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GPs to do weekly care home rounds under new NHS England plan

GP practices around the country will be paired with care homes with the expectation of carrying out a weekly round, NHS England has said.

A report to the NHS England board meeting on a new 'enhanced health in care homes (EHCH)' model, published yesterday, says care home residents 'are not having their needs properly assessed and addressed'.

It says there should be one-to-one mapping of GP practices to care homes, with each resident having a named GP, across the whole of England.

GP leaders are warning that there are not enough GPs to carry out this level of enhanced care, and it will remove the concept of patient choice.

NHS England say that six areas are currently piloting the model, and are 'seeing early results' of enhanced primary care support, including 'a reduction in falls, prescribing costs, reduced ambulance conveyances and fewer avoidable admissions'.

National director of commissioning strategy Ian Dodge said NHS England intends to set out a plan for 'national rollout' of the 'EHCH' model later this year.

The framework published yesterday says: 'Wherever possible, there should be one-to-one mapping of GP practices to care homes within an EHCH as this arrangement simplifies care delivery (e.g. through multidisciplinary and interagency working between primary care and care home teams).

'This arrangement needs to respect patient choice. Each resident should have a named GP to ensure comprehensive assessment, problem identification and care planning.'

And under the plans, GPs have to carry out a weekly round in the care homes they cover.

The document says: 'A weekly "home round" should be held in each care home. This proactive round is a cross between a hospital ward round and a home visit, and it is crucial for reviewing and planning a resident’s care.

'Members of the team who participate in the "home round" are the resident’s GP, the care home team and other members of the local MDT such as nurse specialists and pharmacists.' 

Speaking at the NHS England board meeting yesterday, Mr Dodge said: ''We see significant interest across the country in adopting this model and scope for… rapid national rollout… and so later this year we intend to set out plans for national rollout.'

But GPC clinical and prescribing lead Dr Andrew Green warned that pairing practices with a GP was not in line with the NHS commitment to patient choice.

He said: 'The idea of having all the patients in one care home registered with one GP practice rides a coach and horses through the concept of patient choice, and could leave a patient without a functioning doctor/patient relationship.'

Dr Green also pointed out that there was not enough GPs to roll out this scheme across England.

He said: 'The real difficulty here is providing the recourses required, not only in term of money but in terms of staff too. Our 11,000 patient practice has 10 care homes and we would need another partner to deliver this scheme, a partner who simply doesn’t exist, and the workforce implications of this scheme make the promised 5000 extra GPs look rather paltry.'

Asked how the rollout of the new model would be funded, NHS England told Pulse it will 'set out further details on funding shortly', but said it is likely to form part of the 'sustainability and transformation plans' (STPs) that are currently being drawn up around the country.

A spokesperson added: 'Local areas will have discretion as to how to provide those services but it does outline some of the services that need to be commissioned and the benefits that can be achieved as a result.'

The news comes as in the past there has been calls for GPs to stop charging retainer fees for services provided in care homes and as one in five care homes claim to be overcharged by GP practices.

It also comes as the GPC is in talks with the Government about scrapping the current enhanced service for avoiding unplanned hospital admissions of frail patients from next year.

What are NHS England's new care models?

NHS England's new models for general practice - multispecialty community providers (MCPs) and primary and acute care systems (PACS) - will have budgets based on the population they cover, similarly to the GMS contract, but covering a wider range of services.

The idea is for the new providers to hold a time-limited contract (of up to 15 years) during which they are responsible for the health outcomes of their patient population, and they are paid based on this rather than specific activities they perform.

The main difference between an MCP and a PACS is that MCPs 'integrates core primary care with out-of-hospital services, social care, and some secondary care services where this is appropriate', while the PACS 'expands on this arrangement to include acute and tertiary services where it is wanted and feasible', NHS England says.

NHS England says that the EHCS model 'provides care for a segment of an MCP’s or a PACS’s population: namely those people who are living in care homes or supported living environments or who are at high risk of losing their independence'.

