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A faulty production line

Experts warn of 'troubling' cuts to QOF mental health indicators

GP experts in mental health have expressed their dismay at the decision to drop QOF indicators on cardiovascular and diabetes checks in patients with severe mental illness – changes agreed as part of the cutback in ‘box-ticking’ tasks for next year’s GP contract.

The GPs said the decision ‘sends the wrong signal’ and risks worsening the disparity in poor health outcomes experienced by this group of patients compared with the rest of the population.

The new contract will see over a third of QOF removed from April 2014 – including a large swathe of indicators in the clinical domain worth a total of 185 points.

Amongst these are three cardiometabolic indicators in the mental health domain, requiring yearly checks of weight and blood cholesterol and glucose levels in patients with severe mental illness.

The GPC said GPs should be trusted to use their clinical judgement as to when the checks are needed and the removal of these indicators would not be detrimental to patients’ care.

But in a statement on the Mental Health Partnerships portal, a group of doctors including Dr David Shiers, a retired GP from North Staffordshire, and Professor Carolyn Chew-Graham, RCGP curriculum guardian for mental health, both of whom are members of the National Collaborating Centre for Mental Health (NCCMH) board, said they were disappointed the indicators had been dropped given the importance of monitoring these patients for cardiometabolic changes, and concerned it would mean less attention being paid to severe mental health conditions.

Moreover, the experts said they were ‘puzzled’ by the move, as the Government has repeatedly stated its commitment to reducing premature mortality in this group of patients.

Dr Shiers, who is currently on the steering group for NICE guidance for adults with psychosis and schizophrenia, spoke to Pulse about the group’s concerns, stressing his and his colleagues’ views were independent of NICE and the NCCMH.

Dr Shiers said: ‘Removal of the indicators for cholesterol, glucose levels and weight in patients with severe mental illness is troubling – and has left us quite puzzled, as Government policy priority, repeatedly stated, has been about reducing premature mortality in this population, which is largely due to the increased burden of cardiovascular problems.

‘Cardiovascular disease is a bigger cause of premature death in this population than suicide. Also a lot of the weight gain, changes in glucose levels and lipids in these patients are a result of the antipsychotic medications, so as GPs it is vital to ensure we are not doing more harm than good with these treatments.’

He added: ‘We know from the latest national schizophrenia audit in England and Wales that most patients are still not undergoing adequate cardiometabolic screening. Furthermore there is evidence conditions excluded from the QOF tend to be relegated in importance.

‘So it could send a very dangerous signal and we don’t understand why this condition is being effectively demoted, when the problem hasn’t been solved.’

However GPC negotiator Dr Richard Vautrey, a GP in Leeds, told Pulse he believed the concerns were unfounded.

He said: ‘I don’t think that’s right – we need to move away from the assumption that because it’s no longer in QOF, GPs won’t do it.

‘Just because one person might benefit from an annual check it doesn’t mean every patient with a severe mental health problem or ischaemic heart disease will do – so we need to put more trust in GPs’ professionalism.’

Nonetheless, the removal of these indicators goes further than NICE had recommended.

In a specially commissioned review of how the clinical domain could be revised to cut GP workload, the NICE QOF advisory committee ruled the process checks in mental health were important ‘as they help to improve health inequalities for people with severe mental illness’ and concluded it was ‘important to retain all the indicators for mental health’.

Professor Tony Kendrick, professor of primary care at the University of Southampton and a member of the NICE advisory committee on QOF, told Pulse in his personal view the changes to the QOF seem largely in line with the NICE recommendations although he was disappointed with removal of the weight and glucose checks in patients with severe mental illness.

Speaking in a personal capacity, Professor Kendrick said: ‘The cholesterol checks do not need to be done annually, but I would be sorry to see MH005 and MH006 go – having the check for diabetes and weight is important in these patients. Firstly they don’t exercise much and they’re often overweight so they are at increased risk anyway.

‘And some of the newer antipsychotic medications are associated with an increased risk of developing diabetes – so personally I would have wanted these to remain.’

