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Unplanned admissions DES could cause harm to dying patients, experts warn

Exclusive The new DES for avoiding unplanned hospital admissions could be harmful to patients who are dying unless managers relax stringent deadlines for practices, experts have warned.

National leaders on palliative care have requested that NHS England is flexible on tight deadlines within the unplanned admissions DES as they fear the 1% of the population in their last year of life may otherwise suffer undue distress.

It comes after Pulse revealed that NHS England has advised area teams not to pay practices for the DES if they miss any single aspect, despite previous reassurances from local area teams that they will be given leeway if it benefits patients.

Under the terms of the DES, patients requiring end-of-life care would be part of the 2% of each practice’s patient population that would have to be identified and informed that they were on the practice’s unplanned admissions DES register.

Each patient on the register will have a ‘named GP’, responsible for providing them with a personalised care plan and overseeing their care, with the aim of preventing emergencies that would see the patients admitted to hospital.

But Professor Keri Thomas, a former GP and now national clinical lead for end of life care at the GSF Centre CIC and honorary professor for end of life care at the University of Birmingham, said there was a danger of GP practices rushing to hit all the targets of the bureaucratic DES and ‘missing the point’ in the process.

She said: ‘Some of us are concerned about the way the very rapidly implemented unplanned admissions DES might possibly be negatively affecting patient care, especially for those nearing the end of life. There is a danger of hitting the target but missing the point.’

‘Although we greatly support the drive to reduce unplanned admissions and the need for more proactive primary care and advance care planning discussions, especially for the 1% of the population in the last year of life, we are concerned that the urgent box ticking required, with tight deadlines, might lead to some insensitive discussions and other measures that might cause distress if poorly handled.’

Dr Peter Nightingale, the joint Marie Curie and RCGP national clinical lead for end of life care, has produced a guide for GPs in which he has shared NHS Lancashire North CCG’s model for how to effectively care for dying people while carrying out the duties involved in the DES.

Dr Nightingale said: ‘We are asking for derogation from the local area team of NHS England to hopefully give the GP practices time to produce high quality and useful plans rather than a large quantity of lower quality plans. I understand that local area teams have been instructed to stick to the detail of the agreed DES, but asking for some flexibility in the interpretation of rules may still be worthwhile.’

Other tips include setting up a single IT template including all the codes for the DES as well as codes for a a local Electronic Palliative Care Co-ordination System.

In addition to sharing the guide, Professor Thomas and Dr Nightingale will be running two two-day workshops, endorsed and supported by the GMC, on how to best implement the DES for people nearing the end of life in September in Leeds and in London in October.


Readers' comments (9)

  • Some good things in the DES eg contacting people after admission etc, but the care plan concept is completely the wrong idea. Reminds me of Nurses when I was training. Out of date the moment they are written. Truly integrated IT is the answer. Make us all EMIS web in my opinion. OOH and A&E and Secondary Care. That would achieve more than anything else. But nobody is brave enough to do this.....

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  • system one much quicker and simpler to use than e web IMO but either way all one system. what happened to the spine I wonder?

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  • I prefer vision to EMiS web......and therein lies the problem!

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  • Orwellian double speak in action - 'Unplanned admissions' really means keep the acutely sick at home. Why? because we are shutting your local hospital and there are no beds available. We can't afford hospitals. Why? because too much money has been diverted away to pay for PFI debts, bloated management and pump-priming privatisation.

    By engaging with this latest DES, GPs are bestowing the policy with some credibility. In fact there is no meaningful evidence that producing care plans and trying to guess which of our chronically sick patients identified by expensive risk stratification tools may become sick, will produce any significant cost-effective benefit. It does not work in the UK where we have a well established and good quality primary care network. The policy is adopted from America where it is called 'managed care' and part of the HMO model. We are copying the most expensive and unfair system in the world.
    We are being softened up to accept yet more US healthcare lunacy. Destruction of NHS capacity and reputation is key to drive the middleclass flight to private insurance, the end game. To assist the transition we have Ex-UnitedHealth Global executive Mr Simon Stevens as head of NHS England. Given his previous job was to find new non-US markets for private medical insurance, he seems to be in the right place at the right time. How fortuitous!

    Voltaire - "Those who can make you believe absurdities, can make you commit atrocities"

    It's time to wake up and smell the coffee folks!!

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  • Vinci Ho

    I believe Voltaire was a fanatic of coffee and drank , hence , smelt many times everyday!

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  • Jonathan Pryse is absolutely right paper care plans are out of date the instant they are written, version control and sharing are a nightmare to the point go making them virtually unworkable.

    Electronic care plans that can be shared by the patient with anyone involved in their care, that take a feed from different clinical systems overcome this and could make the UAES work.

    Work that we have done with Patients Know Best at means that this solution to the central problem of this ES is available now.

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  • GPs having the time for genuine continuity of care is better than any DES

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  • GPC and Chand Nagpaul suddenly gone quite over their claims about reduced qof and reduced workload which they negotiated.
    let me tell you- last years qof was 10 times better then the crap we have to do now.

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  • I wrote this article because I believe there is a significant risk that this DES will backfire and give us even less time to spend with patients near the end of their lives, which is often when we are most needed and valued. The best evidence for Advance Care Planning is at the end of life, the rest of the evidence base in weak at best. I have already recently had a partner in our practice resign because this DES was the 'straw that broke the camels back'. I will work hard to try to ensure future deals are an improvement on this- wish me luck!

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