One hundred points, worth over thirteen thousand pounds to an average practice, have been removed from the Quality and Outcomes Framework for England in 2013/14 with similar numbers in other countries. Each country has pledged this back to the general practice budget. In England, however, this is to be used to pay for four new Directed Enhanced Services.
In practical terms these services will be quite similar to QOF indicators. They will be available to every practice although they are officially optional. Practices can pick and choose which they want to participate in. Each is about delivering services to specific, defined groups of patients, again in a similar way to the QOF.
One of the disadvantages of Enhanced Services in the past has been the relative lack of IT support. Practices have had to search for, and compile their own results which have typically been submitted to the PCTs on a spreadsheet. Obviously PCTs no longer exist and submissions will be made to the Local Area Team of NHS England (formerly the National Commissioning Board). More usefully to practices some of the data will be automatically extracted by the same GPES and CQRS systems which will calculate achievement payments for the QOF. This will also mean that the DESs will need the same sort of care about coding which currently applies to QOF indicators. The existing learning disability and alcohol use screening services will be the first to use this system with the new dementia screening DES also to be calculated this way.
There are four new DESs to be introduced at the start of this year with a further two, covering immunisations for rotavirus in babies and zoster (shingles) in the elderly, to follow in the second half of the year.
The first DES is for a risk profiling and case management service. The stated aim is to try to prevent unplanned hospital admissions by targeting care on those patients who have a high risk of admission to hospital. There is particular emphasis that mental as well as physical health should be taken into account when making these calculations.
There are numerous risk profiling systems available from a variety of suppliers. There is also very little published evidence comparing these systems against each other or the judgement of a general practitioner who knows the patient. There is a belief that there are significant numbers of patients who are not visible to GPs, particularly those who are just below the very highest risk. Nevertheless this is already a commonly used tool and it is likely that it will be the CCG that procures the system across an area on behalf of their practices.
There will be significant amounts of data that must be extracted from practice computer systems and data handling agreements should specify how they can be used. In general terms the risk will be calculated based on the age and sex of the patient as well as previous use of health and social services. This risk calculation must take place at least quarterly.
Calculating risk of emergency admission is only half of the story. The real value is in using that information to avoid the need for future admissions. There is some evidence, particularly from the USA, that community interventions can reduce emergency attendances. These community interventions are largely what we would recognise as general practice and community nursing in the NHS. Evidence from the UK is rather less definite although there is some evidence that continuity of GP care reduces emergency admissions.
The proposal is that a proportion of patients considered at high risk should be discussed at multidisciplinary team meetings to form a case management plan. These meetings should take place at least quarterly. There should be nominated professional responsible for discussing the care plan with each patient.
The proportion of patients to be considered and how they are selected will be by agreement with the CCG. As payment is based on total list size it would be most appropriate if the number of patients having case management was also proportional to the list size. With 74 pence for each patient registered on the practice list. Practices will need to consider the potential income against the work specified to produce the management plans. For instance, if each patient requires an hour of GP time before and during the meeting then no more than a quarter of one percent of the practice list should be included at each meeting.
There is no provision currently for the delivery of actual services as part of the service and it is likely that much of the funding will be taken up in the formation of plans rather than in their execution.
The second service offered to practices is screening patients for dementia. The programme does not fit the accepted criteria for screening tests and so was referred to as “case finding” in the initial proposal and “facilitating timely diagnosis” in the final specification.
There has been some discussion since the suggestion of this DES about whether an early diagnosis is useful or desired by patients. Under the terms of the DES patients considered at risk, such as patients over sixty years old with vascular disease, patients with neurodegenerative disease, patients over 40 years old with Down’s syndrome or over 50 with other learning disabilities should be offered an assessment. The assessment will initially consist of just asking whether the patient feels that they have any memory problems. A further test using the General Practice Assessment of Cognition (GPCOG) questionnaire or similar test should be performed if the patients report memory problems.
