Promoting health and wellbeing in NHS Ayrshire and Arran mental health services: a physical health reporting tool

NHS Ayrshire and Arran has developed a tool to pull together details of the physical health of patients with a serious mental illness.

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How it started

Evidence shows that although service users with serious mental illness are at greater risk of physical ill health, they are less likely to be offered health promotion advice. An earlier East Ayrshire project, called the Well Person Service, had made progress in improving access to mainstream services, and increasing patient awareness of physical health. The physical health reporting tool builds on this holistic approach. It aims to ensure that physical health forms part of the integrated care pathway, and to establish uniform access to information and services.


  • working group of: all mental health service areas, including adult inpatients and outpatients, older people, learning disabilities and addiction services, public health practitioners and health promotion officers
  • software designer
  • case workers
  • service users with serious mental health problems
  • GPs


The tool pulls together data from various sources, including:

  • the integrated care pathway
  • the patient’s annual physical health assessment
  • the ‘My View’ self-assessment tool
  • observation
  • patient record.

It flags up specific risks and helps to identify opportunities for prevention or early intervention through better access to mainstream services. The intention is to collect as much physical health detail as possible from a single electronic record, with physical health and wellbeing embedded into the routine work and clinical recording of the case worker. Case workers will update this information and review a patient’s physical health, so the reporting tool may take months to complete, depending on how often someone is seen. The tool offers:

  • an easy way for frontline staff to gather information into one report
  • health promotion guidance
  • links to additional information
  • notifications of review points in someone’s long-term care, such as their age, or links to national screening programmes
  • a reminder of the annual review offered by GPs to high-risk mental health patients under the quality outcomes framework
  • summaries of individual health needs, and any actions required.


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The annual GP review will now be on caseworkers’ radar so they can encourage the service user to attend, and offer to accompany them if necessary. They can also record reasons why someone does not want to attend and discuss this with the patient’s GP. The tool is also good for time management because caseworkers do not have to start from scratch or repeat the process of gathering information. They are able to amalgamate existing data, then update and review it. The physical health reporting tool will now be rolled out across Ayrshire and Arran.


A researcher is developing a framework for evaluation. This framework will incorporate data already captured in existing systems, and will build in longer-term analysis of the impact on the target population.

Lessons learned

Mental health services in NHS Ayrshire and Arran aim to reduce stigma and demystify the mental health client group. Some people, however, need more tailored services because mainstream services can be difficult for them to access. It was also important to ensure that the project had strategic support from senior management.

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Related documents and links


Craig Stewart, locality manager
North Ayrshire Adult Mental Health Community Services
Three Towns Resource Centre
Nelson Road
KA21 5RF

Tel: 01294 470010


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