Advice for PHCTs to complete the Mental Health Quality & Outcomes Framework (QoF)

MH 1: The Practice can produce a register of people with severe long term mental health problems who require and have agreed to regular follow up

When developing a register, it is important to understand the underlying reason and to ensure that it is fit for purpose. The rubric associated with MH2 explains very clearly that registers provide the opportunity to improve the physical health of people with a severe and enduring mental illness. If in doubt as to whom to include, those who have significant physical health needs associated with their severe and enduring mental illness.

Who should be on the Register?

The list of different groups of vulnerable people is not specified, and is left to the discretion of each practice. However, as a minimum it is recommended that people with a psychotic illness (those with schizophrenia and bi-polar affective disorder) are included in the register. This is also likely to include those who are receiving Enhanced Care Programme Approach care packages from the Specialist Mental Health provider. The evidence base for the physical health needs of people with schizophrenia and bi-polar affective disorder is extensive and well developed (see appendix).

It may well be that there are individuals on your practice list who have significant physical health needs as a consequence of their mental health problems, irrespective of their diagnostic label; you may chose to offer this quality level of care to those particular individuals as well.

The evidence is also strong (see appendix) that at least 25%, and in some places as high as 50%, of patients with a severe mental illness are not in contact with a specialist mental health services. The opportunity to offer these people a structured review of their physical health needs and medication review, will often identify unmet social or psychiatric needs. Informal discussions with the local mental health team will often be valuable, as it will provide a route for appropriate referrals to address these previously unmet needs.

It is important to realise that quite separate guidance for Community Mental Health Teams (Policy Implementation Guide), expects them to receive this sort of referral from primary care, and that helping primary care practices to provide this sort of care, is very much part of the care that they should be providing. This provides a route for improved working between the Community Mental Health Team, and the practice.

Practices should be able to describe which individuals have been included on the register and why.

The form of words used might be:

“The practice will include all those with a psychotic illness, as there is good evidence that they will have significant physical health needs. Other patients may also be included on a case by case basis, as they will have significant physical health needs as a consequence of their mental health problems”

The preferred coding for people who are on the register is 9H8

Who shouldn’t be on the Register?

The GMS contract allows for individuals who refuse care that is offered, to be excluded from target calculations.

The patient needs to make “an informed choice” that they do not wish to receive the care that is being offered. There may be some very good reasons why the care is refused – for example, the patient may be working full time, and cannot get to the surgery at a time that is mutually convenient.

Care must be taken to make an assessment on a case by case basis, that the refusal to accept treatment, is a properly informed choice, based on the correct information, and not as a consequence of inappropriate beliefs or ideas made as a result of the illness itself. This highly sensitive issue must lie with the individual practice and requires careful thought; seeking advice and an opinion from specialists within the mental health services may be appropriate.

To comply with the current advice on exception reporting, you will need to keep a record of those individuals who have declined care.

The preferred coding for people who decline to be on the register is 9H7.

How to Compile a Register?  

There is evidence (Kendrick) that suggest a four staged process will produce a register with over 97% accuracy. The four stages are

1) Search practice computer system by diagnosis:

• For those groups of conditions that are included in the register (see above) it is recommended that the Eu[x] codes are used. The reason to use these specific codes is that they map accurately to the ICD10 codes used by mental health trusts. As and when the specialist mental health providers are able to offer electronic links with primary care, using the same coding system will allow more accurate transfer of information.
  1. Schizophrenia Eu20.0
  2. Bi-polar disorder Eu31.0
• Searching at this level will encompass other more specific sub-types of psychotic disorder included lower down the hierarchical tree, for example it will include persistent delusional disorder coded as Eu22.0
• Those patients identified should have their records “tagged” with the code 9H8 (mental health register) to allow for swifter searching at a later date.
• Those individuals who have declined to be offered this service, should have their records tagged with 9H7 (declined to go on the mental health register), and it would be helpful to include on their record the reason that care has been declined. It is very likely that this will be a very small number of individuals.

2) Search the practice computer system for prescribed psychotropic medication. In particular search for BNF categories 4.2 which includes depot phenothiazine preparations, preparations used in bi-polar disorder such as lithium, typical and atypical anti-psychotic medication. The list that is generated needs to be compared to the list obtained in step 1 above, and individual patient records who appear in the therapeutic search, but not in the diagnostic search scrutinised to identify why; it may be that a diagnostic coding has been missed, or that a medication included in the therapeutic search is being used for another clinical indication. As a result of this second stage searching, the register created in Step 1 can be refined.

3) Ask the PHCT: There is a definite value in asking all member of the PHCT, if they believe that there are individuals whom they think have specific physical health needs as a consequence of their mental illness. It is this stage that allows the practice to include specific individuals who fall outside the broad diagnostic groups that will form the bulk of the register. Whilst you should ask the clinicians within the PHCT, both nurses and doctors, there is often a value in asking the receptionists, as their perception and knowledge is often both illuminating and underestimated! Again if the practice has a policy (see above) on whom should be included in their register, such extra patients who are identified in this step, should have their records appropriately tagged electronically.

4) Ask the Community Mental Health Team: It is valuable to compare the list of individuals on your list, with a similar list that the CMHT holds. The value lies not only in ensuring that the list is accurate, but it also promotes understanding of the issues in primary care that impact on specialist mental health services. As described above, it is likely that there will be considerably more people on the primary care register, than on the specialist CMHT register, but particularly in deprived inner city areas with high patient mobility, there may well be individuals that the CMHT know, who are unknown to primary care.

