QOF Mental Health and
Depression Toolkit
Updated Feb 09
Simon Bennett
Mental Health Facilitator
Simon.Bennett@sheffieldpct.nhs.uk
0114 3051687
Aims of the toolkit
This toolkit is designed to answer some questions about the mental
health and depression parts of QOF, to offer practical advice on how to
find the patients who should be included and what to do with them
when you have found them.
Why have a SMI Registers.
As between a half and a third of patients on a practices mental health
register will not be currently known to secondary care, primary care
could be the only contact some of this group of patients have to meet
their health needs. The register will enable practices to offer realistic
advice to a vulnerable group of patients allowing them to make healthy
choices. The Register will allow proactive care to patients including
monitoring medication and care co-ordination. The register and care
plan will enable a practice to intervene earlier if the patient shows a
deterioration, therefore reducing the impact and duration of any impact.
The register helps practices meet some of the requirements of QOF.
People with severe mental health problems have a shorter life
expectancy than the rest of the population with a higher incidence of
cardiovascular and respiratory disease. Physical health is poorer for
this group of patients with higher incidence of hypertension, obesity
and smoking. People with long term physical health problems are more
vulnerable to depression and if this depression is alleviated then the
symptoms of the physical condition can be improved.
Mental Health
MH8 The practice can produce a register of people with schizophrenia,
bipolar disorder and other psychosis
Compiling the register
The SMI register should consist of all the people in the practice who
have a recorded diagnosis of schizophrenia, bi-polar disorder or other
long term psychotic illness. The register should include patients with
chronic conditions not people who have experienced a short term
mental health problem some time in the past. Patients currently
prescribed Lithium should also be included. Typically, between ½-1%
of the practice population will be included in a mental health register.
QOF2 specifies that people with chronic depression and personality
disorder are excluded as are people with dementia. Inclusion codes
9H8 and 9H6 and exclusion codes 9H7 remain unchanged. There is no
longer a need to get permission for inclusion in the register.
Searching
Initial searches of the practice system should be carried out looking for
people who have a diagnosis of schizophrenia, bipolar disorder or long
term psychosis. However some practices do not always have this
information read coded. The clinicians’ knowledge of the patients and
searching for particular drugs may also help identify candidates for
inclusion on the register. Letters in the paper notes may be able to
verify if patients have a particular diagnosis. It is worth noting that when
searching drugs that in the same family as drugs for psychosis as
drugs used for morning sickness and for tranquillisation.
Read Codes
Diagnosis
Eu20 – schizophrenia
E10 – schizophrenic disorders
Eu31 – Bipolar affective disorders
E11 – Affective Psychosis
Drugs
Anti psychotic drugs
Anti manic drugs
Depot injection
Lithium
Coding problems
Over the years there have been people with diagnosis coding that are
inappropriate for their condition, for example people who have been
given a code for a ‘major depressive episode’ some time in the past,
which is in one of the psychosis coding trees. These patients will be
identified when a search is done for the mental health register. There
are several options for overcoming this problem. See appendix 2 for
further information. For more help with this contact your PRIMIS
facilitator. It is important that the practice agrees appropriate diagnosis
codes for depression.
MH9 % of all patients with schizophrenia, bipolar disorder and other psychosis
with a review recorded in the preceding 15 months. In the review there should
be evidence that the patient has been offered routine health promotion and
prevention advice appropriate to their age, gender and health status.
Engaging with patients
Because of the nature of the illness of patients on the register, motivation can
be a problem. Some of the patients will also experience a chaotic lifestyle.
