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GPs go forth

'Named GP' plans thrown into disarray as minister suggests practices can devolve care coordination to district nurses

Exclusive Plans to rollout ‘named GPs’ for all elderly patients from April have been thrown into confusion after a minister’s suggestion that practices could devolve the coordination of care to district nurses was challenged by the nurse’s representative body.

Health minister Dr Dan Poulter said that named GPs would be tasked with working with other parts of the NHS to ensure that all patients aged over 75 had their care coordinated by the ‘most appropriate professional for that individual’s needs’.

In a parliamentary response, he said that while GPs might be the best placed person to fulfil this role, in ‘most instances other professionals are likely to be better suited to take on the care coordination role’, including district nurses.

The suggestion that GPs can delegate care coordination comes despite the Department of Health initially stating that coordination of care would GPs’ responsibility, as it hailed a move back towards ‘old-fashioned family doctors’. The responsibility is due to be introduced in the new GP contract in England from April.

But the DH said that there was ‘no inconsistency’ and that GPs must take ‘lead responsibility for co-ordinating a range of services’ so that elderly patients get the best care.

The Royal College of Nursing challenged the idea that care coordination could be shared, saying that ‘significant investment’ would be required for community nursing teams to take on the additional work.

Dr Poulter told MPs last week: ‘Named GPs will be expected to work with associated health and social care professionals to deliver a multidisciplinary care package that meets the needs of the patient. In some cases this may include working with colleagues such as district nurses, who are well placed to visit patients in the community.

‘Further to this, it will be the responsibility of the named GP to ensure that their patients have effective care coordination in place by the most appropriate professional for that individual’s needs. GPs may be well placed to fulfil this role, but in most instances other professionals are likely to be better suited to take on the care coordination role.’

But his comment that GP practices could devolve care coordination to district nurses was rejected by the RCN.

An RCN spokesperson said: ‘The real issue here is that GPs don’t own or direct district nurses and the community services have to be properly commissioned to take the new service ideas into account. People over 75 who have needs should have a proper person-centred plan of care that identifies the appropriate services they need.

‘If we are going to simply pass the responsibility on to community nursing teams, then there will have to be significant investment for that.’

But the GPC said they ‘hoped’ community services and nurses would work with named GPs.

Deputy GPC chair Dr Richard Vautrey said: ‘There is a difference between the named GP and the care co-ordinator. The former has to be a GP in the practice and is the person who will oversee care delivered. The latter is the person most involved in the direct care giving and could be someone in the practice or the wider health care team, such as a district nurse or a community matron.

‘The practice has no management responsibilities of others outside the practice but this is more about formalising the reality for that patient, and where a community nurse or social worker is the one most closely involved with a patient it would be hoped that they would work in an integrated way with the practice. We need to move to a point in the future where there is greater cooperation and collaboration between members of the wider primary healthcare team, working with a common care plan.’

But Family Doctor Association chair Dr Peter Swinyard said: ‘Until we actually get some contractual buy-in, some contractual tie-down, I think that working on hope is cloud-cuckoo-land, really.  

‘The Government is not a nice, sweet, benign organisation who value GPs and think everything GPs do is wonderful and they should make life easy for us. If the Government writes the rules in such a way that they can screw us, sooner or later they will. So we have to be very careful to ensure the rules are written in such a way that the patients benefit and the GP is protected from unreasonable demands.’

A Department of Health spokesperson said: ‘Under these major changes the buck will stop with GPs for ensuring that older people are proactively cared for better according to their individual needs. But this won’t mean that GPs suddenly start controlling the work of all community health professionals.

‘Whether it’s sharing records more closely or writing joint care plans, the key point will be coordinating all experts to work together closer as team for the good of the patient.’

He added: ‘There is no inconsistency here. We have said all along that GPs must take lead responsibility for co-ordinating a range of services so that vulnerable patients get the best care. But of course there will be frequent instances where it is most appropriate for another health professional to continue playing a leading role in delivering an individual’s care, based on their personal needs.’

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Readers' comments (26)

  • What I want to know is when Ive got time to do this?
    I start at 8. i do a 3 hour surgery from 830 seeing 18-20 patients + extras on a busy day. I have 2-3 visits and on some days a nursing home to visit - I have another 3 hour surgery in the pm seeing another 20 patients. I haven't mentioned, chasing consultants, chasing results, chasing referrals, chasing SWs DNs etc, the 50 letters, 40 results, endless prescriptions requests, sick note requests, insurance forms, EAS forms, holiday cancellation forms, requests to drop everything and go to a case conference, coroners letters, plus running the practice, reading all the crap from NHS E and the CCG, doing all the pointless stuff they want us to do, QOF, and finally on some days im on call and have to see "emergencies" too. Where am i going to find the time to do an MDT on everyone over 70? Need to find some slack in a system that has an aging growing population, with less GPs around.
    My opinion - lets be radical - patients want to go to A&E with minor ailments, let them, change the payments to A&E so they dont admit them all at 4 hours - the only reason why we are all trying to stop them going - free up our time to handle the CDM and then i might have time

