ࡱ> RTQy &bjbjEE .4'' #####7778o {,74t3333333$x583#3##3R##33R2O3073o33041388<O38#O3 3348 :  LMC POSITION PAPER ON GP SERVICES TO NURSING HOMES 1.0 Summary GPs provide medical input to most nursing homes through their GMS or PMS contracts. However, this is a limited service and in the context of the development of intermediate care may need to be reviewed. 2.0 Background The profile of patients in nursing homes has altered radically in the last 20 years. With the closure of long stay NHS beds, the ageing population, and increasing life extension with its associated morbidity, the medical needs of nursing home residents have changed significantly. Nursing home residents contribute significantly to a GPs workload, but the basic GP contract does not provide for a higher level of care for this group of patients. However, changes in the registration and inspection arrangements for nursing homes have led to a higher level of professional nurse input and extra expectations of the GPs NHS provision. This paper considers some of the constraints on this service and suggests some options for improving the quality of care. 3.0 Medical Input Under GMS Although the new GP contract (GMS2) proposes a higher capitation payment for nursing home residents, this is purely to acknowledge the GMS demands that this needy group makes. It is not to fund enhanced or supplementary services. Many GPs provide services to nursing homes that are strictly outside of GMS and the new contract arrangements may bring these into sharper focus. In particular it should be recognised that some services offered by GPs are not contractually required. GPs are not obliged to make any notes in nursing home records. The GPs terms of service requirement is to make records in the NHS clinical notes held by the practice (whether electronic or paper) and there is no requirement under the current or new contracts for the doctor to use the nursing home records at all GPs are not required to make entries on or annotate nursing home prescription (MAR) sheets. GPs are required to issue prescriptions on the NHS FP10 forms provided to them. It is up to the nursing home to make arrangements for the collection of these from the surgery and to ensure that the relevant information is transferred to appropriate documentation within the nursing home. 3.3 GPs are not obliged to visit nursing home patients automatically. Traditionally most nursing home patients are seen at their place of residence. GMS2 clarifies the GPs terms of service requirements about visiting, and it emphasises that during the daytime, as well as during the out of hours period, this is based on clinical need and not convenience. Therefore there will be an increasing expectation that patients who are not completely bed bound will be brought to the doctor when a medical consultation is required. 3.4 GPs are not required to undertake 'routine' reviews of patients. Under GMS2 the requirement to offer a health check to all over 75 year olds will be removed from the GP contract. The provision of services will be based on clinical need. Whilst it is good practice to review the medication of patients on long term medication there will be no absolute requirement that all patients need to be reviewed at particular intervals. GPs are not obliged to see additional patients when visiting. The GP Terms of Service requirement is clear - only patients who require a visit under this need to be seen at their place or residence. Other patients who require attention should be asked to attend surgery where, for example, the medical records will be available. 4.0 Managing the GP/Nursing Home relationship 4.1 Registration of Patients In many localities, patients in a given nursing home may be registered with a number of different practices. Apart from the single benefit of offering patient choice, this has a number of disadvantages. First, there are increasing opportunities for errors in the prescribing/dispensing triangle between practice, pharmacy and nursing home as there may need to be different arrangements for each patient. Secondly, where patients require medical attention it may mean either that the nursing home is taking residents to a number of different practices, or conversely several different doctors may end up visiting the same nursing home in the course of the day. (This is somewhat analogous to the position that arose when individual GP practices were responsible for out of hours visits and which was