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How to... Master the new clinical DESs

Dr Jeremy Phipps on the challenge of meeting clinical DES requirements.

Practices wishing to participate in the new clinical directed enhanced services (DESs) in England need to work quickly as they are already six months behind.

The five new areas for England were only recently published but relate to the year April 2008/9. Consequently, to try to gain maximum benefit, practices have to collate information in half the time.

The new areas relate to

  • Heart failure
  • Alcohol
  • Learning disabilities
  • Osteoporosis
  • Ethnicity

My practice has taken steps to improve care in these areas.
















Heart failure
As with the quality framework, the key for this DES is having robust disease registers. Our heart failure register is regularly updated based on information received from secondary care in particular and we were satisfied with its accuracy.

On checking the register, approximately 20 per cent of patients were already taking beta-blockers, so we should be paid for these at least. We went through the remainder checking which patients had an absolute or relative contra-indication to beta-blockers.

For patients with asthma, diabetes or other contra-indication, a code for exclusion was entered. This also helps with the beta-blocker requirement of the CHD domain of the quality framework (CHD 10) as many are also on the CHD register.

About a further 40 per cent were excluded. For the remaining 40 per cent, a message was attached to their notes to remind doctors about beta-blockers at next attendance and to commence if clinically appropriate.

The relatively small amount of money available per patient means this DES may not be viable for many practices. In addition, the payment is for new registrations in this year, so we have all really missed the boat for half of the potential patients that could be covered.

Although the recommended questionnaires are simple, there is the problem of monitoring and recording their use. There are, however, Read codes for both tests, which help considerably.

For practices that still organise new registration medicals, incorporation of one of these tests should be straightforward. We are looking to incorporate this into a short written questionnaire completed by patients at registration along with recording their smoking status.

Learning disabilities
Again, checking the disease register is sensible. Most of our patients with learning disabilities live in designated accommodation and checking that all residents of these houses are on the register was the first step.

Interestingly, there is no age restriction for this register, whereas the quality framework includes only over-18s.

One prerequisite to claiming is attending a PCT educational meeting, which has yet to be arranged. We have made enquires but it has not stopped us from making progress.

As patients attend for their medication reviews, many of the components of this DES will be checked as a matter of course. The additional elements suggested should be relatively simple to add to these routine consultations and we are developing an appropriate template.

As with most of the areas of the DES, no Read codes are suggested. As long as the practice can demonstrate that the work has been completed by performing an appropriate search, this is not a problem. Practices should decide which codes they wish to use and ensure data is entered appropriately.

There have been clear hints for some time that osteoporosis was likely to be included as a clinical DES. This is for two years only, and affects only newly diagnosed women over the age of 65.

We were fortunate to have an audit of osteoporosis undertaken earlier this year by a pharmaceutical company promoting calcium supplements. This had raised the overall practice awareness of this disease.

We went on to search for recent specified fractures in females over 65 since 1 April 2008 and checked they had been referred for densitometry and/or were taking treatment. Two patients needed referring and three were contacted about possibly commencing medication.

Searches will be repeated throughout this financial year.

This DES requires the practice to record the ethnicity and first language of patients on their list. This will be very hard for most practices, especially the 90 per cent target in the second year. While ethnicity for new patients is usually recorded, their first language is not, nor is the ethnic status of longer-term patients.

We have the ethnic status of just under half our patients recorded but almost no records of first language. However, the majority of these patients are recorded as British and we have added a batch code for 'English as a first language' to all of these and those of Irish descent. We can now aspire to achieve 50 per cent by April 2009, but I doubt we will achieve 90 per cent by the end of the following year.

As with all new work, it is necessary to see whether the extra remuneration merits the additional burden. In most of these areas, practices will already be providing the majority of the designated care. If they are not, however, the extra money is probably insufficient to instigate change.

  • Dr Phipps is a GP in Lincolnshire

Decide which codes the practice will use to allow easier audit.

Heart Failure/beta-blocker

  • Ensure register is current.
  • Enter Read code for those where beta-blocker is contra-indicated.
  • Highlight the remainder for consideration of treatment.


  • Use screening tests on newly registered patients over 16.
  • Make this part of the registration medical or a questionnaire given to patients on registering.

Learning disabilities

  • Check register.
  • Contact your PCT regarding the accreditation course.
  • Start systematic recording of required information now, possibly through a specific template.


  • For new diagnoses since 1 April 2008 in over-65s, females only.
  • Search on new fragility fractures since April.
  • If 65-75, check they have had densitometry.
  • If over 75, then consider for treatment.
  • Pharmaceutical companies may support audits.


  • Consider recording patients' primary language.
  • Use batch code for language in those with British or Irish ethnicity.

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