This site is intended for health professionals only

At the heart of general practice since 1960

Read the latest issue online

CAMHS won't see you now

Practices must implement 'care plans' for 2% of patients by July to achieve £20,000 DES payments

Practices will need to implement care plans by the end of June for each of the 2% most vulnerable patients on their lists as part of the unplanned admissions DES, a task local leaders have warned may not be achievable.

The specifications, unveiled yesterday, reveal that GPs who sign up to the DES will need to identify the 2% most vulnerable patients using an ‘appropriate risk stratification tool or alternative method’ before July as part of the DES, which is worth £2.87 per patient - around £20,400 for the average practice.

The document, unveiled by NHS Employers, states that the payments will be split up into five components, including a payment of 45% upfront, 15% at the end of the year, and a payment at the beginning of each quarter.

GPC has said that the bulk of the work for GPs will be at the start of the year, and the upfront money reflects the amount of work, while local leaders have said this is a huge task that may not be achievable.

The guidance runs to 42 pages, and provides templates for practices to send letters to patients they have identified to put on the risk register, including children with complex needs.

It also includes a three-page template for the personalised care plan, including details about the patient’s medical history, current medication, preferred place of care and an agreed plan for escalating care, including crisis management.

The document states: ‘The practice will implement proactive case management for all patients on the register. This will include developing collaboratively with a patient and their carer (if applicable) a written/electronic personalised care plan, jointly owned by the patient, carer (if applicable) and named accountable GP and/or care coordinator.

‘If the patient consents, the personalised care plan should be shared with the multi-disciplinary team and other relevant providers. Personalised care plans should be in place for all patients initially added to the register by the end of June 2014. Thereafter, any new patients coming onto the register in year should have their personalised care plans created and agreed within a reasonable timeframe, but no later than one month after entry onto the register.’

On the risk stratification tool, the guidance adds: ‘The practice will use an appropriate risk stratification tool or alternative method, if a tool is not available, to identify vulnerable older people, high risk patients and patients needing end-of-life care who are at risk of unplanned admission to hospital. If a risk profiling tool is used, CCGs should ensure that a suitable tool has been procured for practice use.’

Dr Richard Vautrey, deputy chair of the GPC, said this will involve a lot of work in the first quarter.

He said: ‘It is key that practices get on with developing the care register as soon as possible, as they will see from the breakdown of the payments that they are linked per quarter. There is a lot of work to do in that quarter in getting the care register in place and developing the care plans for the individual patients. That is the bulk of the work for the year.’

He added: ‘Practices will also need to ensure they don’t fall below the 2%, even though there is a tolerance involved.’

Dr Paul Roblin, chief executive of Berkshire, Buckinghamshire & Oxfordshire LMCs, warned this workload has been underestimated.

He said: ‘If the [personalised care plans] are going to mean anything, they have to consider every conceivable eventuality and detail what you are going to do in those circumstances. This is not a small piece of work. I think the workload is underestimated.’

When asked whether this was achievable by the end of June, Dr Roblin added: ‘It probably isn’t… [The care plan] is a tool whose value is probably over-emphasised.’

The DES was introduced as part of the 2014/15 contract agreement, and replaced the Quality and Productivity domain of the QOF and the discontinued risk-profiling DES.

The guidelines reveal that, as part of the DES, practices will have to:

• Identify 2% of their patients to put on the risk register, which will worked out as an average of the proportion of patients on the register at the end of each quarter;

• Ensure that emergency service, mental health and nursing home staff should be able to get through to a clinician in the practice within an hour in certain circumstances

• Ensure that patients placed on the register have a named GP and personalised care plan in place by the end of June. Thereafter any patients added onto the register should be informed of their GP within three weeks and have a care plan in place within one month;

• Undertake monthly reviews of their risk register to check whether they need to take any action to prevent unplanned admissions – for example on the basis of whether patients requiring multidisciplinary team input are receiving it, and whether the practice is receiving appropriate feedback from the district nurse team. 

• Agree an action plan for escalating care, including crisis management.

There has been criticism of the unplanned admissions DES from experts, who claim that it could even raise unplanned admissions rates among the 98% of patients not included in the scheme.


Readers' comments (52)

  • for me this is the final straw. eagerly waiting for my pension forcast - nearly 55 and will take early retirement.
    there will be much worse to come

    Unsuitable or offensive? Report this comment

  • Australia and NZ are about to get a few more docs......

