Dr Peter Young (left), Dr Ewa Wisniewska Young, and Dr Roger Paxton say further implementation needs better communication and cooperation between organisations

It is over a year since NICE published the guideline Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care.1,2 Implementation of this guideline has been significantly influenced by a number of major changes in service delivery in primary and secondary care, which are discussed below.

The guideline contains many recommendations that are applicable to healthcare professionals working in primary care, and these are summarised in Box 1.

Box 1: Key recommendations for primary care from the NICE guideline on the management of bipolar disorder1,2

Bipolar disorder should be suspected and patients referred for assessment either if they have periods of overactive, disinhibited behaviour lasting at least 4 days, with or without periods of depression, or three or more depressive episodes and a history of overactive, disinhibited behaviour.

Risk assessment

Patients with bipolar disorder should undergo a risk assessment: at the time of diagnosis; when there is a significant change in mental state or personal circumstances; and at the time of discharge or leave from inpatient care. Those who are a danger to themselves or other people should be referred urgently to secondary care.

Referral

Referral should be considered under certain other circumstances, for example if:

  • there is a decline in function
  • response to treatment is poor
  • there are problems with treatment adherence
  • there is evidence of alcohol or drug misuse
  • the patient is considering stopping prophylactic medication
  • they are newly registering patients with an existing diagnosis of bipolar disorder, who should be considered for referral if they are not already followed up by secondary care services.

Integrated care

Continuity of care is very important for patients with bipolar disorder. The guideline recommends that primary and secondary care organisations should consider integrated care, with healthcare professionals agreeing responsibilities for assessment, monitoring, and treatment. There should be written treatment plans and regular reviews of mental state and personal and social functioning to ensure that symptoms are treated if they significantly impair social functioning.

Advance statements

Advance statements covering both mental and physical healthcare should be developed collaboratively by healthcare professionals and patients with bipolar disorder, especially if they have had severe manic or depressive episodes, or have had treatment under the Mental Health Act.3The statement should be documented in the patient’s care plan and shared with the patient, the care coordinator, and the GP.

Register of patients

All GP practices should include people with a diagnosis of bipolar disorder on their severe mental illness register.

Monitoring physical health

Patients with bipolar disorder have an increased risk of physical morbidity and mortality when compared with the general population and should have an annual physical health review. This should include:

  • a lipid profile for patients over 40 years of age
  • checking plasma glucose level
  • thyroid function tests
  • weight and height
  • smoking status
  • alcohol intake
  • blood pressure.

Patients who are being prescribed lithium should have their lithium levels checked every 3 months, and thyroid and renal function tests every 6 months when stable.

Many medications used to treat bipolar disorder can result in significant weight increase. If a person gains weight during treatment, recommendations are to:

  • give dietary advice
  • advise regular aerobic exercise
  • consider referral to a dietitian
  • refer to mental health services for a weight management programme.

Medication during pregnancy

Long-term treatment of bipolar disorder is usually with lithium, olanzapine, or valproate. Valproate should not routinely be prescribed for women of child-bearing potential, but if no alternative can be identified, adequate contraception should be used and the risks of taking valproate during pregnancy should be explained. The management of bipolar disorder in women who are trying to conceive and during pregnancy and the postnatal period is complex and more frequent contact by specialist mental health services should be considered. A written management plan should be developed with the patient as soon as possible and shared with the woman’s GP, midwife, obstetrician, and health visitor.

Implementation

Issues in primary care

In 2006, the revision of the General Medical Services (GMS) contract and its mental health quality and outcomes framework (QOF) indicators facilitated significant improvements in coordination of care, and monitoring and documenting the physical health of patients with severe mental illnesses.4 Although the original GMS contract did not specify diagnostic labels for inclusion in the register of patients with severe mental illness, the mental health QOF indicators of the revised GMS contract (see Table 1) rectified this by stating that practices should ‘produce a register of people with schizophrenia, bipolar disorder, and other psychoses’.4The QOF requires an annual review of physical health of these patients,4which is in accordance with the NICE guideline.1

The revisions to the contract introduced the need for patients on the mental health register to have comprehensive care plans. The contract suggests the care plan should include current health status, social situation (housing, occupation), social care needs, and current social supports.

Also recommended for inclusion are:

  • coordination arrangements with secondary care
  • details of early warning signs
  • the patient’s preferred course of action in the event of a clinical relapse (as documented in the advance statement).

Many patients who are seen in secondary care will have a Care Programme Approach5(CPA) care plan, which is recognised by the QOF; however, up to 50% of patients with a severe mental illness are only seen in primary care.6 The primary care team needs to take responsibility for ensuring it has care plans for all patients with bipolar disorder, developing care plans for those patients who do not have an up-to-date care plan.

