Supporting people with Severe Mental Illness in North East London

Supporting people with Severe Mental Illness in North East London

Supporting people with Severe Mental Illness in North East London

10 October 2023
Supporting people with Severe Mental Illness in North East London

"This work holds the principles of personalised care at its centre, and is an excellent example of how true coproduction can produce innovative, user led tools to enable everyone to self-manage their mental health and wellbeing.

City and Hackney also holds the impressive achievement of being the first (and only so far!) site to have their PHB support plan and information visible and accessible via the NHS App, and is also the first to flow information from a non-Statutory VCSE to the app through its work with Patients Know Best” 

Janet Blair, Personalised Care Lead, NHS England.


In 2016, the Five Year Forward View Mental Health (MHFYFV) set out NHS England’s approach to reducing the stark levels of premature mortality for people living with severe mental illness (SMI). They die 15-20 years earlier than the general population, largely due to preventable or treatable physical health problems.

The NHS Long Term Plan commits to 390,000 people with a Severe Mental Illness (SMI) receiving a full annual physical health check in 2023-24.

SMI Service Users in North East London are seeing the benefits of being given digital access to their Personal Health Budget (PHB) and Me and My Goals Care Plan within PKB. This is to support them with the wider coordination and management of their condition across the multiple services focusing on improvements to implementation of these initiatives. Uniquely, and in a first of its kind programme, this brings together Primary Care, Secondary Care (mental health trusts) and voluntary sector organisations to collaborate with patients on these shared resources.


Service Users are able to be seen by their clinical team based at their local GP practice Mental Health Specialist Hub. Together they work through their PHB to help them work towards a mental health recovery goal. If appropriate to do so, they also discuss the benefits of accessing it digitally through their PKB record.  This can be set up there and then simply by the clinical team finding their record and adding their email which will send an automatic invite to register.

All people with SMI should be offered an annual physical health check within Primary Care (their GP) to measure and record information on smoking, obesity and high blood pressure. 

To make this work, PKB worked specifically with North East London to expand the initial EMIS integration datasets that were being received by PKB.  This enabled the relevant SMI data to populate the users records.  

Where such conditions are found, they can then be offered appropriate support and treatment, which they can set out in their ‘Me and My Goals’ digital plan, and continue to track their health and wellbeing by recording their measurements independently.

"I've been using PKB to help me track my weight. The graph really helps me to visualise my weight loss journey"

This plan can also help identify a service user’s health and wellbeing priorities (‘what matters to me’). It sets out their personalised recovery plan with support from healthcare professionals involved in their care.  Professionals from the wider framework of recovery services, like Core Arts and Sports, will be able to see the physical health check data and digital recovery plan, giving guidance and support, as appropriate to their role and relationship to the person.

For example, Core Arts and Sports can:

  • Offer Fitbits and blood pressure monitors to members who would benefit from this equipment to meet their goals.
  • Offer an individualised schedule of activities to meet achievable health aims.
  • Offer access to a creative, active community which promotes positive mental and physical health.

User Feedback

Two use cases of Core Arts and Sports service users:

Ngozi, is a 40 year old female with a diagnosis of Bipolar and Emotionally Unstable Personality Disorder (EUPD).  Her health goals include:

  • weight loss.
  • types of sports activities she wants to access to achieve her health goals. 

She uses PKB to: 

  • help to track her moods, sleep, activity levels and healthy eating. 
  • manage appointments and as a calendar guide.
  • tracking her activities.
  • using the diary/journal.

Bi-weekly consultations sent via PKB - supporting her to reflect and answer questions regarding her progress. Provides Core Sport with personal feedback to our sessions (PROMs).

1-2-1 PKB sessions with Core Sport team members & attends our Core Health sessions - share her progress and how she uses the PKB platform with others.  She advocates how supportive and useful she has found it as a self-management tool.

Belu, is a 60 year old man living with paranoid schizophrenia.  Belu is new to Core Sport and using PKB.   He needed some basic IT support to get set up on how to use the platform. Now he uses PKB to communicate with Core Sport regarding:

  • Sessions.
  • Meetings.
  • Volunteering.

Belu also uses PKB to:

  • track medication and moods.
  • update PKB with measurements provided through his Fitbit.

Belu attends Core Sport social group & Core Health sessions.  He also motivates others to gain a better understanding on how to use PKB, the benefits to using PKB and share his experiences.  

Other Service Users of Core Arts and Sports said:

“Core Sports has improved my quality of life. I always look forward to coming to Core Sports, it has hugely improved my sense of wellness.”

“It has everything in one place and I can do this all on my phone”

“I like having access to both my physical and mental health records without having to ask my doctor”

"It's really user friendly. I thought I would struggle to use it way more, but the way i've been shown by Core Arts makes sense"

"I want to use PKB on my phone as a sort of notebook so that when I next see my GP I can just show them this one website on my phone"

"I now use the journal more than I use my own diary"

"The consultations you (Core Sport) send help give me a nudge to use PKB. Usually, once I've completed the consultation I then continue to explore my PKB and track my progress" 

"Linking the Fitbit has been brilliant, i can see the data there and so can my GP"

"The consultations you send help me keep track of my moods because I don't do this of my own accord although I plan to eventually, its showing me how useful it is to"

“I love PKB because I can chat with both Core Arts and my GP on the same platform”

Staff from Core Arts and Sports Said: 

“Patients have fed back to staff that they have found using PKB really helpful. This is nice feedback for staff to hear”

“Having appointment information visible in PKB has been so helpful for my clients to check their appointments and saved me a lot of phone calls and reminding!”

“I was worried that this was going to be a lot of extra work, but once I was shown how to use PKB, it’s a lot easier than I thought it would be”

“It has felt much more professional to introduce PKB to patients and let them know that all the support resources are in one place rather than giving them different website addresses and leaflets and expecting patients to remember them”

National recognition

In September 2021, the recognition for their Digital Recovery Platform for Severe Mental Illness saw the team pick up three awards for their cross sector programme of work at the HSJ Value Awards.  

The collective walked away with:

  • Winner for the Digital Clinical Transformation Award
  • Highly commended for the Primary Care or Community Service Redesign Initiative and the IT & Digital Innovation Award
  • Finalists for the Mental Health Service Redesign Initiative

Read more about their success here.

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