The Crazy World of Mental Health

For the vast majority of practices the clinical data on this site has been automatically extracted from their computer systems. There are various ways that this is done but it is all under the control of the business rules. These determine which codes indicate success or failure in each area and are thus crucial to practices. The original set of rules had a few quirks but these were fairly quickly ironed out and gave two good years of service. With the new, more complex, items in 2006/7 some more rules were needed. Nowhere was the change and complexity greater than in the mental health area. The diagnostic criteria changed from merely having a "severe and enduring" mental health problem to being exclusively psychotic and bipolar disorders. Also the individual criteria became quite involved - the worst being

MH7: The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance.

There have been three sets of rules this year. Version 8.0 - in which the rules for MH7 were completely incomprehensible. Version 8.5 still had problems which I listed at some length and version 9.0 which was released shortly before Christmas. There is no doubt that version 9.0 is much better and solves many of the previous problems, albeit sometime in a somewhat cumbersome way. It does, however still have some problems and has introduced a new challenge to practices. Perhaps the most dramatic change is the abolition of the explicit mental health register. In the original QOF patients were given the option of 'opting out' of the mental health register. Under the new rules entry to the register will be coded on diagnosis rather than an explicit code. This is arguably a better way of doing things - in fact this is the way that the rest of QOF does things. But this is a very late rule change. Systems suppliers and central systems are not yet upgraded. Practices may have a very short time to make sure their data fits the new rules. Finally there is still no provision for the recovery from mental illness. Whilst much illness is lifelong there is a considerable amount that is short lived. Read code 212T means "Psychosis, schizophrenia + bipolar affective disorder resolved" which seems to suggest that active follow up would not be needed. Unfortunately the rules do not look for this code so some of my patients who only had a brief period of postnatal psychosis in the 1970s are included on the register. The solution has been to code them as 9h91 "Excepted from mental health quality indicators: Patient unsuitable". An ugly bodge maybe, and one that will possibly need repeating annually, but it does illustrate the use of exception reporting as a pressure valve for problems in the business rules. I await version 9.5 with interest.