Monday 8 February 2016

GP's and care homes - A relationship under pressure

When I first read that GP's were proposing to alter their current arrangements for visiting care homes, I wasn't surprised. Back when my dad was living in care homes, GP's were already under considerable pressure. I know that one of my dad's care providers had to pay for GP visits, and even then some of the younger GP's in the practice were reluctant to visit the home when residents were quite poorly.

By contrast, the senior GP in the practice visited regularly, had a lovely bedside manner (he was a tall man and would kneel on the floor so that he was at dad's eye level to chat to him), and even attended one of our relatives meetings to discuss providing healthcare for the residents and long-term planning.

I recall arguing with one particular young female GP about whether dad had any 'quality of life' and whether or not he should be given antibiotics for a chest infection (in my view he had quality of life, and he got the antibiotics in the end, which cleared his infection). I also remember possibly the worst experience I'd ever had with a doctor, when an out-of-hours GP visited late one Saturday evening and refused to even touch dad to examine him.

That experience with the out-of-hours GP is perhaps a glimpse into the future whereby the services of the local GP practice could, potentially, be replaced with privately contracted GP's who may not provide the same level of continuity or personalisation. It is not a scenario I welcome or look forward to in any shape or form.

It is my view that a regularly visiting, local GP is absolutely vital to the provision of high quality care in care homes. A good local GP will get to know their patients, pick up on illnesses and conditions quickly, keep medication under review, and provide a useful external oversight role in relation to how well the care home are caring for their residents.

I appreciate that general practice is under severe, unprecedented pressure and needs additional funding, but there is no suggestion that care for other sectors of society needs a separate contractual arrangement with the government and for that reason this feels like victimisation. The argument from GP representatives is that care homes are becoming extensions of hospital wards, and the needs of the people living in them are increasingly unmanageable for local GP's within the current structure and funding of general practice.

It is undoubtedly true that care homes have changed from what they were. Traditionally a residential home accommodated people of relative ability who just needed a bit of assistance with personal care, low level health needs and some companionship, while nursing homes offered the same but with a registered nurse on duty to support people with more extensive health needs, medications etc.

However as people live longer, have more complex long-term conditions, and the NHS is under pressure to discharge people back into the community, it's fair to say that a lot of residential homes have become more like the traditional nursing home model, and the nursing homes of today have morphed into mock hospital wards. But that isn't the fault of the people living there. They aren't in hospital, so don't have access to hospital doctors - the only way they can have care from a doctor is from a GP practice.

By all means GP's need to raise their concerns with the government and seek additional support to continue to provide the care that people in care homes need, but if the government don't agree to a separate contractual agreement to cover GP care in care homes, it would be wholly wrong for care for this sector of society to be withdrawn. People in care homes rarely ask to be living there, and they are as entitled to care from their local family doctor as anyone else. For these individuals, their care home is their home - they shouldn't be penalised for living in a care home by losing their local GP service.

I appreciate that GP practices work best when patients visit them rather than when GP's have to conduct home visits, but if the patient can't get to the surgery then the GP needs to go to them, regardless of where they live. Yes, care homes may have the option of buying in private GP care (if indeed they could afford it, which is highly questionable for many), but from the perspective of residents that isn't the same as having your own local GP who gets to know you and your needs.

If new contractual arrangements with GP's aren't forthcoming, I fear that individuals with dementia may be hit the hardest. For this group of people continuity of care is vital. A good local GP who understands the person - and understands dementia - can make a huge difference to the life of an individual with dementia, as we saw first hand with that senior GP whose interactions with dad were a real joy to see.

Families also rely on good local GP's to help and advise them on the different conditions their loved one has, the various medications they are (or could) be taking, and when discussions need to be had in relation to long-term planning and end-of-life care. Keeping people in their care home for end-of-life care is infinitely preferable to being in hospital, but good local GP support is vital to facilitate that.

I hope that GP's and the government will manage to find a mutually agreeable compromise, and that this issue doesn't escalate in the way the junior doctors contract has. Without such a compromise the people who suffer most will, yet again, be some of the most vulnerable in society, a fact that shames us all.

Until next time...
Beth x

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Please note: This blog was modified on 12 February 2016 due to information received.


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  2. Beth - You raise many good points here. I see the situation from both sides being the daughter of someone with dementia and a GP. The issue, as you rightly say is that people in care homes deserve better routine medical care than they are currently getting. The care home that my practice covers often has residents who have moved from quite a distance due to shortage of beds so they become 'our' patients but we don't know them or their families at all and the concept of 'local GP' is immediately lost. The other issue is that visits to the care home are often squeezed in to increasingly narrow time slots (what used to be know as lunch) and there have been many occasions where my colleagues and I have wanted to spend a considerable amount of time getting to know the patient and their often complex needs but we have to see 6 other residents as well as the other home visits and get back in time for afternoon surgery. As a result those who need the most input are shortchanged. This is not a situation GPs are comfortable with which is why the motion was raised at the GP conference a couple of weeks ago. There has been some work from the British Geriatric Society looking into properly resourced care for nursing / care homes - GPs with a special interest, specialist nursing teams, community geriatricians on hand for advice etc - this would seem to be a good option but only if it is funded correctly. The way that this issue has been reported in the media is 'GPs wash their hands of troublesome care home patients whilst they head off to the golf course etc etc' but the reality is that GPs are not happy with the level of care they can safely provide at the moment. This is true of all of our patients but particularly this most vulnerable group. Something does need to change.