National enhanced service - specialised care of patients with depression
2 May 2003 (updated November 2003)
Introduction
1. All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This enhanced service specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.
Background
2. Evidence shows that:
(i) depression is one of the top three leading causes of disability (see reference 1)
(ii) clinical depression affects up to 2.3 million people in Britain (5 per cent of the population) at any one time (see reference 2)
(iii) one in four patients presenting to their GP suffer with depression (see reference 3)
(iv) 80 per cent of people identified as having depression are managed entirely in a primary care setting – the average GP will see at least one patient with depression during each surgery session (see reference 4)
(v) depression accounts for at least 3,000 of the 4,000 people who commit suicide in England and Wales each year (see reference 5)
(vi) as many as three in four cases of depression are neither recognised nor treated. (see reference 6)
3. Depression causes much suffering to the patient and is potentially life-threatening. It can also severely affect the quality of life of the patient’s family. Untreated, depression is likely to worsen and become more difficult to treat, with both serious personal and financial implications. It is imperative, therefore, that the condition is diagnosed and treated as early as possible in primary care.
4. GPs are well placed to help their depressed patients, who may have social problems and physical illness to cope with in addition to their depression. Treatment at home is usually best for the patient, who is then able to maintain ties with family and friends and may be able to continue at work.
5. Failure of treatment is often due to the patient stopping the treatment too soon. Compliance with therapy is improved through regular monitoring by a healthcare professional.
Aims
6. The objective of this NES is to meet the main recommendations of the Royal College of General Practitioners’ and Royal College of Psychiatrists’ Defeat Depression Campaign, together with the recommendations of the Clinical Standards Advisory Group report, ‘Services for people who have depression’; the end goal of both being the early recognition and treatment of depression. To help to achieve this:
(i) improved training and awareness in the primary care team is necessary
(ii) GPs need to be able to devote more time to patients with suspected and diagnosed depression.
Definition
7. For a patient to be entered into this national enhanced service, their depression should be diagnosed using a combination of evidence-based diagnostic tools as well as specialist clinical judgement.
Service outline
8. This national enhanced service will fund practices to be able to:
(i) produce and maintain an up-to-date register of depressed patients. This would be used as a communication and audit tool. There would need to be mechanisms in place to update the register routinely
(ii) apply a multi-disciplinary approach to the treatment of depression involving CPNs, psychologists and psychiatrists where appropriate
(iii) use cognitive behavioural therapy and other non-drug treatments where appropriate
(iv) use screening procedures. Screening questionnaires or computer-administered interviews have been shown to improve recognition of depression. This is important since recognition improves outcome even when the patient does not comply with treatment
(v) undertake appropriate training. Each practice must ensure that all staff involved in providing any aspect of care under this scheme have the necessary training and skills to do so
(vi) maintain personal health plans. Each patient participating in the NES should have a personal health plan. This plan should include details of his or her diagnosis, investigations, frequency of reassessment, details of other referrals, eg counselling. This could include the use of accredited tools, eg Hamilton D rating Scales, MADRAS assessment scales
(vii) make referrals and inquiries as clinically indicated
(viii) review. All practices providing the service should perform an annual review which could include an audit of:
(a) the register of patients suffering from depression
(b) anti-depressant medication (ie dosage and length of treatment) and its effect on treatment outcomes
(ix) feedback from patients with depression and, where appropriate, their families using the standardised questionnaire.
Accreditation
9. Those doctors who have previously provided services similar to the proposed enhanced service and who satisfy at appraisal and revalidation that they have such continuing medical experience, training and competence as is necessary to enable them to contract for the enhanced service shall be deemed professionally qualified to do so.
Costs
10. In 2003/04 each practice contracted to provide this service will receive an annual retainer of £1,000 plus an annual payment per patient (in arrears) of £80 to £100. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
(1) Clinical Standards Advisory Group. Services for people who have depression. 1999
(2) Mental Health Foundation. Mental illness: the fundamental facts. 1993
(3) Report funded by Lundbeck. Impact of depression: a multi-disciplinary comment on treating depression. 1995
(4) Clinical Standards Advisory Group. Services for people who have depression. 1999
(5) Mental Health Foundation Mental illness: the fundamental facts. 1993
(6) Report funded by Lundbeck. Impact of depression: a multi-disciplinary comment on treating depression. 1995