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A faulty production line

GPs to oversee all vulnerable patients under emergency admissions DES  

GPs will be responsible for case-managing and preventing hospital admissions - through direct phone contact with emergency providers and patients - through a new DES.

The new DES will be funded through the abolition of the quality and productivity domain of QOF and will mean GPs have to improve services for patients with complex health and care needs, who may be at high risk of unplanned admission to hospital’.

This will mean all vulnerable patients will be ‘proactively case managed’ and have a named, accountable GP co-ordinating their care.

The service will require GPs to provide ‘timely telephone access’ to relevant providers to support decisions relating to hospital transfers or admissions, in order to reduce avoidable hospital admissions or A&E attendances.

They will also have to improve access to telephone or, where required, consultation appointments for patients identified in this service.

The DES will also require that GPs review and improve the discharge process, sharing relevant information and whole system commissioning action points to help inform commissioning decisions and undertake internal reviews of unplanned admissions/readmissions.

Funding for the service comes from the retired QP domain of QOF worth 100 points, as well as additional £42 million from discontinuing the DES introduced this year on risk profiling.

GPC deputy chair Dr Richard Vautrey said: ‘Practices need to ensure that if somebody from A&E is treating one of their patients and wants get through to the practice to find out what drugs they are or what happened in a consultation earlier on, there is a swift way of that clinician being able to contact practice.

‘That might mean providing a specific number for A&E or a more dedicated ex-directory line, potentially ensuring there is prompt access for such situations.

‘This applies to the contract so has nothing to do with out-of-hours. This is about the responsibilities for the practice in terms of their contract between 8am and 6:30pm.’

NHS England said GPs would need to offer patients same-day telephone consultations and provide other healthcare professionals with a direct line, but there would be no need to deliver 24-hour access.

A spokesperson told Pulse: ‘There is no 24-hour helpline requirement in the contract. The new enhanced service on reducing emergency admissions includes a requirement that the practice offers a dedicated telephone line.  

‘Practices will provide high-risk patients who have urgent queries with same-day telephone consultations or with follow-up arrangements where required.

‘The second dimension is improving availability for other healthcare providers such as A&E clinicians, ambulance staff and care and nursing home staff, who will be able to use a dedicated ex-directory or bypass number to gain convenient access to the practice to support decisions relating to hospital admissions and transfer to hospital when vulnerable patients present.  This will apply during contracted core hours.’

Readers' comments (18)

  • But surely Dr Vautrey we will be responsible for these patients 24/7 anyway as they will be in the vulnerable/at risk group so we can be called out of hours about them and this will be a contractual responsibility will it not ?

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  • It would be so much better if hospital computer systems were compatable with GP systems. The hospitals already manage timely access for drug history etc - it is called the telephone.

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  • What if it's a weekend or the doctor that knows the patient is around.
    Very I'll thought through scheme again

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  • If a patient with heart failure has a sats of 84 % and. Boba sale creeps with increase JVP.
    How would we prevent admission of this patient.
    Another scheme to cover the Governments invompetence.
    They've not spoken about the botched 111 service.
    What it a patient comes in at 12 midnight.. Do they expect a GP to be up then .

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  • God, will the entire GPC team wake up to the reality!?

    First of all we will be loosing income unless we take part in this as it is funded by the QoF money.
    Secondly, the suggested actions here will require a lot more work by GP then the QoF domains.
    Thirdly, how will the secondary care know which GPs are taking part and which are not?
    Forthly, some of the infrastructural change will cost money in itself (new telephone line anyone?)
    Fifthly, during my 10min consultation (average consultation time 5 years ago was >11min), I don't have the time to talk to someone else. And my surgery runs for 3 hours each session.
    Finally - where are we going with this? As already mentioned this is paving the way for GPs taking on 24/7 care at no extra funding

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  • Patients don't become vulnerable at 75, anyone can become extremely vulnerable when they have multiple problems, regardless of age.

    Are the NHS telling us that if we are under 75 and vulnerable, nobody will care or our care will be of a lower standard?

