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.

Free care

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 [46]

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 [9]

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', [10] 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'. [11] Home managers should know the key principles underpinning the commissioning of GP and primary care services, including:

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.

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. [14]

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'. [15]

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]

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' [21] which raised serious questions about failings in aspects of its design and implementation. The Department of Health (DH) intends to issue revised guidance.


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Available downloads:

  • 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