It says this is likely to include patients at highest risk of unplanned hospital admission and those 'with the highest needs, such as frail older people'. In all three models, NHS England's idea is for GPs to work as part of a larger multidisciplinary team with other health and care staff such as consultants, pharmacists and social workers.

NHS England has been told by the Department of Health to ensure half of England's population is covered by new models of general practice by 2020. NHS England, in turn, has delegated this work to CCGs, trusts and local authorities who are divided into 'sustainability and transformation plan' (STP) footprints.

Readers' comments (40)

  • We have been cornered into doing this already. Trouble is we are a smallish rural practice and value continuity and know our nursing patients really well. Now I find myself having to see patients who my partners are already heavily involved with and I have never met.
    One model does not fit all.
    Just pay us and leave us alone to sort out local clinical issues.

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  • Fine, I will take a morning off seeing patients in the practice, and who will see those patients?......the non-existent GP in hub of course.

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  • Wouldnt it be far more preferable that such patients remain under the care of a GP but that the CCGs employ a geriatrician/GPWSPI who's sole role is to visit homes.

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  • expensive and inefficient

    even if NHSE try to avoid paying for it - it'll mean 1-2 sessions a week doing non urgent work with little clinical relevance.

    The major issue with nursing homes is the lack of qualified nursing staff in them.

    They don't need weekly medical input - they need adequate nursing - its not rocket science

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  • FFS!

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  • Who's the nurse in charge of this floor?
    I am?
    Any problems?
    No idea, I've never worked on this floor before! They seem better but the family demanded a daily GP review, just like Jeremy promised….

    We have this tosh already, FFS pay for proper cover, the NHS funding is not intended for weekly Care home cover. they charge residents enough, if they want a home GP they can pay for that enhanced level of care.

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  • Sounds a good idea.But I dont think it will avoid admissions.GPs will still refer patients as nobody is ready to take the responsibility.

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  • It's pretty hard to avoid this already for nursing homes, given they are used as cut price hospices often, so it is time to be paid for the work already being done.
    To those who can happily triage away most nursing home request you must be confident in the nurses. At our local home 'doesn't look quite right' could be anything between a solitary cough that day or imminent death, with nothing the incomprehensible bank nurses say on the phone giving clues as to what reality is!

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  • and suddenly: POW ZAP WALLOP
    we are now all community geriatricians but the difference is that we are cheaper and espected to do all the work for very little money,
    sorted! (not)

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  • it will be backed by the RCGP and they will send out welcome packs with GP-COG forms to color in, then the GPC will oppose it for a couple of days before caving in and you will all have to do it except for locums who will opt out.

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  • We do it as an enhanced service for hospital step down patients, twice a week, max stay per patient 4 weeks. Max 10 patients, payment appropriate sum (this is not GMS). This nursing home has additional staffing for these patients, on a separate wing. Main let down still is social services delays in sorting ongoing care. Patient returns to own GP if goes back to residential care or own home in the original GP area, or appropriate practice for their ultimate destination. This is not the same as routine rounds for all nursing home patients, that would swamp us. This one home we do for 1 month then alternate months with a neighbouring practice. As a large practice we can cope but we are lucky to have just about a full complement of GPs (but will be short again in 6 months!).

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  • We do this already - we have two half sessions a week to do a round at the nursing home (NB when they say "care home", do they include residential homes?).

    In spite of getting a GP visit twice a week every week, the home still manages to call out the duty doc at least once a week on top of that.

    We are a whole session a week of routine GP appointments down, and struggle to meet demand, but in our case this may be almost worthwhile, as they were regularly calling us out to see 6 or 7 patients a day before this.

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  • I thought the Cardigans always say..."you should consider it a PRIVILEGE to see patients in their home environment"

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  • No. I am not a community geriatrician nor do I have time to play at being one at the expense of doing my own job properly. If NHSE wants this service, it needs to recruit and pay sufficient community geriatricians. We are not even paid a sufficient premuim to cover the daily drip feed of "urgent" visit requests that may ot may not be but one has to go in order to find out

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  • So easy for these people to dream up things for GPs to do. An entire government department of jerk offs charged with screwing around with our job description and micro managing our lives - intolerable

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  • Sounds like NHSE need to get some proper doctor with white coats, consultants,not the lazy good for nothing GPs who are cheaper than the pet insurance for a small dog per patient for a year and already do 90% of the patient contacts in the NHS.