    My GP look after me regardless of my age and vulnerability, when I face a crisis, he is there to support me, exactly what if it that the these people expect GP's to do, become lodgers when someone reaches the age of 75?

    I feel they should leave GP's to decide on what their patients needs are, they have built up a good relationship with us, and we with doctors we know and trust!

    I don't want to need to ask a stranger in a pharmacy to examine me alone, in a small room at the back of the shop. I do not want, and never have needed my GP to work 24/7 or fro my surgery to be open all hours.

    The sad thing is all these changes are being made by 'pen pushers' who haven't a clue what a day is busy surgery really is like. I bet most of them have private care anyway!

    Leave GP's alone, they are the NHS, they are anything but stupid, they know our needs better than anyone sitting in an office, a person that has never even met me.

    Why all the GP bashing anyway, if they all resigned there would be no NHS!

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  • 'GPs will be responsible for case-managing and preventing hospital admissions - through direct phone contact with emergency providers and patients '

    Trying to case manage patients to avoid unnecessary urgent admissions is useless if we cant get hold of our secondary care colleagues who are also involved in the care of certain patients! It takes days if not weeks for some to call back (sometimes no response)- in that time the patient has had to be admitted urgently when a possible planned admission could have been organised with better direct communication. Everyone needs to be involved in co-ordinated patient care not just GPs.

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  • Those that think this is a return to the 'old-fashioned GP' style of medicine are misguided in my view.
    Back then those GP's were able to do what they could in the community setting knowing full well that in general they had the sympathetic local DGH to refer onto who would accept the patient willingly for further care. The pathway was centred on patient need. The pathway now is based on the Exchequer's need with the 'best pathway' the cheapest. That's where the GP (surprise) comes in. Bottomless 'named' responsibility added in for good measure so the lawyers, accountants, politicians and patients know who to aim fire at. Publish their income as well and you've got a rock and a hard place.

    Hunt and his cronies will be dancing down the corridors of the DoH at the ease in which they turned the Profession inside out, given all the responsibility and no real power. There's loads more to come by the way.

    The solution for the Exchequer lies within distant off-shore tax havens, robber barons and bankers, creative accounting and the unaccountable power of multinational corporations to influence politicians. If the
    Exchequer had his legitimate 'take' from that lot, health and all the other cash-strapped public sector services would experience the renaissance they deserve.

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  • maybe i am missing something: We already offer same day appointments ( in person) or via telephone if vetting requests for home visits to all not just the >75. We have an emergency phone number that does not switch off during lunch or until 6.30pm. A&E can already get this information by calling us on the phone and we fax over patient summaries, or we speak to the doctor if they ask us to! We dont have fixed patient lists but we all have patients that 'belong' to us and will always choose to see a specific Dr if they are working that day ( we are all part time) and run a buddy system for when people are away. Ar we not doing everything already or have I missed something out? Admission prevention would be far easier if we had timely out patient appointments or telephone access to consultants for advice, not the ST3.

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  • Don't need a contract to tell highly educated people they can use a telephone....

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  • The real problem in A&E is the fact that everything is attempted to be seen. Have highly skilled triage nurses, GPs and A&E consultants/registrars at the front line telling people to go away with trivial problems , this will reduce the load. As an SHO in A&E I didn't feel comfortable doing that as I wasn't experienced enough. 5 yrs later I can sort the wheat from the chaff very easily!

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  • these people have no idea of what is happening in a GP surgery on daily bases.
    we already offer same day telephone or face to face appointments, it is called "duty doctor".
    we do try to keep patients away from hospital by providing delay scripts of antibiotic for example.
    how on earth can a GP prevent hospital admission if necessary, how would I know if my patients is going to deteriorate over night or over the weekend. that's what is OOH for.
    what happen to patients who do not respond to treatment in the community? don't they then need an IV Abx or IV diuretics for example.
    some people present after an injury (children or sport injury) and when send them for same day XR to A&E they end up having a broken bone, how can I stop them from having injuries.
    I never ever in my hospital rotation as an SHO have any problem of getting any information from GP about their patients, you just need to pick the right time to speak to a GP. and you can ask secretaries to fax medication list.
    no wonder GPs are retiring and there is a shortage of GPs in the UK.