The wording of the invitation will be crucial so that patients can exercise an informed choice about whether they wish to be screened. The specification is clear that this is designed to be opportunistic with the questions included in routine consultations.
If the GPCOG assessment indicates memory problems the patient should then be referred on to the local memory services. These services can probably expect a significant increase in the number of referrals over the next year.
Non professional carers should also be identified and, if they are registered at the same practice, be offered a general physical and mental health check. The specifications are rather vague on what this should consist of and is probably mostly about making sure that their physical and mental health is not actually neglected.
The number of patients involved are likely to be large. The 2011 census reports that seven and a half percent of the UK population is over seventy five years old with another 15% between sixty and seventy five. Not all of this latter group will have chronic disease but overall practices should typically expect to be inviting well over 10% of their list for dementia case finding.
There are two payments for this service. Firstly there is a payment of 37p per patient on the practice list for signing up. The second payment is a little odd. The commissioning board has allocated £21 million for the screening and this will be divided between practices according to the number of assessments (GPCOG or equivalent) carried out as measured by the CQRS. The result is what economists call “the tragedy of the commons” – the more that practices, do the less that each assessment will be worth.
Whilst the first two services are based around identifying patients who would benefit from extra health interventions the second two are based around delivering services. As they concern electronic interaction with the surgery and telehealth they can be seen as appealing more to a younger and generally healthier population.
The first of these is for remote care monitoring. Often this has been described as telehealth although this not the electronic monitoring that is generally associated with the term. Instead this is about the communication of results and suggested actions to patients without them having to make an appointment. In this year no actual communication is required. This is only about preparation for a full launch next year.
The specification for 2014/15 is that test results should be given to patients in a way agreed with the patient and not face-to-face. There is no limit about which means should be used – simply sending a letter may be entirely sufficient although it is likely that electronic means such as email or text message are more what has been intended. These communications should be proactive – sent from the practice. It is unlikely that a system where the patient has to call the surgery would be acceptable for this service.
This year practices will need to agree which disease area will be targeted with their CCG. The opportunities for remote communication of results should be specified and the preferences and contact details of appropriate patients identified.
Patients and practices should be aware of the risks of these forms of communication. Email does not guarantee the security of the message. Neither email nor SMS guarantee delivery or the timing of that message.
The consent of the patient for this form of communication should be recorded in the notes with an appropriate code which have yet to be announced.
The final service is to enable all patient to book and cancel appointments and to request repeat prescriptions online. As long as practices do this in at least one quarter of the 2013/14 financial year then this will be reported by their computer system supplier and payment will be made.
There are separate components for appointment booking and repeat prescription requesting. Each component is worth 14 pence for each registered patient on the practice list.
Practices will be responsible for issuing passwords and verifying patient identity. The Royal College has produced guidelines on how this should be done[1] although it is by no means a detailed manual. Logins and passwords will be specific to each surgery. These is no attempt to allow patients to have a single login at a national level and specific arrangements to access these services will between surgeries.
If 5% of the practice list has a password issued then a payment of £985 will be awarded. This payment is fixed and will be the same whether your practice has to issue fifty passwords or one thousand to meet the target. The level of uptake achieved will be declared by the practice at the end of the year and may be confirmed at a later visit.
Which services patients can access is likely to be defined by the capabilities of practice computer systems. The range of services offered and the ease of their use will be of particular interest to practices when considering changing or upgrading practice systems. Although this particular DES may only be for one year the Department of Health has made it plain that all patients should have online access to their practice records by 2015. This DES is likely to expand over the next couple of years.
None of these services represent easy money. Only the dementia service is what most GPs would recognise as hands on clinical medicine. The others are about practice administration and attending meetings. However they do represent a significant chunk of income and practices will need to consider their capabilities as well as the potential costs and income associated with delivering the services.
References
Royal College of General Practitioners – Patient Online: The Road Map. Issued 6th March 2012 http://www.rcgp.org.uk/p
