The updated QOF indicators will help to improve the physical health of people with schizophrenia, bipolar disorder, or other psychoses, says Dr Caroline Dollery

General practice is the main portal through which patients with mental health disorders access healthcare; over 50% of people with severe mental health problems only receive medical attention via primary care.1 Patients in secondary care may experience gaps in monitoring of physical health because the requisite skills may be lacking in the team. Even within primary care, prevention screening, and treatment of co-morbidities is less effective compared with that in the general population because the focus can often be on the mental health aspect rather than any physical conditions, especially in a short consultation.

The NICE guidelines for bipolar disorder and schizophrenia highlight the high prevalence of co-morbidity associated with these illnesses, due to a combination of the effect of the illness on adherence to lifestyle advice and also to the medication itself.1–3 Metabolic syndrome has a high incidence in psychiatric illnesses and is indicated by central obesity, insulin resistance or glucose intolerance, dyslipidaemia, and raised blood pressure. This leads to a higher prevalence of cardiovascular disease (CVD)—in particular type 2 diabetes—and poorer outcomes because risk factors are not identified early on.3

Mental health in the QOF

The indicators for mental health are grouped into the categories of records, ongoing management, and care planning (see Table 1). The rationale behind the QOF targets relate to:4

  • identification of at-risk patients
  • use of a series of targeted interventions to increase both screening and treatment of risk factors associated with mental health conditions.

Additional features in the 2011/12 QOF that need to be taken into account include:4

  • acknowledging that patients can be in remission, and can therefore be excluded from the register. Advice is given on how to identify this cohort, but practices need to demonstrate a systematic approach with supporting evidence on why patients have been coded as ‘in remission’
  • a list of what features could be included in a care plan, allowing practices to design templates and identify resources to complete the process. There remains a requirement for assertive follow up for people who do not attend appointments
  • greater detail on the physical health checks required, thereby allowing practices to interrelate templates with other QOF areas (e.g. hypertension, hyperlipidaemia, body mass index), and reducing duplication of work
  • measurement of alcohol consumption (but not drug misuse), which should trigger brief interventions
  • specific monitoring of cervical screening
  • organisational indicators for mental health (e.g. significant event audits, assessments for carers’ needs)
  • rescoring of lithium checks in preceding 4 months—a change to the previous QOF target of 6 months.

This article covers the evidence base, rationale, and requirements for each indicator. Careful planning and a systematic approach based on the register will significantly increase uptake of the QOF indicators. The cost to the health economy as a whole is significant if the physical health needs of patients with mental health illnesses are not identified and managed effectively.

Table 1: QOF indicators relating to mental health4
No. Indicator Amendments Points Payment stages
MH8 The practice can produce a register of people with schizophrenia, bipolar disorder, and other psychoses   4  
Ongoing management
  MH11 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of alcohol consumption in the preceding 15 months MH11 replaces MH9 4 40–90%
  MH12 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of BMI in the preceding 15 months MH12 replaces MH9 4 40–90%
  MH13 The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood pressure in the preceding 15 months MH13 replaces MH9 4 40–90%
  MH14 The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of total cholesterol:hdl ratio in the preceding 15 months MH14 replaces MH9 5 40–80%
  MH15 The percentage of patients aged 40 years and over with schizophrenia, bipolar affective disorder, and other psychoses who have a record of blood glucose in the preceding 15 months MH15 replaces MH9 5 40–80%
  MH16 The percentage of patients (aged from 25 to 64 years in England and Northern Ireland, from 20 to 60 years in Scotland and from 20 to 64 years in Wales) with schizophrenia, bipolar affective disorder, and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years MH16 replaces MH9 5 40–80%
  MH17 The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months MH17 replaces MH4 1 40–90%
  MH18 The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range in the preceding 4 months MH18 replaces MH5 2 40–90%
  MH10 The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family, and/or carers as appropriate MH10 replaces MH6 6 25–50%
BMI=body mass index; hdl=high density lipoprotein; TSH=thyroid-stimulating hormone


Sensibly, regular follow up is not a part of maintaining the register of people with mental health disorders, reflecting the large variation in individual need relating to these diagnoses. In addition, remission has now been acknowledged. Making an accurate diagnosis of remission can be challenging and is often based on clinical judgment. A recent longitudinal study of recovery from psychotic symptoms found that 56% of patients recovered from psychotic illness to some extent, but this value drops to 16% if a more stringent definition of recovery is applied.5

In the absence of strong evidence of what constitutes remission from serious mental illness, clinicians should only consider using remission codes if the person has been in remission for at least 5 years based on no:4

  • record of antipsychotic medication
  • mental health inpatient episodes
  • secondary or community mental health follow up for at least 5 years.

