Clinical Governance in Action - (2003) Volume 11, Issue 2
2Clinical E¡ectiveness Adviser
3Community Mental Health Nurse
4Primary Care Clinical Audit Team Manager Primary Care Clinical Audit Team (PCCAT), Clinical Governance Support Team, Edinburgh, UK
Accepted date: April 2003
Aim To audit the management of patients with chronic schizophrenia within primary care in Lothian.Design The Clinical Governance Support Team in Lothian NHS Primary Care Trust developed an audit package to collect data about the quality of care of patients with chronic schizophrenia over the previous year. The package provided guidance on audit methodology, identiŽ cation of patients, and a standardised data collection sheet with explanatory notes.Setting All Lothian Local Healthcare Co-operatives (LHCCs) were invited to participate on an LHCC basis (with aggregated results being fed back to each LHCC). Where LHCCs did not wish to participate, individual practices within the LHCCwere invited to participate.Results Altogether 55 practices returned data on a total of 822 patients. The percentage of patients with schizophrenia in the participating practices was 0.17%. In the previous year 86.3% of patients had been reviewed and of those, 69.4% had beenseen by a consultant psychiatrist, 71.8% of patients had had involvement with the mental health team and 18.9% of patients were only seen by their general practitioner; 21.3% of patients had had a hospital admission; 90.4% of patients were recorded as being on antipsychotic medication.Conclusions For the 86.3% of patients who had a review, 69.4% were seen by a consultant psychiatrist. This falls short of the Clinical Standards Board’s recommendation that 100% of patients with a diagnosis of schizophrenia should be reviewed by a consultant psychiatrist at least once a year. It may be impossible to achieve the 100% standard and therefore it would be helpful to have a standardised template for an annual schizophrenia review. It is hoped that such a template will be developed across Lothian
audit, LHCCs, schizophrenia
Mental health is a priority area for the NHS in Scotland and schizophrenia is a major challenge to the health services. Although the incidence rates for adults are 1–2 in 10 000 per year, the prevalence is between 6 and 10 per 1000 population.[1,2]
People with chronic schizophrenia are now mostly living in the community rather than in long-term wards in large psychiatric hospitals, and are registered as patients on general practitioner (GP) lists. In a recent Scottish study, the provider most commonly seen by community patients in a six-month period was the GP (78% of patients).[3]
Most GPs have little previous experience of managing these patients’ medications, or their ongoing problems. However, resources are now moving into the community. All general practices in Lothian have an identified member of a community mental health team (CMHT) working with them (the teams work with several local practices in areas defined by practice lists). GPs can refer directly to their CMHT. Consultant psychiatrists may also be identified with GP practices rather than hospitaldesignated ‘sectors’.
GPs will continue to play a major part in the care of these patients. With these additional resources in the community, there is an opportunity to improve the quality of life of people with schizophrenia.[4]
The Clinical Governance Support Team (CGST) of Lothian Primary Care NHS Trust developed an audit package that aimed to help GPs identify patients with schizophrenia and review their care. It is based on a previous Lothian audit package on schizophrenia and a package from the University of Leicester.[5,6]
The aim of this investigation was to improve the management of patients with chronic schizophrenia within primary care in Lothian, in order to enable practices to:
identify their population of patients with schizophrenia
establish/update a register of patients with schizophrenia
measure the recording of key variables
and to enable practices/Lothian Local Healthcare Cooperatives (LHCCs) to:
make/monitor changes in practice to improve level of care provided
A package was developed by the CGST that included a paper data collection form based upon strictly evidence-based criteria (see Appendix 1).[7] This was used to collect data about the quality of care of people with a diagnosis of schizophrenia mainly over the last year. The package provided guidance on all the aspects of the audit.
The audit included all adults aged 16 years or more living in the community with a definite diagnosis of schizophrenia. Excluded were patients in long-term care, patients with paranoid illnesses, schizoa¡ective illnesses, personality disorders, bipolar illness or depression, or those with a single acute episode, but no further illness.
For the first time LHCCs were invited to participate on an LHCC basis with results being aggregated for each participating LHCC. Where LHCCs did not wish to participate on this basis, individual practices within that LHCC were contacted and asked if they wished to participate. In addition, practices that were not aligned to any LHCC (though some subsequently did become aligned) were also invited to participate.
Basic demographic information
LHCC participation
North West, North East, South Central and Midlothian LHCCs all agreed to participate on an LHCC basis. Other LHCCs did not wish to participate on this basis, although some practices within these LHCCs did opt to participate on an individual basis.
Figure 1 shows the distribution of the LHCC participation (with participating LHCCs shaded) and the percentage of practices within each LHCC that took part.
Figure 1: LHCC involvement in schizophrenia audit
Practice participation
To date, 55 practices have returned their data. This equates to 47.7% of the total number of patients in Lothian (total list size 397 896 out of 833 663).
Percentage of patients with chronic schizophrenia
The percentage of patients identified, as su¡ering from chronic schizophrenia across the participating practices in Lothian was 0.21% (822 patients out of 397 896; range 0.02 to 0.57%).
Of the 822 identified patients:
mean age was 47 (range 18–93)
61.1% were male, 38.9% female
• 624 (75.9%) were recorded as being on a register.
Care of patients with schizophrenia
Involvement with mental health team in the last year
A total of 71.8% of patients had had involvement with the mental health team in the previous year (see Figure 2).
