Hippo Labs uses the official NHS England QOF Business Rules v50.0 to help practices track patients with serious mental illness (SMI) — ensuring annual physical health checks and care planning are completed consistently.
💬 Just a reminder: these indicators aren’t clinical guidelines — they’re operational definitions used for QOF measurement. They define who appears for recall, how achievement is calculated, and where gaps can occur.
📋 The Mental Health Registers
There are two registers used across the Mental Health indicators:
Register | Includes | Purpose |
MH1_REG | Patients diagnosed with psychosis, schizophrenia, or bipolar affective disorder | The main register for all Mental Health indicators. |
MH2_REG | Patients with a lithium prescription in the last 6 months where treatment has not been stopped | Captures patients on lithium for safe monitoring. |
✅ In short: anyone with an active diagnosis of schizophrenia, bipolar disorder, or psychosis — or receiving lithium — will appear on one of these registers.
🩺 The Indicators
🧾 MH001 — Register Maintenance
Measures:
Practices must maintain a register of all patients with schizophrenia, bipolar affective disorder, or other psychoses, and those on lithium treatment.
✅ In short: this indicator checks that the register exists and is correctly populated.
🧩 MH002 — Care Plan
Measures:
% of patients with schizophrenia, bipolar disorder or psychosis who have a comprehensive care plan agreed and documented within the last 12 months.
Counts as complete if:
The care plan was recorded within the past 12 months, and
Recorded on or after the most recent diagnosis.
Exclusions (Personalised Care Adjustments):
Care deemed unsuitable.
Patient declined mental health care.
Two invitations sent ≥7 days apart with no attendance (for payment purposes only).
Newly diagnosed or newly registered within the last 3 months.
⚠️ Common pitfalls:
Care plan recorded under incorrect code cluster (not MHP_COD).
Plan completed >12 months ago.
Recorded before latest relapse/diagnosis.
✅ In short: all SMI patients (not in remission) should have a current, agreed care plan recorded within the last 12 months.
💓 MH003 — Blood Pressure
Measures:
% of SMI patients with a blood pressure reading recorded in the last 12 months.
Exclusions:
BP procedure declined or unsuitable.
Mental health care declined.
Two review invites ≥7 days apart with no attendance.
⚠️ Common pitfalls:
BP reading entered without both systolic and diastolic values.
BP recorded as text or under incorrect code type.
✅ In short: all patients on the SMI register should have a recorded BP within the last 12 months.
⚖️ MH006 — Body Mass Index (BMI)
Measures:
% of SMI patients with a BMI recorded within the past 12 months.
Exclusions:
BMI unsuitable or declined.
Mental health care declined.
Two review invites with no attendance (for payment purposes only).
⚠️ Common pitfalls:
Recording BMI as text or outside a recognised cluster.
Missing value or invalid date range (>12 months).
✅ In short: all SMI patients (not in remission) should have a BMI recorded within the last 12 months.
🍷 MH007 — Alcohol Screening
Measures:
% of SMI patients with alcohol consumption recorded within the last 12 months.
Exclusions:
Screening declined or unsuitable.
Mental health care declined.
Two review invites ≥7 days apart with no attendance.
⚠️ Common pitfalls:
Recording alcohol screening as free text.
Using non-QOF-aligned alcohol codes.
✅ In short: all SMI patients should have alcohol consumption recorded in the past 12 months.
🧪 MH011 — Lipid Profile
Measures:
% of SMI patients who have had a lipid profile in:
The past 12 months if higher risk (e.g. on antipsychotics, smoker, CVD, diabetic, CKD, overweight).
The past 24 months if lower risk.
Counts as complete if:
Lipid test recorded in correct time window (12 or 24 months based on risk factors).
Exclusions:
Cholesterol test declined.
Mental health care unsuitable or declined.
⚠️ Common pitfalls:
Recording cholesterol test without value.
Not applying correct 12 vs 24 month window based on patient risk.
BMI/ethnicity not coded — system can’t assess overweight criteria.
✅ In short: every SMI patient should have a lipid profile recorded within 12–24 months, depending on risk factors.
🍬 MH012 — Blood Glucose / HbA1c
Measures:
% of SMI patients with a blood glucose or HbA1c recorded in the past 12 months.
Counts as complete if:
Either IFCC HbA1c or glucose recorded in last 12 months.
Exclusions:
Blood test declined or unsuitable.
Mental health care declined.
Two invites ≥7 days apart with no attendance.
⚠️ Common pitfalls:
Using serum fructosamine instead of HbA1c without proper code link.
Glucose entered as free text or outside reporting window.
✅ In short: all SMI patients should have a glucose or HbA1c test recorded in the last 12 months.
🩹 MH021 — Physical Health Check (6 Elements)
Measures:
% of SMI patients who received all 6 elements of the annual physical health check, which include:
Blood pressure
BMI
Alcohol consumption
Lipid profile (12 or 24 months, depending on risk)
Glucose or HbA1c
Smoking status
Counts as complete if:
All six components are recorded within the specified time frames.
⚠️ Common pitfalls:
Missing one or more components (especially lipid profile timing).
BMI or smoking status missing/uncoded.
Not accounting for ethnicity-based BMI thresholds (≥23 vs ≥25).
✅ In short: SMI patients must have all six physical health elements completed within the correct timeframes to count as complete.
🧩 Summary Table
Indicator | Focus | What It Measures | Timeframe | Who It Applies To |
MH001 | Register | Maintained SMI register | Continuous | All SMI patients & lithium users |
MH002 | Care plan | Comprehensive, agreed care plan | 12 months | SMI patients not in remission |
MH003 | Blood pressure | Recorded BP reading | 12 months | All SMI patients |
MH006 | BMI | Recorded body mass index | 12 months | All SMI patients |
MH007 | Alcohol | Alcohol consumption recorded | 12 months | All SMI patients |
MH011 | Lipids | Lipid profile completed | 12–24 months | All SMI patients (based on risk) |
MH012 | Glucose | HbA1c or glucose recorded | 12 months | All SMI patients |
MH021 | Physical health check | All 6 key checks complete | Mixed (12–24 months) | All SMI patients |
🌟 Why This Matters
Following these indicators helps practices:
Identify all patients with serious mental illness.
Deliver consistent, complete annual physical health checks.
Reduce physical health inequalities in SMI populations.
Demonstrate QOF compliance and proactive, holistic care.
✅ In short: the Mental Health indicators ensure that every patient with a serious mental illness is monitored holistically — physically and mentally — every year.
📚 Sources
NHS England QOF Business Rules v50.0 (Mental Health, April 2025)
Primary Care Domain Reference Sets (TRUD Portal)