GP services for older people: a guide for care home managers
Managers' responsibilities and the NHS reforms - Development of a medicines strategy
Care homes should work with their GPs and pharmacists to develop a strategy for medicine management, including regular (e.g. six-monthly) medication reviews conducted by GPs and/or pharmacists. Managers should consider with GP practices how to address medication issues in order to reduce high levels of serious prescribing error, and have a plan to obtain medication out of hours through liaison with GPs and pharmacies.
The home manager's role in developing a medicines strategy
The care home manager can take a lead role in identifying the health care needs of residents, and discussing preferences with residents and/or family members and GPs.  The manager acts as an advocate for residents and takes a leadership role in relation to medical plans.
Various studies [16, 22, 26] and one report  note the importance of leadership or 'persistence' from the care home manager and other care home staff in their relationship with GPs and other health professionals in the multidisciplinary context, and in supporting health care regimes and decisions made by health care professionals.
In two examples, a care home manager prepared medication forms for each resident at her own initiative, to be used in joint medication reviews involving the GP and community pharmacist.  The SCIE Practice Survey  carries an example of a care home that had been involved in designing the pre-admission assessment form, 'so it had the information we need to provide proper care'.
Relatives and carers in one study  suggested that care home managers and staff should take the role of 'medication champions' in the context of managing medication and reducing prescribing and dispensing errors in care homes. In homes having a key worker for each resident, the key worker can be formerly responsible for medication issues and for updating family and carers about any changes.
Two major studies found that about 40 per cent of residents had a prescribing error, linked to harm in some cases, compared to 11 per cent having a monitoring error, 22 per cent having an administration error and 37 per cent having a dispensing error. The prescribing errors were 'incomplete information' in 38 per cent of cases, 'unnecessary drug' (24 per cent of cases), 'dose/ strength error' (15 per cent) and 'omission' (12 per cent). [40, 41]
In one GP practice,  the care home manager, staff and GP decided that the staff, rather than the GP, were best placed to facilitate decisions about health care and end of life care for residents. One care home manager had a lead role in identifying residents' health care needs, discussing preferences with residents and/or family members, and liaising with health care services.
One study  gives an example of GPs, local pharmacies and care homes working together to establish delivery systems to ensure that in cases where GPs cannot prescribe in the care home, medication is received by homes on the day of prescribing without staff having to collect prescriptions and medication.
Medication and broader health reviews
The evidence indicates that the practice of GPs in relation to medication reviews for residents, and broader reviews of their health status, advance care plans and end of life plans, is very variable:
- There are examples in the literature of regular reviews and assessments being part of enhanced service agreements, related to additional payments to GPs, and facilitated by regular GP visits and scheduled surgeries.
- Additionally, individual GPs may regularly assess the health, medical care and treatment of specific residents in response to requests from care home staff on an ad hoc basis, for example in end of life care. 
- A study of hospital admissions from care which had a high mortality rate within 24 hours, and were therefore likely to be inappropriate, found the reasons included a lack of advance care plans and a lack of regular medical reviews by GPs. 
- In a recent survey of GPs,  37 per cent did not know whether new residents would have a medical and nursing care plan within one month of admission and 67 per cent did not carry out a medication review on each resident every six months.
- Other studies also report a lack of advance care and medical plans, medication reviews, initial assessments, end of life plans, decisions and regular medical reviews involving or carried out by GPs. [10, 12, 26, 29, 42]
- There can be a lack of GP follow-up visits after hospital discharge.
Reported beneficial outcomes from medication reviews include:
- stopping potentially hazardous drugs 
- streamlined medication and prescribing procedures 
- adjusting medication 
- reduced dosages of antipsychotic drugs 
- reduction in medication costs (by over 17 per cent in Thames Valley). 
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