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Keeping QOF in mind

25 August 2014

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Mental health has always been a tricky part of the quality and outcomes framework, but our resident expert explains how to maximise your points in this area

The importance of mental health to the overall health of the population has been increasingly recognised over the last couple of years. There is now an aspiration that mental health should have parity with physical health in commissioning, although it is not entirely clear what this means in practice. 

Mental health has also been a difficult fit for the quality and outcomes framework (QOF). While most of the QOF is based around chronic disease, particularly cardiovascular and pulmonary disease, mental health problems tend to have an episodic nature, or at least to relapse and improve over time. 

Although physical health can be relatively easily classified and a specific diagnosis allocated the trend has been in quite the opposite for mental health problems. Specific diagnoses are used less frequently and have been replaced by a more narrative description of symptoms. 

While much of QOF has been based around tests and processes, there are no laboratory or clinical objective tests in mental health and this has caused the indicators to sit awkwardly. They have been repeatedly changed to find something meaningful to include in the scoring system. The mechanics of the indicators are similar to those for physical diseases but the clinical rules are quite different. 

There are two main areas concerning mental health, depression and severe mental illness. These loosely correspond to the traditional classifications of neurotic and psychotic disease, although the only neurotic disease covered is depression. 

In addition there is a single indicator worth four points for compiling and maintaining a register of patients with learning disabilities. Although there are no further learning disability indicators this register will form the basis of participation in the learning disabilities direct enhanced service (DES) if the practice decides to do so. 

There is not a specific indicator covering the register for depression yet it certainly exists and covers all patients who have a diagnosis of depression since the area was introduced to the QOF in 2006. Previously all patients ever diagnosed with depression were included on the register and when this was changed in 2012 there was a significant drop in the register size for many practices. 

There are many codes that will include a patient in the depression register but the common factor is that they need to be diagnostic codes for “depression” rather than a code for symptoms such as “depressed” or “low mood”. When recorded on the computer system clinicians may understand these latter codes in context as diagnostic. The absence recognised diagnostic code will cost the practice money. 

This register is only used for the purpose of calculating prevalence adjustments and the value of a point in the sole indicator. There is no obligation from the other indicators for any action to occur for historical cases of depression. The guidance suggests that a further code should be entered at the end of a depressive episode which would remove the patient from the register. As the 

only effect is to reduce practice 

income there is no evidence that this is widely used. 

Since the cuts to indicators for this year there is now only a single indicator in depression. The need to code an initial assessment at the time of diagnosis has been removed and only the need for a review remains, to take place between ten days and eight weeks after each new diagnosis of depression. It is therefore sensible to enter a diagnostic code only when there is a realistic plan of reviewing the diagnosis within the timescale. 

For the QOF year ending in March 2015 all patients diagnosed since the first of April 2014 will be eligible 

for the review, although if the indicator survives into 2016 then there will be some overlap effect from this year. Some patients with a new diagnosis in February and March 2015 will still be eligible for their review April and so could be counted in that new QOF year. 

There is no problem with the code being repeated and the rules will only look for review codes that occur in the correct timescale. A good habit would be to use a review code (9H91 or 9H92) every time a patient with depression is reviewed. It may mean less need to “tidy up” the coding at the end of the year and will have no adverse effect. 

Exception reporting is available in depression, although the only codes available are the fairly general 9HC0 and 9HC1 where the indicators are not suitable or there is informed dissent respectively. It is most likely that patients will simply not turn up for their review rather than an express refusal. The usual rules about three invitations will applym although in this case the first invitation could be recorded at the time of diagnosis with further invitations by telephone or text message where the timescale is relatively tight. 

There are 10 points available for this indicator for reaching 80%. 

The general mental health area has rather wider inclusion criteria. Almost any diagnosis of schizophrenia or other psychotic disease, and the use of any code mentioning psychosis is sufficient for the patient to be entered onto the register. Additionally all patients with bipolar disorder or taking lithium will be included. There is no time limit for the date of diagnosis. It easy to see which patients are included as there is an explicit indicator for the mental health area which carries four points. 

