GPs are ‘likely’ to have to provide primary care services for inpatients resident at psychiatric and other specialty institutions within their practice boundary, the BMA has said.
The new guidance – published after the BMA took legal advice on the issue – concerns patients residing in care homes, as well as single specialty and psychiatric institutions, following an increase in member enquiries about who is responsible for their primary care needs.
The guidance also says GPs should make decisions on home visits of these patients on a ‘case-by-case basis’.
But other GP leaders argue that practices are neither skilled nor resourced for this type of work, with hospitals urged to take on more responsibility.
The new BMA guidance said that GPs are ‘likely to be responsible’ if:
- the residents fall into the practice’s geographical area, and;
- the institution is registered as a care home by the CQC and is not registered as providing hospital services (in England).
It said practices were ‘unlikely’ to be responsible if:
- the institution is registered with the CQC as a hospital (in England), and;
- the institution provides a full range of medical services e.g. in an acute hospitals setting, rather than being a single specialty or psychiatric institution.
The BMA later clarified to Pulse that they think it is ‘likely’ that GPs will be responsible for patients in single specialty or psychiatric institutions.
But hospital inpatients can also fall under a practice’s remit if the institution does not provide ‘adequate primary medical services’, with the guidance saying that there are ‘unlikely to be reasonable grounds for refusing to register such patients’.
The guidance said that while these characteristics indicate that GPs may be responsible, this is not ‘an exhaustive list’, and they should ‘decline to work outside their normal clinical remit’.
When it comes to home visits, GPs should make clinical decisions on a case-by-case basis. For example, a request to visit a patient in a psychiatric institution ‘will not be appropriate unless the medical condition of the patient requires it’, the document said.
Former RCGP chair Professor Clare Gerada, a GP in south east London, said: ‘These patients often have complex comorbidities well outside the skills or expertise of the average GP, including myself, and yet we are meant to manage three patients at a time when they are acutely unwell. Given the changes in health care its important that we get clarity on accountability and responsibility.
‘Nursing homes on the whole are private, for profit organisations which don’t tend to build in any costs for out-of-hours or indeed in-hours medical care – some do, most don’t. They also don’t consult with local GPs ahead of opening to see if the local area has capacity to take on very unwell patients – and often in large numbers.’
She added: ‘I think hospitals needs to take more responsibility for their population and this includes patients in care homes. I worry its always the GP having to pick up the extra work, with no prior discussion or resource’.
Presenting the guidance, the BMA said there was ‘often confusion over who is clinically responsible for their care, which may present a risk to patient safety’.
It added: ‘GPs must not be forced to accept clinical responsibility for aspects of the care of patients in secondary care institutions, nor for those in any setting where the clinical needs of the patient fall outside the normal skills and contractual requirements of GPs.’
The BMA also warned GPs not to allow themselves to be ‘coerced or contractually threatened’ to provide services beyond their contractual obligations and said that if a GP is ‘working outside their expertise and training they put patients at risk as well as their own registration’.
GPs should contact their LMC and medical defence body if they are being pressured into providing care in hospitals or are unclear about their responsibilities, they added.
Care home residents and GP workload
The debate over workload associated with care home residents is not a new one. In fact, LMCs passed a motion in 2016 for GPs to stop looking after care home patients, because they had complex needs GPs could not meet.
However at the same time NHS England is piloting models which would see GP practices taking a greater responsibility for care home residents. Under the Enhanced Health in Care Homes vanguard scheme, practices are paired up with local care homes and GPs do weekly ’rounds’.
The BMA has argued that there are not enough GPs to roll that particular scheme out nationally.
Elsewhere, GPs in Wales are paid £270 per care home resident under a new enhanced service launched last year. And a CCG in Essex decided a few years ago to set up a dedicated GP service to care home residents to alleviate overworked local practices.