Multimorbidity: what next?

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Your editorial by Mair and Gallacher draws attention to the importance of comorbidity.¹ We have extracted data from NHS Digital, relating to the changes in some mental health indicators of the Quality and Outcomes Framework (QOF). In 2014–2015, indicators for the measurement of BMI, blood glucose or HbA1c, and cholesterol:HDL ratio were all retired. The indicator for blood pressure was retained. The measurement of HbA1c and cholesterol has fallen from around 90% in 2014, when it was included in QOF, to around 50% when it was no longer included. This is important, as the mortality of this group is much greater (they die 15–20 years earlier than people without a severe mental illness, and from diabetic and cardiovascular disease). It also highlights the impact of removing items from QOF.

The Five-Year Forward View for Mental Health states that ‘current incentive schemes for GPs to encourage monitoring of physical health should continue’.² The data show that the retirement of QOF indicators has led to a reduction in screening for diabetes and dyslipidaemia — in a population significantly at risk.

Does this reflect a health force now more influenced by financially incentivised practice than clinical need? Or does it reflect a continuing lack of awareness of the premature morbidity and mortality experienced by patients with SMI?

The physical health of the severely mentally ill (those included in the inappropriately labelled ‘mental health’ domain) remains a source of inequality. It is Department of Health (DH) policy that the physical health of this group should be addressed so that there is ‘parity of esteem’ between physical and mental health patients. Yet, in the same year that the DH introduced a CQUIN for mental health trusts to measure some physical health processes of care, they removed from the QOF those same indicators

We believe that the DH should heed the recommendations of the recent Academy of Medical Royal Colleges report,³ and address the lack of planning, coordination, and leadership in this area.