Restructuring in secondary care

In many parts of the country, secondary care psychiatry services are undergoing major changes in the way patient care is delivered, which influences implementation of the guideline and changes the lines of communication between primary and secondary care. Several mental health trusts have merged, creating bigger organisations. Increasing specialisation in psychiatry—with separation of inpatient and outpatient care and a move away from ‘sector-based’ psychiatry dependant on geographical area to teams based on subspecialty—is resulting in GPs needing to communicate with a larger number of psychiatrists than in the past. Implementation of New Ways of Working for Psychiatrists7is moving psychiatry away from a consultant-led service to multidisciplinary team working. These changes, together with similar organisational upheavals in commissioning arrangements, mean that good communication and coordination at several levels are more important than ever.

A year ago, two of the present authors argued in this journal that communication is key when treating patients with bipolar disorder.8As new NICE guidance on a variety of a clinical areas continues to appear and as the pressure to implement it grows, it is now even clearer that this is true at the clinical level and within and between organisations. The publication by NICE on how to implement its guidance9emphasises that secondary care organisations need:

  • a policy for NICE implementation
  • clear arrangements and responsibilities for anticipating, prioritising, and planning implementation
  • systems for audit and feedback
  • effective coordination between primary and secondary care and commissioners.

With all the other demands on clinical staff in primary and secondary care, achieving this is a challenge. As part of the solution, NICE proposes that local health organisations should establish a shared role—NICE Implementation Manager—with the person appointed having clear authority and the expectation of prominent leadership.9

Improving implementation of the NICE bipolar disorder guidance requires four obstacles to be overcome:

  • clinical staff may need to shift from existing, often familiar, practices to new prescribing patterns, taking account of relapses or persisting symptoms, and monitoring physical health more frequently and systematically than in the past
  • staff within teams and organisations need to work together differently, developing more comprehensive care plans, and encouraging the use of advance directives more often than at present
  • organisations also need to work together in different ways and more closely, first to prioritise the implementation of particular elements of NICE guidance, and, second, to agree responsibilities for implementation. In the case of bipolar disorder this is likely to include clarifying arrangements for physical health monitoring and developing shared care protocols
  • somehow the additional costs of NICE-compliant care must be managed.

Busy clinicians will be most aware of the first of these challenges—the need for changes in individual practice—but they are all linked. Change in individual practices needs to be supported by new ways of working from teams and organisations, and the costs of new guidance can only be managed by collaboration between organisations. In the case of implementing the guideline, clinicians in primary and secondary care must be aware of several things. These are:

  • the significant risk issues—including the likelihood of behaviour that is socially, financially, or personally irresponsible or harmful
  • the likelihood of crises—such as risk of suicide, exploitation, or self-neglect, especially where rapid mood changes are likely
  • possible problems in engagement by patients—through lack of insight, for instance, at certain stages of the illness
  • the continuing need for monitoring physical health.

Good communications between primary and secondary care are essential for all. The impact of the recent organisational changes, especially the creation of some very large mental health trusts, on established contacts between clinicians should be taken seriously, not only by the staff themselves, but also by the organisations that employ them. The NICE Implementation Manager should be central in maintaining and strengthening communication and in developing closer collaboration

Table 1: QOF points for mental health

 

No Indicator

Points

Payment stages

MH 8

 

The practice can produce a register of people with schizophrenia, bipolar disorder, and other psychoses

 

4

 
MH 9

 

The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender, and health status

 

23

40–90%

MH 4

 

The percentage of patients on lithium therapy with a record of serum creatinine and thyroid stimulating hormone in the preceding 15 months

 

1

40–90%

MH 5

 

The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months

 

2

40–90%

MH 6

 

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

 

6

25–50%

MH 7

 

The percentage of patients with schizophrenia, bipolar affective disorder, and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance

3

40–90%

Total points

39

 

Summary

One year on there is still much to do to continue implementing the NICE bipolar disorder guideline. Communication is still key, but now it is clear that the greatest need is to improve communication and cooperation between organisations—primary, secondary, and commissioning.

  • 50% of cases are managed solely in primary care
  • Specialist mental health care is still not covered by the national tariff
  • Patients with bipolar disorder have greater mortality from diabetes and coronary heart disease
  • Effective physical health checks attract QOF points and help prevent physical disease and PbR spend in future
  • Local community weight management services should be commissioned for this group of patients
  1. National Institute for Health and Care Excellence. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Clinical guideline 38. London: NICE, 2006.
  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 and the Royal College of Psychiatrists, 2006.
  3. Mental Health Act 1983. www.legislation.gov.uk/ukpga/1983/20/contents
  4. British Medical Association. Revisions to the GMS contract 2006/2007: Delivering Investment in General Practice. London: BMA, 2006.
  5. www.cpaa.org.uk/thecareprogrammeapproach/
  6. Perry A, Tarrier N, Morriss R et al. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. Br Med J 1999; 318 (7177): 149–153.
  7. Royal College of Psychiatrists and National Institute for Mental Health in England. New ways of working for psychiatrists: enhancing effective, person-centred services through new ways of working in multidisciplinary and multi-agency contexts. London: DH, 2005.
  8. Wisniewska Young E, Ferrier N, Young P. Communication is key to treating patients with bipolar disorder. Guidelines in Practice November 2006; 9 (11): 27–30.
  9. National Institute for Health and Care Excellence. How to put NICE guidance into practice. London: NICE, 2005.G