Figure 2: Involvement with mental health team in the last year by LHCCs
Hospital admissions for schizophrenia in the last year
In the previous year 21.3% of patients had had a hospital admission for schizophrenia (see Figure 3).
Figure 3: Hospital admissions for schizophrenia in the last year
Accommodation status
The accommodation status of patients with schizophrenia is shown in Figure 4.
Figure 4: Patient accommodation status across Lothian
Patients on antipsychotic medication
A total of 90.4% of patients were recorded as being on antipsychotic medication (see Table 1).
Table 1: Newer (atypical) antipsychotic drugs prescribed to patients
Patients reviewed in the last year
In the previous year, 86.3% of patients had been reviewed (see Figure 5).
Figure 5: Patients reviewed in the last year by LHCC
Who saw the patients?
The proportions of patients reviewed by di¡erent professionals in shown in Figure 6.
Figure 6: Lothian patients reviewed in the last year by di¡erent professionals
Health screening in the last five years
The average percentages of patients who had undergone di¡erent types of health screening in the last five years are summarised in Figure 7.
Figure 7: Health screening in the last ® ve years
The data from 55 Lothian practices were returned on a total of 822 patients with chronic schizophrenia giving a prevalence figure of 0.17%. This correlates well with the Clinical Standards Board’s figures where 1144 people with schizophrenia were known to Lothian Primary Care Trust out of a total population of 669 624, giving a prevalence figure of 0.17%.8 The Clinical Standards Board’s figures however included patients in long-term chronic and admission wards and so may re ect a rather smaller number known in the community.
The number of people with chronic schizophrenia per practice was low – even in the practice with the most patients the percentage of schizophrenics was less than 1%. Almost half of the patients lived with family or friends and so were probably not geographically mobile. Most GPs were therefore looking after small stable populations.
These patients were firmly in the community – only 21% had an admission to hospital in the last year, half of them on a section. There does not appear to be a ‘revolving door syndrome’ in Lothian.
The CMHTs are obviously very involved in the care of chronic schizophrenics as they see 71.8% of the patients. However there is a widespread range of involvement – five practices had 100% of their patients involved but another five practices had less than 40% involved. This probably represents uneven access to CMHTs.
An average of 90.4% of patients were taking antipsychotic medication and in many practices this was 100%. However in some practices, a significant number were not on medication.
Consultant psychiatrists were involved with 69% of the patients who had had a review. Because of the disability caused by schizophrenia and the burden of side-e¡ects, many patients could benefit from specialist review. The Clinical Standards Board for Scotland would like to see 100% of chronic schizophrenics reviewed by consultants. Their aim is that ‘every person who has a diagnosis of schizophrenia has their need for antipsychotic drug treatment reviewed regularly and by a consultant psychiatrist at least once a year’.[8] GPs could therefore refer more of these patients.
Currently GPs are managing 17.4% of the chronic schizophrenics without CMHT or consultant input at review.
Physical health screening is impressive overall. Body mass index (BMI) and alcohol intake however are the least asked about, and possibly the most important for this group of patients on antipsychotics. The Royal College of General Practitioners (RCGP) Practice Accreditation Scheme suggests that a sample survey of case records should show that smoking habit, alcohol intake and blood pressure are each recorded in 45% of patients[9] and this audit shows that these standards are being exceeded. However, as this group of patients is seen frequently (86% reviewed in the last year) perhaps it would be appropriate to set higher standards. For cervical screening in the previous three years, the average for this audit was 63% which falls somewhat short of the 70% uptake of screening in the general population in Lothian in the last 3.5 years.[10]
Participation in the audit package was encouraged on an LHCC basis. Four LHCCs adopted the package and encouraged their own practices to participate. Some practices in the LHCCs that did not participate chose to participate as individual practices. For the LHCCs that participated it is hoped that they will find the LHCC aggregated results helpful in providing a profile of how schizophrenia is bothmanaged at practice and LHCC level, as well as providing comparisons across Lothian. The LHCCs will therefore need to consider whether this would be a useful process for auditing other topics, or reauditing schizophrenia.
For discussion at practice/team level
Whether a robust register is in place to facilitate call and recall.
• Identifying which patients are not on medication.
• Identifying which patients are not known to the CMHT and discussing if referral is appropriate and if patients would agree to referral.
• Improving access (if necessary) to the mental health team who can be invaluable in helping with crises and managing ongoing problems, as well as giving support to GPs.
• Identifying other individuals who should be considered for consultant referral.
• Considering whether the carers (family or friends) of these patients need any further support.
• Considering how the physical health results compare with results for the rest of the practice’s patients.
• Whether to carry out a reaudit.
For discussion at LHCC level
• Consideration of standardised template for patient reviews.
Enhancing communication between CMHTs and primary care.
• Improving the availability of CMHTs.
• Training of primary care teams.
• Consideration of whether clinical audits at LHCC level are feasible/useful and should be encouraged.
Although the results are generally positive, practices (and LHCCs) may want to carry out a reaudit of their care of their patients with chronic schizophrenia, particularly looking at areas where their figures are below the standard set by the audit (i.e. the ‘Lothian’ average – the average across all the participating practices) and external recommendations. Any decision by the steering group to recommend that a reaudit be carried out would need to take account of the views of the practices/LHCCs that have participated in the current audit.
Our thanks go to all the participating practices who have undertaken this audit; all the LHCC leads who promoted this audit within their LHCC; Eli Lilly/Mr Colin Beautyman for the valuable information to help develop the audit package; Julie McEwen for the project administration and database management and Pamela Foster for data input and analysis.
