NM108: August 2015 1

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE

Indicators for the NICE menu for the QOF

Indicator area: Mental health

Indicator: NM108

Indicator: NM108

The percentage of patients with schizophrenia, bipolar affective disorder and

other psychoses who have a comprehensive care plan documented in the

record, in the preceding 12 months, agreed between individuals, their family

and/or carers as appropriate.

Please note: NICE inherited this indicator when it became responsible

for managing the process of developing and maintaining QOF indicators

in 2009.

Introduction

This indicator focuses on people with serious mental illness, including

schizophrenia, bipolar disorder and other psychotic illnesses. Schizophrenia is

a psychiatric disorder, or cluster of disorders, in which a person's perception,

thoughts, mood and behaviour are significantly altered. It is characterised by

‘positive symptoms’ (including hallucinations and delusions) and by ‘negative

symptoms’ (such as emotional apathy, lack of drive, poverty of speech, social

withdrawal and self‑neglect).1 Over a lifetime, about 1% of the population will

develop psychosis and schizophrenia.

Bipolar disorder is characterised by episodes of depressed mood and elated

mood (mania or hypomania). Mania is abnormally elevated mood or irritability

with severe functional impairment or psychotic symptoms for 7 days or more,

whereas hypomania is abnormally elevated mood or irritability with decreased

or increased function for 4 days or more. The estimated lifetime prevalence of

1 National Institute for Health and Care Excellence (2015) Psychosis and schizophrenia in

adults NICE quality standard 80

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bipolar I disorder (mania and depression) is 1% of adults, and 0.4% of adults

are affected by bipolar II disorder (hypomania and depression).

Rationale

This indicator measures the percentage of people with schizophrenia, bipolar

disorder or psychosis who had a comprehensive care plan documented in the

previous 12 months. The aim is to encourage coordinated delivery of health

care services for people with schizophrenia, psychosis or bipolar disorder.

Between 18–30% of people with severe mental illness in the UK are

described as being seen only in a primary care setting2 so it is important that

practices take responsibility for discussing and documenting care plans for

these people in their primary care record.3 The NICE guidelines for psychosis

and schizophrenia in adults and bipolar disorder highlight the importance of

care plans for people with schizophrenia, psychosis or bipolar disorder. The

guideline for bipolar disorder specifies that treatment and care of people with

bipolar disorder in primary care should be reviewed at least once a year. It

also specifies that GPs should receive a copy of care plans developed in

secondary care and that people with bipolar disorder should be encouraged to

share their care plans with their carers. This indicator aligns with NICE

guidance to provide an incentive for annual reviews of care plans for all

people with schizophrenia, psychosis or bipolar disorder, which should be

agreed with the person and their family and/or carers as appropriate.

Source guidance and recommendations

Psychosis and schizophrenia in adults (2014) NICE guideline CG178

Recommendation 1.3.3.4: Write a care plan in collaboration with the

service user as soon as possible following assessment, based on a

psychiatric and psychological formulation, and a full assessment of their

physical health. Send a copy of the care plan to the primary healthcare

professional who made the referral and the service user.

2 Reilly S, et al. (2012) The Role of Primary Care in Service Provision for People with Severe

Mental Illness in the United Kingdom. PLoS ONE 7(5): e36468. doi:10.1371/journal.pone.0036468 3 Guidance for GMS Contract Quality and Outcomes Framework 2015/16

NM108: August 2015 3

Recommendation 1.5.3.6: When a person with an established diagnosis

of psychosis or schizophrenia presents with a suspected relapse (for

example, with increased psychotic symptoms or a significant increase in

the use of alcohol or other substances), primary healthcare professionals

should refer to the crisis section of the care plan. Consider referral to the

key clinician or care coordinator identified in the crisis plan.

Bipolar disorder (2014) NICE guideline CG185

Recommendation 1.2.4: When working with people with bipolar disorder

in primary care:

engage with and develop an ongoing relationship with them and their

carers

support them to carry out care plans developed in secondary care and

achieve their recovery goals

follow crisis plans developed in secondary care and liaise with

secondary care specialists if necessary

review their treatment and care, including medication, at least

annually and more often if the person, carer or healthcare

professional has any concerns.

Recommendation 1.3.4: If bipolar disorder is diagnosed, develop a care

plan in collaboration with the person with bipolar disorder based on the

assessment carried out in recommendation 1.3.2 as soon as possible

after assessment and, depending on their needs, using the care

programme approach. Give the person and their GP a copy of the plan,

and encourage the person to share it with their carers.

Recommendation 1.9.4: When making transfer arrangements for a

return to primary care, agree a care plan with the person, which

includes:

clear, individualised social and emotional recovery goals

a crisis plan indicating early warning symptoms and triggers of both

mania and depression relapse and preferred response during relapse,

including liaison and referral pathways

an assessment of the person's mental state

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a medication plan with a date for review by primary care, frequency

and nature of monitoring for effectiveness and adverse effects, and

what should happen in the event of a relapse.

Give the person and their GP a copy of the plan, and encourage the

person to share it with their carers.

Further information

This is NICE indicator guidance for QOF, which is part of the NICE menu of

indicators. This document does not represent formal NICE guidance. The

NICE menu of indicators for QOF is available online at:

http://www.nice.org.uk/standards-and-indicators/qofindicators