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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.

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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.