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

Why this guide?

The health and wellbeing of older people in care homes depends on them accessing GP services in a timely way. Joint working between GP and care home management, the involvement of residents and their relatives and the engagement of care staff are factors that will affect the outcome and lead to quality improvements. The purpose of this guide is to support managers and staff of care homes to work in partnership with GPs and primary care teams, with a view to improving access for residents to good medical services. It seeks to place the resident at the centre of the picture, viewing from their perspective the need for, and benefits of, effective joint working between the home manager and the GP.

Nearly half a million adults, mostly older people, live in care homes in England. Alongside their requirements for care and support, the majority of older residents have significant health conditions and health care needs. Many experience long-term, chronic and fluctuating conditions, often including multiple impairments and co-morbidities affecting their health, intellectual capacity and psychological wellbeing.

Care home and nursing home residents have the same rights as the rest of the population to access the full range of general medical services (GMS) The GP is their route to referral for assessment and treatment by primary and secondary NHS services. The relationship between the home and the residents' GPs is therefore critical to their health and wellbeing.

Yet evidence suggests that many residents are unable to access the GP services they are entitled to and the following obstacles have been identified:

• failure to acknowledge and implement residents' equal rights to appropriate and effective health care
• lack of interest in and commitment to the health care of older people on the part of some GPs
• the effects of excessive GP workloads, and demands on primary care nurses
• an assumption that residents in care homes are at lower risk than those in their own homes, and so should receive lower priority
• acceptance by some residents and care homes of less than optimal standards and expectations for NHS care.

In addition to these barriers, the role of care staff, their lack of status, confidence and competence in working at the interface between health and social care is something that needs to be addressed. As they are part of the context in which older people are able to access services that will affect their health and wellbeing.

Leadership from the care home manager facilitates training, according to a systematic review of international evidence. [1] Dedicated time and resources from managers are needed to enable care home staff to access training which can be facilitated by learning contracts between managers and care staff. Moreover, evidence from the work on effective supervision in a variety of settings [2] suggests that supervision and organisational culture can also play a part in improving practice.

This guide sets out steps the care home manager should take, in areas such as record-keeping, medications management and monitoring resident feedback on their experience of medical care, to complement the work of GPs and nurses. This enables prompt action to prevent ill-health and deterioration in long-term and chronic conditions, and more integrated approaches to assessment and monitoring of related health, support and care needs. It also helps to avoid unnecessary hospital admission and delayed discharge. Residents and relatives should participate as fully as possible in identifying and reporting health needs, and in contributing to decision-making and the discussion of options.

Who will find this guide useful?

• The guide is primarily written for managers and senior staff of care homes.
• It has also been written with GPs in mind, as well as members of CCGs and joint health and wellbeing boards, and should promote improved understanding of joint working.
• The issues addressed in the guide are of considerable importance to current and prospective residents in care homes and nursing homes, to their relatives and advocates, and to social workers, care managers and others helping them find their way through complex social and health care structures.
• Inspectors and other staff, regulating standards in the provision of NHS and adult social care services, may find it useful to reflect on the guide's approach to joint working between GPs and care homes.

The policy context

Although care homes provide care and support for nearly half a million disabled and older people, there is little in the way of positive government policy about what the adult residential care sector is for. It is 25 years since publication of 'the Wagner review - Residential care: a positive choice', which was published in 1988. [3] This review sought to shift the emphasis away from the view that residential care is the 'last resort' and to value its role as a vital part of community care. Government statements and responses to publicity about serious lapses in standards of residential care have until recently tended to regard such care as a regrettable hangover from a past age. Local authorities have for some years been exhorted by government to reduce the usage of, and spending on, care and nursing home placements to meet cost reduction targets.

Purposes of residential care for older people

Residential care meets a variety of positive purposes. As the Residential Forum has consistently reported, [4] this is best seen, not in isolation, but as part of the broad and diverse spectrum of care and support for disabled and older people. Residents vary greatly in their care and support needs, and in the kinds of programmes from which they are likely to benefit. Some examples are:

• people who move into care home settings after trauma and/or hospital admission, who may, with active reablement, be able to regain sufficient capacity and confidence to return to independent living
• people with problems of physical, mental and/or psychological frailty, including some degenerative and neurological conditions and functional mental health problems, who are seeking a positive, stimulating, supportive and caring environment which will help them to maintain and maximise their capability and capacity
• people with Alzheimer's and other forms of dementia, at various stages and levels of severity, whose care and safeguarding require particular forms of skill in communicating and understanding, and expertise in sustaining their personhood, dignity, choice and quality of life
• people who are close to the end of their lives and require good-quality end of life care, catering for their physical, psychological, intellectual and spiritual needs, supporting the active and sensitive involvement of family members and aiming to deliver some of the qualities of good hospice care.

These groups are not self-contained. Individual residents can have the characteristics of more than one group, and can move from one group to another over time. The crucial factor is that the home and its staff, the resident and any relatives, consider and plan for outcomes from the individual resident's stay that are as clear and well defined as possible. Maximising each resident's health, functioning, wellbeing and independence is a purposeful target for staff and residents alike.

Commissioning residential care

As commissioners, local authorities play a large and influential role in the residential care market. This has been changing as larger numbers of older people with housing equity have been in a position to fund their own residential care themselves. Across the UK in 2012, on average, 57 per cent of older residents paid the costs of their own long-term care, in whole or in part. The remaining 43 per cent were funded either by local authorities, or by the NHS under the continuing health care programme. [6] There is wide regional variation with a much higher proportion of 'pure' private payers in more affluent areas of the country, including the South East, South West and East of England. Any effects from government pressure to reduce dependence on residential care have tended to be countered by rising demand as a result of demographic change and increasing levels of need for care and support.

