Scottish guidance


Achieving the indicators for mental health in the quality and outcomes framework (QOF) can do much to improve the health of individuals with severe mental illness. These patients are at risk of suicide, premature mortality and excess morbidity from cardiovascular, respiratory and infectious disease. They have complex physical, psychological and social needs and can benefit from a coordinated multiagency approach in the community.

Much of the evidence base for the indicators is derived from national recommendations for the organisation of care in the NSF,1 and guidelines on the management of schizophrenia,2 bipolar disorder 3 and depression.4 In practice, tackling these problems in a primary care setting may place considerable demands on practices that do not have the necessary skills or access to specialist mental health resources.

Mental health has been described as the most unattractive clinical domain, and the 41 points it offers may be considered disproportionate to the time and effort that practices need to invest to be effective in modifying risk factors and behaviours and in improving concordance with medication as well as quality of life. This attitude compounds the difficulties experienced by these individuals, who are already disadvantaged and stigmatised in our society.

In Lanark, we have endeavoured to overcome some of these barriers by adopting a shared-care approach with the community mental health team.

The register (MH 1)

The first seven points are allocated to the creation of a register for patients with severe mental illness (Table 1, below). The Blue Book’s supplementary guidance recognises that, unlike other clinical areas, no specific diagnostic labels have been recommended. Inclusion on the register is based on perceived need.

Table 1: Clinical indicators for mental health
indicator no
Clinical indicator Points Qualifier Preferred Read code Exception reporting and
suggested Read code
MH 1 A register of patients with severe long-term mental illness who require and have agreed to regular follow up 7   Register 9H8. Removed from register 9H7.  
MH 2 % patients with severe long-term mental illness with a review of accuracy of prescribed medication, physical health and coordination arrangements with secondary care 23 Recorded in preceding 15 months Review 6A6.
Medication review 8B3S
For patients on lithium
MH 3 % patients with lithium levels recorded 3 Measured in preceding 6 months Lithium level 44W8%   25-90%
MH 4 % patients with serum creatinine andTSH recorded 3 Measured in preceding 15 months Creatinine 44J3%
TSH 442W
MH 5 % patients with serum lithium in therapeutic range 5 Measured in preceding 6 months Numeric value   25-70%

As a result, practices and PCOs have interpreted inclusion and exclusion criteria in different ways. This has had implications for practice prevalence figures and, ultimately, income calculated using the prevalence factor formula.

The final prevalence figure for severe mental illness in the four UK countries is expected to be announced soon and is predicted to be around 0.85%. While perhaps a reasonable estimate for schizophrenia alone, this figure is low given the prevalence of major depressive disorder,5 obsessive compulsive disorder 6 and attention deficit hyperactivity disorder.7

In England, being on a standard or enhanced care programme approach package justifies inclusion on the register. In Scotland, the Scottish Executive has produced additional definitions based on functionality (Box 1, below).8

Box 1: Guidance on inclusion on register
""Severe long term mental health problems"”
  • Inclusion based on need
  • All patients with psychotic illness
  • Patients with long-term depression
  • Care programme patients, complex packages of care (multidisciplinary secondary care team)
Inclusions Plus some or all of these:
Patients with a diagnosis of:  
  • Schizophrenia
  • Schizoaffective disorder
  • Bipolar affective disorder
  • Recurrent and/or chronic depression
  • Phobic disorder
  • Chronic anxiety states (including panic disorder)
  • Eating disorders
  • Attention deficit disorders
  • Borderline personality disorders
  • Other chronic disabling mental illness
  • Substantial disability with need for support in daily living
  • Currently displaying obvious and severe symptoms or doing so recurrently or with frequent relapses
  • Requiring frequent intervention or admission
  • Significant risk to personal safety
  • Condition continuing or expected to continue for >1 year
  • Need for multi-agency support, i.e. more than one type of agency
No specific age range

Exclusions (unless there is co-morbidity)

  • Dementia
  • Learning disability
  • Alcohol or drug misuse

Consent and confidentiality

Consent to inclusion on the register has raised a lot of complex issues. Some practices have not sought consent. Indeed, contract guidance posted on the BMA website under the heading ‘Frequently Asked Contract Questions and Answers’ 9 states that consent is not mandatory because the register is electronic. Only consent to follow up is mandatory.

