DESs 2013/4: Which are worth doing and which aren't
As the deadline for signing up approaches, Dr Eithne Cummins summarises the arguments for and against the four new DESs for 2013/4
‘Potentially the most rewarding’: The dementia DES
£0.37 per patient upfront, with an average of £3367 for complete assessments
Improving the diagnosis and management of patients with dementia is a DH priority. CCGs have been asked to prioritise dementia care. Commissioning guidance is awaited for memory services though most localities have access to services they are usually overstretched. This DES is the most clearly structured and straightforward of the 4 new DES for clinicians in practices to partake in. The rules are clear and clinically based and enhance the work you are already doing for QOF. The emphasis on dementia through this DES and QOF is likely to continue for the foreseeable future.
This DES is worth considering because it is potentially the most financially rewarding DES of the ‘new gang of four’. For most practices as the information required to be collected is straightforward and clinical and can be captured using a read coded template. Some of the read codes are already provided in the documentation; others however are awaited in the autumn. Proxy read codes may have to be used at practice level for the interim period.
Within the read codes provided there is room for exception reporting from the DES. This is helpful, particularly where people have capacity to do so. Unfortunately, no consideration has been made of capacity and consent issues.
There is an upfront payment on agreeing to participate in the DES of £0.37 per patient. This moiety is the more generous. It is paid principally to enable you to identify those at risk of dementia and plan practice processes for screening (initial questioning for memory concern) the at-risk population. The population you are expected to screen is clearly indicated and come from a cohort of patients who would normally attend for QOF-based clinical interventions.
The second payment component is for the number of completed assessments done. The payment for this element is based on a calculation:
192/ [1,197,408 x £21,000,000] = £3,367
- 192 assessments is the expected number of completed assessments for an average practice
- 1,197,408 is the total number of expected assessments expected to be done nationally
- £21,000,000 is the total sum available nationally for this element.
I believe fewer assessments will be done nationally because many practices will find this element onerous and laborious. If a practice is ahead of the national cohort and prepared to be industrious, systematic and focused this this could therefore be a good earner for them,
Again a practice template would assist in this process, it could be combined with read codes for QOF indicators.
Whilst referral to a memory clinic is easy to code and links nicely with QOF indicator DEM3 , the carers’ based interventions are often harder to achieve. Carers may not be registered with you even if you are aware of them, or vice a versa. The role of formal carers does not appear to have been considered: I suspect a lot of practices will leave this carers element for the time being.
Top tip: There is a national dementia calculator available to support practices in determining what the recorded prevalence of dementia should be. It is worth looking at just to see how you are faring now, what your expected versus your actual prevalence is and how many additional cases you might be required to assess.
‘Most achievable’: Improving patient online access
£0.14 per registered patient after presenting evidence
This DES is designed to try and create a level playing field in terms of electronic communications for booking of appointments and repeat prescriptions for patients. For many practices, this DES is the most achievable; it offers reward for work already being done. Most computer systems enable remote booking of appointments and repeat prescriptions. Many practices register patients daily and in increasing numbers for online access.
Payment will be based on HSCIC data will be used to confirm evidence of online booking (component 1) and repeat prescribing (component 2) in at least one quarter of 2013/14.The payment is £0.14 per registered patient. the a flat sum of £985 is paid to each practice where they can demonstrate that at least 5%of their registered list have a password for online access, (component 3)
Practices who are already not engaged in these processes should see the monies on offer as a payment for getting things going. Identifying and training staff, a patient awareness and publicity campaign are essential if you are starting from scratch. For most practices this is the easiest and most achievable DES this year.
‘Takes planning, but could benefit patients’: the risk-profiling DES
£0.74 per registered patient based on one GP attending monthly meetings
From a practice point of view this DES requires considerable investment in practice time and thus it could cost a lot, but by planning the approach in advance the costs can be minimized and potentially some patient care can be enhanced and QOF points garnered along the way. The bulk of the practices costs will be in GP and administration time.
It is important to be focused with this DES as dedicated practice staff may over invest their time. It does not and should not require any investment in equipment or expensive computer packages at a practice level. I estimate the cost of GP and admin time, could be close to £2,700 for an average practice, based on one GP attending a meeting for one hour a month, and associated administration which in reality could be two hours per month. Add to this admin or practice manager time and profits are soon been eroded.
There would appear to be three potential audit areas for a CCG charged with monitoring this DES:
- Can the practice produce an ‘at risk ‘register? How many people identified as being at risk have been exceptions reported and why?
- Is there evidence of multi-disciplinary working?
- Is there evidence of a care planning approach for patients?
It is likely that questions two and three above will be weighted more heavily as the bulk of the work lies therein. However this is not specified in the DES: ‘Payment available to participating GP practices under this enhanced service in the 2013/14 financial year will be £0.74 per registered patient’ (NHS England).
All these things considered, preparation and some dedicated time at the outset, as well as clear guidance from the CCG could mean improved quality of care and life for a number of our vulnerable patients, as well as potential additional QOF gains.
I personally believe there is neither the workforce nor the resources in primary care to manage the current workload. It is well known that there is a direct relationship between investment in primary care and the admission rate to secondary care. This DES does not offer that investment. Less money in councils for social care, less available district nursing means that everyone is expecting more of everyone else.
What this DES offers practices is an opportunity to get positioned for the future. The key for maximizing the financial gain with this DES and the future is good working relationships across your primary health and social care team. This is inevitably going to be difficult in this period of dwindling health and social care resources. It remains to be seen whether this approach will lead to fewer avoidable admissions as the specification details. There is very little good evidence for care planning and management in this context doing so.
‘Lots of work for little reward’: Remote care monitoring DES
£0.21 per patient upfront
This DES is about empowering patients to self-care. A priority condition needs to be needs to be identified by the CCG, this is already a stumbling block for achieving this DES . The purpose of the DES is to ready practices for incipient remote care monitoring in 2014/15.This DES asks practices to identify those ready , willing and able to monitor their own health in a given LTC.
There is a small sum available of £0.21 per registered patient available this year for readying the practice for remote monitoring. There is however quite a lot of time involved in attempting to achieve this DES. Suitable and willing patients need to be identified and patient preferences have to be recorded but also governance arrangements need to be considered.
This DES is a lot of work for very little reward. It will rather depend on the condition identified by your local CCG and how many people you have on your register for that condition. If the priority condition is diabetes or heart failure, I can see many practices throwing this one into the long grass.
It has not been well thought through, however I suspect it will return next year in a different guise. Telehealth isn’t going away just yet.
Dr Eithne Cummins is a GP partner in Sheffield