A spokesperson for NHS England said: ‘It is not intended that the retirement of indicators will reduce appropriate clinical workload. GPs will use their professional judgement to treat their patients according to best practice guidelines. The removal of the indicators will however, reduce bureaucracy, unnecessary patient testing and unnecessary frequency of patient recall and recording.’

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Readers' comments (8)

  • the problem with QOF is that it has been monopolised by "EXPERTS"...Those who cannot see the wood for the trees, who have an obsessional interest in 1-2 areas of medicine at the expense of everything else. Thank god, their voice has been drowned out.

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  • Maybe if psychiatric experts are so concerned regarding cardiovascular risk then the mental health teams and psychiatrists should be monitoring these patients. Not everything has to come to GPs to do - we are drowning at the bottom of the NHS ocean. Swamped by everything that no-one else in NHS wants to do. Prescibe , chase, monitor, refer , benefits notes, sick notes post op.

    Let us use clinical judgement, manage our patients appropriately, refer for episodes of care which are completed prior to patient coming back to GP.

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  • Mental health patients are known to die ten years sooner than other folk. It is a fact that many mental health medications cause an increase in weight, not helped by the fact that depression makes it hard for patients to motivate themselves into doing the simplest task.
    Mental health care providers only deal from the neck up, and all you get from a psychiatrist is a prescription for more medication.
    It time we have a mental health revolution and whilst the NHS say 'No health without mental health' it still needs to two doctors to care for one patient, one to deal from the neck up and the other from the neck down.

    Many GP's provide mental health patients with much better care than a psychiatrists who just hand out prescriptions, if one drug doesn't have an effect they just try the next in the BNF. there is no logic behind prescribing, buy the ICD10 and a BNF and anyone can be a psychiatrist!

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  • If only the mental health providers could get at least the "neck up" right!

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  • Vinci Ho

    I can see arguments from both sides . Atypical antipsychotics , for instance, is associated with Type 2 diabetes because of weight gain and these mental health patients are at high risk of cardiovascular and perhaps cerebrovascular diseases due to their life style factors.
    However , it is a struggle in general practice currently to catch up with these QOF points . The funding is not really enough to have dedicated manpower to chase up these patients.
    Yes. there is an argument for psychiatrist to do these checks during their reviews but again it is matter of resources. I slightly favour an 'adequately'( yes, what is adequately ?) funded locally enhanced service .......

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  • These psychiatric experts have nothing to fear.Their employment is secure.According to DSM V we're all mentally ill in some way.According to the modern justice system no one is culpable and if given the right treatment by these experts we're all cured.A SSRI and an anti-psychotic in the tap water for all of us

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  • I feel we should dispense with psychiatrists all together and have good quality GP's who draw rings around psychiatrists with many years experience under their belt.
    Patients are diagnosed using a multiple choice quiz, tick the right answers and no matter what the cause fo the mental illness, you have a diagnosis that fits all.
    Anyone can be a psychiatrist, buy a BNF and the ICD10 and you are to all intents and purposes a psychiatrist.
    The only thing the psychiatrist guarantees the patient is a prescription for medication and nearly all patients are taking the same small group of drugs!
    Nobody look at the cause which is where the help is really needed.
    If you have been abused all your life, anti depressants are not going to resolves that, if your wife has run off with the milkman and you are about to lose your house and family, anti-depressents will not help … but try telling a psychiatrist that!

    Some GP's may lack all the finite details of how the mind works, but they care, they listen, they make time and that is half the battle!

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  • There is a fundamental problem with the QUOF system in that it is supposed to represent " quality elements" and yet practices have become dependant on it for such a large amount of core funding.
    The removal of indicator should provoke a removal of activity , if only so every NHS manager who has ever said " your paid to do it, it's in quof" has to comission the service at a realistic price.
    If we continue the " we can't let the patients down" mentality we let our colleagues down.
    Fair and adequate funding for GP primary care please.

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