Dr Alan Cohen and colleagues at the Care Services Improvement Partnership (CSIP) discuss the implications of the mental health clinical indicators in primary care

The 2006 amendment to the quality and outcomes framework (QOF2) of the GMS contract for primary care services introduced several new clinical domains, as well as amending some of the pre-existing clinical domains. With regards to the mental health domains, the mental health clinical indicators were updated, and two new domains – depression and dementia – were added.

The Care Services Improvement Partnership (CSIP) has produced best practice guidance for primary care staff related to the mental health domains, which will be serialized in Guidelines in Practice, starting this month with the mental health clinical domain. The depression domain will be featured in the December issue of the journal, followed by the dementia domain in January 2007.

Although designed for primary care clinicians so that they provide high quality, evidence-based, essential services, this guidance will also be of interest to specialist mental health trust clinicians; a greater understanding of the level of care being provided in primary care should lead to improvements in the primary/secondary care interface.

The changes to the mental health clinical domain have been made so that there is greater clarity and consistency about which group of patients this domain relates to, and the type of care that is expected to be provided. The domain now specifies the conditions that are to be included, specifically schizophrenia and bipolar depression, as well as people with a psychotic disorder.

Other mental health clinical indicators include:

  • the regular review of people with these conditions, especially a review of their physical health
  • the documentation of an agreed care plan
  • ensuring that those who fail to attend for review are assertively followed-up.

The indicators for lithium are unchanged. The total number of points has been increased to 39 (Table 1).

Table 1: Clinical indicators for mental health
Disease indicator
Clinical indicator
Points Payment stages
      Min (%) Max (%)
The practice can produce a register of people with schizophrenia, bipolar disorder, and other psychoses
MH 9
% patients of all patients with schizophrenia, bipolar 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
% patients on lithium therapy with a record of serum creatinine and thyroid stimulating hormone in the preceding 15 months
1 40 90
MH 5
% patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months
2 40 90
MH 6
% 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
% 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 their non-attendance
3 40 90

Indicator MH 8

As the guidance from the NHS Employers makes clear, the changes to this indicator specify which diagnoses are to be included in the register. The intention is that people with schizophrenia and bipolar affective disorder are to be included, as well as the much smaller number with an, as yet, unspecified form of psychosis. People with chronic depression and personality disorder are excluded, as are children (unless they have one of the above conditions), and older people with dementia (for which there is a separate domain).

Software houses will deliver the appropriate search engines to ensure that registers are created, providing the correct diagnoses are entered clinically.

The codes to use for the register are either 9H8 or 9H6. The code to designate that the individual has been excluded from the register is 9H7. These codes are unchanged from QOF1.

Indicator MH 9

There is increasing evidence that the physical health of people with a severe mental illness is poor. There have been a number of recent publications in this area, but the most recent and most detailed is the outcome of the Disability Rights Commission Formal Inquiry. The details can be found at:

It is appropriate to review annually the physical health of people on the mental health register. The type of review that needs to be undertaken is dependent on the personal circumstances of the individual, but consideration should be given to the following interventions:

Cardiovascular disease

The standardized mortality ratio (SMR) for cardiovascular disease in people with schizophrenia and bipolar disorder is 400. Although figures vary, between 65% and 90% of people with schizophrenia smoke, and 30% to 45% of people with bipolar disorder smoke. A typical antipsychotic medication, such as risperidone and olanzapine, cause prolongation of the QT interval, and as such arrhythmias may be more common. All of these facts indicate that screening for cardiovascular disease is appropriate, i.e. checking blood pressure, pulse, and cholesterol levels.


The SMR for respiratory disease in people with schizophrenia and bipolar disorder is 400. Because of the figures for smoking mentioned above, advice on smoking cessation is appropriate, as well as an assessment of the presence of COPD. This can be done by checking peak flow rates, and, where appropriate, assessing reversibility of any airway narrowing.

Diabetes and glucose intolerance

Diabetes is five times as common in people with schizophrenia and bipolar disorder. There are a number of causes of this, one of which is the newer atypical antipsychotic medication. The first reports of the association between diabetes and schizophrenia were published in the 1920s, before even chlorpromazine was introduced. It is appropriate to screen for diabetes, using either fasting blood glucose or urine analysis, and to record the BMI annually.

Other health promotion advice

Cervical screening does not occur as frequently in this group as others, although there is no increase in mortality from cervical cancer. Dietary advice may be appropriate, as well as other specific 'illness prevention' advice. In some groups of patients who suffer from schizophrenia and bipolar disorder, and who have had a particularly chaotic early phase of their illness, the prevalence of HIV and hepatitis C may be very high. Figures from the USA record rates of 20 times as high of hepatitis C, and 10 times as high of HIV, although the studies have not yet been repeated in the UK. Therefore, depending on personal circumstances, it may be appropriate to consider counselling and testing for these conditions.

