How will GPs' elderly care role change with the new contract?

The DH blames the 2004 GP contract for pressure on A&E, but what impact will 2014/15's elderly care reforms have?

Elderly care: a named, accountable GP will co-ordinate multidisciplinary care for patients over 75
Elderly care: a named, accountable GP will co-ordinate multidisciplinary care for patients over 75

Care of the elderly is a major theme of the 2014/15 GMS contract, as ministers seek to ease ever-increasing demand on stretched acute services.

Following his recent review of emergency care, NHS England medical director Sir Bruce Keogh described A&E as 'creaking at the seams'.

The GP contract deal struck between the GPC and NHS Employers last month aims to address the problem through primary care, reflecting repeated claims from health secretary Jeremy Hunt that the 2004 deal was to blame for A&E pressure.

From April, all elderly patients will be assigned a named GP to co-ordinate their care, while practices will draw up detailed care plans for the most vulnerable patients.

The ultimate aim is to prevent unplanned admissions. The DH says the over-75s account for one-third of the 5m emergency admissions each year, of which more than 1m were avoidable. But how will these new duties work in practice?

GPs' new responsibilities can be divided into two overlapping parts. The first sees each patient over 75 given a named, accountable GP who will co-ordinate multidisciplinary care from health and social services to fit their needs.

Mr Hunt said this move would bring back 'proper family doctors'. But Devon GP and NHS Alliance GMS/PMS lead Dr David Jenner believes that despite the rhetoric, the plan will not fundamentally change the way many GPs work.

How will the named clinician role affect GPs?

Health secretary Jeremy Hunt

The 2004 GP contract broke the personal link between GP and patient. It piled target after target on doctors, took away their responsibility for out-of-hours care and put huge pressure on A&E. This government has a plan to sort this out and the new GP contract is a vital step.

'We are bringing back named GPs for the vulnerable elderly. This means proper family doctors, able to focus on giving elderly people the care they need and prevent unnecessary trips to hospital. Rigorous new inspections of GP surgeries will mean every local person will know whether they are getting the care they deserve.

'This is about fixing the long-term pressures on our A&E services, empowering hard-working doctors and improving care for those with the greatest need.'

Dr David Jenner, NHS Alliance GMS/PMS lead and Devon GP

In my practice and many others, this won't change our responsibilities, because we run a personalised system where every patient is allocated a named GP.

'All practices have to do is make sure that on every patient's notes, there is the name of a GP who has lead responsibility. Normally, it's the person to whom hospital letters come back, nurses relate and pathology notes are sent.

'It fulfils Jeremy Hunt's promise that would give everyone a named GP. If you read his language, he's keen to foster a return to traditional values of personalised and continuing healthcare. Who's going to argue with that? Practices should welcome this. But it has to be interpreted in the context of more part-time working.'

However, the second of GPs' new duties will have far more impact on workload.

GP leaders and ministers have agreed a new £160m DES for GPs proactively to manage vulnerable patients, to minimise emergency hospital admissions (see box below). While all adult patients are eligible, the focus is on older patients.

The unplanned admissions DES

Name - Avoiding unplanned admissions and proactive case management of vulnerable people

Begins - April 2014

Funding - £162m (estimated)

Target group - Vulnerable adults, including high-risk patients, patients needing end-of-life care and those at risk of unplanned admissions to hospital

Actions

  • Use risk stratification to identify a minimum of 2% of the practice's most vulnerable patients who are at risk of hospital admission
  • Use a standard template (due next year) to create a care plan to proactively manage each patient identified. Include a named GP responsible for co-ordinating each patient's care
  • Offer same-day telephone consultations or follow-up to at-risk patients
  • Provide telephone access to A&E clinicians, ambulance staff and care and nursing homes, to help avoid hospital admissions or transfers
  • Work with hospitals to review and improve discharge processes, and share information to inform commissioning
  • Review unplanned hospital admissions and readmissions among at-risk patients, to look at how these could have been avoided

Source: NHS Employers, BMA

Care plans

Under the DES, practices will identify their most vulnerable patients and create care plans to outline the care they should receive.

A named, responsible GP will then co-ordinate health and social care to ensure the plan is followed and to avoid unplanned hospital stays.

NHS England will develop a standard national template for the care plans following discussions between the GPC and NHS Employers.

The new DES replaces and expands on the current contract's risk profiling DES and quality and productivity QOF targets. Practices will need to sign up to avoid losing thousands of pounds a year.

Exact details on how funding will be allocated are yet to be announced. But if 90% of English practices sign up and funding is distributed evenly, an average-sized practice would receive about £22,000.

GP leaders admit the new DES will be challenging. 'The enhanced service will involve a significant amount of work for practices,' says a GPC guide about the new contract. But it insists the DES is 'well resourced' and will make 'a meaningful difference' to patients.

Writing for GP's sister website Medeconomics, Laurence Slavin, a partner at specialist medical accountants Ramsay Brown & Partners, said the large work commitment means practices need to scrutinise the costs of undertaking the DES.

Continuity of care

Londonwide LMCs chief executive Dr Michelle Drage believes the DES will align the many disjointed services that have affected continuity of care for vulnerable patients.

'Under the previous arrangement, care was clearly being fragmented, which doesn't sit with the concept of general practice and continuity,' she says. '[The DES] allows co-ordination of care for patients, without tick-box work around it. It doesn't mean the work will go away - it will be just as hard - but it means it will be more professionally satisfying to do and patients will benefit as care is more joined up.'

Dr Louise Warburton, a Shropshire GPSI in rheumatology and president of the Primary Care Rheumatology Society, also backs the scheme. 'In principle, this seems a good idea; what we need is experienced GPs having responsibility for these complex elderly patients, not new GPs or locums who are likely to refer them to hospital acutely or to outpatients.

'In theory, a DES will put more money into practices and should enable the right GPs to take responsibility. Risk stratification at practice level will help to some extent as well, because it will involve a wider multidisciplinary team who can look after the patient in the community.'

But she said general practice is still under-resourced and this will continue to hamper attempts to concentrate on avoiding unplanned hospital admissions.

Dr Jenner is far more sceptical about the DES. 'It all depends on what is meant by a care plan and the template to be developed by NHS England. Doctors are quite used to looking after and supervising people with long-term conditions who are at risk.

'What it mustn't do is transfer bureaucracy to filling out care plans rather than looking after patients.

'I think that the care plan should be simple and just identify which person is responsible for that area of care - their nursing needs, mental health needs - and be able to describe how that is being provided, rather than a detailed spreadsheet.'

He adds: 'It's crucial, otherwise we remove tick-box bureaucracy from QOF, which is largely done by nurses and healthcare assistants, and burden doctors with even more bureaucracy.'

GPC deputy chairman Dr Richard Vautrey agrees. 'We must avoid the new enhanced service becoming a bureaucratic burden and the care plan template must be as simple and therefore as useful as possible,' he says.

Documentation

'GPs already receive documents described as care plans from a variety of different agencies that are far too long and complex, and they are therefore at best unhelpful and at worst, dangerous, as the key points clinicians need are buried in the detail,' Dr Vautrey adds.

How GPs' new responsibilities will work in practice will become clearer in the New Year, when the full DES specification and further details about the extent of GPs' named clinician responsibilities are revealed.

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