General and enhanced medical services

Primary health care is provided to people in care homes free at the point of contact through GMS delivered by GPs and their teams as well as community health services. In some areas GPs can seek additional NHS funding to provide a range of enhanced medical services, and residents of care homes may be among those to benefit from such arrangements.

Local enhanced service agreements

Typically, a local enhanced service agreement for residents of a care home or nursing home requires the general practice to provide a named lead clinician, a set number of sessions a week, and commitment to:

• a weekly visit (for an expected minimum of three hours)
• a weekly follow-up session (for an expected minimum of one hour)
• appropriate clinical administrative work.

Not all the residents users in a care home will need to be seen weekly. Following a comprehensive initial medical assessment, some will require only routine medical monitoring while others may require a more intense period of medical review. However, some people who are admitted with minimal medical needs may develop complications of existing medical conditions or new medical problems that require increased medical input from that initially thought appropriate. This increase may be temporary or permanent, the latter including the possibility that a resident may become terminally ill during their stay.

Some schemes identify three categories of resident to recognise the medical workload of any residential/nursing home population at any one time, and so that a clinician will prioritise who needs to be seen, based on sound clinical judgement:

• Level 1 residents may have chronic physical or mental health conditions (e.g. dementia, diabetes, hypertension) but are stable and only require follow-up as per national or local guidelines. The person will need to be seen for an initial assessment and annual review as a minimum. Their records will be updated promptly following inpatient episodes, and drug sensitivities and allergies recorded.
• Level 2 residents are likely to have an unstable chronic disease or medical problem, or to have been subject to an emergency admission that requires assessment, possible changes to management and close monitoring. Examples include service users with acute confusional states, urinary tract infections, gastroenteritis, unstable diabetes and respiratory infections. It is expected that these individuals will need an assessment of the acute problem weekly, or more frequent reviews as the condition dictates, until they are stable. The majority of residents who are assessed as Level 2 will return to Level 1 status once the acute episode is resolved. However, some residents will develop life-threatening deteriorations and/or complications of existing conditions or new conditions that may prove terminal. Where the person prefers to stay in the residential/nursing home, and this is deemed clinically appropriate, they will be treated at Level 3.
• Level 3 residents are those with a terminal illness. It is likely that these residents will need a multidisciplinary review prior to any definite decision to manage the final stages of their illness in the residential/nursing home, and weekly, or more frequent, multidisciplinary reviews as their condition dictates. The palliative care team may become involved at this point, to support the person, their family, clinicians and staff.

For residents of nursing homes, the direct costs of services to be provided by a registered nurse are underwritten by the NHS, but not services provided by non-nursing staff under the direction and guidance of the nurse. There are no specialist services for care home medicine nor are specialised geriatric services routinely provided.

Policies and legislation

A number of policy initiatives intended to promote and secure more integrated working between NHS and adult social care services are part of the context for cooperation between care homes and GPs, although this is not explicitly named as their target. Examples include:

• National Service Framework (NSF) for Older People's Services (2001)
• NSF for long-term conditions (including long-term neurological conditions) (2005)
• National Dementia Strategy, 'Living well with dementia' (2009), including provision to increase early diagnosis of dementia, and reduced use of anti-psychotic medication
• National Mental Health Strategy 'No health without mental health' (2011).

The 'UN Convention on the Rights of Persons with Disabilities', to which the UK is a signatory, applies to virtually all those resident in care and nursing homes. Its provisions include Article 19, the right of disabled people to live independently and be included in the community, and Article 25, entitling disabled people to the same health service support, on the same terms, as non-disabled people.

Key relevant legislation in this area includes:

• The Equality Act 2010, outlawing unfair discrimination on a number of grounds including gender, disability and age.
• The NHS and Social Care Act 2012. This contains major NHS reforms including the creation of NHS England and GP-led CCGs; the establishment of local joint health and wellbeing boards to oversee production of joint strategic needs assessments and health and wellbeing strategies; transfer of responsibilities for public health to local authorities; setting up national and local HealthWatch as the vehicle for service user and carer monitoring of health and care services; and changes to service and workforce regulation.
• The Care Bill introduced into Parliament in 2013. This consolidates existing adult social care legislation, setting up new arrangements for care and support needs assessment and eligibility criteria, placing duties on local authorities to promote integrated working with the health service and to work in partnership with a number of local bodies, as well as addressing issues of service regulation in the NHS and social care.

The 2013 NHS reforms provides more details of the legislative changes affecting the NHS and social care, and some of their implications for residents, care homes and GP services.

Care and support workers in health and social care

For more than 10 years, the government has recognised the growing significance of the care and support worker workforce in the NHS as well as in social care. In the wake of the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) [5] on conditions in Staffordshire hospitals, the government commissioned Camilla Cavendish [7] to conduct an independent review into health care assistants and support workers in the NHS and social care settings.

There are over 1.3 million front-line staff who are not registered nurses but who now deliver the bulk of hands-on care in hospitals, care homes and the homes of individuals. The review's terms of reference included recruitment, training, supervision, support and public confidence. It did not include statutory registration, which the government felt would not add sufficiently to the general assurance provided by the CQC.

The report observes that:

The phrase 'basic care' dramatically understates the work of this group. Helping an elderly person to eat and swallow, bathing someone with dignity and without hurting them, communicating with someone with early onset dementia; doing these things with intelligent kindness, dignity, care and respect requires skill. ... Like healthcare assistants, social care support workers are increasingly taking on more challenging tasks, having to look after more frail elderly people. Yet their training is hugely variable.

Cavendish Review [7]

The increasing reliance upon care staff, and the urgent need to integrate health and social care, makes it even more important to boost public understanding and respect.