Survival guide to the new DES: Implications for primary care

After a more than usually bitter process, the new quality and outcomes framework was imposed in April 2013, together with additional 'optional' Directed Enhanced Services. While GPs may reluctantly take on these new services to protect income, it will be practice nurses who put them into practice

In 2004 a new contract was introduced for general practice in the UK. This 'new' General Medical Services contract was one in a series of Government initiatives to make primary care more businesslike, even though anyone who has worked in healthcare in the UK will be aware that the principles of business and the NHS do not always make comfortable bedfellows. At the time the buzz was for performance related pay. And who could argue with that? Of course our patients deserve the best standard of healthcare possible, so the best performance available from practitioners deserves to be incentivised. Accordingly we acquired the Quality and Outcomes Framework, and we were also given a series of Directed Enhanced Services (DES) — optional extra services that general practices could undertake.

This is, of course, not the first time that general practices have been encouraged to do things outside their normal remit. Before 2004, practices were paid extra, for example, for maternity services, contraceptive services and child health surveillance. It makes sense to encourage general practices to do such work — general practices are in an ideal position to deliver these services as they are near to the patients and have, or can easily acquire, the requisite skills. Before 2004, the available extra payments were relatively small in comparison to overall practice budgets. Since the introduction of QOF and DES, more practice funding has depended on specific work being done: for example, in my own practice at present, 15% of all income comes from the QOF attainment, roughly equal to half the pay of all the practice staff. The other thing that has changed is the increasing involvement of practice nurses. Chronic disease management clinics have become more formalised, and more closely linked to the QOF information-gathering requirements. There has been a corresponding increase in the numbers of practice nurses, partly as they are the most reliable people to do the work properly, and partly because GPs have realised what a useful asset to primary care a practice nurse can be.

QOF and DES are based on the idea of targets: if you reach a target for (say) blood pressure control in diabetes then you get some money; if you miss the target you get nothing, despite the work that might have been done. This target mentality has its critics — if you can't reach the target there is no point (except for professional pride) in trying at all. Before 2004, extra services operated on a different system, of payment per patient who received the service. General practices were paid for the work they did so more patients involved meant more payments. This is a rather more obvious 'win-win' than setting targets.

NEW DES FOR 2013

Four new DES have been introduced for this financial year. Rumours were leaked months ago, but final details were only published several weeks after they were due to be implemented. There have been new DESs in the past, usually running in parallel to changes in the QOF. There has been more fuss this year as the British Medical Association and NHS Employers had been in negotiation for 18 months over these latest changes without resolution, so NHS Employers decided to implement their proposals anyway. Since then there have been several few weeks of backtracking and U-turns as it became clear that the proposals were in some respects unworkable and/or unscientific. So what follows is the truth for now, as far as can be determined.

1. RISK PROFILING AND CARE MANAGEMENT

'The aims of this enhanced service are to encourage practices to undertake risk profiling and stratification of their registered patients, to work within a local multi-disciplinary approach to identify, from the list produced, those patients who are seriously ill or at risk of emergency hospital admission and to co-ordinate with other professionals the care management of those patients identified who would benefit from more active case management'.¹

Case management is already a feature of many areas. In my practice area in Sheffield we have nurses who roam around offering care to people with diabetes, heart failure and COPD. They are not part of the community nurse team, but do have close links with secondary care. This has all been set up despite a paucity of evidence that case management is better than normal care.^2,3

By 30 June 2013, each clinical commissioning group (CCG), the local body charged with commissioning services, is required either to use a pre-existing arrangement or to use the DES guidance to set up or continue a service which meets or exceeds DES requirements. The service requirements are vague on detail, which means more work for your CCG to sort out. Patients will need to be assessed for their risk of emergency hospital admission, but the means by which this should be done is not set down. Each at-risk person has to have a named lead professional, and multi-professional meetings should be held at least quarterly to discuss cases and decide what to do, and then feed back data to the CCG. So there is a lot of onus on the CCG to choose the risk stratification tool, set the local DES standards, collate the audit data and then (and only then) make the payment to the practice. So there are lots of new opportunities for practices to be in conflict with their CCG. Making decisions locally also means taking the blame locally.

The money to fund this DES, and indeed all the new DES, is not 'new' money but is money from 'retired' QOF indicators for this year. There are 165 QOF points 'retired' compared with last year: it has been made clear that general practice will still be required to do the work entailed in achieving these 165 points, but will no longer be paid for doing so. The Care Quality Commission will ensure that practices are still doing the work: general practices are required to enrol with CQC so that they can be supervised and periodically inspected, for which practices will be required to pay an enrolment fee.

For those practices that choose to undertake this DES, the practice nurse team will be crucial. The main way of determining those at risk of emergency hospitalisation is to look at people with one or more ongoing disease processes, and these will be the people who are already attending practice nurse chronic disease clinics. Data on eligible patients will be gathered by searching for appropriate codes, and here the scheme links with the QOF data gathering activity. On the financial front, nearly 80% of GPs feel that the QOF and DES changes this year will have a negative impact on patient care and practice finances: staff costs are by far the biggest expense of a general practice, so all practices will be forced to look hard at their staff levels, and this will inevitably include practice nurses.

2. FACILITATING TIMELY DIAGNOSIS AND SUPPORT 
FOR PEOPLE WITH DEMENTIA

'The aims of this enhanced service are to encourage practices to identify patients at clinical risk of dementia, offer an assessment to detect for possible signs of dementia in those at risk, offer a referral for diagnosis where dementia is suspected and support the health and wellbeing of carers of patients diagnosed with dementia'.¹

It is indisputable that dementia should get more attention. It is becoming more common, largely because the average age of the population is increasing; it places an enormous care burden on social care, the NHS and families;⁴ and many cases go undetected. It is regrettable, therefore, that it has not been allocated any extra resources, and that general practices are having to make a judgement about whether or not they are able to take on this extra work.

