Mental Health (MH)

Additional indicators for mental health care are contained within the organisational indictors, relating to significant event audit (especially following suicide or compulsory admission) – see Education and Training 7, and follow-up of patients receiving depot injections in the practice – see Medicines Management 7.

Mental Health - Rationale for Inclusion of Indicator Set
There are relatively few indicators of the quality of mental health care in relation to the importance of these conditions. The reason for this is that, for common mental health problems presenting to general practitioners, there are very few indicators that could be collected using information likely to be found in the medical records. There are few indicators suitable for incentivising the process of care similar to those used in other chronic diseases. This reflects the complexity of mental health problems, and reflects the complex mix of physical, psychological and social issues that present to general practitioners. The indicators included in the Quality and Outcomes Framework can therefore only be regarded as providing a very partial view on the quality of mental health care.

For many patients with mental health problems, the most important indicators relate to the inter-personal skills of the doctor, the time given in consultations and the opportunity to discuss a range of management options. Within the 'patient experience' section of the quality framework, there exists the opportunity to focus patient surveys on particular groups of patients. This would be one way in which a practice could look in more detail at the quality of care experienced by people with mental health problems.

Mental health problems are also included in some of the organisational indicators. These include the need for a system to identify and follow up patients who do not attend where the practice has taken on a responsibility for administering regular neuroleptic injections, significant event audits which focus specifically on mental health problems, and methods of addressing the needs of carers.

Mental Health (MH) Indicator 1
The practice can produce a register of people with severe long-term mental health problems who require and have agreed to regular follow-up

MH 1.1 Rationale
In order to carry out the reviews required below, it will be necessary to have a list of patients with severe long-term mental health problems. There are considerable difficulties around the diagnostic labelling of chronic mental illness. In the Quality and Outcomes Framework, unlike all the other clinical areas, we have not specified specific diagnostic labels to be used. The principle adopted is the construction of a register based on patient need.

Practices would normally wish to consider including all patients with psychotic illness, patients treated under a care programme approach and patients requiring complex packages of care from a multi-disciplinary secondary care team. In England, this would include all patients being treated under the 'enhanced level' of the care programme approach. These are patients with multiple care needs, who often require inter-agency co-ordination, and may be at risk of disengaging themselves from services.

Other practices may also wish to include on a register patients with long-term depression, as there is evidence that the sort of structured care applied to other chronic diseases may also benefit patients with depression. (Wagner EH, Simon GE. Managing depression in primary care: the type of treatment matters less than ensuring it is done properly and followed up. BMJ 2001;322:746-747).

Practices must use their discretion, and should retain flexibility as to who is included on the register. For example, a patient who has had two episodes of mania in the past six years but who on each occasion has returned to work in a position of high public visibility may not be an appropriate individual to place on the register and may object to inclusion. Practices can however, be expected to describe which patients they include, and how, in general, those patients are identified for inclusion on the register.

There is more guidance on setting up a register on pages 29 and 30 of: Gask et al. A practical guide to the National Service Framework for Mental Health. This is published by the National Primary Care Research and Development Centre and can be downloaded from www.npcrdc.man.ac.uk

MH 1.2 Preferred Coding
Mental Health Register 9H8.

MH 1.3 Reporting and Verification
The practice reports the number of patients on its mental health disease register and the number of patients on its mental health disease register as a proportion of total list size.

Verification - PCOs may enquire as to how the practice identifies patients for inclusion on the register.

Mental Health (MH) Indicator 2
The percentage of patients with severe long-term mental health problems with a review recorded in the preceding 15 months. This review includes a check on the accuracy of prescribed medication, a review of physical health and a review of co-ordination arrangements with secondary care

MH 2.1 Rationale
In many cases, the bulk of care for psychiatric care patients with long-term mental health problems will be provided by specialist services, so it is not appropriate to assess the general practitioner on the basis of care which may be largely outwith his or her control. Nevertheless, there are some aspects of management which often lie within the general practitioner's responsibility. One is physical health. Patients with severe mental health problems are at considerably increased risk of physical ill-health. Physical problems are often neglected or managed poorly. It is therefore good practice for a member of the practice team to review each patient's physical health on an annual basis.

A review of physical health will normally include:

- regular preventive care, eg cervical cytology
- issues relating to alcohol or drug use
- smoking and heart disease (including history suggestive of arrythmias – Hennessy et al. BMJ 2002;325:1070)
- risk of diabetes from olanzepine and risperidone (Koro et al. BMJ 2002; 325: 243).