Drug and alcohol use

The use of street drugs and/or alcohol is common in the early chaotic phases of the mental health disorders. Around 70% of all acute admissions to mental health beds in London are due to the combined use of street drugs and/or alcohol with the existing diagnosis of schizophrenia or bipolar disorder. Assessment of the use of drugs and alcohol is appropriate as part of the annual review.

All the interventions that have been undertaken should be recorded in the patient's electronic record, using the standard code for these interventions. The interventions can often be undertaken by a practice nurse, or other suitably qualified professional.

The date of the annual review should be recorded, even though this is done automatically by the practice software. The codes to be used for the annual review are 6A6 or 8BM0.

Indicators MH 4 and MH 5

There are no major changes to the rationale or recording related to these indicators. Relatively few patients are taking lithium, but for those who are, it is important that there is clarity as to:

  • who is prescribing the medication
  • who is responsible for monitoring the medication
  • how frequently the patient is required to have appropriate blood tests that monitor renal and thyroid function.

Indicator MH 6

Up to 50% of patients with a severe mental illness, including those on the mental health register (MH 8), are managed entirely in primary care. People with schizophrenia and bipolar disorder have complex disorders that affect not only their mental health, but also their physical health (see MH 9) and their social functioning including employment and accommodation opportunities.

A care plan provides the opportunity to review what the needs of the patient may be, and who is best able to provide that care. In this case the GP acts not as the person who is going to provide all the interventions themselves, but as the person who will coordinate the care that is needed.

The care programme approach (CPA), for those people who are in contact with specialist mental health service, sets out the same principles, and can be used by the practice as evidence of a comprehensive care plan.

For those people who are not in contact with specialist mental health services, there are two alternatives. Either, with the agreement of the patient, refer them to specialist mental health services, where a CPA will be generated. Alternatively, develop a practice based 'patient-centred audit' (PCA), which addresses the needs of the individual, and details who will deliver those needs.

The principles of either a CPA or a PCA are exactly the same – an assessment of need, an agreement as to who can fulfil that need, and a review date (to complete the audit cycle). Care programme approach or PCA documents require the agreement of the patient (and/or their carer when appropriate), and should cover the following areas listed in Box 1.

Documentation for the CPA should always include the name and contact details of the key worker who is the first point of contact for patients who are under the care of specialist mental health teams.

For individuals who elect to remain under the care of their GP, and with whom a PCA plan is agreed, the GP is the equivalent of the key worker.

It should be made clear that this does not mean that the GP is the key worker, or has the training to become, or is taking on the responsibility of a key worker. It means that the GP and the practice is the first point of contact for that patient as and when it is necessary.

Care plans need to be reviewed at least annually, when both the physical health needs, and broader psychological and social needs, can be assessed.

The codes that describe the presence of a care plan (CPA or PCA) are 8CR7 and 8CM2.

Box 1: Areas covered by either PCA or CPA documents
  • Physical health needs
  • Social care needs
    – Accommodation
    – Employment/meaningful occupation
  • Psychological needs
    – Talking therapies
    – Medication, including adherence to drug regimes
  • Identifying relapse
    – What are the early warning signs?
    – What is the patient's wish in case of relapse (medication, need for sectioning, etc)?

Indicator MH 7

The practice will need to develop a system to:

  • identify people on the mental health register (MH 8)
  • invite them for, at least, an annual review (MH 9)
  • record the date of that appointment
  • record that the patient did not attend
  • record that the patient was followed-up in some way.

The code to use for non-attendance for the annual review is 9N4t.

Follow-up can be undertaken by any member of the practice team,and can be either a telephone call or a visit, depending on circumstances.

The number of non-attendees is, in itself, not a 'QOF scoring' indicator; the points are earned by the follow-up within 14 days of the non-attendance. Thus, experience with other clinical areas is that 'did not attend' rates are significantly reduced if patients are sent reminders before their appointment.

Some practices have become very experienced and innovative in this. For example, some practices have started using text messages to mobile phones to remind people to attend their appointment. Such a system may be very effective for people in this target group.


The author would like to thank:

Professor Jane Gilliard, Social Care Lead, Older People's Mental Health Programme, CSIP.
Ian McPherson, Director, CSIP West Midlands Development Centre.
Ruth Eley, National Programme Lead – Older People, CSIP.
Nadine Schofield, National Lead – Older People's Mental Health, CSIP.
Kate Hardy, Project Manager– Older People & Disability, Directorate of Care Services, Department of Health.
Debbie Nixon, National Programme Lead – Primary Care and Commissioning, CSIP.

This article is reproduced and adapted with kind permission of Dr Alan Cohen of the Care Services Improvement Partnership (CSIP) as part of the Improving Primary Care Mental Health Services resource suite.

For further details about the resource suite, please contact Emma Sarno on: emma.sarno@northwest.csip.org.uk or 0161 351 4920.

You can also access the resource suite online at:


Guidelines in Practice, November 2006, Volume 9( 11 )
© 2006 MGP Ltd
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