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Care and contracts

16 January 2012

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Stewart Harrison

Primary Care Services Consultant

Stewart is an independent primary care consultant with 20 years’ experience, working in North London, Middlesex and Hertfordshire. He specialises in finance, HR and IT management issues

GPs provide medical services to patients in nursing and residential homes through either General Medical Services (GMS) or Personal Medical Services (PMS) contracts.(*) Yet practices often underestimate the clinical time involved in looking after the health needs of these residents.

GP clinicians specialising in this area must be fully trained. This means the number of practices prepared to take on the workload in homes is diminishing, just as our increasingly ageing society means that such residents are increasing, and their medical needs have become more complex.

Authorised care homes can be run as part of a group or by a single operator. All homes have to register with the Care Quality Commission (CQC). The recent demise of Southern Cross – the biggest operator of homes in the UK – owing to financial difficulties has again highlighted the complexities and uncertainties in this sector.

GMS services
Under GMS, capitation payments are received by practices in respect of the residents who live in homes, provided the patient is ‘ordinarily resident’ in the UK. The accepted definition of ‘ordinarily resident’ is living in the UK for a settled purpose for a period of at least six months.

Nevertheless, a number of medical services are typically provided by practices to home residents that are not contractually required under GMS. There is also a widespread variation in the attitude of primary care organisations towards the payment of retainers by homes.

Home operators do not always appreciate that some services are not contractually required under GMS and clinicians are not always aware of it. It is not unlawful for practices to charge a fee for providing services to homes. Care home retainer payments to practices can also leave practices open to the charge of being double-paid for the same service. Practice managers should endeavour to become familiar with the subtle nature of any arrangements to make life transparent for all.

GPs are not automatically obliged to visit patients in the home
Potentially this is one of the most difficult areas to negotiate with the home, especially in relation to the impact on Accident and Emergency attendance and emergency admissions at the local hospital.

GPs are not required to visit patients in their own homes if they feel that it is medically unnecessary. This also applies to residents in homes. Staff shortages and/or transport difficulties are not valid reasons for home visits. Any visiting arrangements involving the district nurse should be made in consultation with the GP.

Routine weekly/monthly ‘ward-style’ rounds, arranged by the practice to the home, are designed to avoid the need to transport patients with minor ailments/conditions to the practice.

GPs are not obliged to see additional patients when visiting
There is, perhaps, an unavoidable temptation to add unscheduled appointments to the weekly ward rounds of the GPs. This should not be onerous as long as they are not frequent.

Homes will pass on requests from family members to check on their relatives. Communication with relatives inevitably involve wider matters than solely medical issues and this must be recognised by the GP.

GPs are not required to undertake ‘routine reviews’ of patients
The provision of health checks for patients over the age of 75 was removed from the 2004 GP contract due to the introduction of the Quality and Outcomes Framework’s use of targets within clinical disease domains. The morbidity associated with older people means that any review is likely to be more specific than previously.

GPs are not obliged to make any notes in the patient’s medical records kept by the home, only the surgery’s records
Most primary care medical record systems allow clinical users to access patient records from a laptop via a secure internet connection at the home. Medical consultations take place and entries are made in ‘real time’. Prescriptions can also be made electronically to local pharmacies.

GPs are not required to make entries on or annotate home prescription (MAR) sheets, only to issue individual FP 10 forms
The GP clinician continues to be involved in the preparation, supervision and checking of the Medication Administration Record (MAR) sheets, annotating where an alteration is necessary. This reduces the need to issue separate FP10 prescriptions separately, reducing unnecessary duplication.

GPs are not obliged to advise homes on the
management of patients with mobility problems
Discussions with other health providers, such as physiotherapists, can be more appropriate in instances such as these.

GPs are not obliged to advise homes on the safe management and control of medicines
GPs should deal with individual, resident-specific issues. Any ad hoc advice on the general safe-keeping of medicines falls outside this.

GPs are not obliged to advise homes on infection control matters
Strictly speaking, this type of general advice falls outside the terms of GMS services, unless it is resident-specific.

