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Five steps to starting the unplanned admissions DES

Dr Martin Duerden explains what practices can do now to prepare to undertake the new enhanced service

The basis of the new unplanned admissions DES for England is that many acute admissions for elderly, frail or vulnerable people with complex physical or mental health needs could be avoided if more coherent care was provided in the community.

Many people are admitted to A&E because this is the only option for providing care at a time of crisis. But such admissions are costly and may not provide the best type of care for these people, who may find the process distressing. 

However, it should be noted that this DES will only lead to fewer such admissions if alternative care arrangements are commissioned, so the onus is on CCGs to put these in place.

It’s strongly recommended you read this in conjunction with the published guidance.1 Unfortunately, at the time of writing, the technical specification with Read2 and CTV3 codes, and guidance on the role of CCGs, were still awaiting publication.

1. Decide whether to participate

The first step is to ensure that everyone in the practice fully understands the DES, wants to participate in it and is committed to delivery.

The 12 key tasks for the DES

1 Identify at least 2% of the practice list aged over 18 at greatest risk of admission, and children with complex care needs.

2 Inform those patients, code them on the computer system and set up a case-management register. Keep this updated.

3 Appoint a named, accountable GP for each patient on the register by the end of July.

4 Identify a designated care co-ordinator (not necessarily the named GP).

5 Agree a personal care plan with the patient and carers by the end of September.

6 Ensure patients on the register can be identified if they call the practice.

7 Implement telephone access for patients or carers to speak to a clinician in the practice on the same day, if required.

8 Develop a ‘bypass’ phone number to give other care providers same-day access to a clinician in the practice.

9 Follow up risk-registered patients three days after hospital discharge.

10 Contact patients on the register not seen by anyone for three months.

11 Review all unplanned admissions and readmissions for patients on the register, plus A&E attendances every month.

12 Produce an end-of-year report for area teams by end of April 2015.

Source: General Medical Services Contract 2014/15: Guidance and Audit Requirements

An ‘average’ practice of 7,000 patients can make around £20,000 from the DES, as the guidance offers practices £2.87 per registered patient for participating. But the scheme is a big commitment and will require a lot of resources in time, energy, and co-ordination. For some practices, the rewards will not be adequate, and some GPs may feel the DES does not address NHS priorities. But although the amount of money available is not great, some practices will want to find ways to recoup the shortfall from the reduction in QOF and other changes to GMS contract such as the loss of MPIG payments.

 I would strongly recommend that practices pursue the DES because they think it will improve patient care – rather than to make up for lost income.

Practices will need to decide by the end of June 2014 whether they are prepared to sign up to the DES. After applying, they will get paid 45% of the overall annual payment to help set up the service by the end of July.

One of the easiest ways to manage the workload for this scheme would be, to my mind, to hire a senior nurse in a less-than-full-time capacity to be the designated care co-ordinator and manage the phone lines.

A final point is that CCGs have been tasked to commission additional services to support this DES worth £5 per patient. Quite how this will be achieved at a time of shrinking NHS budgets is unclear, and there is no requirement for this money to be spent in general practice. But it may be worth contacting your CCG to see if it could help your practice make a decision on whether to take up the DES.

2. Set up the call system

Having taken up the challenge of the DES, practices should look closely at what changes will be needed to enable timely telephone access to the practice for hospital clinicians, ambulance staff, care home staff, and social and mental health services.

Most practices have a bypass number for clinical staff (and their relatives) already and for some practices this single line may suffice for the DES. Some may prefer to add a specific ‘unplanned admissions hotline’.

It would make sense to have a call system that enables the accountable GP – or designated care co-ordinator – to take their own calls to enable continuity of care. They will need to manage all the calls from patients on the risk register, as well as calls between the practice and hospital or community clinicians.

Urgent calls connected with patients on the risk register must be dealt within the required timeframes (an hour for some).

Another challenge is to allow same-day access for people on the at-risk register, or their carers, to a telephone consultation with the practice clinical staff. It is best if these requests come in early rather than late in the day, so clinical work can be planned effectively. Patients on the register will need advice about this.

Most practices already recommend to patients that they request phone consultations and home visits by the end of morning surgery each day – I recommend practices inform patients on the risk register to do the same.

An additional dedicated line into the practice for these patients may be a consideration, but a potential drawback is overdependence on, or overuse/abuse of such a system. As much as possible, it would be best if the accountable GP, or the designated care co-ordinator, is involved in these consultations.