Practices can code people as in remission from 1 April 2011, but must retain them on the register in case of relapse; these patients are excluded from indicators MH10 to MH18. Clearly, cases need to be reviewed annually and altered should a patient relapse. It must be a clinician who assesses and records this information and there should be a practice protocol to support this decision—verification will include a sample of patients recorded as in remission and justification if the decision is based on the above criteria.

Alcohol consumption—MH 11

There is a significant amount of evidence demonstrating the high incidence of alcohol and other substance misuse in schizophrenia and bipolar affective disorder.6–9 Clearly, this has a significant clinical and social impact. Brief interventions for alcohol have been demonstrated to be effective in primary care,10 but direct involvement of alcohol services may be required for complex cases. There is no requirement to either demonstrate the intervention used, which would be useful, or the outcome, but regardless this indicator should provide us with better data on prevalence rates of alcohol use in this population.

Cardiovascular risk factors

In addition to the escalation of cardiovascular (CV) risk factors in the general population, individuals with psychosis are at higher risk due to a number of factors including:11–13

  • more sedentary lifestyle
  • poor diet
  • smoking
  • use of antipsychotic medication, which causes raised cholesterol and increases the risk of metabolic syndrome (a predictor for type 2 diabetes and CVD).

People with schizophrenia have a mortality rate that is two-to-three times higher compared with the general population, which relates to the development of long-term conditions such as CVD, chronic obstructive pulmonary disease (COPD), and diabetes.3,14 A recent prospective record-linkage study in a cohort of 370 people with schizophrenia found that the increased mortality risk is probably lifelong, and that CV mortality has increased over the past 25 years compared with individuals who do not have a mental health condition.14

The NICE guidance on bipolar disorder states that the standard mortality ratio for CV death is twice that of the general population, but this value decreases with adherence to long-term medication.2 There may be a need to target patients who do not attend for normal medication reviews.

Indicators MH12–MH15 will lead to increased uptake of screening for CV and diabetic risk factors, although there is no measure of outcome or the intervention, bar a year-on-year measurement.

Body mass index—MH12
Approximately 40% of patients with schizophrenia are obese13 and this co-morbidity is also common in individuals with bipolar disorder.15,16

Blood pressure—MH13
Prevalence of hypertension is in the order of 19% and 35% for people with schizophrenia or bipolar disorder, respectively, compared with 15% in the general population.3,13–15

Studies suggest that patients with psychosis are far less likely to be screened than those presenting in primary care with other long-term conditions, such as asthma, diabetes, cardiovascular disease and COPD.17

Total cholesterol:hdl ratio—MH14
Patients with bipolar disorder or schizophrenia have a much higher prevalence (23% and 15%, respectively) of hyperlipidaemia compared with the general population.3,18 When added to other lifestyle and medication risk factors, this leads to a two-to-three fold increase in mortality from CVD and diabetes.3,14,16,18

Measurement of blood glucose—MH15
The prevalence of diabetes in people with bipolar disorder has been observed to be 17%.3 The relative risk of developing this condition is two-to-three times higher in people with schizophrenia compared with the general population.18 As there is no evidence to support measurement of blood glucose at all ages, the NICE QOF Committee recommended that this is performed in individuals aged 40 years and over.4 The glucose test can be either random or fasting. This indicator is intended to act as a case-finding one: if the patient is known to have diabetes, they should be excluded from the indicator and treated according to the diabetes indicator set.

Cervical screening—MH16
Women with schizophrenia (aged 25–64 years in England and Northern Ireland, aged 20–60 years in Scotland, and aged 20–64 years in Wales) are less likely than the general population to have had a cervical screening test (63% uptake versus 73%).4,19 This trend does not apply to patients with bipolar disorder, perhaps reflecting an attitude towards women with schizophrenia. This indicator provides a focus for a vulnerable group of individuals, which are, through their illness, potentially at risk of developing cervical cancer.

It will be interesting to see the long-term impact of the childhood vaccination programme on these figures.

