Intended for healthcare professionals


What happens when pay for performance stops?

BMJ 2014; 348 doi: (Published 10 February 2014) Cite this as: BMJ 2014;348:g1413

Re: What happens when pay for performance stops?

Guthrie and Morales conclude that the 2014/15 QOF contract decision in England to remove incentivised measurement of body mass index, cholesterol and glucose/HbA1c could harm the healthcare provided to those with severe mental illness [1]. These concerns appear not to trouble the English QOF negotiators, who also ignored the QOF Advisory Committee of NICE advising these indicators should be retained as they helped to improve health inequalities for people with severe mental illness[2].

The decision to retire these indicators will limit opportunities in primary care to address cardiovascular disease (CVD) risk in people with severe mental health problems, the single largest contributor to a 15-20 year reduced life expectancy in such patients, despite good evidence that the QOF can improve cardiometabolic risk for this population, albeit less effectively than for those with diabetes [3].

Nor is premature death the only concern. The impact of serious mental illness is amplified by the development of obesity, type 2 diabetes and CVD. Table 1 summarises the scale of risk and the opportunities for targeted prevention.

Systematic monitoring of the dismissed indicators provides the bedrock for prevention activities, and early detection of these disorders in patients with severe mental health problems.

The prevalence of metabolic syndrome, predictive of future diabetes, CVD and premature death, for those at the onset of psychosis is similar to the general population [5]. However, by age forty, metabolic syndrome becomes four times more likely than in non-psychiatric populations [6], highlighting how potentially modifiable cardiometabolic risk builds to create a diverging pathway towards multiple morbidities and premature death for those with severe mental illness. For example within 10-15 years of developing schizophrenia, in a group not known to have diabetes previously, systematic screening found 10% already had type 2 diabetes and another 38% were at 'high risk of diabetes' biochemically [7].

One possible justification for QOF indicator retirement is that they have become embedded in routine practice. The National Audit of Schizophrenia (2012), using standards derived from NICE schizophrenia guidelines [8] revealed only 29% of 5091 patients, under community mental health teams from across England and Wales, had record of an adequate assessment of cardiometabolic risk within the previous 12months (weight, smoking status, glucose, lipids, BP) [9]. Weight was unrecorded in 43%. This emphasises the important role primary care has in filling this gap – but this work may not be done when the indicators go.

Notwithstanding concerns over health inequalities and these dismissed indicators being strongly recommended in NICE guidance [8] this QOF disinvestment contradicts the government’s repeatedly stated policy commitment to reducing the 15-20 year mortality gap for this population.[11] Furthermore delegating QOF negotiating responsibility to the NHS Employers (trading subsidiary of the NHS Confederation) would indicate the government values the charitable status of an organisation whose stated purpose is simply described to the Charity Commission:

“The Charity’s objects are the relief of sickness and the preservation and protection of public health”
Objects 4.1 Memorandum and Articles of Association of the NHS Confederation[12]

Guthrie and Morales’ conclusions reinforce the NICE QOF advisory committee’s position and appear at odds with this charity’s declared commitment to preservation and protection of the public health.

The late Professor Lester, leading general practitioner and academic advising on the QOF until her death a year ago, pointed to discrimination as the critical explanation of why this population experience poor healthcare. In the James McKenzie lecture Being Bothered about Billy [13] Professor Lester reminded colleagues from the Royal College of General Practitioners of the poor access and discrimination that Billy and others too often face in primary care. She challenged her colleagues to embrace prevention ‘Don’t just screen, intervene’. She reminded us that much of this is not rocket science; that primary care is ideally placed to improve the health and health outcomes of this population; and that the healthcare of people with serious mental illness is our business.

As Guthrie and Morales highlight, this QOF decision may have made helping Billy just a bit more difficult in England.

Dr David Shiers MB ChB, MRCGP, MRCP (UK), Clinical advisor to National Audit of Schizophrenia, retired GP North Staffordshire, carer of daughter with schizophrenia

Professor Carolyn Chew Graham MD FRCGP, GP Manchester, Professor of General Practice Research, Keele University, and RCGP Curriculum Guardian, Mental Health


Declaration of interests

CCG is a member of the project reference group for the NICE multimorbidity guidelines.

DS is a current member of the Guideline Development Group for NICE guidance for adults with psychosis and schizophrenia, member of NCCMH board, and received a lecturing honorarium from Janssen in September 22nd 2010


1. Guthrie B, Monales DR. What happens when pay for performance stops? BMJ 2014; 348: g1413.

2.NICE Primary Care Quality and Outcomes Framework Indicator Advisory Committee Minutes of extraordinary meeting Sept 18th 2013

3. Mitchell AJ, Hardy SA. Screening for metabolic risk among patients with severe mental illness and diabetes: a national comparison. Psychiatr Serv. 2013;64:1060-3.

4 De Hert M, Dekker JM, Wood D, et al. Cardiovascular disease and diabetes in people with severe mental illness. Position statement from the European Psychiatric Association. Eur Psychiatry 2009; 24: 412-424.

5. Fleischhacker WW, Siu CO, Bode R, Pappadopulos E, Karayal ON, Kahn RS, and the EUFEST study group Metabolic risk factors in first-episode schizophrenia: baseline prevalence and course analysed from the European First-Episode Schizophrenia Trial. Int J Neuropsychopharmacol. 2013; 16:987-95.

6. Saari KM, Lindeman SM, Viilo KM, Isohanni MK, Jarvelin MR, Lauren LH, et al. A 4-fold risk of metabolic syndrome in patients with schizophrenia: the Northern Finland 1966 Birth Cohort study. J Clin Psychiatry. 2005;66:559-63.

7. Manu P, Correll C, van Winkel R, et al, Prediabetes in Patients Treated With Antipsychotic Drugs J Clin Psychiatry. 2012; 73:460-6

8. NICE (2009) Schizophrenia: Recommendation 10.4.1 of Core Interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care. Clinical Guideline 82. London: NICE.

9. Royal College of Psychiatrists. Report of the National Audit of Schizophrenia (NAS) 2012. London: Healthcare Quality Improvement Partnership; 2012.

11. Department of Health (2011) No Health without Mental Health London: Department of Health

12. Section 4.1 Objects; Memorandum and Articles of Association of the NHS Confederation; incorporated on 23 January 2002; Page 2; Company Number 4358614.

13. Lester H.E. Being Bothered about Billy. RCGP James McKenzie Lecture 2012 Brit J of Gen Practice. 2013 608; e232-e234
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Competing interests: DS: Current member of the Guideline Development Group for NICE guidance for adults with psychosis and schizophrenia; member of NCCMH board; and received a lecturing honorarium from Janssen in September 22nd 2010 CCG: member of the project reference group for the NICE multimorbidity guidelines.

11 February 2014
David E Shiers
General Practitioner retired
Professor Carolyn Chew Graham
School Lane, Stoke on Trent ST9 9QS