A concern may be that an individual calling the practice may not be immediately identifiable as someone on the unplanned admissions risk register, and so it might be useful to have this clearly flagged up on an opening screen on the GP computer record.

3. Identify patients for the register, and keep it up to date

The scheme requires that at least 2% of the practice population receive special consideration as being at high risk of admission, readmission or A&E attendance.

There are tools that can help with this, such as the QAdmissions score, which was derived from the UK QResearch database (also used to develop QRISK2). Many GPs will be aware of the relevant patients on their list, for example those who have had frequent admissions already, or vulnerable patients who require lots of input or many home visits. To a certain extent, common sense – and the evidence of the types of patients and conditions where unplanned admissions are common – can provide useful pointers to the profiles of patients suitable for case management and for greater clinical input (see online version of this article for a full list).

The CCG or area team may not announce which risk stratification tool they want GPs to use immediately, so I recommend that once practices have committed to doing the scheme, they start straight away to identify the top 1% of patients who they expect to be on the risk register. Say you have five or six GPs in a practice, each should think of around 20 patients who suffer from chronic disease, often request home visits and are susceptible to emergency admissions. People on 10 or more medications or who have several serious co-morbidities are also likely to be at higher risk of unplanned admissions.

The DES also requires identification of people under the age of 18 years with complex needs, on top of the 2% of people over the age of 18 years. I recommend a 7,000-patient practice puts around 10 under-18s on the risk register.

Practices should also have a plan in place to keep the 2% of the practice population on the DES register ‘topped up’. A 0.2% tolerance is allowed (in the typical practice of 7,000, 14 of the 140 patients on the register) for natural attrition of the list, either due to patients’ deaths, improved health or their moving to another practice. The practice manager should check the list weekly rather than waiting until the monthly review, given that DES income is contingent on maintaining the risk register at 2% of your list. The number on the register will be assessed for purposes of payment verification at the end of each quarter, from September 2014.

New patients will emerge as conditions arise or progress and they will need to be included, so add them to the register during the monthly review meetings. The requirement is to complete their care planning within one month of inclusion on the register.

4. Develop personal care plans

The next step is to ensure that each patient included on the at-risk register is informed of this in writing and comes in to co-write care plans with a GP before the end of September. This will require a fair amount of work for all concerned, but there are template letters and care plans included in the national DES guidance.1

The named GP, alongside the designated care co-ordinator if the practice chooses to appoint one, are responsible for developing a personalised care plan. They are also responsible for ensuring that this plan is followed and reviewed when necessary. Perhaps the trickiest bit – but obviously important in these days of patient choice – is to ensure that patients and carers contribute and agree to the plan. This is most pertinent when it includes items like a patient’s preference for active intervention at the time of acute deterioration. If the patient agrees, the plan can be made available to multidisciplinary teams and other providers.

I recommend the care plan be compiled by the clinical lead, rather than by each of the GPs. Each one will take around 30 minutes, so if the GPs did it the impact on GP access would be high. I also recommend the information is entered directly onto the computer to save time.

What you need in a care plan

• Name, address, date of birth, contact details and NHS number.

• Whether the patient is a nursing/care home resident.

• Named accountable GP, and designated care co-ordinator if different.

• Any other clinicians who play a significant role in the patient’s care.

• Details of consent to share information.

• Names and contact details of next of kin/main carer/responsible adult.

• Details of condition(s), significant medical history and allergies.

• Details of any ongoing medication, including OTC medicines, and review plans.

• Individual requirements or preferences that will aid care and support.

• Key action points, for example early detection of deterioration and crisis management.

Source: General Medical Services Contract 2014/15: Guidance and Audit Requirements

If a patient on the list has no contact with anyone in the multidisciplinary team (presumably anyone in the practice or community care) within three months, the GP should call them to check their care needs are being met.

The intent in the longer term is that this information is all entered into all GP computer systems. As the scheme develops, it might be best to use laptops or tablets to input the care plan directly with the patient.

Note, the patient has the right to ‘opt out’ of inclusion in the register if they wish.

5. Assess unplanned admissions and A&E attendances

The final step is to identify and collate experiences from the scheme in order to improve care, for individuals and for the practice population and the wider locality. Practices will be required to undertake monthly reviews of all unplanned admissions and readmissions and A&E attendances of patients on the register. This will also entail identifying newly vulnerable people for inclusion (for example, patients left with disability arising from an acute event such as a stroke). The intention is that, by these reviews, the practice can see if any admissions could have been avoided and also improve personal care plans for the future. The content of hospital discharge information, and its timeliness, should also be reviewed.

