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.’