General Practice at the coalface of care home medicine
In the context of the King’s Fund ‘Enhanced health in care homes event’, Dr Malcolm Jones, a GP and South Clinical Locality Lead and Primary Care Transformation Lead writes on the growing pressures on general practice and touches on the ‘thorny’ subject of retainers paid to general practices by care homes.
When I was asked to write a short piece for the British Geriatrics Society about a GP’s perspective on care homes, I was genuinely thrilled. Yes, that was partly an ego thing but more than anything, the issue of how primary care best looks after this vulnerable population of patients is an issue close to my heart, both as a clinician and as a commissioner.
My practice is in a small market town in Buckinghamshire. We have a considerably higher than national average over 65 population and about 1 per cent of our practice population is in residential care or a nursing home. In fact, one of the biggest residential homes in the county was opened a mere three minutes walk from the practice about six years ago. The impact that has had on my practice, in terms of demand and challenge, cannot be understated. My own observation over the years is that those patients in residential care are medically every bit as complex as those in nursing care. It was therefore something of an ‘Hallelujah’ moment when I heard Professor David Oliver state recently at a King’s Fund event (Enhanced Health in Care Homes) that, from his point of view, there is no difference between nursing home patients and residential home patients. As it happens, the nursing homes my practice serves pay the practice a retainer – (a thorny topic, I know) – enabling the practice to fund a GP to spend a session each week at the nursing home. This undoubtedly enables a more proactive model of care at those nursing homes. The converse is true of our local, large residential home, where care is provided on a much more reactive basis.
Moral arguments about payments of retainers to general practice aside, there is no doubt that general practice is becoming an ever busier environment. That growth in activity isn’t just a jaded anecdote from cynical GPs but a well-documented phenomenon (see the Kings Fund paper on securing the future of general practice). When I first started general practice just over ten years ago, although busy, there was somehow time for reflection and one could count on a quiet day every now and then. Nowadays I never have quiet days. In fact, I often don’t have lunch, such are the demands on my time. In other words, for a practice to release a GP from surgery to do a round at a care home, is often not feasible - the practice based grindstone is just too busy and all-consuming.
I have an unpleasant and ongoing niggle that the care I provide for my care home patients isn’t as good as it should be. It’s not proactive. It’s done with terrible constraints on time. When I see the patients, I don’t have access to their medical records. When I want to discuss complex issues with family, they’re not around. I constantly feel the complexity and frailty of some of my patients challenges the boundaries of my competence. Indeed, I reflect on my medical training and I don’t think any of it really prepared me for the challenges of care homes. I must confess, when I see a request for clinical input from our care homes on my daily workflow, my heart sinks and my agitation levels rise. I know I am not alone in experiencing those feelings.
There was tremendous energy at The King’s Fund Enhanced health in care homes event and when I can step outside the environment of general practice and into the world of commissioning, I feel optimism [albeit guarded] that in the future, there will be a different and better primary care offering to care home patients. A future with good care planning at its heart, a proactive model of care, a truly multi-disciplinary team working approach, smart use of technology….and above all, better outcomes for this patient group.