    Unsuitable or offensive? Report this comment

  • what cracks me up is
    1. i have to be available for anyone to ring me - yet what would actually keep people out of hospital is some of those people being available when i called. last week i tried to keep an elderly gentleman who lived alone with no carers out of hospital he was off legs, little to find medically, probably more social than anything. no one would take him, couldn't get hold of most people, social services were a joke got a trainee OT who was answering calls for the day who tried to arrange respite for him and failed as her bosses told her (incorrectly in my opinion) that he would have to pay. after 2 days gave up sent him in on a friday and i thought he might die over the weekend. they gave him a couple of litres of fluids to rehydrate, a bath a wash some laxatives and he was home on monday fine. moral of the story don't bother trying to avoid hospital - its actually quite a good idea if you are ill.

    Unsuitable or offensive? Report this comment

  • 2. the document says things like your doctor will review your care or your childs as often as you like - have they any idea? some of my patents ring daily as it is. I've spent an hour with one girl in the last few days. telling her yes she has a sore throat and it will get better. she keeps getting in - she tells the reception another horror story and when she gets in my room she is no worse than the day before.

    Unsuitable or offensive? Report this comment

  • this will be a tick box exercise, but until we join together the GP service will self destruct - and I'm not talking federations here!

    Unsuitable or offensive? Report this comment

  • Don't fret, there's an easy solution to this.

    Every month (or week if you wish, just ensure patients are re-admitted within a month so as to avoid charge for admission) plan to admit all of the patient on register. All you need on the care plan is "admit once/month or more if unwell". If anyone calls, you'll need an automated telephone line to say "my plan for all of my vulnarable patient as stated in the care plan is to be admitted if they are unwell. Please follow this plan and do not attempt to disturbe me in my clinic as I will only tell you the same". Doesn't matter if they are well - they are vulnarable as far as the DoH is concerned so admit them routinely every month to avoid unplanned admission. Get the reception to call the bed manager and admit the entire list (about 170 for my practice). Preferablly on monday morning before the ward round or friday after 5pm. There will be no need to review the care plan each month as you will get a new discharge summary every month.

    As all of them will be planned admission, I'm sure our esteemed honorable minister would be happy.

    Unsuitable or offensive? Report this comment

  • Bob Hodges

    CARE PLAN: If in doubt - PANIC. Please contact me from the ambulance on the way to A&E with the patient if you really have to 'let me know'.

    This DES contains absolutely NOTHING to match 'what it says on the tin'.

    It won't work because its all about the process and not about the patient. There is NO TIME LEFT IN THE DAY for the patient even with the ridiculous paperwork proliferation. Sustained investment is needed to recruit/retain MORE STAFF. No one in their right mind would employ another doctor to help with capacity on this derisory amount of money which is NON RECURRING in an ear of 'NO NEW MONEY' (unless you run a bank).

    We all know that the 'money' will disappear next year, but the requirement to do this work will not.

    My gut instinct is to say 'no thanks'.

    Unsuitable or offensive? Report this comment

  • Chris Kenyon

    While the sentiment of this initiative may be laudable, what's difficult is that we all already do our best to look after these vulnerable people. What this exercise could be seen as is withdrawal of the money that used to be paid for this work which can now only be earned back with enormous extra (and mostly meaningless) work, in addition to what's already being done for these people. Very tiring and demoralising.

    Unsuitable or offensive? Report this comment

  • Rather spend my time watching paint dry in the waiting room than waste any time on this meaningless exercise, Kings Fund has not found no evidence it has any impact on admissions.

    Unsuitable or offensive? Report this comment

  • Anyone taking on this DES is not going to do it properly as it CANT be done properly without taking up too much time and effort badly needed elsewhere in the practice .
    It will be in effect taking public money without really doing what you are supposed to do for that money but instead pretending to do it, and then hoping nobody checks out what you are doing ,or at least turns a blind eye to it.There are some strong words that could be used to describe that sort of activity.
    Anyway with a 40 % tax rate plus other deductions its not worth it, and you would be better off retiring early and living off the pension which will still be bigger than most people who retire much later.
    General Practice will all be private in 15 years as nobody will want to be a partner (its happening now and I stood up at a big meeting and announced if any salaried GP present wants to swop positions with me ie a Partner then to see me after the meeting and of course nobody took my offer up!)
    Most practices will be taken over by Private companies with purely salaried GPs and Nurse Practitioners - its inevitable .

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page50 results per page

Have your say