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  • No. Don't do it unless it's funded properly....and fat chance of that!

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  • Answer is simple - employ geriatricians - or GPs for that matter to deliver the care for all NH residents - not on an individual practice level but on a locality/network/mcp/ccg level - scrap the AA DES.

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  • Been doing this for years for free until recently.
    Benefits us as we do all the visits in one session( usually) and benefits them because they get all their problems sorted in one .
    Recently found out that some practices were paid for this when we weren't
    Now of course we all get some payment.
    Then of course are the ANPs, who should also be doing this, but when they're too busy, we pick up the extra work( shouldn't it be the other way round?)

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  • We already do this as part of a LES in Scotland. Payment works out at £420 a week so justifies me or 1 other partner going in 1 afternoon a week. Means between us we get to know staff and patients well, have a chance to speak to relatives, update anticipatory care plans, assess capacity, complete DNACPRs and do polypharmacy reviews (generally stop most of their drugs). It's a good idea if paid properly and you can spare a partner 1 afternoon a week which did require some reorganisation.

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  • this is awful - care home patients can get sick more than once a week - why not daily rounds including weekends from 8am to 8pm a day. Surely GPs are best placed and they can do their other (best placed) jobs in between. come to think of it care home patients can get sick OOH as well - we need to look at that as well.

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  • My 11,000 practice has 200 patients in homes. Many other local practices refuse to take on care home patients. That's going to be an awful lot of wardrounds. Who will see the other 10,700?

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  • Have done this for years - originally as a paid pilot through the PCT - found it saved time as has massively reduced call outs to the homes as most things wait for the weekly visit - staff like it as consistent message and patients and families also seem to like the continuity. Difficult to get other practices in area to adopt - we did try dividing homes out but apart from ours, little progress in changing. Paying a LES would probably accelerate this!

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  • The reallity is that this group of patients, is often neglected at present. Many of the reader's comments made about lack of GP workforce, inadequate nursing quality in homes and workload are valid. But to claim that we are being asked to become community geriatricians is wrong. We are not.
    These patients mostly need GP expertise and care but they just don't get enough of it. If GP's feel that these patients are in need of a geriatrician they can always refer. Let us not conflate volume of work with complexity of work.

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  • I saw this was being organised by Ian Dodge. No track record for GP-friendliness or realism...

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  • 10:36, still not sure why patients in nursing home need a weekly visit, they are already getting 24 hour care and support. What about all the single vulnerable elderly and disabled patients (who have next to no support as care being cut for "efficiency") who are not getting their weekly visits - surely their need is much greater? Maybe we should be visiting everyone over 75 every week? Completely unworkable and financially unviable. No other patients get a weekly GP appt all still for the same basic funding. Are we really worth only £2 per week to go out and in our car, pay insurance, time etc to visit someone weekly at their place of residence? Also amazing how many patients in homes manage to get to hospital OPA but cannot come to the GP surgery!

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  • I am just so relieved to have walked away from GP 15/12 ago. My main reason for departure was the popular perception that old age is a treatable illness and the responsibility for it's prevention and treatment is the GP's. I realise my thoughts might offend some but when one of the commonest comments from carers/staff/relatives and pretty much anyone visiting many Nursing Homes is 'I hope I never reach this state!' then might it be time to consider what we are trying to achieve here. On my farm when animals are immobile lying in their own excrement and unable to feed the vet is called to do the decent thing, this applies to both livestock and pets. When patients were in that condition I recall nappies and PEG's. I think that rather than weekly visits to assess, what we actually need is a frank discussion about quality of life issues and then a sensible decision about treatment or it's withdrawal. Then we need to explain to the politicians, journalists and general population that life expectancy has increased almost 20yrs in the last century but you might not enjoy or want to experience the last bit.

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  • Peter Mcevedy | GP Partner03 Oct 2016 9:00am

    Are you doing this as an unpaid privilege?