Lithium therapy and monitoring—MH17

Serum creatinine and thyroid-stimulating hormone
Overt hypothyroidism has been observed in between 8% and 15% of people receiving lithium.3,13,20 Hypercalcaemia and abnormal renal function are also much higher. The NICE guidance on bipolar disorder recommends 6-monthly checks of thyroid function, together with thyroid antibodies, if clinically indicated, in addition to 6-monthly renal checks, or more frequently, if renal function is affected.2

A number of approaches might be taken to verify uptake of this indicator, including review of a:4

  • computer search to provide information on this indicator
  • sample of patient records to determine the proportion of individuals taking lithium therapy who have had their thyroid-stimulating hormone (TSH) and creatinine recorded in the previous 9 months
  • sample of patient records to confirm that there is evidence to support any claims (e.g. documentation of serum creatinine, TSH and thyroxine in previous 9 months).

Lithium levels
Lithium has a narrow therapeutic range, with a high risk of toxicity from intercurrent illness, declining renal function, or co-prescribing of drugs (e.g. thiazide diuretics or non-steroidal anti-inflammatory drugs), which reduce lithium excretion. As a consequence, particular care is required in elderly patients. The National Patient Safety Agency demonstrated that wrong or unclear dose/strength, as well as monitoring were key issues for adverse effects of lithium therapy.20,21 The NICE guideline on bipolar disorder states that prescribers of lithium treatment should monitor:2

  • all patients every 3 months for lithium levels
  • older adults carefully for symptoms of lithium toxicity, particularly as they may develop elevated levels, even in the normal dosage range, and toxicity is possible at moderate serum lithium levels. Generally, laboratories prefer to know the brand of lithium prescribed, and advice should be sought on the timing of blood tests to obtain an accurate reading.

The aim of lithium treatment is to achieve levels between 0.6 and 0.8 mmol/L for first-time recipients of therapy; if they relapse at this level, or have sub-threshold symptoms, the range can be extended to between 0.8 and 1 mmol/L for a 6-month trial, and the PCT will accept this.4 The practice is responsible for ensuring that the patient has 6-monthly tests for lithium, even if it does not organise them; and for chasing defaulters.

Care plans—MH10

The QOF indicator on the use of comprehensive care plans supports good practice as recommended by NICE guidance.1,2,4 Over 50% of all people who have a serious mental illness are seen only in a primary care setting and it is therefore important that a clear care plan is documented, especially if a relapse has occurred.1 The plan should be accurate, easy to understand, reviewed annually, and discussed with the patient.4 Where appropriate, it should be agreed with patients and families and carers. If patients are under a care programme approach (CPA), a documented CPA plan is acceptable for QOF requirements.4 Suggested content is shown in Table 2.

If a relapse occurs, it is important to restart the CPA and provide appropriate documentation. A care plan that was put into place prior to a relapse will not be acceptable.4

Table 2: Recommended content of care plans for people with mental health conditions4
  Care planning requirements 2011/12 Comment on rationale
  Current health status, social care needs, patients’ expectations and how they are to be met
2 Social support available: friends, family, third sector, social network Many people with serious mental health problems have a very limited social network, often only with health agencies involved in care. This is made worse if they are unemployed22,24
3 Employment status People with serious mental illness have the lowest employment rate in England, of 24%.22,23 In addition, if employed they only earn two-thirds of the national hourly rate; 90% wish to return to work24
4 Clarity on coordination with secondary care services or other agencies involved, and what services are being received
5 Early warning signs (of a relapse) Documented opinions of patient, family/carers, as well as healthcare professionals, and steps to be taken25,26
6 Patient's preferred course of action in the event of a relapse (discussed when the patient is well), who to contact and wishes around medication

Other considerations

It can be very difficult to resolve the financial and social situations of many patients, without proper signposting to third-sector services such as the Citizens Advice Bureau. Additionally, some patients, because of their illness, find it hard to start a process of working with other agencies and refuse to attend meetings. Recording the outcomes of discussions with these patients would be good practice.

Future QOF indicators

It would be helpful for future QOF guidance to link indicators to outcomes, for example, if blood glucose level is raised, has the patient been referred for diabetic support and has control been achieved? This feature would require association with other QOF indicators as part of the verification process.

It is surprising that substance misuse is not included as part of the QOF given the known high prevalence within patients with mental health illness, and its impact on success of treatment.


A methodical approach to managing patients with serious mental illness, based around good-quality evidence, supports reduction in harm, both physical and mental, to patients, families, and carers. The clarification of physical health risks is to be welcomed, given the well-documented incidence of long-term conditions in patients with mental health illnesses, and the consequent and significant burden of ill health and costs to the health economy as a whole. Although, implementation of the cervical screening will prove challenging, it is well supported by evidence as a cohort of this patient group is at high risk of cervical cancer.

