GP services for older people: a guide for care home managers

GPs' role in relation to the resident, the home and the wider NHS - Managing relationships

Care home managers and GPs should agree how to handle relationships, communications and joint working between the home and the practice, to deliver what works best for residents.

We don't actually have a retained GP here as such, so they would, I mean, there are a couple of surgeries that are quite local so they're sort of like the surgeries probably of choice. But you know what I mean, at the end of the day it would be down to the resident to choose, wherever they wanted to have a GP, wherever they wanted to register.

Care home manager/owner/matron [28]

Well, I think if they've known the resident for twenty, thirty years, they should continue that. I don't see any point in changing, because they know them best. They've dealt with all their illnesses for the last X number of years. So, we wouldn't, you know, we wouldn't change, unless we were forced to for some reason.

Care home manager/owner/matron [28]

Effective working relationships

No single model for relationships and communication between care homes and GPs has received universal endorsement. Practice varies across England and even within a given locality.

A number of different models appear capable of working effectively. As with other aspects of joint and integrated working, structures and systems for improved cooperation will fail without the will to cooperate. If the parties share a commitment to working together, and preferably a shared value base, they can make most structural arrangements work.

Home managers taking part in the SCIE's Practice Survey, 2013 said that, whatever the arrangement was in practice, it should be designed to meet the health care needs of the residents, rather than being chosen primarily to suit the GP or the home. Issues to be considered include GP availability and interest; alignment of practices and homes; continuity, joint protocols and role clarity; and development of shared understanding through, for example, use of end of life frameworks and pathways.

Close, effective working relationships between care homes and GPs are reported by care home staff, GPs and other stakeholders. These are associated with several positive outcomes including:

• better access to services such as regular visits, prescriptions and out of hours contact, greater continuity of care and higher service efficiency
• better partnership working between care homes and GPs
• better end of life care (reported to be more important than the use of end of life tools) [30]
• reducing care homes' isolation and supporting them in their caring responsibilities [17]
• care home staff feeling more confident about their judgement to refer residents to the GP and other health services [12, 31]
• professional advice from GPs to care homes. [24]

Factors aiding or hindering relationships

Enhanced service agreements, preferred practice arrangements, having just a few GP practices per home, regular visits and meetings, and other forms of contact are reported by residents, relatives, care home staff and GPs to contribute to and sustain positive relationships. However, in the SCIE focus groups and managers' questionnaires, the system of residents using their own GP was also reported by care homes to facilitate good relationships between the GPs, 'their residents' and the care home staff.

Research identifies a number of factors likely to enhance or detract from the quality of relationships between homes and GPs:

• Lead roles and responsibilities. It is important to agree roles and responsibilities. Inappropriate and harmful prescribing is linked by care home staff and relatives in qualitative studies to a lack of clarity around lead responsibilities. Studies suggest a leadership role. For example, a 'medication liaison officer' for GPs, pharmacists, care home staff, nurses and relatives. This person would be responsible for ensuring medication reviews are carried out regularly, would oversee and attend medication reviews and take responsibility for medicines in individual care homes. [22]
• Trust and mutual respect. Several studies report that relationships between care homes and GPs need to be trusting and supportive, and to involve sensitivity, recognition and mutual respect to have the most impact on partnership working and the medical care of residents. At best, in the SCIE survey, this relationship was 'friendly, relaxed and informal while remaining professional'.
• Tackling negative attitudes. Several studies and reports refer to the need for GPs to respect the knowledge of care home staff about individual residents, and their skills and decisions. Some care home staff describe health professionals generally, and GPs specifically, as sometimes patronising, condescending and even 'discriminatory'. Care home managers in the SCIE focus groups spoke about some health professionals being preoccupied with identifying and reporting safeguarding concerns.
• Different professional values and priorities. Communication and understanding may be hampered by different professional values, priorities and working cultures among health service practitioners, including GPs and care home staff. There are also reports of a power imbalance, with health professionals (not only GPs) feeling more powerful, professional and higher in status than care home staff, and expecting to set the agenda and priorities, which can make equal partnership working difficult.

Communication

Several studies and reports mention the importance of effective communication in promoting better joint working between GPs and care homes; reducing hospital admissions; reducing medication errors; and resolving difficulties obtaining medication. Care home staff and GPs say that they value their contact out of hours, using a variety of media (email, fax, mobile phone), as well as having regular meetings.

• Greater clarity. In one study, nursing home staff used collaborative learning groups and action learning sets to look at how they worded requests to GPs, assumptions they were making about the GPs, and ways that they could make options more explicit when making decisions about end of life care. This approach was effective in building up trust and getting some GPs to collaborate with nursing home staff in using end of life documentation. [18]
• Use of telephone. Studies report how GPs and care homes use the telephone – for example for advice, and for requests for prescriptions, equipment and medical tests, especially where a GP feels they know enough about a particular resident and their medical conditions, and/or trusts the care home staff and has a good relationship with them, and/or has regularly scheduled visits to the home. The telephone may be used by GPs specifically as a strategy to reduce the workload created by face-to-face visits to the home. [12, 24, 26, 28]
• Telephone problems. In some cases (SCIE focus groups and questionnaires), 'over-enthusiastic gatekeeping' by other practice staff could hinder communication between care homes and GPs, and there could be 'lots of waiting on the phone and then not being able to get through to the right person'. One study reports that the telephone replacing visits out of hours may be a factor in increasing hospital admissions. [32] Two studies [9, 28] and the SCIE focus groups report concern by care home staff or relatives about telephone prescribing and consultations.

• Practice examplesOpen

  One care home developed positive working relationships with health practitioners and staff other than the GP, such as the receptionist at the practice, which facilitated quick and effective handling of their calls about a resident. [17]

  A scheme in Leicester [12] piloted shared management of care home residents between GP practices and community geriatricians. The pilot involved access for GP practices to comprehensive geriatric assessments, care planning, rapid written feedback and a telephone advisory service. It is reported that, after the first six months, out of hours consultations reduced by 16 per cent, and requests for visits by 37 per cent. Hospital admissions fell by more than 50 per cent. The total cost of hospital admissions fell by 60 per cent.