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  • This will change nothing. It is simply a mechanism to identify who to blame if things don't go right...i.e the GP. It's completely driven by the needs of A&E under the erroneous belief that the elderly end up there for want of a single GP visit or phone call...'if only they could have seen a GP they would have been fine'. ..this is complete rubbish. The elderly end up in hospital often through a combination of multiple minor health issues and the lack of an ability to cope with this at home. This requires major attention to how we organise social care in our society..which isn't being addressed. Fast track telephone treatment for suspected UTIs is not a solution....a three day course of trimethoprim is not a social care package. We are medicalising what is actually a social care issue..which is the responsibility of society as a whole - not the GP. Making GPs personally responsible for something that belongs to society as a whole is dishonest and will cause us no end of bother...although it suits everyone else as it conveniently enables them to avoid responsibility themselves.

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  • Anon 8.05pm- why has this not happened? Seems so simple!
    1) it is not the minors that breach the 4hrs. It is the majors who are waiting for a bed. The more minors you can see the higher your denominator and the more likely you are to hit the 4 hr target.
    2) streaming lots of minors to primary care may free up a few junior drs but isn't going to help find a bed in MAU.
    3) Minors are a cash cow for hospitals, why would they relinquish them when it will destabilise their finances.
    4) there is commissioner / provider collusion as both want to hit 4hr target. Payment and target needs to change to reduce the payment of minors to cost price, and the target needs to be split to take account of minors and majors.

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  • Anon 11.25.
    I agree with much of your post. Hospital consultants know the issues. We spend a good deal of time chatting to patients on the emergency take who have been admitted because of some form of social crisis or breakdown in usual care processes. Invariably this admission has been dressed up as 'off legs' 'UTI' 'falls'.

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  • Who are the GPs providing all this access? Partners ? Will our salaried colleagues expected to do so too?
    Can we commission this to our very efficiently run OOH provider? How will the patient contact them / us, via 111 ?
    Whom am I expected to communicate with? We have our new 'Health Hub', who is supposed to take all our community referrals for almost anything. However, it does not always work, as they lack capacity. Also, there are too few community hospital beds, which are never available when needed urgently, i.e. OOH.
    All rather ill thought out and this will just push more GPs in their 50s to retire early and put young doctors off going into General Practice and rightly so !
    Maybe, we all should go salaried, or maybe turn into locums, with the demise of the partner, the political class, media and our patients will then see, what it means, when we start working to rule, not doing any extra, unfunded work and stop going the extra mile and being innovative. Sadly, the foundation of UK General Practice, and therefore the NHS will be lost and there will be no way back.

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  • Dear Colleagues

    I have great respect for colleagues' nervousness regarding duties superimposed on their already-full working day. However, this shows we are missing the point. The majority of modern GPs have taken 10-11 yrs to train, and earn over £100K pa. What should a professional at this level be spending their time on? Typing (how many hours a day do you use up doing this)? Making banal decisions about repeat prescription? Diagnosing viral pharyngitis? Wading through hundreds of normal lab results? Filling in ridiculous forms (eGPRs, DWP, approval of 'homely remedies', 'fit for tandem parachute jump' etc, etc.)

    No, such highly-trained, highly-paid clinicians should be making high-level clinical decisions, ONLY. We should be part of large teams with appropriate skill-mix. Less highly trained/paid professionals should be doing all the above. A model that we might look to would be the modern solicitors' partnership. Every decision/action is devolved to an appropriately trained/paid team member.

    I'm sorry, dear colleagues, but what we need is an IMAGINATIVE REVOLUTION in the way we work.

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  • I am with David Lewis, it is a quirk of history that medical Professionals are the only professional group(apart from professional footballers as a colleague recently advised me) who do not have formal assistants in the model of practice. I am very interested in the University of Warwick Physician Assistant program, and I too think a redesign of our medical model of practice is needed. it is utterly unique that so much medical tasks have ended up being transferred to a Nursing Profession.
    Please do not take this as saying Nurse colleagues perform poorly, they do not , but they do start from a different professional value base and system of practice compared to a medical model.

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