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 (SMI) can be a powerful mechanism for closing the physical health gap, but only when services treat them as a governed pathway rather than an occasional task. Within the Physical health, dual diagnosis and parity of esteem resources and the wider Mental health service models and pathways collection, the operational problem is familiar: checks are offered, people do not attend, abnormal findings are not consistently acted on, and “completed” does not mean “improved”. This article sets out a practical operating model for providers and commissioners that increases completion, ensures follow-through, and evidences impact in a way that stands up to audit and inspection.
Why annual health checks fail to reduce inequality
Annual health checks often fail for reasons that are operationally predictable:
- Access barriers are not addressed (anxiety, trauma triggers, executive dysfunction, literacy, distrust, chaotic routines).
- Responsibility is unclear for booking, chasing, and closing the loop on results.
- Findings are not translated into a Health Action Plan that staff use day-to-day.
- Follow-up drifts (repeat tests not booked, referrals not attended, medication reviews delayed).
A defensible approach treats annual checks as a pathway with stages: identify who is due, broker attendance, receive results, convert results into actions, and review outcomes.
The operating model: end-to-end delivery with closed-loop follow-up
1) A “who is due” register with active ownership
Maintain a simple register of people eligible for SMI annual health checks, with status fields that show what stage they are at: due, booked, attended, results received, action plan agreed, follow-up completed. Assign named ownership for keeping the register current and escalating when progress stalls. This converts “we reminded them” into “we can evidence completion and follow-up”.
2) Brokerage and reasonable adjustments built into the pathway
Brokerage is not an optional extra; it is the mechanism that turns invitations into attendance. Practical adjustments may include supported booking, quiet appointment slots, longer appointments, accompaniment, transport planning, pre-visit preparation (what will happen, why it matters), and post-visit debrief. Where people decline, document informed choice, explain risks in plain English, and agree when the offer will be revisited.
3) Health Action Plans that translate findings into daily routines
A Health Action Plan should not be a leaflet. It should convert findings into practical actions that staff can support: diet and activity routines, smoking reduction steps, medication monitoring, appointment scheduling, and escalation triggers (e.g., new chest pain, worsening breathlessness, rapid weight gain). Plans should include who is responsible for each action, timescales, and how progress will be evidenced.
4) A follow-up cadence and escalation standard
Agree a clear follow-up cadence. For example: results reviewed within a set timeframe; abnormal results trigger same-week escalation to GP/practice nurse; follow-up appointments booked before the case is marked “complete”. Where repeated non-attendance or self-neglect creates significant risk, ensure safeguarding pathways are understood and used proportionately.
Operational examples (minimum three)
Operational example 1: Increasing completion through barrier-led brokerage
Context: A person with schizophrenia is eligible for an annual health check but has not attended for three years due to paranoia about clinical settings and fear of being judged about smoking and weight.
Support approach: The service uses a step-by-step brokerage plan with reasonable adjustments and consent-led preparation, aiming for attendance without coercion.
Day-to-day delivery detail: Staff co-produce a “visit plan” over two short sessions: what will happen, who will be there, and how long it will take. The GP practice is asked (with consent) for a quiet slot and a longer appointment. Staff accompany the person, arrive early to reduce waiting, and use a pre-agreed grounding strategy. After the appointment, staff debrief and capture outcomes immediately in the register: tests completed, results timeline, and next steps. A follow-up call is scheduled in seven days to confirm results were received and reviewed.
How effectiveness is evidenced: Evidence includes successful completion after sustained non-attendance, documented reasonable adjustments, and a completed results-to-action record showing what happened next (not just “attended”).
Operational example 2: Turning abnormal findings into a usable Health Action Plan
Context: An annual health check identifies raised BP, weight gain, and high diabetes risk indicators. Historically, findings were filed but not translated into daily practice, leading to deterioration and urgent presentations.
Support approach: The provider creates a Health Action Plan that integrates into weekly support routines with clear ownership, timescales, and escalation triggers.
Day-to-day delivery detail: Within one week of results, staff hold a structured review with the person: explain findings in plain English, agree priorities, and map actions into the weekly plan. Practical steps include: supported booking for repeat BP checks; meal planning and shopping support; a low-demand daily walking routine; smoking reduction support if the person wants it; and a clear escalation trigger for symptoms (dizziness, chest pain, marked breathlessness). Staff record progress weekly, confirm GP follow-up dates, and ensure any medication review discussion is documented. The plan is reviewed at four and eight weeks, with adjustments based on what is working.
How effectiveness is evidenced: Evidence includes follow-up checks completed, documented GP engagement, and measurable improvements or stabilisation (repeat BP results, weight trend, completed diabetes screening) alongside reduced deterioration-related urgent contact.
Operational example 3: Managing repeated DNA and self-neglect risk with proportionate escalation
Context: A person with SMI and dual diagnosis repeatedly misses follow-up appointments after abnormal results. They present with dehydration and infections, and self-neglect escalates during periods of heavy substance use.
Support approach: The service links health check follow-up to a risk plan and uses stepped escalation, including safeguarding consideration where harm risk is unmanaged.
Day-to-day delivery detail: Staff increase contact intensity temporarily (daily brief check-ins for one week) to stabilise routines and support appointment attendance. They coordinate with the GP practice for flexible appointment formats and ensure the person understands what is urgent and why. Where consent allows, staff share a concise risk summary with primary care (patterns of DNA, deterioration indicators, substance-related risks). If engagement remains low and risk indicators worsen, the service documents a multi-agency review and considers safeguarding procedures due to self-neglect and repeated harm episodes, while continuing to offer support and adjustments rather than closing the case.
How effectiveness is evidenced: Evidence includes reduced missed follow-ups, documented escalations within agreed timescales, and a clear record of risk management decisions. Over time, the service can evidence fewer avoidable urgent presentations and improved completion of follow-up actions.
Explicit expectations (mandatory)
Commissioner expectation
Commissioners typically expect improved completion of SMI annual health checks and, critically, evidence that abnormal findings lead to action and improved outcomes. They will look for reliable reporting (due/attended/results/actioned), reduced DNAs through reasonable adjustments, and demonstrable impact on avoidable deterioration and crisis use. Commissioners also expect providers to be transparent about barriers and to show learning when completion and follow-up fail.
Regulator / Inspector expectation (e.g., CQC)
Inspectors typically expect safe, person-centred practice that recognises physical health risk as integral to wellbeing. They will look for clear ownership, timely escalation, and evidence that services follow through on findings rather than recording them. They will also expect safeguarding awareness where repeated non-attendance and self-neglect create unmanaged harm risk, and they will examine whether reasonable adjustments are used to enable access.
Governance and assurance mechanisms
- Monthly register review with exception reporting for overdue checks and overdue follow-up actions.
- Closed-loop audit sampling: attended → results received → action plan agreed → follow-up completed and reviewed.
- Supervision prompts requiring staff to evidence how they removed barriers and what outcomes changed.
- Deterioration and incident reviews that explicitly test whether annual health check findings and actions were implemented.
When annual health checks are delivered as a pathway with ownership and follow-through, parity of esteem becomes operational: access improves, deterioration reduces, and evidence becomes commissioning- and inspection-ready.