Liverpool Care Pathway - The DES

What's the difference between a lawyer and a doctor?
The one chases patients and ambulances; the other chases CQUINs and DESs.


What is DES? DES is Directed Enhanced Services. The Clinical Directed Enhanced Services are payments made when DoH service priorities, subject to audit by the PCT, are met. In 2012/13, these were £2.38 per patient.

Effectively,the DES is a CQUIN. According to the Coventry and Warwickshire Partnership NHS Trust report to the Public Trust Board, 25 June 2013 -

2.0 Background to the 2013/14 CQUIN Indicators

CQUIN indicators attract an additional 2.5% non-recurring income over and above the standard contract values, which this year represents £3,650,291 for the new Clinical Commissioning Groups, and £371,308 for the Specialised Commissioning Group.

Furthermore,

Throughout CQUIN negotiations for 2013/14, the need for improvement in physical healthcare has arisen as a recurring theme. For learning disability services, this has been manifested as a CQUIN designed to support the existing DES agreement for GPs.

The GP says -

GPs must offer dementia checks to millions of patients with conditions such as cardiovascular disease and diabetes to win back lost QOF money, the NHS Commissioning Board (NHSCB) has revealed.

A Pulse exclusive report reveals -

GPs across England are facing complaints or objections from patients who ‘resent being asked’ about symptoms of dementia as part of the controversial case-finding DES, a Pulse survey reveals.

A snapshot poll of 501 GPs in England who are taking part in this year’s DES has found that around one in five - 21% - have seen patients protest about the process, which involves asking those considered at risk if they are concerned about their memory.

This is 2013, the year of the Snake and the Cameron ‘challenge on dementia’.

Under the DES, GPs are encouraged to make opportunistic offers of dementia assessment to at-risk patients where they consider it appropriate.

Dr Zishan Syed, a locum GP, said: ‘Patients feel it is a tickbox exercise.’

'...there seems to be a political drive to push up prevalence levels for the sake of numbers and the care of patients suffers consequently as expectations of treatments do not actually match the results of the treatments that are currently available.’ - Pulse Today

This is a tick box exercise to downsize care. 

To be eligible, according to Anna Gutierrez, Primary Care Facilitator at Barts and the Royal London, the New Dementia DES requires the following criteria :

• Patients aged 60 or over with CVD, stroke, PAD or diabetes
• Patients aged 50 or over with LD
• Patients aged 40 or over with Down’s syndrome
• Patients with long-term neurological conditions which have a known neurodegenerative component, e.g. Parkinson’s disease

This is Pulse –

GP commissioners are prioritising reductions in emergency admissions and increases in dementia diagnosis rates to achieve their quality premium payments, as figures obtained by Pulse reveal CCGs’ commissioning intensions on a national basis.

The NHS England figures reveal for the first time what CCGs are choosing - in agreement with their local area teams and health and wellbeing boards – as their localised targets, worth up to 37.5% of the quality premium total or around £420,000 to the average CCG.

However, Dr Nigel Watson, chair of the GPC commissioning and service development subcommittee, warned: ‘Mid Staffs taught us that targets per se can be destructive as well as constructive. The BMA’s view is that CCGS should agree what they are aiming at but should not be financially penalised if they fail to get there.’

The Clinical directed enhanced services (DESs) for GMS contract states -

There is good evidence that patients with learning disabilities (LD) have more health problems and die at a younger age than the rest of the population. The existing QOF registers do not differentiate LD by severity. 

This DES is designed to encourage practices to identify patients aged 18 and over with the most complex needs and offer them an annual health check. Local authority (LA) lists of people known to social services primarily because of their learning disabilities, are to be used as the basis for identifying patients to be offered the checks. The rationale is to target people with the most complex needs and therefore at highest risk from undetected health conditions (usually people with moderate to severe learning disabilities). From the prevalence figures available, it is estimated that approximately 240,000 patients fall into this category across the country. Generally LA criteria for access to social care services are related to complexity of need, although sometimes individuals with mild learning disabilities and other additional health needs, usually associated with mental health needs, will meet social services eligibility criteria.

 This is all about identifying suitable candidates for downsized care.

Learning disability (LD) register

PCTs should work with their LA (or LAs where practices’ registered patients are resident in more than one authority area) to produce a register of patients who are known to social services primarily because of their learning disabilities, determine which practice they are registered with and share this with their constituent practices.

Using this information and integrating it with data about patients already on the practice’s register, practices should establish a health check learning disabilities register using the following recommended Read Codes which are in line with those used for the QOF learning disabilities register:

- Clinical directed enhanced services (DESs) for GMS contract

Readers of these pages will be familiar with the LES (Local Enhanced Services). This is the Dementia DES and the Bristol LES –

This reads like the 'Find your 1%' documents...

Demographics
1 in100 patients has dementia,10-20 per GP

• Around 4,300 people estimated to have dementia in Bristol
• However we have only diagnosed 50%
• All incentives schemes & QOF & new health checks amount to about £16,000 per average list size of around 7000 to support this growth

This sounds lucrative...

People are 'happy' with a diagnosis. With application of appropriate grooming techniques, 'Mickey Mouse' will happily downsize his care expectations...