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


People in Greater Manchester living with a severe mental illness (SMI) are increasingly accessing vital support thanks to grass-roots innovations by health and care teams across the city-region.

Life-changing work by teams in Greater Manchester’s 66 primary care networks (PCNs) features in a new national case study, which explores how to support people with an SMI to easily access important annual physical health checks.

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

The study focuses on the experiences of staff and service users at a ‘one stop shop’ monthly clinic in Denton, Audenshaw and Droylsden (DAD) PCN, where the percentage of its SMI population receiving annual checks has risen from 19 per cent in 2020 to 70 per cent in 2023.

The DAD team offer all the checks in the same appointment in a community setting, using a digitally-enabled innovation called point-of-care testing alongside other services including mental health, pharmacy, wellbeing and social prescribing support.

The aim is to harness every possible opportunity to support the attendee at the time of their appointment and into the future.

GP Dr Vinny Khunger, Clinical Lead at Health Innovation Manchester Academic Health Science Network (HInM AHSN), said:

“People living with severe mental illness often die earlier than the background population because of unmet physical healthcare needs like high blood pressure, undiagnosed diabetes or high cardiovascular risk.

“Initial indications suggest a big improvement in full health check uptake across Greater Manchester since we launched this project. We are continuing to see the development of PCN-based approaches that are starting to reduce unwarranted variation within localities.”

DAD service user Ruby said:

“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.”

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.

The case study has been released in partnership with the NHS National Innovation Collaborative for digital health, a learning and support network for health and care professionals across the country who are delivering local technology-enabled services to support people at home and in communities.

Explore this case study and hear from other contributors by clicking on the link here.

Health and care professionals are encouraged to join the Innovation Collaborative to access more inspirational case studies about local teams like those in Greater Manchester, alongside best practice, resources and shared learning.

To request to join visit:

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