Title: Does better quality of primary care influence admissions and health outcomes for people with serious mental illness (SMI)? A linked patient-level analysis of the full patient care pathway
Funder: Department of Health and Social Care

Abstract: The UK government’s mental health strategy recognises the huge personal, social and economic costs of serious mental illness (SMI). In England, general practitioners (GPs) play a central role in the care of most people with SMI, with 57% of people with schizophrenia and 38% of people with bipolar disorder treated in primary care with little or no contact with secondary care services. Under the Quality and Outcomes Framework (QOF), introduced in 2004, general practices receive financial rewards for achieving specific quality targets for patients with a range of chronic illnesses, including SMI. Quality indicators cover both mental health care, such as monitoring lithium levels, and physical care, such as routine health promotion. The QOF however only paints a partial picture of quality and may neglect other important unmeasured dimensions. Our key research question is whether better management of SMI in general practice improves health outcomes and health care utilisation for people with SMI. The quality of SMI management will be measured in two ways: i) by achievement on relevant QOF indicators using SMI QOF indicators (e.g. management of blood glucose, since antipsychotic drugs increase the risk of metabolic syndrome, a predictor of Type 2 diabetes); and ii) by non-QOF measures selected on the basis of findings from the literature and informed by Patient and Public Involvement (PPI) and the Scientific Steering Committee (SSC), and will include measures such as inappropriate polypharmacy, frequency, and continuity of GP consultations. The outcome measures to be assessed include i) hospital admissions for SMI, ii) emergency admissions for Ambulatory Care Sensitive Conditions (ACSC) which primary care can influence; iii) costs for SMI patients in primary and secondary care; iv) mortality; and if feasible v) the number of A&E attendances; and vi) Health of the Nation Outcome Scale (HoNOS) scores (a clinician rated outcome tool). We will investigate these questions by creating, for the first time, a full picture of the care pathway in primary, secondary and, if feasible, community care for this patient group, enabling us to track care received by individual patients through time and across settings. We will achieve this by assembling several complex longitudinal datasets based on routine data: the first at practice level linking achievement data for QOF indicators and Hospital Episodes Statistics (HES); the second at individual patient level linking HES, ONS mortality data, and the Clinical Practice Research Datalink (CPRD) which is collected in primary care; and, if feasible, the third linking HES, CPRD, A&E data and the Mental Health Minimum Dataset (MHMDS) which covers community and social care. We will apply statistical methods that take into account the longitudinal data structure to examine the association between quality and outcomes. Policy seeks to improve the quality and accessibility of effective care for people with SMI. NHS England s Call to Action seeks to strengthen the role of general practice, to play an even stronger role at the heart of more integrated out-of-hospital services that deliver better outcomes, and the most efficient possible use of NHS resources. Our research will address these issues.

Lay abstract: Serious mental illness (SMI) such as schizophrenia and bipolar disorder can have a devastating impact on those with the disease, their families, carers and society. For SMI patients, the first point of contact with the NHS is usually their General Practitioner (GP). GPs oversee care, prescribe medication and provide both mental and physical care. This last point is important as people with schizophrenia die on average around 15-20 years earlier than the general population because they are more likely to suffer from preventable physical illnesses like obesity, hypertension, diabetes and smoking-related diseases. Strategies to improve the quality of GP care should help reduce the impact of mental health problems. The Quality and Outcomes Framework (QOF) offers financial rewards to GP practices for good quality care, including payments for treating people with SMI. QOF indicators require GPs to closely monitor the dosage of particular medicines; to ensure that people with SMI have a comprehensive care plan; and to undertake annual reviews including physical health checks. Our study will examine whether better quality primary care can improve outcomes for SMI patients. We will examine both QOF and non-QOF quality measures. The outcome measures we will examine include emergency admissions, costs, mortality, and if feasible, A&E attendances, and Health of the Nation Outcome Scale (HoNOS) scores. The potential impact of the research is on (a) NHS providers and practitioners to ensure the way services in primary care are provided deliver improved outcomes; and improve integration through strengthening links between primary, secondary and community care; (b) on policy makers to ensure SMI management (both QOF and non-QOF) is linked to better patient outcomes; amend the current incentive scheme to improve the link between financial payments and better outcomes; change the nature or scope of coverage of the incentive scheme; and re-allocate resources between primary and secondary care; (c) on service users who will benefit from better quality care; and potential inclusion of more appropriate SMI quality indicators in the QOF and (d) taxpayers through a more efficient use of NHS resources. We intend to answer the research question by linking data on general practices, individual patients, and use of hospital and community mental health services. This requires strict data governance and security measures and we have substantial experience in handling these assurance requirements. As we are analysing secondary data in which patients cannot be identified, there are no ethical implications from the study. The research will be jointly undertaken by the Centre for Health Economics, Department of Health Sciences, Hull York Medical School, all at the University of York; and Primary Care and Population Sciences at the University of Southampton. The team is experienced and multi-disciplinary with a track-record in mental health services research and analysing large complex datasets. The linked datasets are complex and will require considerable effort to clean and analyse. This has not been undertaken by any research group before and will be an important resource for future research.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH