How to maximise QOF depression points
Dr John Hague passes on some tips on how to gain points and have more fulfilling consultations
Recent Government statistics highlighted that depression is the area of the QOF where GPs are dropping the most points. GPs in England scored 80.8% of available points, Wales was lower at 73.9%, and in Scotland and Northern Ireland, GPs did better. That is still a good performance – but in every other QOF area, practices scored higher. But it is possible to gain more points and, in the process, enjoy the consultations more. Meeting the QOF requirements in depression can actually enhance your practice.
The crucial third question
Screening those on the diabetes or CHD register for depression – using the standard two questions – can often be a lifesaver, as treating those with depression and diabetes improves glycaemic control. In CHD a trial published in January showed a 42% drop in death or recurrent MI in a sub group of those with CHD and depression, when they were treated with an SSRI.
So, if it makes sound clinical sense, why do we find it so difficult? It can feel artificial to bring up the screening questions. One way we prepare our patients is to give everyone with CHD a leaflet about the care that they can expect, which includes a paragraph explaining about depression screening – so it does not come as a surprise to them.
Our leaflet says: ‘Up to a third of people who have a heart attack will develop depression, so you may be asked questions to see if this is the case – it is important that you are able to live as full a life as possible, and detecting and treating depression will help you to do this.'
Adding a third question to the two questions, by asking: ‘Is this something with which you would like help?' increases the negative predictive value to 94%, meaning that a no to this question (as opposed to yes, or yes but not today) essentially means that the patient is not depressed. If they score positively, then you or your nurse in the clinic just move straight to using a depression rating scale. And, of course, you won't forget to record the result on the computer.
In the past few years I have had the privilege to meet many prominent figures in mental health in this country. One thing that stands out is how many of them find psychological rating scales genuinely helpful in their day-to-day practice. They may have started using them for data collection during clinical trials but they have now become routine in their practice.
In contrast I know many in primary care find scales intrusive and difficult to use.
I think that this is best compared with taking a sexual history – something that we all found difficult at first, but got better at over time.
The first step is to have a supply of scales in every room, properly printed, not a poor photocopy. Second, become comfortable with a form of words that is non-intrusive in a consultation, such as ‘please would you fill this in while I type up your notes, as it will help me to decide what treatment we need to discuss next'. Next, give the patient the form to fill in, in the room in front of you, not later in the waiting room or at home. While they are finishing you can add the score up, and enter the score on the computer immediately the last question is completed – job done.
The next trick is to get used to using the scores in your clinical practice. Patients with ‘normal scores' below the diagnostic threshold may be simply unhappy, or upset, and can often benefit from similar advice to those with mild depression. Patients with mild depression do not generally benefit from antidepressants, and are best helped by practical assistance with any life problems that they have – for example, simple advice on sleep, exercise, caffeine and so on, and a period of watchful waiting. They could also look at a CBT-based self-help book, or a computerised CBT programme or website (see page 42). Only consider drugs if they fail to respond to these steps.
Moderate and severe depression benefit best from immediately starting an antidepressant, as well as the self-help advice for mild depression. People suffering with severe depression or those with suicidal ideation need close monitoring, and referral needs to be carefully considered. You should also use the scores to monitor response to treatment, and to guide your follow-up decisions. If talking treatments such as CBT are available, you can use them when you would use an antidepressant.
A rational practice
Looking at the depression indicators as an integral, logical, professional, normal practice gives them a meaning beyond ‘box ticking', which they coincidentally allow you to achieve. I had used rating scales routinely in practice for several years before the QOF was introduced, and we had a local enhanced service in Ipswich using scales before the depression indicators were introduced.
Having the courage of your convictions and allowing the score to guide your actions works a treat. It gives you a logical plan to follow, which your patients can understand too. We would not dream of managing diabetes without knowing a patient's HbA1c, and the scores are exactly the same.
Dr John Hague is a GP in Ipswich and mental health adviser to Suffolk PCT
Competing interests Dr Hague recently received fees from Wyeth and Pulse for lectures and sits on the expert reference group of the IAPT programme