GP services for older people: a guide for care home managers
Residents' entitlements and requirements - Access to quality GP services
Providers and managers of care homes should take necessary steps to ensure residents have appropriate, high-quality general practitioner (GP) and primary care services readily available to them. These include daytime and out-of-hours general medical services (GMS) commissioned by NHS England area teams, and enhanced medical services commissioned by their local clinical commissioning group (CCG). Current variable standards need to be identified and harmonised by primary care leads in area teams. Quality of life and good end of life care are of particular importance to residents and relatives.
One GP asked for £3,000 a quarter to look after the home's residents. I said it is your duty. They are registered to your surgery, why should I pay you extra? It is your duty to care for the residents registered to you, so why should I pay you a retainer?Care Home Manager 
Personally I do not think any care homes should pay a retainer, service users have a right to basic medical care and it's not right that care homes should pay for this. They would get this care free of charge in their own homes and frankly a care home is their home.Care Home Manager 
Policy is very clear that NHS services are provided on the basis of need and free at the point of delivery. In spite of this, there is evidence of variations in the provision and funding of key elements of NHS services for care home residents. The variations can result in unfair access and even discrimination. In its review report 'Health care in care homes',  the the Care Quality Commission (CQC) found surprising variations between care homes in the services provided by GPs and who pays for them: 33 per cent of homes said that GPs did not provide post-admission assessments for residents; 53 per cent said they were provided and paid for by the primary care trust (PCT); and 7 per cent said that they were provided but paid for by the care home. In the last case, the costs were presumably reflected in the home's fees to residents. More than half of homes (54 per cent) did not provide residents with information about which health care services were included in the home's basic fees in their care contract and agreement.
Expectations of GPs
What is expected of GPs was set out by NHS England in the document 'Securing excellence in commissioning primary care'.  Home managers should know the key principles underpinning the commissioning of GP and primary care services, including:
- Quality will be the overriding principle. Everyone in the system must focus on clinical effectiveness, safety and patient experience, although their role will differ depending on their job and the area in which they work.
- Patients' experiences are the main driver of the primary care commissioning arrangements.
- The system will be clinically led through a range of mechanisms, including central and local clinical leadership teams and explicit partnership arrangements with CCGs and local professional networks for dental, pharmaceutical and optical services, which will include relevant public health clinicians.
NHS England's area teams are responsible for commissioning standard GMS. These take the form of a daytime service Monday to Friday and an out of hours service. In some cases, the same practice provides daytime and out of hours cover, but this has become the exception in most areas. The result is that homes often have to rely on independent out of hours services, where a significant proportion of medical staff are locums who are unlikely to have prior knowledge of the resident or the home. When CCGs consider commissioning enhanced services they should include the benefits of continuity of service that could be provided by the existing GP practice.
Proactive health care
It is important for the care home to be confident its GP service will respond if asked to examine a patient, or in an emergency, but good GP care also needs to be proactive. This involves the clinician reviewing a resident's health condition on a regular basis; monitoring progress, taking steps to prevent decline and identifying scope for health improvement; and working closely with other agencies to maximise the individual's wellbeing.
In Sheffield, a pilot of a local enhanced GP service was evaluated (2008-09) through feedback from residents, relatives and care home staff, and before/after comparison of outcomes after one year. The scheme was based on a service level agreement, and residents had the choice whether or not to register. GPs provided annual medical reviews, medical care plans, end of life planning, weekly surgeries in care homes, six-monthly medication reviews, access to a community geriatrician, and shared learning and review following emergency hospital admissions. It is reported that almost all residents agreed that the GP service gave them the help they wanted and needed, and that they understood more about their health. Eighty-four per cent of relatives agreed that the resident received better care. 
One scheme paid particular attention to the resident's voice. The service provided advance care plans which incorporated the wishes of residents. It asked residents and families about their preferences, recorded these in care plans, made sure they were carried out, and then audited the care given to check whether this had happened. They carried out a 'gap analysis' where the outcome did not follow the plan. GPs saw relatives as requested during their routine visits. The scheme also offered a GP available on the telephone out of hours (nights and weekends) to advise care homes on the care plans that had been written. Usual out of hours GP services were still available if a resident needed a GP visit. 
Multiple and complex health needs
An increasing proportion of residents, in care and nursing homes, are coping with multiple and complex physical and mental health problems. A recent cohort study of the health status of residents in UK care homes, with and without nursing, observed that:
The mean number of diagnoses per participant (6.2) and the prevalence of stroke, dementia, Parkinson's disease and osteoporosis were higher than previously reported for similarly aged UK community-dwelling cohorts, confirming the hypothesis that multi-morbidity is a defining feature of the care home population, and implying a requirement for expertise in geriatric medicine that may be beyond that of some GPs. 
Moreover, this study found that while there might be an increased need to access services due to cognitive impairment, behaviour disturbance or malnourishment, residents had contact with the NHS on average once per month.
End of life care
Providing good end of life care has become a core function of many care and nursing homes, as recognition has grown that moving into hospital simply to die is neither necessary nor desirable for many residents. In 2006-08, among people aged 75 and over, 12 per cent of deaths took place in nursing homes and 10 per cent in care homes. The proportion of deaths in care homes increased with increasing age. It was 6.8 per cent in 75 to 79-year-olds compared with 17.9 per cent of the 90 and over group. The proportions in 'old people's homes' were 3.7 per cent and 18.8 per cent for the same age groups. In people aged 90 and over, 36.7 per cent of deaths were in nursing homes or 'old people's homes'. 
Homes have worked with GPs and palliative care teams to increase their knowledge and skill in this field. There is evidence from qualitative studies and reports that the use of end of life pathways and frameworks can facilitate positive relationships and joint or partnership working between GPs and care homes, but using these tools is not essential: the relationship between GPs and care homes is more important than the tools themselves. [16, 17, 18, 19]
Care home staff attended multidisciplinary end of life and palliative strategy meetings in the PCT which took place in local GP surgeries. The staff reported that they had developed support from a wider network than before which reduced their reliance on GPs. 
A GP was involved in initiating a local palliative care in dementia group of a range of health professionals from primary and secondary care, including GPs and care home managers, which (among other initiatives) has created protocols for use by care homes. 
Many local initiatives to improve end of life care have used the Gold Standard Framework associated with the Liverpool Care Pathway. Use of the Pathway has been discontinued in the NHS, in the light of the 'Neuberger report'  which raised serious questions about failings in aspects of its design and implementation. The Department of Health (DH) intends to issue revised guidance.
All SCIE resources are free to download, however to access the following downloads you will need a free MySCIE account:
- Evidence review on partnership working between GPs, care home residents and care homes
- GP services for older people: a guide for care home managers
- Improving access to and experience of GP services for older people living in care homes: practice survey