Transformation Directorate

Bringing holistic services within reach for people with severe mental illness: how digital, data and people are combining in Greater Manchester to enrich lives and reduce inequalities.

Delivered in partnership with the AHSN Network.

Primary care network (PCN) teams across Greater Manchester are harnessing the power of human and digital innovation to drive inclusive change and encourage greater parity between mental and physical health.

The city region is championing a PCN-led grass roots approach to service design, supporting teams to offer annual physical health checks for people with severe mental illness (SMI) through point-of-care testing (POCT) digital devices that return results within minutes rather than days.

Health checks are crucial in detecting signs of preventable disease like diabetes and involve a minimum of six elements: blood glucose, blood lipid, blood pressure, body mass index (BMI), alcohol and smoking status.

Different approaches include a ‘one stop shop’ monthly clinic in Denton, Audenshaw and Droylsden (DAD) PCN, which is advocating the ‘make every contact count’ principle. The aim is to harness every possible opportunity to support the attendee at the time of their appointment and into the future.

This means the DAD team offer POCT side-by-side with other services including mental health, pharmacy, wellbeing, and social prescribing support. We explore this approach within this case study.


United through shared learning and a focus on integrated care, teams across Greater Manchester’s 66 PCNs are working to turn the tide on avoidable deaths, disease and socio-economic inequalities for some of the most vulnerable people in society.

Around 25,000 people in Greater Manchester live with an SMI like schizophrenia or bipolar affective disorder.

Statistically, people with SMI experience poorer health compared to the general population and are likely to die 15 to 20 years earlier. Nationally it’s estimated two thirds of these deaths, caused by factors including preventable physical illness like diabetes, and socio-economic inequalities like unemployment, could be avoided.

GP Dr Vinny Khunger, is Clinical Lead for the SMI POCT project at Health Innovation Manchester Academic Health Science Network (HInM AHSN). He explained the uptake of annual physical health checks by the SMI population in Greater Manchester, similar to other regions, has varied in recent years between 20 and 40 per cent.

“People living with SMI often die earlier than the background population because of unmet physical healthcare needs. It might be high blood pressure, undiagnosed diabetes or high cardiovascular risk are not picked up. POCT machines create a much more efficient process for the service provider and the patient. You can have your full check done all at once including blood pressure, BMI, smoking and alcohol status, as well as blood tests to check for cholesterol and diabetes through a finger prick rather than intravenous test.”

GP Dr Vinny Khunger

Clinicians like Vinny have been central to successfully leading regional and PCN-led work to embed POCT in close collaboration with other professionals and regular consultation with service users.

GP Dr Vikas Gupta, DAD PCN Clinical Director, explained how bringing patients and different professions together has been essential to the success of POCT as part of the broader ‘one stop’ innovation.

“These are vulnerable patients who really need their health checks and we were determined to come up with an idea that could improve engagement and increase uptake. It was a team effort to make things easier for them by bringing all the people that could help them together under one roof. The technology is giving patients results almost on the spot, while the supporting services are there as part of one appointment and can all be seen within about a 30-minute circuit of the room.”

GP Dr Vikas Gupta

Heather Palmer, DAD PCN Manager, reaffirmed the importance of patient engagement and said the one stop approach was shaped by feedback from COVID vaccinations in community settings, where people were offered routine health checks at the same time.

“It's saving time and travel for patients. It just makes it so much easier and less disruptive and that’s why I think it is so successful. The opportunity is there to speak to the people face-to-face, which patients really like. Talking to clinicians, these are the kind of services patients may need to be referred to as a result of their health check, so we wanted to get them all on board under one roof.”

Heather Palmer, DAD PCN Manager

Alongside professionals offering POCT and mental health support, other specialist services at the DAD clinic include smoking cessation, alcohol and drug use support, exercise and wellbeing help and social prescribing. The PCN also benefits from access to an onsite pharmacist.

Mental Health Nurse Ed Hinfey works across DAD PCN’s nine GP practices and attends the one stop clinic. Part of his role is to support patients on each of the practice’s SMI registers with an annual mental health care plan.

The idea that somebody can come and get tests done in the same day is a game changer. In the current times we live in people want to know there and then what’s going on. Having the opportunity to come to an event like this means I can have a brief discussion with the patient about their mental health and if we identify any concerns, I can arrange a follow-up or signpost any referrals. Ultimately, it’s about doing that introduction because I don’t think a lot of people are aware there are mental health practitioners like me they can access. It can be a new development for them, and they might want to see me as a mental health practitioner and a non-medical prescriber rather than a GP. The feedback generally is that people have really appreciated the opportunity to come and be awoken to what services are out there. It’s exciting and I do hope other PCNs can really embrace it, and other mental health professionals also see this as part of their role too.


SMI Health Check Programme Manager Stuart Hall is supporting PCN teams to implement POCT, tailored to their individual population's requirements. He emphasised the importance of discovery work as a key success metric at the start of the project.

Stuart said:

It’s so important to take the time to understand what the problems are before finding the potential solutions to fix them. The original project looked at putting the POCT machines into secondary care and we undertook a small proof of value (POV) test to see how this would work. Alongside, we made the initiative PCN-driven and supported teams to decide how to successfully use the machine within their respective practices. What we found was when we put a POCT device into a PCN, it created an opportunity for a one stop shop for people. They could get their results in 10 minutes, allowing professionals to not just screen but intervene without the patient having to wait for the results from a lab.

