The 2014/15 QOF settlement for England 1 will remove three key cardiometabolic indicators from the severe mental illness (SMI) domain. This appears at odds with the government’s repeatedly stated policy commitment 2 to address the 15-20 year mortality gap for this population compared to the general population 3.
The decision to abandon the QOF requirement to monitor regularly weight, blood glucose and lipids is particularly puzzling given that cardiovascular disorders constitute the single most important cause of premature death for this population and the main reason why the mortality gap continues to widen 4. This decision is disappointing as it has been shown that QOF can improve cardiometabolic monitoring albeit this appears stronger for people with diabetes than those with severe mental illness 5. Moreover we know that the attention provided by primary care to diseases outside the QOF scope may receive less attention 6.
Changes to weight, lipids and glucose regulation can appear within weeks of commencing antipsychotics and then steadily climb on a trajectory that diverges from the level of cardiometabolic risk present in the general population as evidenced by a 4-fold increased prevalence of metabolic syndrome by the age of 40 7. Indeed by the age of 38 yrs 38% can be defined by blood glucose assessment to be at high risk of diabetes 8, emphasising the prevention opportunity that may be sacrificed by removing the blood glucose QOF measurement. The findings from the National Audit of Schizophrenia emphasise the need to encourage systematic monitoring when we know only 29% of 5091 patients from across England and Wales had record of an adequately assessed cardiometabolic risk in the previous 12 months (weight, smoking status, glucose, lipids, BP) 9. Weight was unrecorded in 43%. Moreover when cardiometabolic complications are discovered, too often these are ignored in clinical practice particularly when compared with patients without mental illness 10.
Responding to this evidence of inequalities in care, the Lester Positive Cardiometabolic Resource 11 embraced the very measures that this latest QOF deal has removed, using the mantra ‘Don’t just screen, intervene’. Endorsed by the Royal College of General Practitioners (RCGP), the Royal College of Psychiatrists (RCPsych), the Royal College of Physicians (RCP), Rethink Mental Illness and Diabetes UK this resource is now recommended by the National Audit of Schizophrenia 9, National Institute for Health and Clinical Excellence (NICE Guideline CG155: Psychosis in children and young people) and the Schizophrenia Commission 12.
QOF has never provided the whole solution to addressing the high rates of diabetes and cardiovascular disorders affecting people with severe mental illness. These patients still struggle to access our care, they get lost between primary and secondary care, often trapped in a cycle of disadvantage and loss of hope. But whatever the limitations of the QOF it did bring attention and investment to support a group of patients who traditionally got a very poor deal from healthcare. Taking away these particular QOF indicators will relegate this population to even greater disparity.
The late Professor Helen Lester, lead author of the Positive Cardiometabolic Health resource and a scientific advisor to the QOF until her death this year, powerfully challenged her fellow general practitioners in her RCGP James McKenzie lecture 2012 to be Bothered about Billy 13. Professor Lester reminds us that much of this is not rocket science; that a few minor adjustments could be in place by tomorrow; that primary care is ideally placed to improve the health and health outcomes of this population; that this is our business; and in the end, as Professor Lester concluded, it boils down quite simply to being bothered about Billy.
Professor Carolyn Chew Graham, MD FRCGP, GP Manchester, Professor of General Practice Research, Keele University, and RCGP Curriculum Guardian, Mental Health
Dr Anand J Chitnis, FRCGP, Chair and Mental Health Lead, Solihull CCG
Dr Paul Turner, FRCGP, GP, Karis Medical Centre Birmingham, Mental health and wellbeing lead for Edgbaston Network, Birmingham South Central CCG
Dr Alex J Mitchell, MD Consultant Psychiatrist, University of Leicester, LE1 5WW
Dr Sheila Hardy, PhD MSc BSc RMN RGN, Education Fellow UCLPartners and Visiting Fellow University of Northampton.
Dr David Shiers, MRCGP, retired GP North Staffordshire, carer of daughter with schizophrenia
Declaration of interest
Dr David Shiers is a current member of the Guideline Development Group for NICE guidance for adults with psychosis and schizophrenia. Dr David Shiers and Professor Carolyn Chew Graham are members of the National Collaborating Centre for Mental Health (NCCMH) board
1. British Medical Association (2013) General practice contract changes 2014-2015. http://bma.org.uk/news-views-analysis/general-practice-contract/qof-changes-2014
2. Department of Health (2011) No Health Without Mental Health: a cross-government mental health outcomes strategy for people of all ages. London: Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf
5. Mitchell A.J., et al (2013) Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Journal of Psychiatric Services. 2013 Oct;64(10):1060-3. doi: 10.1176/appi.ps.201200514.
Doran T., et al (2011) Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework. British Medical Journal, 342:d3590. doi: 10.1136/bmj.d3590.
8. Manu P., et al (2013) Prediabetic increase in hemoglobin A1c compared with impaired fasting glucose in patients receiving antipsychotic drugs. European Neuropsychopharmacology. 2013 Mar;23(3):205-11. doi: 10.1016/j.euroneuro.2012.05.002. Epub 2012 May 29.
9. Royal College of Psychiatrists (2012) Report of the National Audit of Schizophrenia 2012. London: Healthcare Quality Improvement Partnership. http://www.rcpsych.ac.uk/pdf/NAS%20National%20report%20FINAL.pdf
10. Mitchell A.J. et al (2013) Is the prevalence of metabolic syndrome and metabolic abnormalities increased in early schizophrenia? A comparative meta-analysis of first episode, untreated and treated patients. Schizophrenia Bulletin. 2013 Mar;39(2):295-305. doi: 10.1093/schbul/sbs082. Epub 2012 Aug 27. Review.
11. Lester H., Shiers D.E., et al (2012) Positive Cardiometabolic Health Resource: an intervention framework for patients with psychosis on antipsychotic medication. Royal College of Psychiatrists, 2012 http://rcpsych.ac.uk/pdf/RCP_11049_Positive%20Cardiometabolic%20Health%20chart-%20website.pdf
12. Schizophrenia Commission (2012) The abandoned illness: a report from the Schizophrenia Commission. London: Rethink Mental Illness. http://www.rethink.org/media/514093/TSC_main_report_14_nov.pdf
13. Royal College of General Practitioners (2012) Helen Lester, Being Bothered about Billy, The James McKenzie Lecture 2012. http://www.rcgp.org.uk/news/2012/november/professor-helen-lesters-presentation-of-the-james-mackenzie-lecture.aspx
14. Royal College of Psychiatrists (2013) Healthy Active Lives (HeAL) international consensus statement. London: Royal College of Psychiatrists. http://www.rcpsych.ac.uk/mediacentre/pressreleases2013/healconsensusstatement.aspx http://www.iphys.org.au/media/HeAL_declaration.pdf