Similarly, disclosure of unidentifable information such as that required for contractual obligations does not require consent. However, according to ‘Fair Processing of Information’, in Scotland, data subjects must always, where possible, be informed that their data are being processed for this use to be legal.10

GMC guidance on confidentiality states that disclosure of identifiable information requires express consent if the information is being disclosed beyond those who need to know in the practice.11 However, in England, Section 60 of the Health and Social Care Act 2001 allows a wide range of NHS bodies access to confidential information. This does not apply in Scotland.

Individuals with mental health problems may hold beliefs that they are being watched and registered. If a patient does object to inclusion on a register you should explain why information is needed and how this may benefit his or her care. Checking awareness and understanding of information strengthens implied consent to disclosure and is empowering for the patient.

Our practice’s consent form was developed in conjunction with Clydesdale Resource Network,the local community mental health team (CMHT) (Box 2, below). One of the team, a community psychiatric nurse (CPN), key worker or social worker, seeks consent during a routine contact.

Box 2: Wording of the Lanark consent form
"I have had the joint working arrangements between the Clydesdale Resource Network and Woodstock Medical Practice explained to me. I give my informed consent to be included on a practice list which will allow my medication to be carefully monitored and reviewed to prevent side-effects and my personal needs to be assessed, where appropriate, to make sure I get the right treatment and care. As always, I understand that my identifiable information will not be passed to any other agency, department or team without my agreement.”

The consent form has been couched in language that demands a reasonably high reading age, and for individuals with learning disabilities the statement is explained and signed before a witness. Efforts will be made to make the form more user-friendly with greater use of ‘plain English’.

Although informed dissent raises important ethical issues, it should be respected unless it would put patients or others at risk of death or serious harm. Compulsory treatment is also highly controversial. In these situations, an individual’s carer should be involved. Refusal to involve the carer must be reviewed on an ongoing basis and recorded in the case-notes.

Annual review (MH 2)

The majority of the points available (23) are achieved by reviewing the individual’s prescribed medication and physical health and the coordination arrangements with secondary care. Our practice elected not to have a dedicated clinic, to avoid stigmatising these patients further. Instead, a shared-care approach with an agreed pathway was adopted (Figure 1, below) using a structured assessment form or protocol (Figure 2a and 2b, below).

Figure 1: The practice's shared-care pathway for patients with severe mental illness
Figure 2a: Front page of the structured assessment form
Figure 2b: Reverse of the structured assessment form

Once consent has been elicited, during a routine clinic appointment, a CPN documents all relevant personal details, including next of kin or carer. Patients are asked if they wish to make an advance directive to ensure that their wishes are respected in the event of a crisis.

Practice nurses, who are unfamiliar with dealing with disturbed or disruptive patients were, understandably, concerned about their personal safety. Consequently, in addition to suicide risk assessment, individuals are screened for potential aggression. Hospital admissions are quantified, and key contacts, principal diagnosis and related psychiatric morbidity are recorded.

Review of medication includes appropriateness, effective control of symptoms, adverse effects using the LUNSERS instrument (Liverpool University Neuroleptic Side Effect Rating Scale),12 drug interactions and level of concordance.

The shared-care approach involves examining the coordination arrangements with social work (suitable housing,employment status, benefits), occupational therapy and secondary care. Importantly, information and advice on self-help groups and voluntary agencies is provided.

Where possible, the CPN explores social interaction and the interface with families and carers. Then, with the patient present, the CPN phones the medical centre to arrange a half-hour appointment with the practice nurse for the annual review.

The knowledge and experience of the CPN has been invaluable in the review process.

At the annual review, the practice nurse screens patients for cardiovascular risk factors, respiratory disease, including peak flow measurement, and diabetes. Lifestyle factors, such as smoking, alcohol and substance misuse, poor diet, obesity and exercise, are discussed and advice is given. The patient’s inclusion on the flu register is confirmed.

Women’s health issues, including cervical cytology, are addressed where appropriate. Routine haematology and biochemistry, including lithium levels, thyroid function tests and cholesterol are performed where indicated.

Finally, the patient makes a routine appointment to see a GP. The GP’s role is to summarise the findings and take appropriate action regarding medication, referral and review interval.

While in terms of points our achievements in the first year have been modest, among those we screened we identified a high prevalence of cardiovascular risk factors, particularly hypercholesterolaemia, smoking and obesity.

