Carolyn A. Chew-Graham is a general practitioner and professor of general practice research at Keele University
David Shiers is a retired GP and carer
Ben Perry is associate clinical professor of psychiatry, University of Birmingham
Tim Doran is professor of health policy, University of York
We all know about the mortality gap for people with Severe Mental Illness (SMI) – that someone with SMI will die 15-20 years earlier than a person without SMI.1 This ‘mortality gap’, mostly due to the risk of physical health problems including cardiovascular disease (CVD) and metabolic problems such as diabetes, is widening. The late Professor Helen Lester asked us to be ‘…bothered about Billy’, and to be more invested in managing the physical health of people with SMI.
The Lester Positive Cardiometabolic Health Resource supports healthcare professionals in monitoring the physical health of people with SMI, with the aim of improving patient outcomes. The resource supports NHS England’s Core20Plus5 framework, which targets healthcare improvements towards the most deprived and under-served populations, with a focus on SMI and cardiovascular disease.
The Lester resource emphasises the need not just to ‘screen’ for risk factors: smoking and raised blood pressure, BMI, HbA1C and lipids but also to ‘intervene’, identifying when interventions should take place.
The Lester resource emphasises the need not just to ‘screen’ for risk factors: smoking and raised blood pressure, BMI, HbA1C and lipids but also to ‘intervene’, identifying when interventions should take place. A barrier already exists to appropriate assessment of risk as QRisk3 is not embedded in general practice IT systems. Most practices continue to use QRisk2. All Q models, however, under-estimate risk in people with SMI – especially young adults.
Many people with SMI are managed solely in primary care and everyone with SMI should be invited to attend their general practice for an annual physical health check.
The Quality and Outcomes Framework (QOF) sets targets, or financial incentives, for general practices to achieve. Practices develop protocols and processes to ensure they achieve the range of targets set, to maintain the practice income. Each year, the QOF targets are revised and in April 2025, the target to maintain a register of people with SMI which had been included in the QOF since its inception in 2004, was removed:
“MH001. The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses, and other patients on lithium therapy.”
Indicators relating to ‘ongoing management’ remain, with incentives for recording a care plan, blood pressure, BMI, alcohol consumption, lipid profile and blood glucose or HbA1C. The indicator for the percentage of patients with SMI who have received all six elements of the physical health check also remains.
As part of the re-focusing of the QOF towards cardiovascular risk prevention, NICE (National Institute of Health and Care Excellence) suggests that the key focus of the physical health check should be to identify individuals at increased risk of developing CVD and type 2 diabetes, given that these conditions are much more common in people with SMI and are major contributors to their reduction in life expectancy.1 NICE cites evidence that there is a tendency for obesity, hypertension, glucose and lipid disturbances to cluster, due to the accumulative impact of the adverse metabolic effects of psychotropic medications and health behaviours such as smoking, sedentary lifestyle and limited diet.2
This focus on cardiovascular risk is understandable, but it is not clear why the requirement to maintain a register of people with SMI has been removed, other than possibly to free up financial resources. The need to provide denominators for the remaining clinical indicators may mitigate the loss of specific incentives for maintaining a register, but we know that when QOF indicators are removed, clinical activity in that area is typically reduced,3 and this disproportionately affects care for population groups with high prevalence of the condition. SMI is the QOF area with the greatest socioeconomic gap in prevalence, whereas quality of care (or, at least, achieving the QOF targets) is pretty equitable, with no significant socioeconomic gaps in achievement rates for most SMI indicators. Any reduction in practice performance as a result of the withdrawal of incentives will affect socioeconomically deprived patients the most, increasing the very health inequalities practices and policy-makers have been trying to overcome.
Any reduction in practice performance as a result of the withdrawal of incentives will affect socioeconomically deprived patients the most, increasing the very health inequalities practices and policy-makers have been trying to overcome.
In the calculation of achievement rates for QOF indicators, practices currently make a case-by-case decision on removing patients from the denominator if they decline screening/treatment or are deemed unsuitable. While this so-called ‘exception reporting’ does not guarantee all eligible patients will receive an intervention it does at least require a conscious decision by practice staff and provides an opportunity to consider ways to improve that person’s access. Recent evidence suggests that exception reporting is increasing for SMI incentives, particularly for people of Black and Asian ethnicity.4 Removing the need to maintain a register will further diminish the opportunity to improve access for this particularly vulnerable group to preventive care through quality improvement approaches.
Finally, there will be people being prescribed antipsychotics who have diagnoses other than SMI who are also at increased risk of CVD and diabetes due to side-effects of these medications.5 These drugs will usually have been commenced in specialist care but people will have been discharged for primary care, and we continue prescribing, What, as GPs, should we be doing to reduce risk in this other high risk group of patients? We should be asking ourselves: How can we continue to be ‘bothered about Billy’?
References
- Ma R, Romano E, Ashworth M, Yadegarfar ME, Dregan A, Ronaldson A, de Oliveira C, Jacobs R, Stewart R, Stubbs B. Multimorbidity clusters among people with serious mental illness: a representative primary and secondary data linkage cohort study. Psychol Med. 2023 Jul;53(10):4333- 4344. doi: 10.1017/S003329172200109X.)
- Vancampfort D, Stubbs B, Mitchell AJ, De Hert M, Wampers M, Ward PB, Rosenbaum S, Correll CU. Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta- analysis. World Psychiatry. 2015 Oct;14(3):339-47
- Morales D et al. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ 2023; 380 https://doi.org/10.1136/bmj-2022-072098
- Launders et al. Characteristics of people with severe mental illness excluded from incentivised physical health checks in the UK: electronic healthcare record study. The British Journal of Psychiatry. Published online 2025: 1-8.doi:10.1192/bjp.2025.49
- Pillinger T et al Comparative effects of 18 antipsychotics on metabolic function in patients with schizophrenia, predictors of metabolic dysregulation, and association with psychopathology: a systematic review and network meta-analysis. Lancet Psychiatry 2020; 7: 64–77 https://doi.org/10.1016/
Featured Photo by Stefano Pollio on Unsplash
Important article. Thanks for highlighting this. It will be important to track what happens to the denominator for the remaining SMI indicators, as this seems likely to increase inequality over time.