At the State Hospital in Carstairs, more than 70% of patients have a diagnosis of schizophrenia, 10% have learning difficulties and many have a history of substance misuse, poor nutrition and unhealthy lifestyles associated with deprivation and violence.
Dr Jill Murie said patients experience significant adverse effects from long-term antipsychotic and anti-epileptic medication, and, while some are allowed limited grounds access, most suffer from a lack of solar exposure aggravated by the use of sunscreen and clothing.
Four GPs provide primary care services to the patients from modern purpose-built premises within the hospital grounds. A practice nurse triages requests for appointments with GPs, which take place in routine surgeries three days per week.
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All patients are offered annual physical health assessment by self-report questionnaire, routine blood tests and physical examination, and every attempt is made to ensure that patients are provided services that are as conducive to 'normal' consultations as possible.
But the health centre's exclusively male patient population is at higher risk from cardiovascular disease, and comorbidity in schizophrenia accounts for 60% of premature deaths. More than 83% of patients are overweight or obese and 13% are diabetic.
Low vitamin D intake has been found to be associated with a doubling of the risk of death from cardiovascular disease, and hypovitaminosis D is also thought to aggravate depression, psychoses, convulsions and epilepsy.
Dr Murie, found that four out of five patients undergoing annual physical examination had hypocalcaemia and deficient or insufficient vitamin D, and three of these patients had secondary hyperparathyroidism.
Screening was clearly necessary but such a study could not be conducted without ethical approval because of barriers including consent issues, materials for people with learning difficulties and the exclusion of patients either too unwell or too violent to be screened.
Eventually, patients unable to consent for themselves, who are often the most vulnerable, were included under section 5 of the Adults with Incapacity (Scotland) Act 2000.
The study involved 33 patients (40% selected; 21% of population) and demonstrated severe deficiency in 58% of patients and insufficiency in 36%, with only two patients presenting with vitamin D levels in the normal range.
Five patients with vitamin D deficiency had secondary hyperparathyroidism, two of whom had osteopenia on DXA.
Dr Murie said: 'Overwhelming evidence of vitamin D deficiency was demonstrated in individuals consenting to screening, and consideration is now given to vitamin D enriched diets, supplementation and improved access to adequate sunlight.'
Blithehale Health Centre, Tower Hamlets, London
This practice in a deprived area of east London started an after-school club to help improve health literacy levels.
Children from years 5 and 6 visit the surgery for an hour, once a week during term times, for sessions led by members of the healthcare team.
Topics include basic first aid, hygiene, food, family health and lifestyle, and have even inspired some of the children to consider a career in medicine!
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