Many GPs have discovered that achieving points in the mental health domain is among the biggest challenges in the quality framework.
Even setting up a register is not a simple task when it is applied to severe mental illness.
The rationale for the register is that patients with severe mental illness have increased mortality and morbidity from CHD, diabetes and respiratory disease. Their medication may exacerbate morbidity, especially atypical anti-psychotics that cause dramatic weight gain.
As well as searching practice records for relevant diagnoses and anti-psychotic medication, setting up the register involves checking with the community mental health team (CMHT) for patients on the Care Programme Approach (CPA).
Do not be surprised if you find that only one in three of the patients you identify are in contact with mental health services. Including patients with a relevant diagnosis in the last 10 years makes sense. About a third of patients who have recovered from psychotic episodes will have relapsed in this time.
It also makes ethical sense to include people on atypical anti-psychotics who are not on other registers. They have increased morbidity and it is likely that mental health services have not done the necessary screening tests or recorded their weight.
Health check template
You may need to contact mental health services for clarity about some diagnoses.
With some patients, diagnoses change every year. For others, a diagnosis has not been recorded in the last 10 years. My practice includes severe obsessive compulsive disorder patients on olanzepine and has put them in the register for monitoring purposes.
We use a health check template devised by Cumbria PCT, which includes a patient’s smoking, use of non-prescribed drugs, alcohol, weight, BP, exercise levels, mental state, carers and details of involvement with care services, CPA level and sexual health. The template also covers side-effects and compliance with medication, leisure activities and access to benefits advice.
At my practice, the nurse most interested in mental health is responsible for patient reviews. Because she had not had any mental health experience or training, we decided she should take a primary CHD prevention stance, which she felt safest with.
The nurse phones patients to explain why it is important to come in for a physical health check. They are told they could attend with a relative or community worker and then booked for a double appointment with the nurse and GP of their choice.
All but one of the 35 patients contacted in this way attended. The patient who did not preferred to see the psychiatric services.
Consent to go on the register was addressed at the end of the consultation. Only one patient refused, although she did agree to an annual recall.
Many patients with psychosis have learning difficulties such as dyspraxia and dyslexia. They are very anxious. Some have paranoid ideas. They need a careful explanation in order to give consent properly. Using the primary CHD prevention approach encouraged this.
Training may be needed to spot medication side-effects. Most patients were unaware of them, although about a fifth were experiencing problems. These included loss of libido with olanzepine, fine tremor with lithium, oro-facial dyskinesia and Parkinsonian symptoms.
Some of those noticing side-effects had not mentioned them for fear of appearing critical.
The comprehensive care plan indicator made us think about the two-thirds of our patients not in contact with mental health services.
St Helens GP Dr Laura Pogue has devised a well-being care plan that we have modified for local use. The plan could be extended to cover any patient presenting with mental distress.
Birmingham GP Dr Anand Chitnis has created a list of appropriate Read codes that practice staff can use across the spectrum of mental health difficulties. We can sort out the recent large increase in our mental health register by changing Read codes from E to EU.
Reviewing mental health patients is rewarding. They seem to trust us more and are more likely to report side-effects of medication and to talk about sexual difficulties. Their carers are relieved there is another resource. And we are more confident about managing difficult behaviour and treating people with mental health problems.
Dr Young is a GP and family therapist at a Cumbria practice
|MENTAL HEALTH INDICATORS|
|Total 39 quality points||Points||Payment stages|
Score the maximum points
Community health team records.
Co-ordination of care.
Medication (including non-prescribed), compliance, side-effects.
Bloods for FBC, U&E, LFTs, cholesterol, TFTs, RBS (Prolactin) if indicated.
Sainsbury Centre for Mental Health www.scmh.org.uk
Mental Health Foundation www.mentalhealth.org.uk
National Electronic Library for Health www.nelh.nhs.uk/mentalhealth
Read code queries, Dr Anand Chitnis firstname.lastname@example.org
Well-being care plan, Dr Laura Pogue Lancaster House Medical Centre (01744) 617000