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.
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 and although they are officially optional, practices can pick and choose which want to participate in.
Each is about delivering services to specific, defined groups of patients 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 require the same care around 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. A further two, covering immunisations for rotavirus in babies and zoster (shingles) in the elderly are to follow in the second half of the year.
Risk profiling
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 on the fact 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 the CCG procures the system across an area on behalf of their practices.
Significant amounts of data will need to be extracted from practice computer systems, and data handling agreements should specify how the data 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 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 a 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. There are 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 % 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.
Dementia
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 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 is likely to be large. The 2011 census reports that 7.5% of the UK population is over 75 years old with another 15% between 60-75. 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 37 pence 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.
Health interventions
Whilst the first two services are based around identifying patients who would benefit from 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.