Your local residential home insists on calling a GP to visit a resident who has had a fall. The patient did not require admission to hospital and seems perfectly well, but the care home will not accept telephone advice, citing a directive set out by management. What do you do?
GP trainer: Offer to see the patient at the practice
As a GP partner at a busy practice of 11,000 patients, I consider GP time a finite resource that has to be managed responsibly. It is hard to justify visiting one patient who is reportedly ‘perfectly well’, merely to satisfy a managerial policy. Residential homes know that all appointment requests have to go through telephone triage – something that is made clear in our practice booklet. Despite this, our practice has noticed an increased frequency of calls from care staff wanting to transfer responsibility for trivial scenarios to us.
It is important to manage the initial request before taking steps to prevent recurrences. The GMC’s Good Medical Practice states that ‘good clinical care must include an adequate assessment of the patient’s condition, based on the history, clinical signs and, if necessary, an appropriate examination’.1 Could there be an unidentified clinical concern, for example, a head injury? In the unlikely event of an adverse outcome, the GP needs to be able to justify their decision for declining a visit.
Then explore the urgency. Can it wait until the next care home ward round? Next, tackle the need for a home visit. As the patient was mobile enough to fall and is not deemed unwell enough to trouble our A&E colleagues, could the home bring the patient to your surgery? This seems like a reasonable compromise.
Previously, residential patients accounted for around a third of our visiting workload. By adopting a collaborative relationship, we have improved care while reducing our workload. We now employ an advanced nurse practitioner to perform weekly care home rounds, and barely receive any additional visit requests.
Dr David Coleman is a GP trainer in Doncaster
Senior GP partner: Suggest to the care home you will charge
This seems to happen a lot. Resident has a fall, is assessed by the paramedic or out-of-hours GP, and you get a call the next day. The caller states there is no apparent injury, but the home wants you to see the patient under its ‘company policy’.
If the resident has already been seen by another clinician, it seems excessive for you to see them again. However, countless defence union reports emphasise the importance of seeing a patient yourself, and not relying on another colleague’s initial impression.
Nevertheless, I believe you should only see a patient who has been assessed by a colleague if you perceive a clinical need. Taking an adequate history is key. If the patient appears to be deteriorating, you should attend. If they are back to their normal self and causing no concern, there is little to gain by going out. If you can establish the latter, I would politely decline, and send a letter to the management outlining that while it might be company policy, a second visit is not clinically warranted.
You may also want to advise the carer that you charge fees for visits you do purely to fulfil the home’s contractual requirements. Recently I was asked to carry out six-monthly medication reviews because of a home’s policy. I advised that we only do such medication reviews based on clinical need and suggested we bill the home each time we are called out for this reason. Similar requests have since stopped.
Dr Matt Piccaver is a GP in Suffolk
LMC view: Direct the carers to urgent services
Care homes often assume that a directive written into their policy transforms magically into a contractual obligation for the GP.
As a trainee I was taught ‘visit first and educate after’. However, residential homes tend to have high staff turnover, so educating one carer after an unnecessary visit is unlikely to prevent another inappropriate call. I would therefore immediately tell the carer I am not obliged to visit just because it is the home’s policy. The GP’s duty is to provide appropriate care for a patient who ‘is or believes themselves to be ill’.2 As this patient is reportedly well, these criteria would not seem to apply. If the carers are genuinely concerned the patient might be injured, they should arrange to take them to a minor injuries unit or A&E.
You must take a good history, not least to be able to answer any complaint. The GMC’s Good Medical Practice requires GPs to ‘make the care of the patient their first concern’.3 If, however, you feel there is no clinical need to visit, the GMC also requires you to ‘maintain good relations with colleagues’,3 so be sensitive with the carer in refusing.
If this is a regular occurrence, arrange a meeting with the care home management. Avoid charging a fee for visiting the patient as this could backfire – technically the home could argue the carers believed the patient was unwell.
You could, however, write to regulators such as the CQC, or the local council, to ask them to take action. Your LMC can support you in this.
Dr John Allingham is medical secretary at Kent LMC