The practice will have to take account of this and be more proactive in getting
people in than it may have to be for other groups. QOF recognises the
difficulties of this and asks that non-attenders be followed up within a twoweek period. As well as a letter inviting people to review appointments it has
shown to increase attendance to make telephone contact close to the
appointment to remind the patients of the time and date of the appointment. It
may also be helpful to take advantage of patients opportunistically attending
the surgery. Appendix 3 sample letter
Mental Health Review
Physical health checks, Health promotion and prevention advice
There is no prescribed list of physical health checks for the mental
health reviews as the clinician sat with the patient when undertaking
the review is the best person to decide what is and what is not
appropriate for that patient. Some suggestions of what to include could
be
o BP
o Height, weight, BMI
o Smoking Status – consider referral to Stop smoking services
o Alcohol intake
o Contraception advice
o Smears
o Advice about healthy living, exercise, healthy eating – consider
exercise referral scheme
o Employment opportunities – consider signposting to FST, bridge
employment etc.
Medication Review
A check should be made on the appropriateness of the patients
prescriptions of medications and side effects. Consideration should be
given to non-psychiatric drugs. As some of these patients get their
medication prescribed in different places this is an opportunity to
consider interactions. LUNSERS could be used as an objective
measure of side effects.
Mental Health checks & care plan
Liaison with secondary care
Carers details
MH7 % of patients with schizophrenia, bipolar affective disorder and other
psychosis who do not attend the practice for their annual review, who are
identified and followed up within 14 days of their non attendance.
Following up non attenders
Read Code for non-attendance for annual review is 9N4t
One of the requirements of the mental health parts of QOF is that
people who do not attend for their annual review are followed up within
14 days by the practice teams. This means in practical terms that the
practice should contact these patients if they miss their appointments
to rearrange another one. As this group of clients have problems that
affect their motivation this has the potential to happen. In these
circumstances the patient may benefit from the personal contact of a
telephone call, if this is not appropriate then a letter offering a further
appointment or advising contact with the practice could be sent. The
number of non attenders is not a QOF scoring indicator, the points are
earned by the follow up within 14 days.
Appendix 3 sample letter
MH4 % of patients on lithium therapy with a record of serum creatinine and
thyroid stimulating hormone in the preceding 15 months
MH5% of patients on lithium therapy with a record of lithium levels in the
therapeutic range within the previous 6 months.
Lithium
These indicators remain unchanged. Relatively few people take lithium,
however for those who do it is important that there is clarity about who is
prescribing the medication, who is monitoring the medication and how
frequently the patient is required to have appropriate blood tests. In Sheffield
we have a different therapeutic range than in other areas of the country (0.4 to
0.8 mmol/l).
MH6 % of patients on the register who have a comprehensive care plan
documented in the records agreed between individuals, their family and/or
carers ass appropriate.
As up to 50% of patients on the register will not be in contact with secondary
care services, the practice needs to develop a care plan. For those people on
Enhanced Care Programming Approach (eCPA), the CPA care plan is
sufficient evidence that a comprehensive care plan exists. Appendix 4 is an
example of a care plan the practice could use (More involved care plans are
available and can be forwarded if requested). It could be sent out to the
patient in advance of the review meeting and the patient and carer could
begin filling in parts of it, this will allow the patient and carer to take more time
and care over the content of the care plan. However for some people this will
not be appropriate and it will need to be completely filled in during the review
meeting. The practice representative carrying out the review meeting will have
to agree a course of action with the patient and carer of how they can receive
appropriate help in circumstances that they require it. It will be important to
use the systems that already exist within the practice so that consistency is
maintained.
Depression
DEP1 % of patients with diabetes and/or heart disease for whom case finding
for depression has been undertaken on one occasion during the previous 15
months using the two standard screening questions.
As part of an annual review of people with diabetes and heart disease the two
question screening should be used.
The Questions are
During the past month
 Have you often been bothered by feeling down depressed or
hopeless?
 Have you often been bothered by little interest or pleasure in doing
things?
It is important to emphasise the word often whilst asking the questions. If this
is not done there is potential for patients to answer yes to the question without
there being sufficient reason for them to need to be followed up more
thoroughly. If the patient answers yes to either question then they should be
investigated further so appropriate interventions can be given. A validated
questionnaire such as the PHQ-9 could be used to assist the clinician who
sees the patient to assess the severity of the condition and therefore the
intervention that will be best suited for them. Read code for screening 6896
DEP2 In those patients with a new diagnosis of depression, recorded between
the preceding 1 April and 31 march, the percentage of patients who have had
an assessment of severity at the outset of treatment using as assessment tool
validated for use in primary care.
