If an audit finds that only 25% of people received appropriate physical-health monitoring, another reminder to clinicians is unlikely to be enough. The key educational question is how to redesign the service so that each person’s checks are due, delivered, reviewed, and acted on—with no gap where everyone assumes someone else is responsible.
That 25% figure is a signal to investigate, not an explanation of the failure. Before changing the service, confirm the audit’s denominator, time period, and definition of appropriate monitoring. Then check whether the other records reflect care not delivered, care delivered elsewhere but not shared, or incomplete documentation. Those problems need different fixes.
Find where the pathway breaks
Map the monitoring pathway from the moment a check becomes due to the point where results lead to care. A patient can be missed at several stages: the service list may be incomplete; nobody may invite or book them; a check may be only partly completed; results may not reach the clinician who needs to review them; or an abnormal result may have no clear follow-up route.
| Where the gap appears | A service-level response | What to track |
|---|---|---|
| People due for checks are not identified | Maintain a register or electronic prompt that shows who is due and what has already been completed | Eligible people due; records reconciled across services |
| Appointments are not completed | Offer checks during routine contacts where practical; use outreach and reasonable adjustments when access is difficult | Invited, offered, completed, and partially completed checks |
| Results are missing or duplicated | Agree how results are recorded and shared between community mental-health and primary-care teams | Results received, reviewed, and entered in the relevant record |
| Abnormal findings do not lead to action | Name who reviews results and define referral and escalation routes | Follow-up arranged and completed, where indicated |
A “completed check” should not just mean that someone opened a template or took one measurement. The audit definition should match the relevant clinical schedule and distinguish full from partial assessments. That makes the next audit useful: it can show whether the intervention improved the actual point of failure rather than just changing how forms are counted.
Assign coordination—and make handoffs explicit
For each person, designate a professional or role responsible for coordinating the monitoring pathway. That person need not perform every measurement or make every medical decision. The practical task is to track what is due, confirm who will deliver it, notice missing results, and make sure findings reach someone qualified to review and act on them.
This coordination must sit inside a clear agreement between services. NICE guidance for adults with psychosis or schizophrenia places responsibility for monitoring physical health and antipsychotic effects with the secondary-care team for at least the first 12 months, or until the person’s condition has stabilised, whichever is longer. Monitoring may then transfer to primary care through shared-care arrangements. A transfer should be a documented handoff, not an assumption made because the patient has a GP. Record who has accepted the ongoing task, how results will be shared, and who will follow up a concerning result.
The clinical schedule also matters. A routine annual physical-health check is not a substitute for the early monitoring associated with starting an antipsychotic. For example, weight monitoring has early time points after treatment starts; pulse, blood pressure, glucose or HbA1c, and lipids also have checks before or during early treatment as well as later follow-up. The service’s prompts should reflect the person’s treatment stage, not apply one annual reminder to everyone.
Train for the task, not just the topic
A one-off lecture on the physical-health risks associated with psychosis may raise awareness without changing practice. Build a continuing, role-specific training plan instead. Staff delivering measurements need the practical competence to perform the elements assigned to them, record results accurately, explain the process accessibly, and know when findings need clinical review or escalation. Staff who do not perform checks still need to know how to spot a missed check and route the concern to the right person.
Education should run in both directions. Mental-health staff may need training in physical-health assessment, prevention, and follow-up. Primary-care staff may benefit from practical learning about severe mental illness, communication, reasonable adjustments, and the risk of attributing a physical symptom to psychiatric illness without adequate assessment. Joint sessions can clarify what each service can provide and how results will move between them. Including people with lived experience in training can help teams understand why an invitation, appointment, or follow-up may feel difficult to access.
Training will not solve a capacity problem on its own. The service also needs protected staff time, suitable equipment, access to relevant records, a way to arrange blood tests when required, and a reliable route for results to be reviewed. If the check is delivered on site, staff roles and the limits of each person’s competence should be clear. If primary care delivers it, the mental-health team still needs to know whether it happened and what follow-up is planned.
Close the loop—and measure what changed
Use the audit as the start of a quality-improvement cycle: identify the missed step, implement a targeted change, and repeat measurement. Keep measures distinct: check completion, whether results were reviewed, and whether indicated follow-up was arranged are related but different outcomes. Where possible, examine variation in access between groups; an overall rate can conceal who is being missed.
Review the findings at team level and through the service’s governance process. If completion improves but results are still not reviewed, the next intervention should address ownership and follow-up—not simply send more appointment invitations. If recorded completion remains low but primary-care records show checks occurred, improve data-sharing before redesigning the appointment system.
The goal is not to make a patient responsible for reminding the service. It is to build a dependable system in which responsibility is visible, staff are equipped for their roles, and no result disappears between mental-health and physical-health care.
Practical takeaways
- Verify what the 25% audit measure includes before interpreting the gap.
- Map the pathway from identifying who is due through results review and follow-up.
- Assign a named coordination role for each person and document any transfer of monitoring responsibility.
- Train staff to the tasks they perform, including communication, recording, and escalation.
- Provide the time, equipment, records access, and referral routes needed to make training usable.
- Re-audit completion and follow-through separately, then target the next change at the step still failing.
