Dementia DES, Out of Area Registration DES and Co-Commissioning
Date sent: Tuesday 9 December 2014
Email sent by Wessex LMCs, on Saturday, 6 Dec 2014
Over the last week or so there are three issues that have generated a significant number of questions seeking the LMC’s advice or opinion.
The new Dementia Identification DES
Out of Area Registration
I felt that it might be of help to clarify these issues now rather than waiting for my next email update.
The Health and Social Care Act 2013 implemented the largest change to the organisation of NHS in a generation. This resulted in the responsibility for commissioning primary care services moving from a single organisation namely the PCT to 3 separate organisations, the CCG, NHS England via the Area Team and Public Health via the Local Authority.
This division of responsibility for commissioning of primary care has resulted in a number of challenges not least, rather than enabling the development of general practice it has been seen as a barrier.
The NHS has been given significant additional funding in the Autumn Statement and a significant amount of this budget needs to be invested in general practice and out of hospital care.
If you read the Five-Year forward plan for the NHS it is clear where and how the additional funding will be invested.
NHS England has been consulting on plans to transfer some of the responsibility for commissioning primary care from Area Teams to CCGs.
The possible benefits of co-commissioning include:
• Improved provision of out-of hospital services for the benefit of patients and local populations;
• A more integrated healthcare system that is affordable, high quality and which better meets local needs;
• More optimal decisions to be made about how primary care resources are deployed;
• Greater consistency between outcome measures and incentives used in primary care services and wider out-of-hospital services; and
• A more collaborative approach to designing local solutions for workforce, premises and IM&T challenge
The options for the CCGs are:
Model 1 – Greater involvement in the commissioning of primary care.
Model 2 – Joint Commissioning – the CCG could form a Joint Committee with the Area Team to commission primary care. This has been made possible by new enabling legislation. CCGs will need to change their constitutions to undertake this and will therefore need to consult with their member practices.
Model 3 – Full delegation – this would mean that CCGs assumed the vast majority of the responsibilities from the Area Team.
At present there are a number of responsibilities that lie with the NHS England that are delivered by their Area Team and include:
- Performers list
- Performance procedures
- Quality and Outcome Framework
- Directed Enhanced Services
- GMS and PMS contract – performance monitoring and compliance
- Maternity, paternity and locum reimbursement
This is by no means a comprehensive lists but gives you a flavour of the area of responsibility.
The LMC’s view is that:
- The performers list
- Performance procedures for individual GPs
These must remain the responsibility for the Area Team. CCGs are generally too small and assuming responsibility for these area would pose a significant and unacceptable conflict of interest for CCGs.
PMS and GMS contracts – the CCGs should know their practices better than the Area Team. So if there are issues, CCGs should be able to understand what the problems are, help and support the practice, peer review and pressure. Contract disputes, breach notices or termination of contract should remain the responsibility of the Area Team as CCGs would have have significant conflicts of interest.
QoF and DESs - The LMC has concern if CCGs were unilaterally able to replace the QoF or DESs with their own programmes. The LMC’s understanding is that the national QoF and DESs would be an option for all practices, but CCG would be able to negotiate an alternative where appropriate. This would be similar to the Somerset QoF arrangements where the majority of practice have opted to accept the local rather than the national QoF.
Maternity, paternity and illness locum cover - In the past PCTs calculated what the entitlement was for reimbursement but the % paid varied from very little to almost full reimbursement. NHS England has introduced a more consistent approach to these calculations. There is little to be gained by delegating these responsibilities to the CCG and the LMC believes this should be retained by the Area team.
Premises – over the last 5 – 10 years there has been insufficient investment in practice premises. The future will be looking for new investment (but this will be tied into the wider NHS agenda – including out of hospital care and working at scale) but may also be using existing premises in an acute or community hospital or even in local authority buildings.
CCGs and the Area Team need to be jointly responsible for the development of the infrastructure in the community.
The LMC’s view is that most CCGs are not looking for full devolved responsibility but do want more control than they have now, therefore Model 2 will suit most.
The LMC will continue discussions with CCG and will ensure that all CCGs consult with their members especially where a change in constitution needed.
The Dementia Identification DES
This DES was announced recently as a time limited DES and will end on 31st March 2015.
NHS England has invested £5 million in this scheme that aims to address the discrepancy between the number of patients with a diagnosis of dementia vs. the predicted prevalence.
There are 800,000 people who have been diagnosed with dementia and it is estimated that this only accounts for 50% of the true prevalence.
International evidence suggests that it is possible to achieve a rate of 60 – 80% of the expected prevalence. The latest data for England show a significant variation in practices from 38% to 75% of the expected prevalence.
NHS England have agreed a national ambition for diagnosis rates that by 2015 two-thirds of the estimated number of people with dementia in England should have a diagnosis, with appropriate post-diagnosis support
Following the announcement of the DES there has been much negative criticism of this initiative, with comments such as it was “unethical” to sign up to the DES because you were essentially being paid to diagnoses these patients and this might be perceived as pressuring GPs to diagnose patients inappropriately.
I have more faith in GPs and believe that as a profession we practice in an ethical way that puts patients first.
I have been asked if the LMC advises practices to sign up to this DES or recommends a mass boycott.
The LMC’s advice is that it is a decision that individual practices should make.
My practice has signed up to the DES and I am leading the work on dementia within my practice.
What has my practice done to increase the prevalence of dementia?
