05 / 9 / 2016 Midnight
The requirements for enhanced services are defined in DES Directions or
This section includes FAQs for the following areas:
Avoiding unplanned admissions: proactive case finding
and care review for vulnerable people (AUA)
Facilitating timely diagnosis and support for people
with dementia (DEM)
Learning disabilities health check scheme
Q: Can the nationally defined service specifications for
enhanced services be amended locally?
A: No. The
service specification is a legal document and commissioners cannot make
changes to the content. Should they wish to do additional work relating to
the enhanced service in their local area, this would be for local
discussion, agreement and payment outside of the arrangements for the
nationally defined ES.
This is the same for all nationally defined service specifications,
including the minor surgery and violent patient schemes which allow for
the local determination of pay.
Q: Can practices with a 'closed list' still participate in
there is nothing to prevent practices participating in enhanced services if
they have a closed list.
Q: Does signing up to participate in a service on CQRS satisfy
the requirement for contractual sign up?
Practices are required to agree to participate in a service with their area
team based on the service specification. Sign up on CQRS is confirmation
from the practice to the area team that CQRS will be used to calculate the
Q: Where a practice has been using Read codes not included in
the service specification, guidance and audit requirements, Business Rules
or technical requirements document, are practices expected to re-code
A: Yes, all
services being supported by CQRS, require that practices who intend to
participate in these services record their achievement in the clinical
systems using the appropriate Read codes. This should be recorded using the
relevant Read codes in the service specification, guidance and audit
requirements, technical requirements document or Business Rules from the
date those services commence. As such, practices would need to re-code
using the relevant codes.
Q: Where can I find details of the arrangements for the violent
patients and minor surgery scheme?
details for these schemes are included in the Primary Medical Services
(Direct Enhanced Services) Directions 2014. Minor surgery is also
outlined within The National Health Service (General Medical Services
Contracts) Regulations 2004.
Q: How long are practices required to retain evidence regarding work completed which is related/attributed to ES achievement?
A: Practices are required to retain evidence of work completed which is attributed or related to payment, for up to six years. This evidence could reasonably be requested by any local commissioner or NHS England. Some of this evidence would be available from practices clinical systems but hard copies would need to be filed or digitised and held electronically.
Avoiding unplanned admissions: proactive case finding
and care review for vulnerable people (AUA)
Q: When are practices expected to review patients by in order to meet the criteria for payment under component 2?
A: Practices are required to develop a care plan for a patient newly added to the care plan register. Where this relates to a patient on the register from the previous year who is now due to receive a care plan review, this is expected to be within 12 months of the original care plan.
Q: How often does a care plan need to be reviewed for patients remaining on the
AUA register from previous years?
A: Practices are expected to review a patients care
plan at least once during 16/17. The service specification requires that a
review is carried out within 12 months of the creation or last review of the
care plan and the Business Rules are structured to look back 12 months,
therefore the data collection at the end of September 2016 looked back to 1
October 2015 and for the March 2017 collection it will look back to 1 April
Practices should review care plans more
often if appropriate to the patients, but care plans must be reviewed at least
once in a rolling 12 month period in order to meet the criteria for payment.
Q: Why is there a 12 month timeframe requirement for care plan reviews rather than it being an annual review?
A: If no timeframe was specified this would mean that some patients could go up to two years without a review and given the nature and purpose of this ES, it is not in line with the aims of the programme to provide proactive care.
It was identified for the 2015/16 ES that in order to deliver a mid-year payment to practices, they would have been required to review all patients in the first six months of 15/16 if not set up this way. This is also how the timings run for the 2016/17 ES.
As this would have put pressure on practices to deliver against the requirements, whilst only one care plan review is required, the review is required within 12 months of the original care plan and also the payment dates. This ensures patients benefit from proactive care planning within a reasonable timeframe and allows practices to deliver a single care plan for each patient within the financial year. It also ensures practices are eligible for the mid-year (component 2) and year end payment (component 3).
Q: Where practices have failed to meet the criteria for the component 2 payment, will there be any concessions?
A: A number of practices failed to achieve component 2 of the ES in 2015/16. A review highlighted some practices failed to achieve for a number of different reasons including failure to meet the minimum percentage of patients on the register (1.8 per cent) and failure to record that an accountable GP had been identified.
NHS England agreed a flexible approach to component 2 for 15/16 that rewards practices for work undertaken in good faith. There are no concessions for this ES for 2016/17 as practices should now fully understand all requirements for this ES.
For full details of the requirements for this ES, see the 'NHS England service specification', the 'GMS guidance' and the 'technical requirements' documents.
Q: What Read codes does a practice need to enter in order for this data to be collected by GPES in order to calculate achievement?
A: The Read codes for this ES are detailed in the Technical requirements document. Practices must code the activity in line with the technical guidance or they will not be paid. Further details are also in the Business Rules.
Where a practice has failed the component 2 payment, they should ensure that they have used the codes provided in the technical requirements as this may be the cause.
