GP services for older people: a guide for care home managers
Managers' responsibilities and the NHS reforms - Actions as a result of listening to residents and relatives
Care homes managers should establish ways of listening to and regularly checking the views and experience of residents and relatives regarding their medical care. Managers and care staff can take leadership and advocacy roles in relation to the health care needs and preferences of residents, relatives and carers. Managers and GPs should ensure that local pharmacists, dentists, opticians and hearing services, CCGs and NHS England area teams understand the needs of their residents.
Co-production and participation
Sharif et al.  consider the factors that older people say are fundamental to participation. These are:
- a proactive approach
- timely involvement
- clarity of purpose
- willingness to work in partnership
- a devolution of power.
These authors also consider the barriers to participation such as negative and ageist attitudes from staff, practical support such as transport, lack of support for older people to develop personal skills and inappropriate forms of communication. Their report suggests senior management involvement, sustained training and supervision in order to make participation a reality in practice.
It is worth noting that in satisfying CQC essential standards, forms of evidence around the quality of care can be found in supervision notes and in talking to staff about what training they have undertaken.
Hearing from residents and relatives on medical matters
Many homes arrange regular residents' meetings, sometimes but not always inviting relatives to attend. If the meetings are well conducted, residents should be free to place items on the agenda and able to air and share common concerns. These meetings offer one way for managers to hear residents' experiences and views of the GP services and medical care they receive. Managers in the SCIE survey of practice also mentioned periodic resident satisfaction surveys as another source of information. They thought it would be straightforward to include questions about accessing GP services, and the quality as experienced by residents.
Alongside these more formal processes, care staff in their day-to-day contact with residents are well placed to pick up and respond to informal accounts of their experiences with GPs and the NHS, both positive and more critical. This kind of feedback can help to improve service quality and working relationships between homes and GPs. Although it is harder to gather feedback from residents with the more serious degrees of dementia, staff are often able to pick up non-verbal indications of increased anxiety or distress, and may be able to guide the GP or nurse towards ways of acting and communicating which will cause the resident the least upset.
Studies and reports [13, 22, 24, 38] emphasise the importance of the 'voice' of residents and relatives, and their advocates, in determining medical and end of life care. An enhanced service scheme  had the aim of incorporating residents' wishes in care plans. No evidence was found in the research literature of studies which evaluated the participation of residents and relatives in shared decision-making.
The contributions and requirement of relatives
Homes should enable relatives to be present during GP visits if they wish, and the resident agrees, so that they can talk to a GP directly. Alternatively, they should update relatives afterwards on outcomes from a GP consultation, including any medication changes. Relatives in two studies [22, 29] reported feeling frustrated that they weren't told by care home staff or GPs about important developments in their relatives' care such as changed medication. They weren't involved in shared decision-making, nor invited to attend or updated about GP visits. They said GPs tended to visit care homes when family or carers were not there.  Sometimes a GP would be happy to share information with a relative, for example when they took the care home resident to an appointment, treating them as an advocate, and such information-sharing was appreciated by relatives. 
Residential/nursing home staff, patients and their families/carers should be aware that they can raise concerns with the visiting clinician at the weekly visit and a mechanism should be in place to ensure the visiting clinician is made aware of any new problems. An agreed standard and system for referral should be documented and available to all.
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