Another difference from the register of patients with depression is that there is no way for patients to be removed from the register once they are on it short of removing the original diagnosis code which should only be done in the case or error. There is no concept of the resolution of psychotic disorder in QOF; it is a chronic illness. 

Many patients who have suffered from a psychotic disorder can be without symptoms or other manifestations of the disorder for many years or decades. Although they cannot be removed from the register, patients who have no current symptoms and have not needed either pharmaceutical or secondary care treatment for at least five years can have the QOF requirements suspended. They will still be included in the register for prevalence calculation purposes. 

When it comes to coding these patients, none of the codes which specify that the condition is resolved will be counted. Only codes for a psychotic condition in remission will apply. There are almost as wide a range of remission codes as diagnostic codes and these are mostly quite specific. There is no technical need for these to match the original diagnosis but it would certainly make more sense in the clinic notes if both the diagnosis and remission codes were consistent. In these cases the patient will remain on the register but none of the other indicators will apply to that patient. 

Normally there is a three-month period of automatic exception reporting after a patient is newly diagnosed. The applies normally for patients when initially diagnosed with a mental health problem but it does not apply to a patient whose condition was previously coded as being in remission who suffers a relapse. 

There are six indicators which apply to patients on this register although not all of the indicators are applicable to every patient. Five of these indicators are linked to physical observations, or interventions underlining the difficulty in finding an effective indicator concerning treatment for mental health problems. 

The first indicator rewards the construction and documentation of a care plan for patients with mental health problems during a primary care consultation. This should be discussed and agreed with the patient and with their carers if appropriate. The emphasis should be on the action to be taken if there are any signs of relapse. This plan should be recorded in the patient records and will need to be updated at least annually. The majority of patients will be reviewed only in primary care and part of the plan will be the criteria for referral back to secondary care services. There are five points available if ninety percent of patients have a care plan recorded. 

Although the previous indicators requiring the checking of blood cholesterol and glucose levels have been retired there are still two indicators about physical health. There are four points for recording the levels of alcohol use in all patients on the register and a further four points for a measurement of blood pressure during the QOF year. The upper threshold is set at 90% in both cases. With a total of eight points these actions are quite well rewarded and certainly more so than the production of care plans specified in the first indicator. 

The final three indicators related to specific groups of patients. There are five points for ensuring that 80% of eligible women on the mental health register have had satisfactory cervical cytology. This is in addition to the indicator which applies to the whole eligible female population. The same rules for eligibility apply which will vary slightly across the UK. The rules for exception reporting are also the same as for the main cervical smear indicator. As the number of patients on the mental health register is likely to be a small proportion of eligible women the point value of each patient is rather higher. Each completed smear test of a woman on the mental health register will be worth around ten times as much as a test on a patient who is not on the register. This should be a strong incentive to practices to target this group quite intensively. 

The final pair of indicators only apply to patients who are receiving lithium therapy – defined as receiving a prescription for lithium after the first of October. Although there is a code (665B) for recording that a patient is no longer taking lithium this does not affect the eligibility for these two indicators if they have a diagnosis of bipolar disorder. 

There is one point for a record of a blood test for serum creatinine after the first of July in ninety percent of patients taking lithium. In a separate indicator there are two points for a measurement of lithium levels in the therapeutic range after the first of December, again in ninety percent of patients. If a laboratory level is recorded levels in the range 0.4-1.0mmol/L will be counted as therapeutic. It is possible to manually mark a level as therapeutic with the code ‘Lithium Level Therapeutic’ (44VE). This will only be counted if it is entered on the same date as a code giving an actual lithium level. This can occasionally be useful if the patient has stopped lithium therapy close to the end of the QOF year and the ‘therapeutic level’ would be zero.

As only the final reading of the QOF year is counted it is advisable to check all patients during December which will allow treatment to be adjusted and further blood tests to be taken.

However if the practice has not patient receiving lithium prescriptions then it will be impossible to gain any of the three points available.