These four steps will provide two lists, the first tagged with 9H8 are those who wish to be included in the register, and will be offered proactive structured care.

The second list tagged with 9H7, are those few individuals who have declined to accept the proactive care that is being offered.

The two lists should be run every three months to identify those who need to be actively recalled for their review – see below for what a review might contain.

New patients, when registering, should have their clinical records reviewed, and where appropriate their names added to the register. This will ensure that the record remains both up to date and accurate.

MH2: The percentage of patients with severe long term mental health problems, with a review recorded in the preceding 15 months. This review includes a check on the accuracy of the prescribed medication, a review of the physical health and a review of the co-ordination arrangements with secondary care

What is involved in a medication review?

1. A review of what medication is intended to be prescribed, by the practice, and by the mental health team, if they are under the care of the specialist mental health provider.
2. A review of what the patient is actually taking
3. A review of what other medication may be being prescribed for other disorders by other professionals
4. A review of what “over the counter” medication is being taken, if any
5. An assessment of any potential conflicts, side effects and interactions
6. An assessment of the level of concordance with prescribed medication
7. Providing information on the benefits and risks associated with prescribed medication, and the effects of sudden cessation of treatment
8. It is considered good practice to offer referral to a specialist mental health team/psychiatrist if a patient has not had their medication regime reviewed in the last five years

What is involved in a review of physical health needs?

The interventions that need to be undertaken can be deduced from the evidence base.

1. Standardised Mortality Rate (SMR) for cardiovascular disease in people with schizophrenia and bi-polar disorder is in the order of 400. An assessment of the cardiovascular system is therefore necessary – checking the BP and reviewing the history is appropriate
2. Standardised Mortality Rate (SMR) for respiratory disease in people with schizophrenia and bi-polar disorder is in the order of 400. An assessment of the respiratory system is therefore necessary – checking the peak flow rate, and reviewing the history is appropriate
3. 90% of people with schizophrenia smoke, whereas about 30% of people with bi-polar disorder smoke. Enquiring about the smoking habits is therefore appropriate, and consideration of smoking cessation interventions discussed with the patient is appropriate.
4. Diabetes Mellitus is about five times as common in people with schizophrenia and bi-polar disorder. A review of symptoms related to depression, and either urine analysis or fasting blood glucose is appropriate, as well as measuring the BMI.
5. Alcohol and substance misuse is increased in people with schizophrenia and bipolar disorder. The rate varies considerably in published studies from 10% - 70% of patients. Nevertheless, it is appropriate to enquire about alcohol and substance misuse, and consider referral to a drug and/or alcohol team if considered appropriate.
6. A review of cervical cytology in line with current guidance. Although people with schizophrenia and bipolar disorder are not more at risk than other groups, they must not be excluded from being offered screening because of their mental illness.
7. HIV has been shown to be eight times more common, and Hepatitis C fifteen more times common in people with schizophrenia and bi-polar disorder. The studies are however unique to the East Coast of America, and have not been replicated in the UK. The practice should therefore take a considered view as to whether it may be appropriate to assess the HIV or Hepatitis C status of any individual on the register.
8. Offer protection against influenza. Considering the significant morbidity of people with schizophrenia and bi-polar disorder, the practice may wish to review their policy of whom is included in the “at risk” categories that are offered protection against influenza. It should be noted that the current DH guidance does not include people with schizophrenia and bi-polar disorder.

The clinician undertaking the review should also enquire about the development of any new physical symptoms or signs, including weight loss.

What is involved in a review of co-ordination arrangements with specialist mental health services?

For those patients who are on the register, but not in contact with the specialist mental health services (usually around 25% – 30%), the review is an opportunity to consider if referral is now appropriate. The patient should be fully included in any decision to refer on to specialist services. Such a patient might be one that has recently joined the practice, and this is their first review.

For those patients already in contact with the specialist mental health services the following data should be recorded:

1. Name of key worker: every person in contact with the specialist mental health services will be on either standard or enhanced care programme approach. As part of this care, there will be an assigned “key worker” who is responsible for co-ordinating all aspects of care from within specialist mental health services and for co-ordinating with external organisations including primary care. Their name should be recorded, as well as contact details both in and outside of office hours. The key worker may come from a number of possible professions including CPNs, OTs, or the psychiatrist.
2. Contact details for the mental health trust, both in office hours and outside of office hours, as well as who to contact, and what to do, in emergencies.
3. The name of the carer, if the patient has a named carer, together with their contact details.

The following three indicators all relate to the management of patients who are taking lithium.

MH 3: The percentage of patients on lithium therapy with a record of lithium levels checked in the last six months

Patients who are maintained on lithium salts should have their renal function, calcium levels and thyroid function tested every six months.

The preferred coding is 44W8%

MH 4: The percentage of patients on lithium therapy with a record of serum Creatinine and TSH in the preceding 15 months

This demonstrates that patients who are taking lithium have had the appropriate blood tests to ensure that they have not developed any side effects of their medication

The preferred coding is:

Thyroid function tests: 442%
Serum Creatinine: 44J3%

MH5: The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the last six months

This demonstrates that the results of the blood tests are influencing care, and that the prescribing physician is appropriately monitoring the effects of the medication

The preferred coding for the lithium level is: numeric value

n.b. the therapeutic range will be advised by the path lab undertaking the assay.