Obesity was common in patients taking lithium. Some 60% of patients taking lithium are reported to gain weight, 25% of whom become obese.13 There was also evidence of the diabetogenic effects of olanzapine, which is well documented.14

We identified one man who had suffered a cerebrovascular event while taking risperidone. His pulse was irregular and an ECG confirmed a cardiac arrhythmia and he was referred to hospital for investigation. Cardiac arrest and ventricular arrythmias are known to be associated with antipsychotic drugs.15

The most common interventions arising from the annual review were dietary and smoking cessation advice. Nicotine replacement therapy and referrals to the asthma/COPD clinic were frequently initiated.

Anecdotal evidence suggests high levels of patient satisfaction with the service.

Lithium monitoring (MH 3, 4, 5)

The remaining 11 points are awarded for lithium monitoring.

We discovered a disparity between the reference ranges for MH 5 (see Table 1 above) and those used in local biochemistry laboratories.The laboratory acknowledged that the therapeutic range for prophylaxis (0.4-0.8 mmol/l) is lower than that for treatment (0.6-1.0 mmol/l) thus reducing adverse effects, particularly in older people.

The Logical Query Specification for the QOF offers two options for coding this indicator:

  • Read code 44W8. This means ‘serum lithium level’ and is accompanied by a blood value between 0.6 mmol/l and 1 mmol/l).
  • Read code 44W80. This means ‘serum level therapeutic’ and does not have to be accompanied by a blood test result.

The contract’s supporting guidance documentation states that serum lithium levels below 0.6 mmol/l are acceptable, and for this reason, the top standard for this indicator has been set fairly low, at 70% in 2004/05. However, the range 0.4-1.0 mmol/l has been discussed by the national plenary group and will probably be agreed for use in 2005/06.


The new contract has provided an opportunity for general practice teams to improve communication and collaboration with CMHTs and specialist mental health services with the development of joint care pathways and protocols.

Our approach has embraced capacity issues, with most of the interaction taking place opportunistically within the context of the routine psychiatric appointment with the CPN. The disadvantage of this is that the process took longer than anticipated because the patients’ appointments with the CPN were distributed evenly throughout the year.

Work continues, to achieve these targets and reduce the burden of ill health on these vulnerable individuals.

I would like to thank George Cruikshank, CPN, Clydesdale Resource Network, Nadine Harrison, Medical Adviser, Primary Care Division and Rod Muir, Programme Clinical Director and Caldicott Guardian, Information and Statistics Division, NHS Scotland, for information and advice.


  1. Gask L, Rogers A, Roland M et al. Improving quality in primary care: a practical guide to the National Service Framework for Mental Health. Second Edition, Autumn 2003. National Primary Care Research and Development Centre.
  2. National Institute for Clinical Excellence (NICE). Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. NICE Clinical Guideline 1. London: NICE, 2002.
  3. Goodwin GM. Evidence-based guidelines for treating bipolar disorder: recommendations from the British Association of Psychopharmacology. J Psychopharmacol 2003; 17: 149-73.
  4. National Institute for Clinical Excellence. Depression: Management of depression in primary and secondary care. Clinical Guideline 23.London:NICE,2004.
  5. Katon W, Schulberg H. Epidemiology of depression in primary care. Gen Hosp Psychiatry 1992; 14: 237-47.
  6. Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry 1988; 45: 1094-9.
  7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). 4th ed. Washington, DC: American Psychiatric Association, 1994.
  8. register guidance 22-11-04.doc
  9. ‘Frequently Asked Contract Questions and Answers’ 3 March 2004, p. 8.
  10. NHS Scotland Confidentiality and Data Protection. Fair processing of patient information in general practice.
  11. General Medical Council. Confidentiality: protecting and providing information. London: GMC, 2004.
  12. Day JC,Wood G,Dewey M, Bentall RP.A self-rating scale for measuring neuroleptic side-effects. Validation in a group of schizophrenic patients. Br J Psych 1995; 166: 650-3.
  13. Taylor D, McConnell H, McConnell D. The South London and Maudsley NHS Trust. 2001 Prescribing Guidelines. 6th ed. London: Martin Dunitz, 2001.
  14. Koro CE, Fedder DO, L’Italian GJ. Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. Br Med J 2002; 325: 243.
  15. Hennessy S, Bilker WB, Knauss JS et al. Cardiac arrest and ventricular arrhythmia in patients taking antipsychotic drugs: cohort study using administrative data. Br Med J 2002; 325: 1070.

Guidelines in Practice, June 2005, Volume 8(6)
© 2005 MGP Ltd
further information | subscribe