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Feature: Home grown

Feature: Home grown
13 November 2013

Providing GP services for older people living in residential care homes is a challenge for commissioners
We all know about the so-called postcode lottery. But there is one group for whom this lottery seems particularly harsh: the over 400,000 older people who live in care homes.
That many GPs go out of their way to provide excellent primary care for people living in care homes is undeniable. 

Providing GP services for older people living in residential care homes is a challenge for commissioners
We all know about the so-called postcode lottery. But there is one group for whom this lottery seems particularly harsh: the over 400,000 older people who live in care homes.
That many GPs go out of their way to provide excellent primary care for people living in care homes is undeniable. 
But many do not – and those campaigning on behalf of care home residents suggest that this is an area where clinical commissioning groups (CCGs) can make a real difference.
Dr Eileen Burns is the British Geriatrics Society lead on care homes and she is pretty blunt in her assessment: “Care home residents are substantially disadvantaged compared to people living in their own homes with regard to a range of NHS services,” she says. 
For a start, many care home residents find it difficult to register with a general practice: “We have even heard of general practices asking care homes to pay them a retainer,” she adds. 
Now bear in mind that these residents – both in care homes and nursing homes – are among the oldest and frailest in our society. One in five is aged over 85 and all have some disability. Many have dementia and collectively they have high rates of both necessary and avoidable hospital admissions.1
“These are very vulnerable people,” says Professor Martin Green, chief executive of the English Community Care Association. “We see some excellent practice from fantastic GPs but we also see some areas where primary care ignores care homes and some areas where they demand money even to step through the door. That’s totally unacceptable.”
Inequality doesn’t stop with GP care though, says Dr Burns, who is also a community geriatrician in Leeds. Residents are often unable to access NHS services such as podiatry, dentistry, physiotherapy or specialist nursing services. 
Pitched against this are areas – especially in cities and towns – where one general practice may have residents in multiple homes making anything other than a purely reactive service impossible to organise. Similarly, residents in a single home may be registered with multiple practices, meaning the home is rarely visited by the same GP twice in a row. 
No-one wins and the rate of avoidable admissions of care home residents to acute hospitals via A&E continues to rise. 
This autumn, the British Geriatrics Society (BGS) is undertaking two important initiatives to raise the profile of commissioning care in care homes: a conference and the launch of guidance for commissioners (see insert in this issue).
Dr Burns’ idea is simple enough: “For CCGs to commission pro-active care by GPs supported by access to geriatricians with the ability to make appropriate referrals.”
Professor Green adds: “What we want is collaboration,” he says. “There are so many benefits, ranging from fewer hospital admissions through to improved health and wellbeing of care home residents. We need to move to a position where we commission for outcomes.”
But there is a problem, says Dr Burns: “There is no evidence-based model that will deliver cost effectively everything that a care home resident will need,” she says. “There is nothing we can hold up and say ‘this is the gold standard’.” 
Rather, there is lots of local experience from GPs and geriatricians who have tried different models. 
Among them is Dr Gillie Evans, GP Principal at the Jenner Health Centre in Peterborough and Associate Fellow of Green Templeton College, Oxford. 
Just over a decade ago, she recognised that the care her practice offered to 140 patients resident in half a dozen local care homes was just not good enough.
It was triggered by a care home resident with a long-term condition (LTC). Dr Evans visited in an acute episode, noted the LTC and expected something would be done to manage the patient. Six months later, when she revisited in another acute episode, she realised no one had picked up the ball. 
“Our care was very reactive,” she says. “I decided that the way to improve care was for GPs to take personal responsibility for a care home each.” 
She persuaded her partners of the case – largely by volunteering to take on the home with the largest workload where all the residents had advanced dementia – and the practice has never looked back. 
“It means we can be proactive,” she says. “Yes, any one of us can go out to any home when there is an acute illness, but each of us can visit the home we are responsible for regularly, build relationships with the staff, get to know the patients and the subtle changes in behaviour that indicate something important is happening and plan care.”