Q: When a patient moves from practice A to practice B mid-year and then returns to practice A for whatever reason before the end of the financial year, will they count towards the achievement for both practices?
A: Where a patient has left the practice and then come back (eg if they have gone into respite care), the patient would be classed as a new registration therefore the work would need to be done from the point of re-registration in order to qualify for payment. The practice would need to decide if the patient should go back onto the AUA register at this time.
Practice B is also eligible for payment provided they can provide evidence to their commissioner that they delivered the care as described in the service specification when that patient was registered with them. However, this practice would only need to consider this action if they do not meet the target of 1.8 per cent for the six month period, or two per cent overall for the year.
Q: Can the care plan development begin when the GP starts
reviewing the patients’ medical record but without involving the
patient until they are seen in practice?
A: The care
plan should be developed collaboratively with the patient. While the care
plan contents may be prepared by reviewing the patient’s medical
record, the GP or care co-ordinator (if different to the GP) will need to
ensure that it is then discussed with the patient before the initial draft
is finalised and coded accordingly. The practice will need to ensure that
this is done within the timeframes outlined in the guidance i.e. within one
month of any new patient being added to the register.
Q: Can the care plan be done by a Practice Nurse?
initial care plan can be developed by a practice nurse if they are the
patient’s care coordinator. However, the named accountable GP still
has overall responsibility for the creation of the care plan and therefore
should have some input and assurance of its delivery.
Q: What happens if a patient is included in the case management
register but after being notified of their named GP and that they are on
this register, they decline?
A: If a
patient does not wish to be part of this service (i.e. does not want a
named GP, does not want urgent telephone access etc.) then they should be
removed from the register. In order to remove the patient from the
register, the practice would need to use the ‘admission avoidance
care ended’ code. However, if the patient wants to benefit from all
other aspects of the service and declines the care planning element only,
then they will remain on the register and the practice will need to apply
the care plan declined code.
If a patient does not want to be on the register, but does want the care
elements of the ES then the practice would need to decide whether or not
they are prepared to provide the patient with the benefits of this ES
without them being part of the register. In this circumstance, the practice
would need to remove the patient from the register and discuss with the
patient whether or not they can receive the care elements. It is
important to note that if this is agreed with the patient, then the
practice would not be eligible to use this patient to contribute to the two
per cent required for payment under this ES but in line with good medical
practice, the patient is entitled to appropriate care.
Q: Will patients refusing a care plan and coded as such still
be counted as part of the two per cent?
who wish to benefit from some aspects of this ES but do not wish to have a
care plan, will count towards the two per cent. Practices will be required
to add the patient to the case management register using the required code
and code ‘declines care plan’ as required. While care plans can
be declined, it must be based on true informed dissent from the patient and
not only because the patient did not attend an appointment.
Q: If a practice has over 2% of their registered patients aged
18 and over on their case management register, will each patient require a
payment purposes, providing that a practice has a minimum of 1.8 per cent
of its adult population (i.e. those aged 18 years and over) on their case
management register and coded with a care plan by the end
of the payment period, they will meet the requirement for the associated
payment of that period. Note that this 0.2 per cent tolerance is designed
to help practices if any of their patients move or die during this period.
However, across the service as a whole practices must achieve at least two
per cent of their adult population on their case management register and
all these patients should have an agreed care plan in
place, otherwise payments may be clawed back by commissioners at the end of
Q: Are patients and/or carers required to sign the care plan
when it is agreed and again when it is reviewed?
A: It is
for the patients and the practice to decide if having the patient and/or
carer’s signatures is appropriate, but it is not a requirement. The
same would apply for any review of the care plan. The key point is that the
care plan is developed and reviewed with the patient’s involvement,
not whether or not the patient signs the paperwork.
Q: Should a copy of the care plan be shared with the
A: Yes. The
patient and where applicable their carer should have a copy of the
patient’s care plan. With the permission of the patients, the
practice may wish to consider sharing the care plan with other relevant
health care providers.
Q: Do practices need to review every patient on their
register, or just those who have had an unplanned admission, re-admission
or an A&E attendance?
A: The ES
requires that practices undertake monthly internal practice reviews on the
case management register to cover two aspects:
- proactive planning, and
- reviews of unplanned admissions, re-admissions and A&E
The monthly review referenced in section 2 of the
guidance relates to proactive planning for patients on the case management
register, considering what steps the practice (or multi-disciplinary team)
can take to prevent unplanned admissions of these patients. It does not
relate specifically to a review of all patients on the register, but more
about having knowledge of circumstances relating to these patients that
could result in A&E attendances or unplanned admissions.
The review referenced in section 2 relates to the question in the reporting template about reviewing
any unplanned admissions, re-admissions or A&E attendances of patients
on the case management register or newly identified as vulnerable. In other
words, this review is limited to those patients who have had admissions,
re-admissions or A&E attendances.
Q: Do we use the ‘review of admission avoidance care
plan’ Read code regardless of the kind of review?
‘review of admission avoidance care plan’ Read code relates
specifically to any reviews that are undertaken either for the purpose of
reviewing the patients care plan, or as a result of something that then
leads to a change in the care plan.
