GPs in Sheffield are carrying out weekly ‘ward rounds' at local care homes as part of a pioneering local enhanced service initiative. Dr Eithne Cummins explains how it works
Our local enhanced service (LES) for care homes allows GPs to regularly visit patients and recognise their complex needs. It also helps reduce preventable hospital admissions. The LES covers 80 homes and around 4,000 beds in Sheffield.
The LES contractually aligns every care home with a named practice and GPs. Residents not already a patient of the practice are asked to consider swapping their registration. The practice provides a weekly ‘ward round' at a time agreed with the home and an annual care plan for every resident. The rate of pay for the LES varies depending on the level of need for each patient group.
The need
Historically, we have had different GPs seeing different patients in homes.
Medical cover has tended to be haphazard, evident in a rising and variable rate of emergency admissions that is unacceptable.
A local bed usage survey in 2004 showed 23% of admissions were preventable, 40% of these being for exacerbations of long-term conditions. Some 25% of admissions from care homes were preventable.
Previously, the PCT has invested in a care home support team to provide training and support to care home staff and align a district nurse to every residential home.
The LES was initially funded as a pilot.
How we set it up
Many of the patients already had a relationship with a particular practice. We went through all the registered lists and worked out who had the bulk of patients from a given home, then approached that practice about taking on everyone who wanted to join from that home. Where there was a very big home, several neighbouring practices were asked.
From there, once consent had been gained, the PCT dealt with managing the patient registrations.
Overall, there was a strong appetite among GPs to take this on. It basically amounts to a session – morning or afternoon – per week, so it's doable.
After a series of meetings, we drafted a service agreement that we give to each care home signed by both parties saying that we will visit on a certain day, do a regular ward round and that there will be a member of care home staff available to help out.
A handful of patients have decided not to register for the service and want to stay with their own GP.
The service
It takes at least half an hour with each patient to review their care properly and to do a thorough care plan. We try to be proactive rather than reactive and make sure we cover every eventuality. While preventing admissions is obviously important, the main emphasis is on quality care.
The focus of the LES is in developing a care plan for the individual patient, including planning for crises and a medication review. If a patient has a non-urgent healthcare problem between visits, staff will sometimes wait for the GP's next visit to raise it instead of ringing the practice – although they can, of course, ring if it's urgent.
Every practice has a different approach, but in mine we have a template care plan that we can go through on the ward round, which prompts us to ask the right questions.
Savings
The LES will cost £831,000 this financial year (2011/12), and initial indications suggest for this financial year the cost of the LES will be covered by reducing avoidable hospital admissions.
However, it's not that straightforward, and there a number of factors that affect the risk of hospital admissions. We are reviewing this on a quarterly basis with colleagues in the PCT.
Learning points
Those looking to implement a similar scheme may find the following learning points useful:
• The LES needs to be delivered across a whole commissioning locality to have a chance of being cost-neutral. Some care homes have low admission rates already and it's how admission rates overall balance out that will make it cost-neutral. It is worth getting the practices to agree who will take what home before writing the business case. If they cannot agree, don't start the process.
• Split bigger (40+ bed) homes between two practices if you need to – but only if you can get one practice aligned to a specific wing or floor.
• Make sure practices know the LES work can't be squeezed in after normal visits. Get the contract in place between the practice and the home – establish when the weekly ward round will be and which GPs from the practice will provide the LES.
• Get patient-level data to practices showing the number of admissions every month. This helps to show who ‘frequent fliers' are and enables a focus on care planning for these vulnerable people. We are now going to write down exactly what data is required, how often and who needs to collect and share it – and get director backing for this. Verbal agreements have not worked.
In summary, I'd say the vast majority of my colleagues think it's a very good idea. We've had a lot of inquiries from other areas, plus the patients love seeing a regular GP.
Every health economy has different needs, but quality of care for the frail elderly has to be high up the agenda.
Lessons from the LES pilot
A two-year pilot of the LES scheme in Sheffield began in 2008. This involved 11 practices providing the LES to 527 beds in 14 residential and nursing homes within one PBC consortium.
Practices were paid £250* per bed, per year. The LES cost £125,000 a year.
At the end of the first year, looking at spells by month of admission, the LES had an immediate impact on admission rates and the pilot prevented 58 admissions, saving £145,000 – breaking even, ahead of schedule.
While the data was treated cautiously, as spell costs can only be updated once the patient is discharged, in a comparison of 2008-09 spell information based on month of discharge with the previous year the LES saved about 10% on admission costs or £96,000.
Reviewed against a comparator group of homes matched for size and type, the LES homes admission costs came down by 10% versus 3% in the comparator homes.
The LES sought to tackle:
• inefficient systems and poor communication, with many residents registered with multiple practices
• lack of GP time for visits, proactive care in managing chronic disease and medicines and care planning, especially around discharge and end-of-life care
• over-reliance on emergency services for crisis management
• uneven GP workload
• lack of resource or incentive for GPs to provide appropriate care.
Lessons learned
• Every home in a consortium needs to be covered, but not every practice needs to provide the LES. The practices that have historically taken on the lion's share of care home cover work usually want to consolidate the work they are already doing, especially if they are being paid to take on the extra GP capacity needed to do it well.
• When re-registering patients, make sure you brief practices outside the consortium boundary who may lose patients (only a handful but it can create bad feeling).
• Plan for under-occupancy: at month six, rates ranged from 70-100%. Several homes admitted significant numbers of residents for short-term or respite care to fill empty beds. GPs who are providing the LES feel duty bound to accept these residents on a temporary basis given that they are covering the rest of the home. While they are not being expected to provide more than reactive GMS care for them, these are frail elderly people where there is a high chance of their requiring GP input, and this is made difficult by the aligned GP having no access to their GP records. Nor do GPs receive payment for care of temporary residents. While it was originally envisaged the LES would cover long-stay patients, it has been extended so that short-term residents are treated under the ethos of the LES, minus the requirement for a care plan – within agreed costs.
* In 2011/12 payments for the LES were adjusted to £220 per bed per nursing home and £200 per bed per residential home. Source: NHS Sheffield. 12-month progress report of the pilot for the Local Enhanced Service for care homes. 2009
Dr Eithne Cummins is clinical lead at Hallam and South CCG and city-wide project lead
‘Working with patients and the public' will be one of the track sessions at this year's NAPC annual conference. The session will look at how how to engage and communicate with patients and the public, care planning and shared decision making. To view the full programme or to book, visit www.napcannual.co.uk
60-second summary
Initiative: LES that pays practices to do a weekly ‘ward round' to enhance care and tackle rising admissions. An estimated 25% of admissions from care homes were preventable
Cost: £125,000 per year
Results: Some 58 admissions prevented in first year, saving £145,000. Reviewed against a comparator group of homes matched for size and type, the LES homes admission costs came down by 10% compared with 3% in the comparator homes
Contact: For an information pack, email PBC manager Agnes McAuley (agnes.mcauley@nhs.net)