  • Although GP commissioners will not be directly responsible for commissioning services that they themselves provide, they will have a duty to work with the NHS Commissioning Board to improve quality
  • Thus commissioners could look to agree standards for mental health reviews and care plans as described in the article
  • Mental health services will be included in the PbR tariff from April 2012 so effective primary care management will become important as both a financial and a clinical driver for commissioners
  • Effective interventions to manage co-morbidities or risk factors in people with mental health disorders is likely to reduce demands on other budgets such as hospital referral and future prescribing
  • Commissioners will need to carry a rapid review of the way they contract for mental health services when the new tariff and PbR guidance is published.

PbR=payment by results

  1. National Institute for Health and Care Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. Clinical Guideline 82. London: NICE, 2009. Available at: nhs_accreditation
  2. National Collaborating Centre for Mental Health. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. London: British Psychological Society, 2006. Available at:
  3. Kilbourne A, Cornelius J, Han X et al. Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord 2004; 6 (5): 368–373.
  4. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at:
  5. Harrison G, Hopper K, Craig T et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br J Psych 2001; 178: 506–517.
  6. Banerjee S, Clancy C, Crome I, editors. Co-existing problems of mental disorder and substance misuse (dual diagnosis): an information manual. Final report to the Department of Health. London: Royal College of Psychiatrists' Research and Training Unit, 2001.
  7. Meltzer H, Gill B, Pettigrew M et al. OPCS survey of psychiatric morbidity in Great Britain. Report 3: economic activity and social functioning of adults with psychiatric disorders. London: HMSO, 1996.
  8. Farrell M, Howes S, Taylor C et al. Substance misuse and psychiatric comorbidity: an overview of the OPCS National Psychiatric Morbidity Survey. Addict Behav 1998; 23 (6): 909–918.
  9. Kessler R, Rubinow D, Holmes C et al. The epidemiology of DSM-III-R bipolar I disorder in a general population survey. Psychol Med 1997; 27 (5): 1079–1089.
  10. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. London: NICE, 2011. Available at: nhs_accreditation
  11. Heiskanen T, Niskanen L, Lyytikainen R et al. Metabolic syndrome in patients with schizophrenia. J Clin Psychiatry 2003; 64 (5): 575–579.
  12. McCreadie R, MacDonald E, Blacklock C et al. Dietary intake of schizophrenic patients in Nithsdale, Scotland: case-control study. BMJ 1998; 317 (7161): 784–785.
  13. Mackin P, Bishop D, Watkinson H et al. Metabolic disease and cardiovascular risk in people treated with antipsychotics in the community. Br J Psych 2007; 191: 23–29.
  14. Brown S, Kim M, Mitchell C et al. 25 year mortality of a community cohort with schizophrenia. Br J Psychiatry 2010; 196 (2): 116–121.
  15. Hennekens C, Hennekens A, Hollar D, Casey D. Schizophrenia and increased risks of cardiovascular disease. Am Heart J 2005; 150 (6): 1115–1121.
  16. Elmsie J, Silverstone J, Mann J et al. Prevalence of overweight and obesity in bipolar patients. J Clin Psychiatry 2000; 61 (3): 179–184.
  17. Roberts L, Roalfe A, Wilson S et al. Physical health care of patients with schizophrenia in primary care: a comparative study. Fam Pract 2007; 24 (1): 34–40.
  18. Oud M, Meyboom-de Jong B. Somatic diseases in patients with schizophrenia in general practice: their prevalence and health care. BMC Fam Pract 2009; 10: 32.
  19. Hippisley-Cox J, Pringle M. Health inequalities experienced by people with schizophrenia and manic depression: analysis of general practice data in England and Wales. Nottingham: QRESEARCH, 2005.
  20. Prescribing Observatory for Mental Health. Topic 7 baseline report. Monitoring of patient prescribed lithium: baseline. POMH, 2009.
  21. National Patient Safety Agency. Patient safety alert 005. Safer lithium therapy. NPSA, 2005. Available at:
  22. Office for National Statistics. Labour force survey, autumn 2003. Available at:
  23. Black C. Dame Carol Black's review of the health of Britain's working age population. Working for a healthier tomorrow. Presented to the Secretary of State for Health and the Secretary of State for work and Pensions. London: The Stationery Office, 2008.
  24. Grove B, Drurie S. Social firms: an instrument for social and economic inclusion. Redhill, Social Firms, 1999.
  25. Birchwood M, Spencer E, McGovern D. Schizophrenia: early warning signs. Adv Psych Treat 2000; 6: 93–101.
  26. Birchwood M, Spencer E. Early-intervention in psychotic relapse. Clin Psychol Rev 2001; 21 (8): 1211–1226. G