Maximising your QOF income: Mental health area

GP Dr Gavin Jamie provides tips on how to meet targets within the mental health area of QOF’s clinical domain

Summary – indicators and value

• Indicators: 8
• Points: 38
• Prevalence: 1% (this is an estimate based on latest available QOF data and current trends)
• Estimated value per patient:  £87

Background

Recently, QOF saw an extra three indicators introduced to the mental health area, giving a total of seven indicators and a high number of points – and potential income – per patient.

One of the additional indicators was a former QOF indicator on keeping a record of alcohol consumption that was reintroduced.

The other two were new indicators for blood lipid and blood glucose checks.  Past indicators for blood tests in patients on the mental health register had a lower age cut-off at 40, but now the indicators have no age limits (although most patients are adults).

For 2023/2024, there is an additional indicator (MH021) for patients on the mental health register having all six physical checks during the QOF year. There is no new activity here but the effect of this indicator it to increase the value of having all of the checks for one person.

The indicators can be summarised as:

• Indicator MH001: Maintain register of patients with mental health problems (4 points)
• Indicator MH002: Annual comprehensive care plan in 90% of patients (5 points)
• Indicator MH003: Blood pressure measurement in 90% of patients (3 points)
• Indicator MH006: Measurement of BMI in 90% of patients (3 points)
• Indicator MH007: Record of alcohol consumption in past 12 months (3 points)
• Indicator MH011: Measurement of lipid profile in past 12 months in patients currently prescribed antipsychotics, and/or at high CVD risk (7 points)
• Indicator MH012: Measurement of blood glucose/HbA1c in past 12 months (7 points)
• Indicator MH021: Patients receiving all six elements of the physical health check as defined in the NHS Long Term Plan (6 points).

Although the number of patients on the mental health register has been rising over the years, there is still a relatively high payment per patient. This reflects the importance placed on the identification and treatment of mental health problems by NHS England.

Indicator MH001 – Maintain register of patients with mental health problems (4 points)

There are many codes that will place a patient on the register. Any mentioning psychosis, schizophrenia, mania or bipolar disorder will be effective.

There is no way to remove patients from the register. Although codes for psychosis resolved exist, they do not have any effect on QOF. Instead, patients who have not received medication or a secondary care review for five years can be coded as being in remission. This will leave the patients on the register for prevalence purposes but excuses them from the other indicators.

There are a number of codes that can be used for patients in remission, corresponding to the various diagnostic codes, although the QOF rules don’t insist they match. For instance, if a patient has a diagnosis of hypomania, a code of paranoid state in remission would record them as being in remission for QOF.

Tips:

• Diagnoses from secondary care can be vague. It is vital that patients have a recognised diagnostic code so that they become eligible for the other indicators. Performing a search for antipsychotic drugs or lithium may identify patients who have been missed. Appropriate codes for psychosis can then be entered.
• The number of patients on antipsychotic medication is likely to be small, so even a single extra code will pay for the time that you spend checking the records.
• If a patient has a relapse following remission, they will need a new diagnostic code.

Indicator MH002 – Annual comprehensive care plan (5 points)

Five points are available if 90% of patients have an annual care plan. The official guidance gives some detail on what should be included in this.

Agreeing or reviewing a mental health care plan will fulfil the criteria and there are a number of valid codes for the Care Programme Approach, where a patient has agreed a plan with their community worker.

Tips:

• It can be difficult to arrange a review with this group, particularly if they are already under active review by mental health services. Where patients are receiving medication from the practice a reminder can be sent with a prescription.
• Occasionally it may be necessary to give a shorter course of medication on each prescription, giving the message that this is to tide them over until a review is undertaken for their own safety.
• Patients who are usually under the secondary care mental health services should also be invited. Working with community mental health services can give extra encouragement for these patients to attend.
• Patients can be exception reported (now under the ‘personalised care adjustment’ codes) if they dissent or fail to respond after two invitations. The practice should then consider if they should continue to prescribe.
• There are general exception reporting codes and a three-month period of automatic exception reporting following a new registration. This only applies after the first diagnosis; after a relapse the care plan will be due immediately.

Indicator MH003 – Blood pressure measurement (3 points); and Indicator MH006  – BMI measurement (3 points)

Both these indicators can be incorporated into the annual plan and both offer full points for recording the information in 90% of patients. Together they also carry more points than the generation of the care plan.

The BMI indicator was reintroduced in 2019; after its removal from QOF in 2015, measurement rates fell from 90% to 60%.

Tips:

• There is no maximum acceptable blood pressure in this QOF indicator. Simply recording a measurement is all that is required.
• Remember that the BMI measurement applies to all patients, whether overweight or not.
• Weight and height can be measured by suitably trained reception staff but provide a template to enter the data so they are reminded to make the BMI calculation.
• Searching for patients with a weight measurement but no BMI record in the current year can be a quick way to boost achievement rates.
• There is exception reporting if the patient refuses to have their blood pressure taken, as well as the usual three-month grace period after registration or a new diagnosis (but not relapse).

Indicator MH007 – Alcohol consumption record in preceding 12 months (3 points)

All patients on the register should have a record of alcohol consumption each year. This indicator was removed in 2019 but returned unchanged.

It is not an especially difficult indicator if patients are having an annual review and carries four points. Most of these patients will need to have smoking status recorded as well. The most important thing is that it is part of your templates from the start of the year to ensure that the information is efficiently recorded.

It does not need to be a face- to-face review – it could be by phone or electronic questionnaire.

Indicator MH011– Lipid measurement in preceding 12 months (7 points)

There are seven points if 90% of patients on the register have a cholesterol measurement during the year. There is no age limit here other than all patients on the register must be over 18 years old.

Technically the annual check is only required if the patient:

• Is currently taking antipsychotic medication or
• Have pre-existing cardiovascular disease or
• BMI ≥23 (25 if coded as white) or
• Smokes.

However, if the patient does not meet any of the above criteria the requirement then becomes every two years and with the HbA1c indicator (see below) it is probably simplest to check lipids annually.

Indicator MH012 – Blood glucose/HbA1c measurement in preceding 12 months (7 points)

There are a further seven points for reaching 90% of patients on the register, of any age, with a HbA1c measurement. Although not required this should normally be the same blood sample as the cholesterol measurement above. If you are efficient the two blood test indicators could be considered as a single indicator worth 14 points. The blood tests are worth over two times the value of the annual review!

Patients who already have diabetes will not count towards this indicator. If the result is raised patients can be added to either the diabetes or non-diabetic hyperglycaemia register – increasing income. 

Indicator MH021 – Patients receiving all six elements of the physical health check

The checks are:

• Alcohol consumption history
• Smoking status
• BMI
• Blood pressure
• Blood glucose or HbA1c measurement
• Lipid profile in the last year (last two years for lower risk patients, but as practices take blood annually for glucose anyway, I advise checking annually in all patients).

There are six points for achieving a target of between 50% and 80% of patients. Patients can decline individual parts of this and will be excluded from the whole indicator e.g. if a blood test is coded as being declined then they will not appear in the denominator.

Dr Gavin Jamie is a GP in Swindon and runs the QOF Database website

Further reading/resources

• NHS England – Quality and Outcomes Framework guidance for 2023/24. Published 30 March 2023.