There are several tools that have been validated for use in primary care. The
most common ones are the Beck Depression Inventory (BDI), the Hospital
Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire
(PHQ-9). The first two are available from different publishers and cost
between 30p and 50p per copy, usually bought in batches of 50 or 100. The
PHQ-9 is the scale that was specifically designed for use in the primary care
environment and is free to use. It measures severity and can be used for
initial diagnosis, to monitor progress and to highlight specific areas of concern
for the patient. Appendix 1 includes a copy of the scale and scoring
instructions.
Read Codes
388f. Patient health questionnaire (PHQ-9) score
388g. BDI second edition score
388P. HAD scale: depression score
Appendix
1.
2.
3.
4.
PHQ-9 and scoring
Paper by Simon Clay
Letters
Care plan sheet and crib sheet
Appendix 1
Appendix 2
Depression, Mental Health & avoiding writing unnecessary Mental
Health Care plans in QOF 2006 – How to sort out the mess:
The problem.
Until April 06, it really didn’t matter what Read code GP’s used for depression.
However since depression has been included in QOF, it matters a lot,
because of a potentially messy duplication between depression codes &
mental health codes.
The Mental Health (MH) register:
Under QOF rules before April 06, the only pts who were on the MH register
were deliberately put there by the active addition of one of 2 Read codes that
defined the presence of a “Mental illness” (9H6 or 9H8, - “On NSF Mental
Health register” or “On Severe Mental illness register”, respectively).
Under QOF 06, there are now 3 different ways by which pts may end up on
the MH register:
1. The presence of a “psychosis” Read code as defined by the MH
ruleset, anywhere in the record.
2. Having a script for Lithium in the 6/12 before each “Reference date”
(1st April each year.)
3. The presence, anywhere in the record, of one of the two “defining” MH
codes listed above, 9H6 or 9H8.
The Depression Read codes:
The depression Read codes are roughly divided into a neurotic depression
chapter & a psychotic depression chapter. So if GP’s have previously added
any depression read codes that come from the psychotic depression chapter,
they will now also have accidentally defined the pt as psychotic under QOF 06
& the pt will need a Mental Health care plan drawing up to score points.
Many of these psychotic depression codes are not obvious, e.g. .E112
“Single Major depressive episode”, which may have the alternative rubric
“Agitated depression”, or E1137 “Recurrent depression”
There is no time window within which these psychosis codes must have been
added, in order to trigger the psychosis definition. So codes added at any time
in the past all “count”
Once a psychosis code is added to the record, there is no easy way to
remove the pt from the psychosis register under the MH disease category.
This is because the original Read code that was introduced to remove pts
from the MH group in the previous QOF (.9H7, “Removed from Mental illness
register” ) does not remove the pt from the MH register if the reason the pt is
on the register is the presence of a psychosis Read code. It only removes the
pt if the only reason they are on the register is due solely to the presence of a
9H6 or 8 Read code – a very unlikely situation. (Most pts will have a
psychosis code too!)
The solution:
Produce a list of all those pts with historic codes for depression that will now
put the pt into the MH register. To do this run a report, searching for pts with
the following codes added ever:
1. E1... & all subordinate codes EXCEPT the following 5:
E118 SAD syndr’,
E11z1 Rebound mood swings,
E11z2 Masked depression,
E140 to E140z Autism,
E135. Agitated depression,
2. Eu204 [X] Post-Schizophrenic depression.
3. Eu323 [X] Severe depression with Psychosis.
Then exclude those pts with a genuine reason to be in the list, perhaps by
cross checking that list against last year’s list from your Mental health register.