Service level agreements (SLAs)
The objectives of an SLA between the practice and the home are to set out the services to be provided by the practice to the home. Two types of service are provided by practices for residents: essential services and enhanced services.

Essential services are provided under the NHS and are non-chargeable. Here there is no difference between a GMS and a PMS contract. Practices are obliged to provide care and treatment to those on their list who are, or believe they are, ill during the core hours of 8am and 6.30pm during the week.

This is unaffected by extended hours arrangements. Most practices have opted out of out-of-hours provision. This currently means that between 6.30pm-8am and at weekends the responsibility for patients lies with the local primary care organisation – though this is likely to be clinical commissioning groups by 2013 – who will commission a provider. This will also include bank holiday cover.

Enhanced services are provided under agreement between the home and the practice for an annual fee. This would, however, exclude charging for flu immunisations as this is provided free-of-charge for all patients over the age of 65.

See Box 1 for a breakdown of information to be included in an SLA. Caroline Peters-O’Dwyer, Practice Manager at Oak Lodge Medical Centre, Middlesex, says such a service level agreement provides “a clear understanding of the relationship and responsibilities between both parties, alongside regular contact between the operator and the practice”.


Financial issues
GMS enhanced payments/PMS contract objectives
Practices are obliged to register all patients in their defined catchment area if their patient list size is open. This includes residents of homes, irrespective of whether the home has a relationship with the practice.

There are no national or directed enhanced services for homes under GMS in England. However, a number of primary care trusts have introduced local enhanced services (LESs). Some of these have continued despite the ongoing reorganisation of primary care structures. These LESs are generally arranged with practices already dealing with homes but may also be available to practices with only one or two patients in a particular home and not previously paid a separate retainer by the home operator.

Typical examples of LESs for the care and provision of older people in homes have concentrated on increasing quality using target achievement, such as reducing emergency admissions to hospitals. In these cases, practices would consider forgoing an annual retainer because their extra work is being rewarded via the NHS and they thereby avoid any charge of duplicated payments for this ‘enhanced service provision’.

Another route is using PMS contracts to reflect the unfunded care, including objectives relating to the care of older people (although these may have been removed/modified since the inception of the local negotiated contract).

A good example of this type of PMS contract continues to be commissioned by NHS Wandsworth and provided by the Balham Park Surgery to the 200-bed Nightingale House in South London. Again, this has removed the need for the home to pay a retainer.

Natalie Goldsmid-Whyte, Managing Partner of Balham Park Surgery, said: “The PMS contract has worked very well for both the practice and the residents over the last six years and we hope it will continue in the future.”

Standard retainers
In circumstances where no enhanced services are available, annual fees can and often are negotiated by the practice. The British Medical Association (BMA) is unable to publish any suggested pay rates because the Office of Fair Trading has previously ruled that it is up to individuals to negotiate fees themselves. This has meant wide variations in the level of retainers.


Charging structures
Practices need to ensure that any negotiated fee accurately reflects the actual costs of looking after home residents outside the GMS/PMS contract. This must also take into account all NHS fees associated with the home, such as capitation fees, enhanced services and QOF payments.

For example, a clinician might do a weekly ‘ward round’ at the home lasting several hours. This clinical time must be replaced internally, in which case there is an ‘opportunity cost’, or externally with a locum. The hourly cost of a locum in a city would be between £70 and £80 per hour. This is not reimbursed directly under the NHS payment tariffs.

Fees agreed with home owners should include a provision for an annual increase in chargeable fees (eg, RPI or 3% – whichever is lower). Nevertheless, the majority of resident funding is received from local authorities currently experiencing severe financial pressure, so practices may choose not to implement increases, or agree a lower increase. This can be discussed with the home on an annual basis.

Alternatively, if the level of fees cannot be increased to reflect the non-essential services to be carried out routinely, discussions about reducing the amount of time spent by the clinician on enhanced services can be fruitful. Workload should be reviewed with respect to the number of residents, so that chargeable fees could be based on demand or a per patient charge made based on tier levels/bands. 

*Increasingly, the distinction between the terms ‘nursing’ and ‘residential’ has become blurred – for the purposes of this article, the term ‘homes’ is used to cover both.