- We searched the patient database for those who were on drugs to treat dementia but did not have a diagnosis of dementia.
- There has much publicity about the use of anti-psychotic medication used to treat the behavioural aspects of dementia – so we searched for those prescribed these drugs without a diagnosis of dementia.
- It is well recognised that patients who are residents of care homes are at high risk of hospital admission and would represent a significant number where admission to hospital is not always the most appropriate course of action.:
- My practice has therefore produced Care Plans for the Admission Avoidance DES on all residents of Care Homes.
- As part of this process and working with the Care Homes we found a number of patients who clearly had advanced dementia but did not have the appropriate Read Code on the patient records.
- I have written to each Care Home in my practice area to confirm which of our registered patients do they believe have dementia and also who have the registered for DOLS. We will then compare the patients who the Care Homes believe have dementia with our register and record on the patient records those with a DOLS status.
- For all newly registered Care Home patients we will arrange to visit them within a couple of weeks of registration. This will enable us to ensure we are aware of the medication the patient is taking, understand their past medical history, assess their physical and mental well-being and produce an Admission Avoidance Care Plan for them. This will also ensure the patients with dementia are correctly coded.
So do I think this funding is unethical?
No I do not.
If I were asked to design a scheme to identify those with dementia who are miscoded, not coded or have dementia without a formal diagnosis, I would have designed a different scheme but this is what we have.
I see this funding being made available to help fund the work as described above. In my practice I have already identified 14 patients with dementia who were not on our register. This has increased the prevalence by about 10%.
Whilst producing the Admission Avoidance Care Plans for the residents of Care Home we identified a number of patients with know dementia who were not coded correctly and therefore not on the register. Unfortunately this work was undertaken before the 30th September and therefore did not count toward Dementia Identification Scheme.
For the Dementia Identification DES.
There will be a comparison of the practice prevalence taken on the 30th September 2014 compared with the 30th March 2015. A payment of £55 per patient will be paid if the prevalence has increased.
Practices need to submit a plan on how they will identify the undiagnosed patients.
If you practice wishes to sign up to the DES then the plan you might wish to consider is details in action points 1-5 above.
If your practice has not signed up to the DES then you were asked to do this by the 17th November 2014. If your practices wishes to reconsider this decision please contact your CCG.
The attached document might also be of some help to you and your practice.
Out of Area Registrations
Out of Area Patients - Choice of GP Practice
NHS England has released guidance on the new out of area patient registration arrangements during November, click here to access this.
What does this actually mean?
Within the guidance that has been issued it identifies 2 elements to this scheme which are:
- Out of area registrations – changes to the GMS contract enables you to have patients with a registration status of ‘out of area registration’. Practices do not need to opt in to provide this it will be the choice of the practice as to whether you offer this option to patients when registering.
- In hours urgent primary medical care enhanced service – Where patients choose to register out of area, when they have an urgent care need NHS England working with CCGs need to ensure they can access urgent primary medical services from the 5th January 2015. You can choose to opt in or out of providing this; there is no requirement to undertake this service.
The following provides guidance in relation to out of area registrations:
Process for registering a patient as out of area:
- Completion of GMS1 or equivalent registration form
- Registration on GP system as normal with a note on the registration page of out of area, the following provides the agreed text:
- OUT OF AREA REG
- OUT OF AREA SCHEME
- OOA REG
- Information on how to access urgent care arrangements in the event the patient becomes unwell at home to be given to patient, however in the first instance they should contact their registered practice
2. Funding mechanism for out of area registrations
You will receive the same funding (GMS/PMS) as you would normally receive for any other NHS registered patient. This is being reviewed and consideration is being given on a small reduction in capitation payments for these patients to assist with funding the urgent care needs when home. Further detail to follow on this.
3. Existing patients
- Patients that are currently registered with the practice and are living outside of the practice boundary cannot be re-registered as out of area with no home visiting obligation. This would be unreasonable grounds for removing such patients from the practice list (NHS England interpretation of regulations)
- Where patients currently registered within the practice area and then move out of the area (outer boundary) you can either:
- choose to continue to register the patient in the normal way where home visiting would still be required.
- choose to register them as an out of ‘area registration’. This would need to be agreed with the patient and you would be required to de-registered them from the practice on the grounds they are out of area and then re-register them as this scheme is only available to new patient registrations.
4. Registration Status
- If in an area there are a mixture of out of area registrations and normal NHS registered patients, you will not be required to undertake home visits for patients that are out of area registrations
- Where a patient falls ill and needs to register with a practice near their home, if the patient is within your boundary you will need to register them in the normal way as an NHS registered patient
- You will need to ensure that when refusing an out of area registration that this is justified on clinical & practical grounds. Each registration will need to be completed on an individual basis and be accepted where clinically appropriate.
- If an out of area patient develops a condition that you feel makes it inappropriate for them to continue being registered in this way, you need to discuss this with the patient and recommend they register with a practice closer to their home
- Students will need to continue to be registered as an NHS registered patient
- If a student wishes to be registered with their ‘home’ practice this is possible. It is reliant on the choice of the patient and whether it is clinically appropriate and practical to be registered. They would need to be able to attend for routine appointments which are unlikely to be practical.
- The area team cannot assign patients to practices as an out of area registration and the same applies to violent patients as this would not be appropriate
This scheme only applies to practices within England and will not be able to register patients who live in other countries of the UK.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: DPC-introduction-v4.pdf