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Thursday 27 October 2016
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Contract changes

The latest evolution of the general medical services contract has brought about differences for practices to consider concerning directed enhanced services and the quality and outcomes framework 

The enhanced services have increased greatly in their importance and complexity over the past few years. A considerable amount of money has been taken from the quality and outcomes framework (QOF) and moved to directed enhanced services (DES). In addition, since the commissioning of health services was reorganised things  have become more fragmented. Commonly, practices will have different services commissioned by their clinical commissioning group (CCG), council and NHS England. Contracts and reporting requirements will vary according to the commissioner.
DES are specified by NHS England and their monitoring reports are now laregly collected automatically through the general practice exemption services (GPES) and calculating quality reporting service (CQRS) systems in the same way as QOF data. The practice must use the codes defined in the business rules.
However, there are two important differences from the QOF. Firstly, a lot of other data is collected at the same time to monitor the service without being used directly for the calculation of payment. There is much more of this management data collected than payment data. This may seem unusual to practices with experience with QOF, although in 2016 some non-payment data will also be extracted about retired QOF indicators.
Secondly, payment data may be taken at various points throughout the year. While QOF data is collected monthly, only the data taken at the end of March is used for payment. DES payment data may be taken more often.
There is little consistency between DESs and it is vital that the codes have been entered correctly by the time the data is extracted, as there may not be an opportunity to correct this later.
There are four DESs this year and the extended hours DES does not involve any data extraction. There are also a number of immunisation DESs for which data and payment will be calculated monthly. I will discuss the three other DESs below.

Unplanned admissions
The biggest changes are around the unplanned admissions DES. The reporting requirements for this have changed quite considerably since its introduction last year, but due to automated extraction the deadlines are more important than ever.
Overall, things are simpler with only two payment deadlines at the end of September and March. Practices then have a month to upload or enter their data. At the end of each six-month period the risk register should contain 2% of adults (over 18-year-olds) on the practice list. This can be quite a dynamic list as the patients on the register are some of the sickest in the practice and may die or move away to more suitable accommodation as their care needs increase. For this reason there was an allowance last year for the register to drop to 1.8% of the practice list as long as the average was 2% over the year. This continues this year so a register of 1.8% in September will need to be at least 2.2% in March.

New features
A new feature this year is that practices can include patients who have died or moved away in the previous six months on the register. They will not be picked up by automatic systems and will need to be entered on CQRS manually but could be vital in making sure that you have the correct number of patients on the register.
This is a valuable enhanced service with total payments of £2.87 per patient on the practice list (or up to £144 per patient on the at risk register). Just under half is paid for signing up for the service with the remainder being split between the two reporting periods. However, part of the first payment may be clawed back at the end of the year if the practice fails to achieve the other components.
The coding requirement is that 2% of patients over 18-years-old should be on the register, be allocated a named GP and have had a care plan agreed, reviewed or declined in the previous 12 months.
When a patient registers with a practice and has been on the at risk register of their previous surgery, none of the codes, either for the register or any care plans, carry forward and may need to be re-entered.
It has been a contractual requirement this year that all patients must have a named GP – which broadly takes us back to the situation before 2004. With this change in requirement has come a change in the codes that should be used. As this is a contractual requirement rather than an enhanced service there is no payment associated with it, although data will be collected from practices.
The same codes are required by the unplanned admissions DES and must be entered before the date of submission. Last year the code “informed of named GP” (known as 67DJ) was sufficient. This should still be used at the point where the patient is informed and certainly before the end of March. The most essential code is “patient allocated named GP” (known as 9NN60) that must be entered for every patient on the at risk register. This code is very new and became available to practices only at the start of this financial year.
Dementia screening
The dementia screening facilitating diagnosis DES can also appear complicated, although practically it is rather simpler. A potted summary of the requirements is that patients at risk of dementia (basically patients over 60, who smoke, are obese or have a chronic disease) should be offered a memory check. If they are happy with this and have any concerns about their memory then they should have a formal memory assessment. It is this assessment that attracts the payment for the DES.
There are a number of other requirements such as the identification and coding of carers and the production of care plans for patients who have received a diagnosis of dementia. The latter is also covered by the dementia area
in QOF.
The method of payment is unique. The initial payment of 37 pence per registered patient is simple enough and will cover the identification of carers as well as contributing towards care plans.
The second half of the funding is fixed at £21 million and will be distributed to practices according to the number of assessments (such as mini mental state or the general practitioner assessment of cognition (GPCOG)) performed and coded. If only one such assessment occurs in the whole of England then that practice will receive £21 million for it. If 21 million assessments are carried out then each will be paid at £1. Practices will not know how much each assessment is worth until summer 2016 although the experience of previous years suggests that the payment for each is relatively high.
The data will be extracted quarterly but payment will only be based on the data at the end of
March 2016.

Learning disability DES
The learning disability DES has also had little change from previous years. All patients on the learning disability register should be offered a health check and a health action plan. The register for the purposes of the DES is defined by the same set of learning disability codes as the QOF register.
The code 69DB should be entered for a health check or 9HB6 if the check is declined. Payments are made quarterly and, as the data is extracted automatically, there is no opportunity to catch up if codes are entered after the time of the check. It is essential that codes are entered promptly. A flat rate of £116 will be paid for each health check.
There are a variety of other codes that will be extracted for management and monitoring purposes and these could be used within a template although they do not directly affect payment.
These, along with the many other codes require for the various enhanced services, can be found in a fairly readable format in the document Technical Requirements for 2015/16 GMS Contract Changes that can be found on the NHS Employers website (see Resources).

Gavin Jamie, full-time GP in Swindon with an interest in health informatics. He runs the QOF database website.

NHS Employers. Technical Requirements for 2015/16 GMS Contract Changes. (accessed 8 October).