Patients in Care Homes, Deaths in Care Homes and GP responsibilities.
LMCs often receive questions from practices about the provision of medical services for patients in nursing and residential homes. Most care home patients will fall within the remit of standard primary medical services contracts but sometimes, with the rise in number of complicated patients being cared for in the community, expectations to provide extra care may arise. The general principle is that GPs should never be forced to work outside their clinical competence. The GPC guidance “How to identify when services provided to care homes may be deemed as essential or additional” (BMA 2012) deals mostly with demands for services in institutions registered with the CQC as hospitals but does have something to say about some patients in care homes receiving continuing nursing care who may have complex needs.
“GPs should not allow themselves to feel morally blackmailed or contractually threatened to provide services beyond their level of competence. In providing care GPs must always:
- recognise and work within the limits of their professional competence
- consult colleagues if they have any concerns (eg LMC Officers, colleagues in the practice, MDO Advisors) · be competent when making diagnoses and when giving or arranging treatment
- ensure they are properly indemnified for the services provided
Patients receiving NHS continuing care will often need an increased level of care such as the input of a specialist or GP with a Special Interest. Institutions and PCOs [i.e. CCGs] should be made aware that asking GPs to provide services outside their competency can put patients at risk and that failing to provide proper care for patients could lead to enquiries by the relevant regulatory bodies and referrals to the GMC.”
Services provided outside standard GMS or PMS contracts should be contracted for separately by the care home but practices, should they be approached in this regard, are advised to make sure about what can and cannot be charged for privately. One source of information is the BMA Focus on Private Practice 2004 (updated 2010).
Despite most care home patients falling within the remit of standard primary medical services contracts questions often arise in the course of medical management and these often concern completing nursing home records, prescribing, do not attempt resuscitation orders and expected deaths in care homes.
Records: there is no contractual obligation to complete care home records nor to follow up verbal advice with written confirmation, often requested by fax. It is the care home staff’s responsibility to keep accurate records about what has been done and what advice has been received. This is true despite the guidance sometimes provided to care homes by some CQC inspectors. However, GPs may well wish to make written confirmation to make sure that complicated instructions are followed.
Prescribing: patients in care homes have the same right to obtain medication from their own choice of pharmacy or dispensing practice as any other registered patient. Nowadays many care homes have arrangements with a single pharmacy contractor which may not be a local firm. If the patient or his or her family or representative is unhappy with this arrangement then they are entitled to continue to receive pharmacy services from their preferred contractor. This is, therefore, primarily a matter between the patient and the care home but one in which GPs may well become involved.
No not attempt resuscitation orders: from time-to-time care homes sometimes report that some ambulance trust staff will not accept DNAR forms that are copies of an original. The SWASFT has confirmed to the LMC that copies of properly completed DNAR forms are valid.
Expected deaths: Under the law there is no obligation for GPs to be required to confirm death nor are GPs legally required to see the body in order to certify death. Of course, GPs are required to see a body before completing a cremation certificate. The CQC advises care homes that “any competent adult” can confirm an expected death and that there is no need to call a GP in this case. The deceased’s registered GP should be informed as soon as possible and, although there is no legal requirement to attend, if a doctor chooses to do so, this will be as soon as practicable as living patients must receive priority.
Expected deaths that occur in the evening or a weekends and bank holidays should be reported to the out-of-hours GP service by the care home but, as any competent person can confirm death and as the OOH GP cannot certify the death, there is no need for him or her to attend. The OOH GP can advise the care home staff to contact a local undertaker to remove the body and inform the registered GP of the death on the next working day.
Care home staff should also be aware that if an undertaker who is not local is engaged, usually to be nearer family who live away, the registered GP cannot be expected to travel outside the practice area in order to complete cremation forms. Funeral directors are aware of this and may have reciprocal arrangements with colleagues.
BCM with acknowledgement to Bedfordshire & Hertfordshire and Wessex LMCs.