At the same time, the accuracy of medication which the general practitioner is prescribing can be checked. In particular, where the GP is prescribing for the patient, it is important to review medications on a regular basis, as with all repeat medications where the patient may not be in regular contact with the GP.

In addition, an annual check is an opportunity to review co-ordination arrangements with secondary care, eg for details of CPN and other services to be recorded in the notes, and to summarise what services are actually being received. This information can be invaluable if the patient presents to the GP with a deterioration in his or her condition.

There is more guidance on regular reviews of patients with mental health problems on pages 30 and 31 of: Gask et al.A practical guide to the National Service Framework for Mental Health. This is published by the National Primary Care Research and Development Centre and can be downloaded from www.npcrdc.man.ac.uk.

MH 2.2 Preferred Coding
Medication review* 8B3S

*It is proposed to use this code to record annual review of patients on the register.

MH 2.3 Reporting and Verification
The practice should report the percentage of patients on the mental health register who have been reviewed in the last 15 months.

Verification may involve randomly selecting a number of case records of patients in which the review has been recorded as taking place to confirm that the three components have been undertaken and recorded.

Mental Health (MH) Indicator 3
The percentage of patients on lithium therapy with a record of lithium levels checked within the previous 6 months

MH 3.1 Rationale
Lithium monitoring is essential due to the narrow therapeutic range of serum lithium and the potential toxicity from intercurrent illness, declining renal function or co-prescription of drugs eg thiazide diuretics or NSAIDs which may reduce lithium excretion.

www.jr2.ox.ac.uk/bandolier/band74/b74-6.html).

It is therefore necessary to check calcium and thyroid function on a regular basis as well as renal function.

There is no definitive evidence on the frequency of lithium level checks but most practitioners would monitor lithium levels when stable every 3 to 6 months. Where a practice is prescribing, it has responsibility for checking that routine blood tests have been done (not necessarily by the practice) and for following up defaulters where responsibility has been accepted for administering treatment.

MH 3.2 Preferred Coding
Patients on lithium will be identified through a drug search.
Serum Lithium 44W8%

MH 3.3 Reporting and Verification
Practices should report the number of patients being prescribed lithium therapy by the practice. The practice should report the percentage of these patients who have had a serum lithium level in the last 6 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1. Inspection of the output from a computer search that has been used to provide information on this indicator

2. Inspection of a sample of records of patients prescribed lithium to look at the proportion with serum lithium levels in the last 6 months

3. Inspection of a sample of records of patients for whom a record of serum lithium in the last 6 months is claimed, to see if there is evidence of this in the medical records.

Mental Health (MH) Indicator 4
The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months

MH 4.1 Rationale
There is a much higher than normal incidence of hypercalcaemia and hypothyroidism in patients on lithium, and of abnormal renal function tests. Overt hypothyroidism has been found in between 8% and 15% of people on lithium.

MH 4.2 Preferred Coding
Thyroid function tests 442%
Serum Creatinine 44J3%

MH 4.3 Reporting and Verification
MH 4.3.1 Practices should report the percentage of patients on lithium therapy with a record of TSH in the last 15 months.

MH 4.3.2 Practices should report the percentage of patients on lithium therapy with a record of serum creatinine in the last 15 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1. Inspection of the output from a computer search that has been used to provide information on this indicator

2. Inspection of a sample of records of patients on lithium therapy to look at the proportion with recorded TSH and creatinine in the last 15 months

3. Inspection of a sample of records of patients on lithium therapy for whom a record of TSH and creatinine is claimed, to see if there is evidence of this in the medical records.

Mental Health (MH) Indicator 5
The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months

MH 5.1 Rationale
See MH 3.1
The therapeutic range for patients on lithium therapy is normally 0.6 - 1.0 mmol/l. If the range differs locally the PCO will be required to allow for this. Levels below 0.6 may be acceptable, depending on the clinical circumstances of the patient. For this reason, the top standard for this indicator has been set fairly low at 70%.

MH 5.2 Preferred Coding
Lithium Level numeric value

MH 5.3 Reporting and Verification
Practices should report the percentage of patients on lithium whose last serum lithium level is in the therapeutic range. The level should have been undertaken in the last 6 months.

In verifying that this information has been correctly recorded, a number of approaches could be taken by a Primary Care Organisation:

1. Inspection of the output from a computer search that has been used to provide information on this indicator
2. Inspection of a sample of records of patients on lithium therapy to look at the proportion with recorded serum lithium between 0.6 and 1.0 mmol/l
3. Inspection of a sample of records of patients on lithium therapy for whom a record of serum lithium in the therapeutic range is claimed, to see if there is evidence of this in the medical records.