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  • What a sour old bunch GP's are becoming. DN's work bloody hard. Most will see patients all day 9-5 & then return to base for a couple of hours to undertake paperwork. No cosy 7 sessions a week full time for them . no its five days a week plus weekends-something else GP's dont offer-. on a rota.DN's have far more patient contact than GP's.You neasure quantity we are about quality! As for berating time spent on training & development you really are dinosaurs who ever thought to put you guys in charge. And as for a recruitment & retention crisis see how big that becomes if some bright spark suggests GP's directly employing DN's.

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  • Peter Swinyard

    There is a shocking and serious shortage of District Nurses - makes GP recruitment look rosy - linked to atrophied training schemes. In the last year, just 5 newly qualified District Nurses in the whole of London. Not sustainable when we are trying to look after people at home. I am engaging with Health Education England to flag up shortage of DNs, lack of training schemes and career pathways for practice nurses and lack of genuine General Practice exposure during nurse training. Inevitably, there is a working party now looking into this - but before you groan, that is 100% better than nothing! (and thanks to anonymous 1130!!!)

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  • Not sure what data was used to evidence that DNs seeing only 3.5 patients a day . The issue is that DNs don't have the time to input the data therefore it is unfair to make such remarks . Generally my DNs see above 20 patients a day which tells me that quality of care is questionable . I agree that true integrated working is the future with a case manager for each patient . I find it soooo frustrating that collaberation and integration has been talked about for so long but in reality we are still working in silos . It's not the GP v DN it's who's best to coordinate the care with the GP who has the medical authority at the helm

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  • Vinci Ho

    (1) don't fall into this trap of the government trying to divide the whole medical profession-
    GP against consultant , GP partner against salaried GPs , GP against nurses /DN , Male doctor Vs Female doctor . Can you not see that is a prerequisite to divide amongst factions and then burn the flag of NHS?
    (2) 'My name is left hand, what is yours?'
    ' Oh! My name is right hand, do I know you?'
    (3) For information , my District Nurses work bloody hard.....
    (4) 19 years in the business, I thought I had seen enough nonsense but life just keeps giving surprises.

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  • As a gp I agree completely with the rcn position. The gpc and government are wrong on this issue

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  • Our district nurses too work very hard. They see fewer patients per day but tend to spend longer with each patient. I do not know of any district nurse who sits there twiddling thumbs all day.
    There are certain things the GP has to organize and are in the better position so to do. Likewise, certain things should remain within the remit of the DN to organise. We work as a team.
    I do however think the CCG commissions DN services so I think we do have a say in the service they provide.
    For the comment about DN working 7 days a week - it wont be the same DN - they will still get their days off and if they work at night not be on the following day.
    Our DNs do seem to push off at 4.30pm when 'twilight' starts. The day and night staff were all fabulous when my Mum was dying. Let's not argue.

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  • Surely a patient registered with a GP: is the responsibility of that GP anyway?

    It is a fact that the more folk that get involved, the less likely any system will work, then when one chain in the link goes on leave, all hell breaks loose.

    It is wrong that this approach applies only to the over 75's, surely it should apply to all vulnerable patients?

    I know of 85 year old much fitter than I am, and 60 years olds struggling with multiple health problems. Care / extra services should be available according to needs, not age.

    My thousand dollar question has to be why the government don't mind their own business and allow GP's to decide on how to care for their patients, something they trained for so many years to do, and do very well!.

    All these hair brain ideas that fall flat, cost the NHS millions, then we wonder why services are at breaking point!

    If the government worked as hard as GP's and cared as much about voters as GP's do about patients, this country would be fabulous … but sadly we are closer to being 'third world'!

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  • The DOH comes out with a idea to dump work on district nurses, and the RCN said no in about 30 seconds - 'No to any extra work, and even then if we did consider it it would need massive investment to provide it'

    Virgin who own Community services in Surrey and run the district nursing services, are doing any work they are explicitly contracted to do - that isn't written in stone, and would charge millions to provide the extra hours and manpower.

    DOH tells the media GPs are all to blame for sticking the elderly in hospital, gives GPs to take a pay cut, and then get us to do extra work to sort out the problem - our representatives tell us its imposed and we should get on with it or face more cuts.

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  • this is not just divide and conquer but perhaps a plan to water down proposals so GPs can be blamed for the plans being watered down 'cos GPs are too powerful (sic) and forced politicians into a corner, CONLIB will then propose to the electorate vote for us and we will make those troublesome GPs accountable and push legislation for 24hr 7 day a week cover with named clinician for all patients. We have health policy by the press - Telegraph are already moaning about elderly out of hours / disastrous 2004 contract etc.

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