largely resolved by the introduction of GP co-operatives). Finally, working relationships between the nursing home and practice are likely to be better and stronger if only a limited number of individuals are involved. The impact of Intermediate Care It is clear that nursing home beds within the private sector will increasingly be regarded as part of intermediate care. Patients are likely to be discharged early from hospital into either individual nursing care beds, or into those contracted to a PCT which may have put in supplementary funding or resources. Early discharge is a particular problem area as these patients may well have needs that are definitely outside GMS provision. Furthermore, the complexity of the medical cases in nursing homes maybe outside the skill range of most GPs - particularly in specialist areas such as PEG feeding and the management of dementia. There is also the difficulty in dividing nursing services between those which the home itself should provide and those which are the responsibility of the PCT, or even an outreach team from the relevant acute trust. A particular contentious example maybe the management of pressure sores where expensive equipment maybe of benefit. Visits to nursing home are a significant component of GP out of hours work which will largely need to be continued when PCTs assume responsibility for this service sometime in 2004. 5.0 Options for Extending Patients Access to Medical Care 5.1 Private Contract Between Nursing Homes and Practices A number of nursing homes and practices have bilateral agreements for the provision of a higher level of medical input then specified under GMS. Typically this includes a routine periodic visit to the nursing home to avoid the need for transporting patients with minor conditions to the surgery, and also the involvement of the GPs in preparing, supervising and checking medication sheets and also in maintaining a clinical record at the home. We anticipate that arrangements of this sort may become more widespread Local Enhanced Services PCTs are already able to commission additional services from GPs for nursing home patients under paragraph 23 of the 1977 NHS Act. Local Development Schemes are established in some parts of the country to do this and it is likely that Somerset PCTs may wish to increase the level of clinical input into some nursing homes (especially those in which they have contracted extra care beds).If GP practices are to be the providers, then the model of a local enhanced service would be appropriate. 5.3 PCT Provider Medical Input In some localities community hospital patients are managed in the main by a sub-consultant grade specialist or a GP with a special interest (GPwSI) employed on a sessional basis by the PCT to do this work. A similar model could be applied to nursing homes. This would have the advantage of providing a consistent level of care and supervision that would complement basic GMS treatment provided by GPs. 6.0 Conclusion The service currently provided by GPs to nursing home patients is limited by the terms of their contracts. The introduction of GMS2 is likely to make practices more aware of this, The demands of the current change programme on primary care services mean that any developments or enhancements of medical input to nursing homes will have to be funded from outside the existing GMS resource. Dr Harry Yoxall July 2003     78D  !  7 X\Y9jm> =]W_!w!g##%*%&&&&&&&&&& hn5 hn6hn5CJH* hn>*CJ hn5CJ hnCJ hn5CJhnjhnU578D  !   7 \XYd^8d^8 $ & F `a$$^a$$^a$  d^$ a$$a$$a$$a$ F&&#$/9 > $ & F <a$ 88d<^8 $ 8`a$$ a$ & F dd^ $ 8a$$a$$ 8h^h`a$d8d^8<=]*+W]!_!{ $ h8a$$ h88^8a$ $ 8^a$$ a$ $ hh^ha$ $ 88^8a$$ & F 88^8`a$$ ha$ $ & F a$$ & F <a$_!w!f#g##%%*%&&&&&&&&&&&$ 8^a$ $ 8a$ $ 8^a$ $ h8a$$ h88^8a$$ & F h88^8`a$&&&&&& $ h8a$,&P . 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M?'RT0E;C p\oq W2rC<5[\~;Gq] 1Cb n!@x@UnknownG* Times New Roman5Symbol3. * Arial?= * Courier New;WingdingsA BCambria Math"Ah&&w5757!0d2HX $P!2!xx.Position Paper on GP Services to Nursing HomesLMC Dr Anne Hicks<         Oh+'0 4@ ` l x 0Position Paper on GP Services to Nursing HomesLMC Normal.dotmDr Anne Hicks2Microsoft Office Word@@O#R@*ꗍ@*ꗍ5՜.+,00 hp  Somerset Health Authority7 /Position Paper on GP Services to Nursing Homes Title  !"#%&'()*+,-./0123456789:;<=>?@BCDEFGHJKLMNOPSRoot Entry F-UData 1Table$8WordDocument.4SummaryInformation(ADocumentSummaryInformation8ICompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q