From 1 April 2014, GP practices will be offered the opportunity to take part in an enhanced service which is designed to reduce avoidable unplanned admissions by improving services for the most vulnerable patients and those with complex physical or mental health needs. The key components of the enhanced service will be for practices to:
- ensure that other clinicians can easily contact the practice by telephone to support decisions relating to hospital transfers or admissions;
- carry out regular risk profiling to identify at least two per cent of adult patients – and any children with complex needs – who will benefit from more proactive care management;
- provide proactive care and support for at-risk patients through developing and regularly reviewing personalised care plans and by ensuring they have a named accountable GP and care coordinator;
- work with hospitals to review and improve discharge processes and undertake internal reviews of unplanned admissions/readmissions.
All of these elements, taken together, will lead to GPs being more clearly ‘accountable’ for coordinating the care of patients with more complex needs.
We have been able to create this enhanced service as a result of significantly reducing – by about a third – the scope of the QOF. The reduction in QOF will allow GP practices a greater opportunity to understand the needs of the patients who most need their support to stay well in the community and avoid unplanned hospital admissions.
This approach needs to be a real partnership between CCGs and GP practices. There are clear benefits for appropriate use of hospital resources if practices are able to fulfil their new duties under this enhanced service. And the CCG can play a part in this too. The NHS planning guidance ‘Everyone Counts’ sets out an expectation that every CCG should identify £5 per patient from its allocation for 2014/15 and use this to support practice plans for improving services for older people. (*) This is intended to fund additional services – over and above those provided for by the new enhanced service and that complement its objectives.
This funding might, for example, be used for new services based in general practice or for new or additional community services, such as rapid response community nursing, additional support from mental health service providers, designated district nursing, additional discharge coordinator services or targeted social care services, or additional services from third and voluntary sector providers. However, this is not an exhaustive list and I have no doubt that CCGs and GP practices will devise other innovative ways of supporting GPs in this role.
(*) ‘CCGs…will be expected to provide additional funding to commission additional services which practices, individually or collectively, have identified will further support the accountable GP in improving the quality of care for older people. This funding should be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over. Practice plans should be complementary to initiatives through the Better Care Fund.’ (Everyone Counts – December 2013)
Deputy Medical Director