    If you are , do you not recognize that you are a part of the problem (all be it by being very nice)?

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  • Not sure if anyone has realized - this is to be paid out of STP scheme.

    CCGs are forced to form STP with no funding provided upfront for organizational work. Employing managers and directors does not come free. Now the transformational money is meant to address such short form but other schemes such as this seems to be hijacking it.

    Am I the only one who wonders when the SHAs (sorry, I mean STPs) are established, we suddenly realize all such funding is in "the baseline" and no new real money added to healthcare. Effectively, as members of CCG, we will end up doing this for free?

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  • 11.42
    Actually was paid handsomely for pilot and found that it actually saved time and visits during this. So yes, we do it without payment now but because it is prudent to do so in the homes we have chosen. If a payment system comes in, we would welcome it and it might encourage a broader take up especially for those homes which are less viable but I make no apology for saving my time and offering a better service at the same time. Has also reduced the prescribing in this home massively.

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  • Geriatricians charge for domiciliary visits.

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  • Peter Mcevedy | GP Partner

    thank you, at least you found you had a clear benefit.

    I'm pretty sure we would have not had any benefit from a weekly round from the last Nursing home i was involved in. but that was because very little visits were generated by them.

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  • The reason care home patients require more GP visits - is they are supervised by poorly trained, poorly paid care staff who request GP reviews to cover.

    The more times they are seen - the more chance of hospital.

    There is a vast cohort who live at home - just as co-morbid as the care home population - who never ask for a visit year to year because they're not being stared at 24/7 by a CQC fearing care home manager / relatives.

    Early results will turn into nothing - and this will be scrapped a few years down the line as the unplanned admission scheme was/is.

    Probably created by the same muppetologists who created the unplanned admissions scheme.

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  • @ Anonymous | Sessional/Locum GP03 Oct 2016 11:14am from 10.36
    I agree that a weekly round would not be necessary for every patient and I am not giving unqualified support for the scheme in its entirety. I was trying to emphasise the fact that these patients often do not receive the GP care that they need.
    You quite rightly point out that many other patients have the same needs but I suppose this is a start which focuses on those who are well defined as being at greater need. The presence of "nurses" in nurses homes is tokenistic, and in my experience, is no indicator that these patients are in receipt of much more care than those at home with carers.

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  • Anon1:43 yes CCGs will have to pay for this, but GPs will not.
    We need to remember always to separate the commissioner aspect of being forced into a CCG from the provider part.
    If CCGs want/must do this then they must pay.
    Where they get the money from is only our concern if they try to take it from the LCS budget, then they will get a fight from the membership

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  • What a lot of bull* We already do with all the demand and workload.

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  • Why should commercial care homes not be required to, by law, to have a fully trained and qualified nurse supervisor at all times.This would help the NHS to avoid unnecessary doctor visits.

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  • Just "do the math" as they say in the USA. At least one hour per home per week makes a load of GP surgery appointments gone West. (and don't these nursing homes have nurses in them?)

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  • Why not get the benefits and insights of those CCGs which have provided this service to their care home patients before rolling out a half baked scheme.

    Even at £200+ extra per patient per year this is unviable for a lot of practices and if they think it will save money it won't, as if seen more often they end up in hospital more often. But don't take my word for it, there are CCG s who have had the full lifecycle of this and it doesn't save money. The service is better and the initial costs look promising, but burden on practices is immense.

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  • Anonymous | GP Partner01 Oct 2016 7:13pm -"It's a good idea if paid properly and you can spare a partner 1 afternoon a week which did require some reorganisation" what needs OVER and FOREMOST is GERIATRIC CARE ASSISTANTS/HCA-Geriatric and Geriatric Trained (if not yet)/Recruitment of Community MATRONS. The complex cases to GPwSI's in GeriatrIcs/Comm. Geriatricians. I am really tired about the "choice"; what needs being chosen is EXPERTS in Care for the Elderly, WHATEVER THE NAME. Maybe because I am a Locum I am more INTERESTED in TREATING the ILLNESS rather than the appealing of the CARER!!

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