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Deciding which DESs to undertake

Dr Jeremy Phipps says the workload involved, clinical benefits to patients and potential income will determine whether his practice takes on the new English DESs.

One of the new DESs: extra work, patient benefits and modest fees are considerations (Image: iStock)
One of the new DESs: extra work, patient benefits and modest fees are considerations (Image: iStock)

The GMS contract for England for 2013/14 includes four new directed enhanced services (DESs): 

  • Dementia diagnosis and support
  • Improving online patient access
  • Risk profiling and care management
  • Remote care monitoring

While some final details in their specifications are still to be sorted out, practices are being asked for expressions of interest and  to sign up to these DESs.

So how do GPs decide which to take on?

DES assessment criteria

My practice is mirroring others in cautiously studying the specification for each of the four DESs as we cannot afford to ignore any potential new income streams. We are using to following criteria to determine whether it is worth us doing each DES:

  • How much of this work are we already undertaking?
  • What is the extra workload?
  • Are there real benefits to patients?
  • How much income after expenses will the practice earn?
  • Will this income continue in the medium to longer term?

If there are few clinical benefits and a lot of extra work, any financial benefit of taking on a DES is unlikely to sway us in its favour.  

In particular, I believe every practice should be cautious about workload involved in the online access DES.

Can we take on the extra work?

Talking to my practice colleagues and to GPs at other practices, most of us think there is too little spare capacity to absorb extra work as  our existing workload is continuing to increase.  

Also, the DES payments are relatively low.

So unless there is real benefit to patients or to the running of the practice I don’t believe many principals will rush forward to take on these new areas.

That said, our practice is likely to express an interest in all four DESs, pending further clarification, especially as there are overlaps with work we already do.

Remote care monitoring

The specification for this DES is very open-ended. It involves preparatory work only in 2013/14 and then agreeing to take on specific areas of care and implementing them in 2014/15.  

However we already have the ability to undertake much of this preparatory work.

We are accustomed to taking on responsibility for various patient-monitoring services previously provided in a hospital setting.

All our patients should be coded on the practice computer system already for their specific disease area(s) with up to date contact details, so most of the required work is already done. We will need to negotiate with our CCG on which clinical condition they are prioritising.

Next follows liaising with our patients over how they wish to be given their results: my guess is that most will opt by phone call.

We will want the CCG to prioritise a condition with low prevalence – and preferably, low incidence – and to ensure the CCG acknowledges that the DES guidance states a single condition rather than several clinical areas.

Having established what the condition is, our own priority will be to ensure our disease register is accurate.

The real work will start next year and although the target group is yet to be defined, I suspect we are already be undertaking much of the required work.

Dementia diagnosis and support

This is the most controversial of the new DESs.  

GPs are concerned whether it is ethical to screen for dementia opportunistically: as current treatment is not always of great clinical benefit shouldn’t primary care be targeting resources at other areas?

Much of this DES is already part of established general practice. Two of the four requirements are:

  • Offering a referral where dementia is suspected
  • Supporting patients and their carers where a diagnosis has been confirmed.

But what about the requirement to look for dementia both opportunistically and in designated ‘at risk’ groups using dementia assessment tools?

With two of the at risk groups - patients with Down’s syndrome or with other learning disabilities - diagnosising patients may prove nearly impossible for non-specialists.

The other patient groups to be targeted are those with long-term neurological diseases (such as Parkinson’s) and over-60s with known arterial disease or diabetes.

At our practice this represents several hundred patients.Although I can see our practice signing up to it, I doubt there will be widespread uptake as there are few clear clinical benefits from early diagnosis unless the patient or their family have raised concerns.

Improving patient online access

This initially seems the simplest area for us as we already provide much of what is required.  

Fortunately some of my more technophile colleagues have already enabled our patients to order prescriptions and book appointments online.

On the whole this has gone very smoothly. The only problem is that we have a branch surgery and patients very occasionally book for one site and turn up at the other. 

However the third element of the DES, patients' access to their own medical records, is potentially an enormous headache. Beyond the confidentiality issue of individuals other than the patient viewing records either maliciously or through error, there is a huge workload problem.

As with copying a patient’s records for a legal report, all third party references - for example, to family members’ health - must be removed along with any information deemed detrimental to the patient’s health.  

This will mean someone suitably qualified - for example, me - going through all the patients’ notes and letters in detail to check for and remove such references.

Should the specification be changed?

It is possible that NHS England will listen to the comments of bodies such as the RCGP and suggest that access should be prospective from a future date to be decided later. But this is probably too big a climb-down to actually happen.

Also, much of the clinical information recorded will be in a form that many patients will struggle to understand.Such patients may wish to speak practice staff for clarification.

This DES’s payment structure is broken down into separate parts with online access fees being a payment per practice rather than per person, making it less attractive to large practices like ours.

We will be reimbursed less than £1 for every complete patient record a clinician goes through.

I am not in favour of taking on this part of the DES and it is likely that we will claim only for the services we already provide.

Risk profiling and care management

A 'posh' term for admission avoidance, this is another woolly DES with imprecise aims.

There is also heavy emphasis on working with the CCG to identify at risk patients so that we can try to support them in the community.

However, this aim is laudable and builds on much of the work already being done by practices, including ours.

I am sure we will sign up to this DES. But I am doubtful about the real impact on cutting emergency admissions as there will still be many cases where being admitted will be the safest option for patients.

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