nGMS and Mental Health

NIMHE, Primary Care Programme

Where does Mental Health fit?

• Quality and Outcome Framework

• National Enhanced Service for Depression

• Patient satisfaction questionnaire

• Medicine Management

• Significant Event Monitoring

Quality and Outcome Framework

• 41 points of 550 are related to severe mental illness

• Different to other clinical domains – patient has to agree to be included

• Three parts:– Develop a register– Monitor physical health– Manage lithium appropriately

The Q & O Domain

Indicator Points Payment Stages

Register of people with a severe long term mental illness

7

Percentage of patients with a review recorded in the last 15 months

23 25 – 90%

Percentage of patients on lithium with a record of lithium in last 6 months

3 25 – 90%

Percentage of patients on lithium with a record of renal and thyroid function

3 25 – 90%

Percentage of patients on lithium with a recorded lithium within therapeutic range

3 25 – 70%

Develop a register

• Who to include?– People with schizophrenia and bipolar affective disorder– On a case by case basis for others with significant mental

health and physical health needs

• What to call it?– Be aware that registers ( e.g.like supervision registers)

mean something different to users

How?

• Search by diagnosis– Schizophrenia Eu 20.0– Bipolar disorder Eu 31.0

• Search by therapeutic category

• Ask the PHCT

• Ask the CMHT

• Label with 9H8

• Label those who do not wish to be included 9H7

Why do it?

• SMR for schizophrenia and bi-polar disorder is about 200

• Cardiovascular and respiratory disease SMR is 400

• Diabetes is 5 times as common

• 90% of people who have schizophrenia smoke (30% of people with bipolar disorder)

• Drug and alcohol misuse

• HIV is 8 times as common

• HCV is (perhaps) 15 times as common

What to do?

• Physical health review

• Medication review

• Communication review

Physical Health• Cardiovascular disease

– BP

– History of arrhythmias

• Diabetes and obesity

– Urine analysis or blood glucose?

• Respiratory disease

– Peak flow

• Health Promotion

– Smoking

– Substance/alcohol misuse

– Cervical cytology

– Influenza?

• HIV/HCV?

Medication Review – 8B3S

• Review what medication (all) is supposed to be prescribed

• What is the patient actually taking?

• Is the patient taking any OTC medication?

• Review side-effects, interactions etc

• Review concordance

• Consider referral to CMHT if medication has not been reviewed in the last 5 years by psychiatrist

Communication Review

• Name of Key worker (if known to CMHT)

• Contact details for key worker in office hours and in emergencies/OOH

• Contact details for carer (if the patient has nominated a carer)

Lithium Review

• Proportion that have had their lithium level checked in the last six months – Serum lithium 44W8%

• Proportion that have had their renal and thyroid function tested in the last six months– Thyroid function tests 442%– Serum Creatinine 44J3%

• Proportion that have their lithium level within the therapeutic range

NES for Depression

• What is it?

• How much will it cost?

• Who can do it?

NES Depression – What is it?

• Essential or additional services delivered to a higher specified standard

• Commissioned by PCTs

• Generally placed with GMS/PMS providers but need not be [2.15(iv)]

• Can be provided by the PCT itself [2.38 – 2.43]

NES Depression – What is it?

• Aim: To meet main recommendations of Defeat Depression Campaign.

• Definition of Depression: Clinical judgement and evidence based diagnostic skills

• Service Outline:– Register of patients– Multi-disciplinary approach– Use CBT– Use screening procedures– Undertake training– Maintain personal health plans– Make referrals/enquiries– Review and feedback

NES Depression – ££££ ?

For a PCT population:

• Use ONS data for prevalence

• Calculate % of patients between 16 – 65

• Weight the target population by the DH Mental health index

• Assume only 50% identified

• Assume that 90% will be treated in primary care

• Multiply that total by £100.00

• Light the blue touch paper and retire!

NES Depression – Who can do it?

• GMS/PMS primary health care teams

• Mental health providers

• Voluntary Sector organisations

• PCO itself [2.44 – 2.46]

Patient Satisfaction Questionnaire

Length of consultation

10 min booked, 8 min open surgery

30 points

Undertaken an approved survey annually 40 points

Undertaken the survey and reflected on changes if appropriate

15 points

Undertaken approved survey, discussed results as a team, an d with patient group of NED of PCT, and proposed changes with some evidence that some had been enacted

15 points

Patient Satisfaction Questionnaire

• There is no approved questionnaire that is specific to mental health

• Yet– NIMHE Primary care programme is developing such a

questionnaire, which will need to be tested for face validity etc, and then approved by the National Panel.

– Available in 12 months?

Medicine Management

• 10 indicators

• Medicine 7 is specific to mental health – 4 points

• “Where the practice has responsibility for administering regular injectable neuroleptic medication, there is a system to identify and follow up patients who do not attend”

Medicine Management

• Practice Guidance– Good to involve CPN (if available)– Relatively small numbers

• Written evidence– Grade C i.e. optional

• Assessment Visit– Practice should be able to demonstrate system

• Assessors Guidance– If the patient is under the care of the mental health team,

and receives the medication from the team, then they should be excluded from the practice responsibility.

Significant Event Monitoring

• Part of Organisational Indicators – Education

• 9 indicators

• Education 7 - 12 Significant events in 3 years – 4 points

• Education 7 – should include the following (if they have occurred)– Any death on practice premises– 2 new cancer diagnoses– 2 deaths which occurred as part of terminal care– 1 patient complaint– 1 suicide– 1 Mental Health Act assessment

Significant Event Monitoring

• In line with RCGP Occasional Paper. Reports should be laid out in one of two forms:– Description of Event– Learning outcomes– Action plan

– What happened?– Why did it happen?– Was insight demonstrated?– Was change implemented?

• Non confrontational, multi disciplinary team activity

In conclusion

Quality and outcome framework

Severe and enduring mental health

41 points

NES Depression Depression £100 per pat.

Patient Experience Questionnaire

Mental health (?) patients 100 points

Medicine Management Those on depot neuroleptics

4 points

Significant Event Monitoring

Suicide and/or MHA Assessments

4 points