The learning disability enhanced service (DES) has been around for several years with the requirements remaining relatively stable, although the payment has risen over that time.
Key aspects to running the service well are keeping an up-to-date register, providing staff training and performing patient-centred health checks to encourage uptake.
Guidance and audit requirements are set out in the 2015/16 GMS Contract Guidance; coding is set out in the Technical Requirements for the 2019/20 Contract. Payment remains the same as in 2018/19.
Patients over 14 years old at the end of the quarter who have learning disabilities should be included on the health check register. The codes that put a patient on this register are the same as those for the learning disabilities QOF register, but the latter includes patients of all ages.
The average prevalence in QOF is around 0.5% of the total practice list. This does vary quite significantly between practices, but most have between 0.2% and 0.9%.
Obviously a limiting factor for payments will be the number of patients on the register. You should be able to liaise with the local authority to share information about patients who can be added, which will help increase your QOF payment, and also the number of patients who should be invited to have a health check under the DES.
There is a requirement in the enhanced service for practices to have multidisciplinary education about learning disabilities. In practical terms this is about keeping up skills in all parts of the practice to make appropriate adjustments to communicate effectively with patients with learning disabilities and their carers, if they have one.
All patients on the register should have an invitation to annual health check. Good communication is essential to make sure that the patient can understand the invitation. In some cases it may be more appropriate to send the invitation to the carer. Information about literacy and the carer should have been collected in previous health checks so make sure that this information is used. New patients should have this information captured at the time of the registration and these questions are a useful addition to registration forms for all patients.
There are good examples of ways of communicating with patients in an RCGP training guide.
As payment only happens when a review is completed there is no exception reporting or equivalent, although there are codes for recording if a review is declined, which can be useful.
The RCGP guide also includes the Cardiff template for the health check itself. The review should include any current problems as well as chronic conditions. There should be a review of medication, if any, and a check of preventative care such as immunisations and national screening programmes.
From 2022-23, there are points available from the Investment and Impact Fund for patients having an annual check and the production of an individual Health Action Plan. The computer system templates will help you produce this after the check. The plan will vary greatly according to patient need but will be informed by the questions in the check.
The IIF specification also asks practices to record the ethnicity and degree of learning disability of patients on the register.
This will be adjusted for prevalence so that, in addition to the QOF and DES monies there will be about £13 of IIF funding per patient if your PCN conducts checks and writes plans for 80% of the patients on the learning disability register.
The Cardiff template is the version that is most likely to be used for patients who are housebound or who live in a residential institution. There is little in the template that will need items that can’t be found in a GP’s bag. Height and weight are the two items that may require special equipment. Some patients, such as those with Down’s syndrome, may also require a blood test.
Housebound patients may be well known to the practice but, once identified are most conveniently recorded on a list to enable them to be easily contacted for next year.
There is an electronic template available on practice computer systems, but personally I find this fiddly and prefer a printed version of the Cardiff template that allows me to spend more time looking at the patient.
Ultimately your success in encouraging patients to have the checks will be down to your personal relationship with the patient and their carers, and how useful they find the check. The guidance does not specify who should conduct the review, or even that it should all be done by one person. The practice should, however, address any issues that come up at the review and develop an appropriate health action plan.
In practice the most successful reviews are likely to be with a person that the patient, or carer, knows and trusts. A useful review makes it more likely that they will be motivated to come again next year.
Once a patient has had their review, a code should be entered on their record saying that they have had a learning disabilities health action plan or annual health assessment. This, along with their entry onto the register, will be extracted quarterly and paid a month or so later.
Dr Gavin Jamie is a GP partner in Swindon and runs the QOF database
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