Delivering Annual Health Checks and Health Action Plans for People With Serious Mental Illness: A Practical Operating Model
Annual health checks for people with serious mental illness are often described as “available” but not consistently delivered in a way that changes outcomes. The operational challenge is predictable: missed appointments, unclear ownership between services, and a lack of follow-through once results are known. This article sits within Physical Health, Dual Diagnosis & Parity of Esteem and aligns with Service Models & Care Pathways because annual checks only work when they are embedded into pathway routines, with accountability and governance that can be evidenced.
Why annual health checks do not translate into reduced harm
In practice, annual checks fail to close the physical health gap when services treat them as a single event rather than a managed process. Typical failure points include:
- Uptake is passive: the person is told to book, but support is not provided to overcome barriers.
- No reasonable adjustments: anxiety, trauma, sensory needs, cognitive impairment and stigma are not planned for.
- Results are not actioned: abnormal findings do not lead to timely referrals, medication review or lifestyle support that is realistic.
- Follow-up isn’t closed: “referred” is recorded, but the outcome is not confirmed and the plan is not updated.
A credible model treats the annual check as a pathway with inputs (booking and preparation), delivery (the check itself), and outputs (a Health Action Plan with confirmed follow-up).
Commissioner expectation
Commissioner expectation: Providers can evidence an operating model that increases uptake and closes follow-up loops. Commissioners typically expect data on (1) who is eligible, (2) how many completed checks, (3) how many Health Action Plans were created or updated, and (4) whether follow-up actions were completed (referrals, medication reviews, onward assessments). They also expect explanation of how reasonable adjustments are provided so the model works for people with fluctuating engagement.
Regulator / Inspector expectation (CQC)
Regulator / Inspector expectation (CQC): People receive safe, person-centred care that addresses physical health needs, reduces avoidable harm and makes reasonable adjustments. Inspectors will test whether the service has mechanisms to identify missed checks, escalate concerns, and ensure that actions from checks are integrated into care plans and reviewed. They will also look for evidence that the person understands the plan in an accessible way.
The operational model: from eligibility to follow-up closure
A practical annual check model typically includes:
- Eligibility register: a live list of people due/overdue, reviewed monthly.
- Booking support: appointments booked with the person present, plus reminders and practical attendance support.
- Preparation: explaining what will happen, consent to share information, and agreement on reasonable adjustments.
- Results review: a structured review of outcomes with the person, and clear actions with owners and timescales.
- Follow-up closure: confirmation that actions happened and the plan was updated accordingly.
Operational example 1: Anxiety and trauma leading to repeated non-attendance
Context: A person with psychosis and longstanding trauma repeatedly misses GP appointments, particularly blood tests and physical checks. They agree in principle but cancel on the day due to panic and fear of being judged.
Support approach: The provider uses a staged, trauma-informed pathway with reasonable adjustments, treating attendance as a skill that can be built up rather than a compliance issue.
Day-to-day delivery detail: Staff agree a step plan: first a short visit to the practice to meet reception and see the environment; then a brief appointment at a quiet time of day; then bloods with agreed coping strategies (choice of staff, stop signal, breaks, option for a different clinic if available). The care coordinator books appointments during a routine contact and uses reminder methods the person prefers (text, phone call, written card). On the day, staff provide accompaniment and a calm pre-appointment routine (arriving early, waiting in a quieter space, grounding strategies). If the person cannot proceed, staff document what prevented attendance and adjust the plan rather than repeating the same approach.
How effectiveness or change is evidenced: Evidence includes reduced “did not attend” outcomes over time, completion of checks previously missed, and a Health Action Plan that documents reasonable adjustments used. Governance includes case audit verifying that appointment outcomes were confirmed and plans updated.
Operational example 2: Abnormal results with unclear ownership across services
Context: An annual check identifies high blood pressure and raised cholesterol. The person assumes “they’ll call if it’s serious”. The mental health team assumes the GP will manage; the GP expects the person to book follow-up.
Support approach: The provider adopts a “shared-care follow-up closure” rule: if the service is aware of an abnormal result, it must confirm that follow-up is in place and recorded, not just signpost.
Day-to-day delivery detail: With consent, the care coordinator contacts the GP to clarify the plan: repeat readings, medication review, referral if needed, and timescales. The person is supported to attend follow-up, with reasonable adjustments agreed. Staff record the plan in the mental health care plan and review progress in weekly/monthly contacts until actions are completed. Where the person declines follow-up, staff document the discussion, provide accessible information, explore barriers, and escalate for clinical review if risk is significant.
How effectiveness or change is evidenced: Evidence includes confirmation of follow-up appointments, outcomes recorded (medication started/changed, referral made and completed), and documentation of decision-making where the person refuses. A monthly dashboard shows how many abnormal-result follow-ups were closed within a defined timescale.
Operational example 3: Homelessness/unstable housing and lost continuity
Context: A person with bipolar disorder is in temporary accommodation and frequently changes address. Letters do not reach them, appointments are missed, and registration at a GP practice is unstable. Physical health needs are largely unmanaged.
Support approach: The provider builds an “access and continuity” pathway that stabilises primary care registration and creates multiple contact routes for results and follow-up.
Day-to-day delivery detail: Staff support GP registration and ensure the practice has an agreed method of contact (phone number, email where appropriate, nominated contact consent). The annual check is booked at a location the person can access. Staff record key details in the Health Action Plan: where the person will receive results, what happens if contact fails, and how follow-up will be arranged. The service also includes contingency: if housing changes, the care coordinator updates the practice promptly and checks whether any open follow-ups are outstanding. Where safeguarding or self-neglect risks are present, multi-agency meetings clarify roles and escalation routes.
How effectiveness or change is evidenced: Evidence includes continuity of registration, completion of checks despite housing instability, and closed-loop follow-up. The provider can demonstrate reduced missed follow-ups and a documented pathway that prevents people being “lost” between services.
Governance that makes annual checks auditable
To evidence parity of esteem, providers should be able to show:
- Overdue lists reviewed routinely with actions recorded (not just noted).
- Audit trails showing results reviewed and follow-up closed.
- Supervision prompts that ask “what is still open from the annual check?”
- Learning actions from repeated DNAs, late escalations or preventable deterioration.
Annual checks become meaningful when they reliably trigger practical changes in care, and when services can evidence that the person’s physical health risks are actively managed across the year, not revisited only at the next annual cycle.