Her practice website2 is packed with useful information and articles on anything from practical advice for cooks in care homes, to end-of-life care, that she and colleagues have developed over the years. 
“This is now an area of my work that I enjoy enormously and that’s important,” she says. “Before it was a real…” she breaks off with a heavy sigh. 
She has also persuaded colleagues across Peterborough to align practices to care homes – a model that has been used successfully in other areas too. 
“When we looked at the situation in Peterborough, we found there were 18 GP practices going into the homes. GPs were visiting all over the city for perhaps one or two residents and some care homes potentially had as many as 60 GPs visiting.” 
Now individual practices look after whole care homes. A year after this alignment there were 125 fewer emergency admissions from care homes – a 27% drop. 
She is concerned, though, that the move to CCGs may have unforeseen consequences for this work. The money that came with the old local enhanced service – under which practices were paid to align with care homes – may not be replaced or may be replaced only for nursing homes. 
“As a practice with 140 beds where quite a proportion are residential home beds, this has quite an impact,” she says. 
In Liverpool, commissioners have tried a different model. Dr Becky Bancroft is a community geriatrician whose post is jointly funded by the Royal Liverpool Hospital and Liverpool community trust. 
Since 2009 she has looked after 3,200 care home residents, supported by a team of community matrons, spending half her time in the hospital and half in care homes. “The community matrons are my case finders,” she says. “About 80% of my referrals come from them and 20% from GPs.” 
The team provides anticipatory care planning that avoids unnecessary admission, especially of people at the end of their lives.
“When we started working this way, a quarter of care home residents died within 24 hours of being admitted to hospital,” she says. “Within 18 months we had reduced that number by 52%.”
Last year, BUPA and the former primary care trust invested £300,000 in a research project to look at the outcomes and patient and family experiences of anticipatory care. It is due to end next summer. 
Elsewhere, CCGs have identified commissioning NHS care in care homes as 
a priority. 
Last year Professor Stephen Singleton, Medical Director of NHS North East, commissioned Dr Elizabeth Kendrick, a GP with a special interest in older people’s care at County Durham and Darlington trust, to look into this locally. A conference with 120 stakeholders uncovered a multitude of problems. 
“There was a disjoint between health and social care, there was difficulty measuring care in care homes, there was difficulty in achieving quality standards and measuring quality, there was a difficulty in assessing whether we were commissioning something that is dignified care,” she says. She could go on.
“Nobody knew what was the best model of care,” she adds. “The idea of one GP, one care home was attractive but there is no real evidence to suggest what might be best.”
Now local CCGs are examining her report in detail and deciding the way forward with commissioning. “The GPs here are very keen,” says Dr Kendrick. “Care homes are perceived to be a key area for improving care.”
Southwark is another area where CCGs are keen to improve the care in care homes but here they are widening their view to include not just the NHS care they provide but also the whole piece by working jointly with the local council.
In September this year, the council drafted a strategy to improve the quality of care in care homes with a wide set of measures. They include beefing up the council’s care home support unit, improving pay rates for care home staff, and improving the quality of NHS care for residents. 
It proposes joint working by GPs, geriatricians and social services to review, for example, admissions of patients from nursing homes to hospital via A&E.
At the time of writing, it was being discussed by the CCG and was due to be signed off by elected members of the council. 
According to Ray Boyce, head of older people’s services at the London Borough of Southwark, this work is very much a joint venture between the CCG, the council and nursing homes. Yes, he says, CCGs have a responsibility for commissioning NHS care in care homes while the council has a different role in safeguarding and ensuring the overall quality of care provided in the homes – but by working together, the two sectors can improve the overall quality of life care home residents and their health and wellbeing.
“This is all of our responsibility,” he says. “We know that there are clear responsibilities and we do not intend to blur them but we need to make sure we are all contributing to improving the lives of care home residents.” 
 1. BGS Commissioning Guidance: High Quality Health Care for Older Care Home Residents. October 2013

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