The findings may give information on amending or improving the hospital admission and discharge processes and it is important that this is fed back to hospitals. If there are problems with community and social care provision these can also be flagged up, and all this information brought to the attention of the CCG, if necessary.

Practices are specifically required to carry out regular reviews of admissions and attendances of patients from care and nursing homes. Possible improvements in processes of care by nursing homes, community services, or in practice availability may all need to be considered. Any change to care plans resulting from these reviews should be agreed with patients.

Evidence that you have done all of this will be required by area teams, so be prepared to collate this information at the end of the year to ensure your practice gets paid.

Dr Martin Duerden is a senior clinical lecturer at Cardiff and Bangor universities, and a part-time GP in Conwy, north Wales.


1 General Medical Services Contract 2014/15: Guidance and Audit Requirements. London: NHS Employers; 2014.

2 ClinRisk Ltd. QAdmissions risk calculator.

Readers' comments (8)

  • In a time of competing and at times oppressive demand we have to use ourselves (GPs) as a resource, very carefully. If we lose an income stream then either we have to work harder or stop doing something and as most of the things we do are not wasteful this would impact directly on patient care.
    Managing the care plans is probably the single most onerous element of this DES and I believe it is unmanageable with a paper based system.

    I have put together a UPA DES calculator which practices can download and populate with their own figures here
    I hope this will help practices decide where and how to spend their effort.

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  • How on earth did our negotiators come up with this beaurocratic nightmare. I never thought I would say this, but QOF suddenly looks attractive again.
    There is very little research evidence to support this kind of programme .More mindless box ticking beckons .

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  • Reinventing community matron service which involved identifying at risk patients, formulating crisis care plans, liaison with hospital, other mdt members, to reduce admissions. This was a full time job for one person with a caseload between 30-50.
    Could GPs group together to employ an advanced nurse to help them manage this group of patients and cope with the increase in home visits which will come.

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  • Drachula

    Yes, we could employ another matron, although the Community provider is already funded to do this. But if we do that, we will lose all of our DES money. We have to do this by the quickest, least effective method. We have to earn the money by commenting briefly where we have to, and then getting on and doing the real work which no one actually sees.
    Does anyone remember the GPC saying "no new work without new money"? That was the basis on which I voted for the new contract.
    Hey ho. Australia anyone?

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  • 12 points of utter rubbish , 10 yrs of training To become a GP. , please give us some respect to decide who needs hospital admission , simply mind boggling how we have got to this point .

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  • Half the patients on the list won't be able to meaningfully add to their care plan due to cognitive disturbance/general frailty. The major difficulty will be upkeep of the register from an eagle-eyed individual who can flag up when the numbers are low giving enough time to draw up new plans. I have already found a few patients flagged up in our 2% from the risk profiling software (acg) who I can't understand why they're on it- they've not had recent admissions. We're waiting on a care plan template which we can hopefully auto-populate with relevant info from a summary consultation. Once this is done, it's the monthly reviews of A&E from the 2% and N homes + the upkeep/monitoring which will be the onerous problems to overcome. EMIS prompts when their record is loaded, phone number to call on the standard letter for the 2%, and weekly auto reports counting the codes for active case management will help this process. The what-to-do (key action points) is relatively easy- in the letter we can include a patient leaflet which can be written up focussing on the time-critical illnesses for 999, and everything else the practice/111.

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  • 3 Identify patients for the register, and keep it up to date.

    Can some one please tell me what this really means.

    The way I read this is in Q1,2,3,4 the 2% most at risk patients should be on the register. There is a LARGE claw back if not completed,

    "natural attrition of the list, either due to patients’ deaths, improved health or their moving to another practice"

    Improved health = Looking at our CCGs risk stratification program risk is a very transient value. in Q1 you could be at risk Q2 same patient could be out of risk group and need replacing and this is with out any intervention just pure luck.



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  • Sounds like a lot of hard work for a mere glass of water!
    Sadly I feel vulnerable patients will take up so much of the GP's time that other patients will suffer.
    I wish the government would trust our very valued GP's and go and pick on someone else.
    How would they like somebody scrutinising how many times and how a long a visits they spend going fro a pee?

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