held in long term mental health units Nationally 60% of people with diabetes accepted all 8 interventions Nationally treatment targets were higher across all indicators when compared to both mental health units.

13 So what? Both units were good at offering the interventions (84%) compared to the national average (60%) But despite offering the interventions, treatment target achievements were worse than the national figures, and worse at Broadmoor than at WLFS What could explain this? Smoking? Antipsychotics?

14 Smoking Smoking (nicotine) induces liver enzymes Which increases the metabolism of anti-psychotic medication So to achieve the same therapeutic effect in a smoker, a higher dose of medication is needed When a smoker stops smoking, it is recommended that the dose of medication is reduced by about 25%, otherwise the drug level will increase to potentially toxic levels 68% of WLFS patients smoked But they had better diabetic control

15 Antipsychotic medication No electronic data at WLMHT as to overall comparative use of antipsychotics No information on relative diabetogenic effects of different antipsychotics, alone or in combination.

16 Some thoughts Setting up the organisation of care was straightforward Getting the data was straightforward Interpreting the data was straightforward But Diabetes is more complex to manage in forensic settings The treatment target achievements were poor despite offering all the interventions recommended by NICE The role of smoking is ill-understood The role of antipsychotic medication is ill-understood

17 and some questions Are psychiatrists (or psychiatrists in training) the best people to offer diabetic care to a group that are more complex to treat than most other diabetics? If not psychiatrists then who (and how)? Why don t we have better information about medication use? Why doesn t the National Diabetic Audit include mental health trusts? Is this what is called Parity of Esteem?

18 In Summary We have the tools to deliver high quality physical health care When we start to do so, it raises clinical questions that are complex We do need some national leadership (politically and administratively) which is effective But

19 Thank you Dr Alan Cohen