You will then be left with a list of pts, some of whom will have no active
psychotic problem & who should not be in the MH register, & perhaps some
who actually DO have an active psychotic problem, but were “missed” from
your previous register of pts with a Mental illness, & therefore were not within
the MH register last year due to the practice having previously added 9H6 or 8
to their record.
A clinician is probably the only one who can differentiate these two groups,
(though evidence of active antipsychotic medication being prescribed might
be used as a screener perhaps?)
Having derived a list of pts that should not apparently be in the list, you need
to identify the code that’s putting them in there (remembering that they may
have more than one code triggering insertion.
You then have 4 choices:
a.) Add the exception Read code 9h91 “Mental Health: patient unsuitable”
to relevant pts’ records to remove them from the MH register. (You will
need to do this annually as this is an expiring Exception Read code,
and so lasts for one year only.
b.) Change the triggering code(s) to another one with a similar meaning in
terms of depression but not within the Psychotic depression chapter.
(See below)
c.) Leave their record alone, & do a Mental health care plan on lots of pts
who have no need for one.
d.) Don’t do anything much & waive some or all of the points available for
the indicators involved (29 points for MH6 & 9.)
Changing historic depression codes:
Clearly, a practice needs to be clear about what they are doing if following this
plan, as the record is being altered.
However, one is able to alter a record if the record is factually incorrect, so if
the practice feels that it can argue that depression codes were used
previously when the clinicians were not aware that they were technically
psychotic depression codes, it might be felt that that is a valid reason to alter
the Read codes to ones which do not have that serious implication, neither
clinically, nor with the additional false consequences foisted upon the practice
& the patient by the new QOF Rulesets.
Particular codes that we found had been used extensively in records included
the following:
E112 whose rubric variants included “Endogenous depression”, “Single major
depressive episode” & “Agitated depression”.
E113 “Recurrent Major depressive episode”
E1137 – “Recurrent depression”
A clinician needs to review the notes of patients with these codes – especially
where they were added a long time ago & where the pt seems to have no
recent Hx of any psychiatric illness, where suggesting to the pt that a Mental
Health care plan should be drawn up would seem to be inappropriate &
possibly offensive.
Final task:
The final section has nothing to do with the depression disease area or its
Read codes.
But we also found a number of pts who had had MH codes added in the past,
which are technically psychosis codes, but where the illness had long-since
resolved & again, a care plan was clearly unnecessary.
Such pts usually had not had 9H6 or 8 on their records last year, & were
therefore not in the MH register previously, but would be now, due to the
presence of an historic psychosis code.
Such codes included:
Eu30. “Manic episode”
Eu30z “Manic episode unspecified.”
Again, as the rules stand, there is no code that may be added which would
permanently except a pt with these codes from the MH register, & the best
option may be to add the expiring exception code 9h91 “Mental Health:
patient unsuitable” to the pt’s record & do it again next year unless the QOF
rules are improved in the interim.
Clinician record entries:
It is important that all clinicians realise the relevance of psychotic depression
codes & avoid adding them unless they truly want to label a pt with a
psychotic depression.
Some clinical systems, e.g. Premier Synergy, will allow the addition of “hooks”
which can be added to particular read codes, which, if chosen, pop up a
message warning the clinician of the implications of their proposed code. e.g.
to E112 “Agitated depression”.
Summarising:
It is also important that, once a practice has been through this tidying process,
the good work is not undone by summarising staff adding psychosis codes to
pts with a Hx of simple depression. Practices need to give summarisers a list
of acceptable depression codes to use when needed, until such time as
electronic record transfer comes about.
Simon Clay.
July 2006.
Simon.Clay@Gmail.com
Appendix 3
Sample letter of invitation
Dear……………….
As you are or have been receiving care for mental health difficulties we are
writing to invite you to attend the practice for your annual review. In this
review we will do a physical health check, a review of your medication and
look for any advice we can give you to improve your health.