Stuart highlighted the vital role of teamwork across the city region and the importance of clinical leadership and communication to embedding new practice within PCNs.

GP Dr Saif Ahmed is HInM Clinical Lead for Digital Transformation and Senior Responsible Officer (SRO) for the SMI Health Check Programme.

He explained how, alongside overall uptake, a variation in access to POCT among PCNs was a key driver for seeking national funding for extra devices from NHS England.

By doing these checks, we’re able to pick up any issues earlier and stop chronic conditions from progressing. This has such a big impact for people and for services. Before we started, POCT was fairly sporadic. We wanted to get kits to all PCNs so, from the ground up, they could start to use POCT. It’s been interesting to see the different models created and we’ve evaluated how each of them has worked.

"Some PCNs have moved POCT from practice to practice. Other have nominated a practice to invite patients from the PCN in. We’ve really seen benefits from the DAD PCN clinic because it’s more holistic for patients and it brings them into a community setting."

GP Dr Saif Ahmed

Tools and technology

POCT technology is defined as any medical device or system that enables diagnosis, monitoring or screening of patients at the time and place of care by appropriately trained users.

Almost a third of Greater Manchester’s PCNs, 21 of 66, are now using POCT with further roll-out planned.

Health and wellbeing practitioners like Sarah Bonnie use an Afinion device to carry out vital blood tests alongside other physical health checks like height and weight measurements.

Sarah, one of the DAD PCN team, said:

It’s very important to ensure people get their annual physical check and that we can look at their medication and overall health and wellbeing, to give them any advice and support they need. Before we got the machine, we would do home visits or offer clinics to carry out intravenous blood tests. Then the patient would have to contact their GP practice, or the GP would contact them, for the results at a later date. We’re using the machine for several clinics so it’s not just helping people living with SMI, but with conditions like hypertension for example.

"I think POCT really helps to reduce anxiety, especially as it’s a finger prick test and not intravenous. People seem happy that they get the results there and then and are reassured on the day, or if there is something wrong, they get information and advice straight away."

Health and wellbeing practitioners like Sarah Bonnie

Saif said:

POCT has helped us to think differently about our Greater Manchester integrated care record and how we can enable PCNs and GPs to work better together. We are launching an SMI dashboard to help PCNs, so at one stop clinics like DAD the healthcare professional can use their smart card to access one patient list for the PCN rather than log into different GP lists. It will help avoid duplication and repeated tests while supporting economies of scale.


The city region is driving a shared learning culture where local health and care teams feel enabled to use innovations like POCT in ways they feel work best for individual communities.

Every area is different, and this is very much about getting practices at the start of the journey to feel their own way as a ground-up approach, rather than putting a mandated model upon them. The idea is to harness those ways of working and models of care and use evidence-based shared learning across Greater Manchester.

Heather said:

It’s important that if we get projects that are benefiting patients that we share that experience with others across PCNs in our region and nationally. We want to ensure the population gets equal access. DAD PCN’s approach is also indicative of a shift in thinking when it comes to traditional service design, with a move towards offering integrated, holistic care in settings not previously associated with physical and mental health services. We did COVID checks for people with learning disability in a sports hall and people said they felt safe there and wanted clinics in non-health related building's. People like the fact they don’t have to go to the GP practice and that the venues are easily accessible by public transport.

Ed said:

For me it’s about trying to break down the stigma about mental health, and for people to come to places like this and feel they will be taken seriously and there will be understanding and empathy, and to see mental illness on a par with physical illness. My feeling is that having the opportunity to come to something like this, if we make it as comfortable as possible and when you bring all these services into one place, it empowers people to make the changes they’ve been thinking about, like seeking help for drug and alcohol issues.


Vinny said:

We are continuing to see the development of PCN-based approaches towards SMI physical health checks which is starting to reduce unwarranted variation within localities. Initial indications are that there has been a big improvement in full health check uptake across GM since we launched the point of care testing project. Uptake amongst PCNs remains strong and to date four have come forward to say they have done at least 200 full SMI health checks using the POCT devices. The DAD one stop clinic has helped more than triple the percentage of people with SMI receiving their annual physical health check, from 19 percent in March 2021 to 70 percent in March 2023 within the PCN.

Vikas said:

Engagement has improved and the data we have had so far has shown us we have achieved what we wanted to in the first year. We are aspiring for all patients to have their checks and I’m really hoping this model is repeated.

Service user Ruby, who lives with an SMI and attended a recent DAD clinic, explained how she found the experience. Ruby said:

“It’s nice to know there is help out there. I think people should try and engage with things like this just for the possibility of a benefit and knowing there is someone there, that there is a lifeline for people to turn to and ask about things. You can probably gain benefits in ways you didn’t expect. The blood checks I had done were very quick and easy and the longest test result took seven minutes, so by the time I’d gone round and met everyone else, the medical practitioner could tell me that my bloods were fine and there was no risk of diabetes. That really puts you at ease.”

Service user, Ruby

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