This DES targets specific groups of patients in whom dementia is known to be more common. When being seen for other reasons ('opportunistic case finding') the following groups should be offered a memory assessment:

• Patients aged 60 or over with cardiovascular disease, stroke, peripheral vascular disease or diabetes
• Patients aged 40 or over with Down's syndrome
• Other patients aged 50 or over with learning disabilities
• Patients with long-term neurological conditions that have a known neurodegenerative element, for example, Parkinson's disease.

Members of these target groups will already be well known to practice nurses who undertake chronic disease clinics. Often questions are already being asked about evidence of depression. It would be a small step to include a further question on any concerns about memory, and a few enthusiastic practice nurses may even want to administer a dementia assessment tool. But a word of warning: nearly everyone (certainly including me) would like a better memory, and occasionally cannot bring a word or a name to mind immediately. This is not dementia, or even memory loss: it is a temporary failure of memory retrieval.

The required assessment starts by asking if the patient or family member has any concerns about memory, and then can go on to formal memory testing. A number of formal tests are used in general practice to detect dementia, and the DES does not specify which should be used, but quotes the example of the General Practitioner assessment of Cognition (GPCoG). This is freely available on-line,⁵ so you might like to try it yourself. Other than the requirement to case-find, the recommended care pathway (i.e. a referral to the local memory service and appropriate care and social needs assessments for patient and their carers) will already be familiar to practice nurses as this is what is happening already.

In its original version, the DES included a requirement to offer a test for anyone over the age of 75 years. This caused a howl of protest from doctors prompted by the lack of evidence that this screening approach would do any good.⁶ In the past, a lack of evidence would probably not have deterred any government from a politically expedient policy, but now that QOF is linked to NICE, the lack of an evidence base became an embarrassment.

3.REMOTE CARE MONITORING (PREPARATION)

'This enhanced service is designed to encourage practices to undertake preparatory work in 2013/14 to support the subsequent introduction of remote care monitoring arrangements for patients with long-term but relatively stable conditions in 2014/15'.¹

'Remote care' is the delivery of healthcare without a face-to-face consultation. Implementation will require considerable work for each CCG as this DES will vary from locality to locality:

• Which condition(s) to include (local priorities)?
• What measurements/readings are relevant and how can patients report them?
• What is the best medium to gather the data (phone, email etc) and what are the governance implications?
• How should records be kept?
• How should patient's consent be obtained?

For example, people with hypothyroidism should be checked periodically. A check might include:

• Enquiring about relevant symptoms — fatigue, weight gain, constipation
• Measurement of weight and thyroid stimulating hormone.

Most households have a set of scales, so patients can weigh themselves. Blood can be taken at the practice, at home, or by the local hospital, so only one contact would be needed, but the review of results and a recommendation about the dose of levothyroxine could be done remotely.

There is little evidence that a programme of this type would improve patient care, a point that the BMA made very strongly to NHS Employers. It would certainly increase expectations about services that patients can access without a face-to-face assessment, which (if the poor attendance at my practice asthma clinics is anything to go by) would be popular. However, remote access means that a clinical examination cannot be done, and it is not clear for how many years' patients would be safe collecting prescriptions without being seen. This DES is about preparing for the future, but obviously the writing is on the wall.

4.IMPROVING PATIENT ONLINE ACCESS

'The aim of this enhanced service is to establish patient online access to practice information systems through enabling and utilising electronic communications for booking/cancelling of appointments, enabling and utilising electronic communications for repeat prescriptions and registering patients (issuing passwords and using verification practices) to enable patient online access'.¹

This is another 'preparation' DES for full implementation later. Many general practices are offering these services already, and often more. In its first incarnation, this DES also included patient on-line access to medical records, test results, and electronic communication (i.e. email consultations), but an appropriate U-turn was secured when it was pointed out what confidentiality and governance issues would be raised. And remember the track record — the plan to unify all NHS records in primary and secondary care now appears to have died a death despite the tens of billions of pounds being spent on it.

CONCLUSION

It has become a bit of a ritual every April. The new version of QOF is announced, and new directed enhanced services are offered. They always come late — it has never yet been possible for practices to prepare for the changes by the time they are due to be implemented. GPs always moan about the changes, as they do about any change, and then settle down to tackling the new targets — often getting their practice nurses to do most of the work.

The changes for this year give an indication of the way Government is thinking about primary care, and so have implications for the future. In many respects the new DES for 2013/14 highlight important areas for care. It is therefore unfortunate that, in the context of already contracted budgets, general practice will be tasked with making the new services work despite the reduced resources available.

REFERENCES

1. 2013/14 General Medical Services contract. Guidance and audit requirements for new and amended services. NHS England, NHS Employers April 2013. http://www.nhsemployers.org/Aboutus/Publications/Documents/2013-14-GMS-contract-Guidance-audit-requirements.pdf

2. Smith S et al. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. BMJ 2012;345:e5205

3. Huntley A et al. Is case management effective in reducing the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis. Family Practice (2013) doi: 10.1093/fampra/cms081

4. Alzheimer's Research Trust. Dementia 2010. http://www.dementia2010.org/reports/Dementia2010ExecSummary.pdf

5. The General Practitioner assessment of Cognition. http://www.gpcog.com.au/

6. Brunet et al. Screening for dementia has no evidence base. BMJ 2012;345:e8588