If you are not on CPA please complete the enclosed care plan sheet as much
as you can, this should be done with your carer if you have one. A carer can
be a relative, friend, neighbour who helps you out or looks after you when you
are unwell. Bring the care plan sheet to your appointment with you, the rest
can be filled out at your appointment. You will know if you are on CPA as you
will have regular reviews and a care co-ordinator.
Your appointment is
Or
Please contact the surgery to arrange an appointment
Or
Please book an a double/triple appointment with Dr …………
Please contact the surgery if you are unable to attend or there is a problem
with your appointment.
Sample letter for people who do not attend initial appointment.
Dear…………..
As you missed your appointment on…………….. we have made a further
appointment for you on…………. Please contact the surgery to re-arrange if
this appointment is not suitable.
This appointment is for an annual health check so we can monitor your health
with things like blood pressure and to look for ways you can improve your
health.
Enclosed is a copy of a care plan sheet which we would like you to fill in as
much as you can, with your carer if you have one, if you are not on enhanced
CPA. Bring it to your appointment so it can be completed. This will help if you
become ill again.
Appendix 4
Mental Health Care Plan
To be completed if you are not on enhanced CPA
Your Details
Name
Address
Your Carers Details
Name(s)
Address
DOB
Contact Numbers
Contact No’s
Filled in with carer Yes/ No
Are you
Employed Full Time (more than 30 Hours)
Employed Part time
Doing Voluntary work
In education or training
Unemployed
Homemaker
Tick appropriate
Do you see a Doctor, Nurse or Social worker secondary care? Yes/No
Name address phone number
What are your social care needs? – Housing, benefits etc
Who is helping you with these?
Others Involved – eg voluntary or community agencies. Other Relatives or Friends
Contact details
What are your main symptoms
Are your symptoms currently well managed? Yes / No
List of previous symptoms
Action to be taken if symptoms not controlled
What signs are there that you could be becoming unwell again?
Early Warning Sign
What to do, who to contact
1
2
3
Longer Term Plans eg education training employment
Useful contact numbers
Signed and dated by patient, carer and practice representative
Review date
Copies to be taken away by patient and carer
Notes on Care plan
Do you see a Doctor, Nurse or Social Worker in secondary care.?
If the patient has a care co-ordinator and is on a care programme this care
plan is not needed for QOF as the care programme plan is sufficient.
What are your social care needs?
This could include housing difficulties and benefit or employment problems.
The patient carer could be signposted to agencies to support them with this,
such as CAB if they are not already engaged.
Others involved
This could include NHS non mental health workers, voluntary sector workers,
church and faith groups, friends and informal support. This will help the
practice judge how much support is being received by the patient. It will also
give the practice an idea of who is involved and who they can contact if the
patient has problems.
What are your main symptoms
Here a framework like HoNOS could be used, or the patients own description
of their symptoms. However, this may have to be interpreted by the person
carrying out the review so to aid communication with other members of the
practice team if they needed to use the care plan.
Action to be taken if symptoms not controlled
Here is a record of the actions to be taken by the patient and practice team to
help control the symptoms of the patient. This could include signposting or
referral on to a specialist agency. Despite best efforts some symptoms can
not be controlled better than they are, however a reappraisal may help to find
better solutions.
What signs are there that you could be becoming unwell again
In developing a relapse signature the patient should be encouraged to seek
help as early as possible so to potentially reduce the length and severity of
the relapse. The earlier the warning signs are noticed and action taken to
resolve the problem the better to prognosis.
Early Warning Signs / What to do
When an early warning sign has been identified a plan of action should be
developed. This could include things the patient can do themselves, E.G.
managing stress and relaxation more effectively or manage medication in a
different way. It could also include what the practice could do. If an agreement
is made about how a patient can contact the practice to highlight a potential
relapse the usual practice systems should be used so that a consistent
approach can be taken by all the practice.
Longer term plans
This could include things like access to education and employment. How
current and potential social needs could be met, including housing issues.
Who the patient has been signposted or referred to, to meet these needs.