Summary
Although population achievement and exception rates vary by indicator,31,32 when directly comparing indicators of the same type, higher exception rates and lower payment and population achievement rates were found for BMI and blood pressure recording in MMI compared with diabetes and CKD across the whole of the UK. Population achievement rates for the MMI indicators were also found to be lower in Scotland and Wales but higher in Northern Ireland than in England, although absolute differences were small.
To the authors’ knowledge, this is the first study to directly compare measurement indicator population achievement rates for different chronic diseases across the whole of the UK. The clinical, societal, and financial implications of undetected raised BMI and blood pressure are likely to be significant, especially for individuals with MMI.
Strengths and limitations
To the authors’ knowledge, this is the first study to directly compare payment, exception, and population achievement rates for individual mental health indicators with other individual chronic disease indicators across the whole of the UK and between nations. The national scope and the high level of uptake of the QOF within UK practices contributes to the strengths of the study, but some limitations are acknowledged. First, QOF data is a payment rather than quality monitoring system and was obtained at a practice; rather than patient-level basis, meaning patient-level case mix adjustment was not possible. Given that individuals with MMI are more likely to have physical health problems,33 it was not possible to assess the effect of multimorbidity on payment, achievement, and exception rates. As individual patients can appear in more than one chronic disease indicator denominator, it was not possible to determine the level of patient overlap between the chronic diseases investigated. This could only be studied by detailed auditing within practices. Exception reporting is under individual practice control and so variation in practice policy, both locally and between countries, may occur. Differences in practice performance are associated with choice of clinical computing system,34 and given that data were obtained from the whole of the UK, variation in clinical computing software likely occurred and may be a confounder. While data from one contractual year have been presented, further longitudinal work is required to determine whether these patterns are sustained over a prolonged period and represents a further limitation to the work of this study.
Comparison with existing literature
Ten years after the introduction of the QOF, very few studies have compared indicator achievement rates across different countries within the UK. Cross-jurisdiction comparisons are helpful to determine possible trends, potential areas of concern, and differences in practice that might occur across UK primary care.30
The findings of higher population achievement rates in Northern Ireland and lower population achievement rates in Wales relative to England have been reported elsewhere, namely, for mean population achievement rates for intermediate outcomes and treatment indicators in coronary heart disease, stroke, hypertension, and diabetes.35
Reasons for higher population achievement rates in Northern Ireland may include greater health and population stability or a younger population than in the rest of the UK.36 Differences in prevalence across the four nations may also have influenced achievement rates.
The finding of lower population achievement rates due to higher exception rates for BMI recording in MMI relative to diabetes are of concern, as BMI recording and monitoring is important for health promotion and is recommended in the National Institute for Health and Care Excellence (NICE) guideline on obesity.37 Given the move towards primary prevention, recording of BMI in 82% of patients with MMI in Scotland and Wales suggests that while most patients are receiving QOF-level care, there is room for improvement. Whether this improvement is possible, given that the onus is on patients to attend their practice, is unclear and warrants further investigation. Reasons for lower achievement rates for MMI likely include both patient and practice factors. The QOF does not incentivise home visits and so, if patients do not attend, they are more likely to be excepted, and it is well recognised that individuals who are housebound have higher rates of mental illness.38
Although obesity is recognised as a major public health problem, there are many barriers to its management, including lack of motivation on the patient’s part,39 and practice-level factors, such as GPs or practice nurses perceiving a lack of training in obesity management.35 Given the high rates of obesity within the UK, and the particularly high rates in people with MMI,22 the planned retirement of the BMI indicator for the 2014/2015 QOF in England40 is concerning because opportunities to intervene and improve the physical health of individuals with MMI may be lost.
Significantly lower population achievement rates were found for blood pressure recording in MMI relative to CKD. While it is unclear what proportion of patients had normal or elevated blood pressure, it is recognised that frequent, accurate recording and monitoring of blood pressure is associated with reductions in systolic and diastolic blood pressure and therefore better control.5 Blood pressure monitoring while on antipsychotic medication has also been recommended in the NICE guidelines on schizophrenia since 2009.41,42
Although the drive towards a more integrated approach to the management of the physical health of those with MMI has been relatively recent,43,44 the evidence for poor cardiometabolic health in this cohort has been clear since the late 1990s and early 2000s,45,46 and is reflected within all clinical guidelines over the past 5 years.
Other factors may contribute to the lower payment and population achievement rates observed for patients with MMI. First, the mental health BMI and blood pressure indicators were introduced in 2011/2012, while the BMI indicator for diabetes has existed since 2004/2005 and, similarly, the blood pressure indicator for CKD was introduced in 2006/2007. It is recognised that indicator payment rates improve with time and then plateau,47 and so this disparity may contribute to the differences observed. Furthermore, blood pressure and BMI recording have long been recognised as important in the management of CKD and diabetes, but are relatively new for MMI. GPs may also regard blood pressure measurement inappropriate for younger patients with MMI because of uncertainty around therapeutic options.
Further possible explanations for the findings might include stigma associated with mental illness, as well as the perceived separation of physical and mental health care by the patient, their carer, GPs, and psychiatrists. Although individuals with MMI have more physical health problems than the general population,48,49 inequalities are persistently reported for both the access to, and the quality of, a range of physical healthcare services.50–53 While payment rates across the indicators were similar, exception rates for the MMI indicators were markedly higher than for those in patients with diabetes and CKD. This suggests that although practices may be attempting to engage individuals, the QOF may not provide the flexibility needed to overcome non-engagement for patients with MMI, leading to higher exception rates.
Implications for research and practice
Evidence of lower payment, higher exception, and lower population achievement rates were found for BMI and blood pressure recording in MMI relative to diabetes and CKD throughout the whole of the UK. Variation in payment, exception, and population achievement rates were also found between countries. It is likely that this is multifactorial, reflecting a combination of patient, clinician, and wider organisational factors. However, these findings suggest possible inequality in access to certain aspects of health care for patients with MMI: as demonstrated by inequality in access to QOF recording of BMI and blood pressure. Further investigation, for example, through detailed auditing of patient level data, is needed.