If a patient has an emergency admission to hospital, then there is a
specific code to use for this purpose i.e. to identify that they had an
emergency admission. However, if the practice then reviews the
patient’s care in order to try avoid such an admission in future and
this impacts on their care plan then the care plan review code can be
At present there is no specific code for reviewing the care plan post an
admission but the practice can add free text notes to indicate that this
was the reason for the care plan.
Q: Patients on the case management register should be
contacted/reviewed within 48 hours of receiving notification of an
emergency unplanned admission. How will this be monitored?
are no Business Rules to support an automated collection for this element
of the ES and therefore no codes have been identified for patients
contacted within the three days of discharge. However, a code is available
for ‘emergency hospital admission’ to help practices identify
those patients on the register who have had an admission and therefore
require a review post discharge. It will also be used for management
information purposes to collect data on the number of patients on the
register who have had an emergency hospital admission in the reporting
Practices will need to use their own systems or methods to identify
which patients on the register require contact post discharge. However, the
question of a Read code for recording the practice contacting patients has
been raised previously by practices, clinical leads and the DH. It was
identified that while we do not currently have this code, it would be
sensible to request one for the next code release. This is being discussed
further with the coding and classification body with a view to hopefully
having a Read code for this going forward.
Q: Is there a code that can be used to postpone or exception
report a patient on the case management register for when a patient is in
A: There is
no Read code currently available that can be used to postpone a care plan
for patients on the management register. However, it may be suitable for a
practice to leave the patient on the case management register providing
that they will not be in hospital for a long period of time and then
undertake the care plan discussion when they are discharged.
This ES is aimed at proactively managing patients in primary care. It is
therefore not possible to do this if patients are being treated by
secondary care services for a long period of time. Practices would need to
consider the length of stay a patient is having in hospital, in deciding
whether or not they are suitable for this service. If the patient is going
to be in hospital for a short period, then it will probably be alright to
leave them on the case management register as the practice can
deliver/review their care plan following discharge. However, where the
patient is likely to be in hospital for a prolonged period then the advice
would be to remove them from the case management register, for the reasons
Q: Are there codes available for the risk stratification
stratification Read codes are not specified. This guidance states that
“a practice should use an appropriate risk stratification tool or
alternative method, which may include using clinical judgement and
knowledge of the practices' patient population with regards to those
patients who would benefit from this service, to identify vulnerable older
people, high risk patients and patients needing end-of-life care who are at
risk of unplanned admission to hospital.”
If a practice requires a particular Read code for risk stratification
score we recommend that you contact the UK Terminology Centre (UKTC), which
is part of the Information Standards team within the HSCIC and who are responsible for the UK management of Read
codes, using the following email address: firstname.lastname@example.org.
However, this code would not be picked up as part of any national collections.
Extended hours access
Q: If extended hours are provided on a bank holiday do they
need to be re-provided on a day later in the week?
A: Commissioners are
expected to maintain agreements for extended hours inherited from PCTs for
this financial year. In the event the inherited agreement includes
re-provision of extended hours that fall on bank holidays, then this should
continue. Where this is not stipulated in the inherited agreement, the
expectation is that commissioners will ensure they are seeking good value
from the service and are pragmatic.
Where no agreements are in place (i.e. not inherited from PCTs) then
commissioners should seek to ensure that they are obtaining good value from
their extended hours proposals.
Extended hours access questions
Facilitating timely diagnosis and support for people
Q: Can practices re-examine the same patients assessed for
dementia in previous years who were not subsequently diagnosed with
A: Yes. If
a patient does not have a diagnosis of dementia and the clinician believes
the patient to be at risk of dementia, then if it is clinically appropriate
and with the consent of the patient, the dementia assessment can be
repeated in 15/16 regardless of whether one was delivered previously. It is
not however, a requirement of the enhanced service to repeat the assessment
annually where a patient was not subsequently diagnosed with dementia if it
is not indicated.
Learning disabilities health check scheme
Q: Why are there new codes in the learning disabilities health check cluster?
A: As part of a review of April Read release two new codes for ‘learning disabilities health assessment’ were identified as more appropriately reflecting the requirements and aims of this ES.
The codes are:
- 9HB5 Learning disabilities annual health assessment
- XaL3Q Learning disabilities annual health assessment
These two new codes will be added to the code cluster and therefore count towards achievement for the 2016/17 LD ES. The ‘learning disability health examination’ continues to count towards achievement for 2016/17 to ensure practices do not need to recode all patients in one quarter in order to be paid. Practices should begin to migrate patients over to the new codes when they are available. However, these changes will not be picked up until the Business Rules have been updated and republished by NHS Digital.
As the new ‘learning disability health assessment’ codes more accurately reflect the requirements of this ES, the ‘learning disability health examination’ codes will be removed from the ES from April 2017. This means that only the ‘learning disabilities assessment’ codes will count towards achievement from this point. For details of these changes see the updated Business Rules, which will be published by NHS Digital in due course.
Learning disabilities health check scheme questions