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Care Standards Update

Edition No. 12 February 2002

FREE NURSING CARE - GP SERVICES

Introduction

I find it intriguing that the Government continue to issue guidance with regard to GP services and nursing homes. This latest set of guidance is published on the Joint Unit website at the Department of Health. It is presented as a series of questions and answers addressing the more common issues.

Guide to Care Home Managers on GP Services for Residents

Background

The NHS is an organisation made up of different groups engaged in planning or providing health care. GPs are not NHS employees but are self employed professionals who have a contract with the NHS to provide personal medical services free to the patients who are registered with them. It can sometimes be unclear to those without an intimate knowledge of the NHS where the line is drawn between what a GP provides as part of the NHS contract and what constitutes private practice.

This guide has been put together to explain the distinction and to assist care home managers in knowing how best to contribute to the planning and providing of healthcare to their residents.

Q: How can a person who lives in a residential care home consult a GP ?

A: All residents of care homes, both residential and nursing, should be registered with a local GP so that they can have access to the full range of NHS services which are, and must be free for patients. Some residents may wish to remain registered with a GP who provided services prior to their admission to the home. This is acceptable as long as the GP is local and willing to continue providing services. A number of local GPs may provide services to residents in the home.

Q: The local practice says their list is full. How do we get our residents registered with a GP in these cases ?

A: Everyone has the right to be treated by a doctor, although it may not be possible for patients to register with the GP of their choice. Health authorities have powers to assign patients to a doctor if they have difficulty in finding one. It is important to tell your health authority if care home residents are having difficulty finding a GP because it will help the health authority plan for the provision of health care for all the population in that area.

Q: We approached the nearest GP practice to ask for our residents to be registered and we were told we would have to pay a retainer ? Is this right ?

A: All patients in nursing and residential care homes can expect the full range of personal medical services and the same rights of access to primary care as any other patient group. And, as for everyone else, this service is free at the point of delivery. GPs should not, for example, charge residents of care homes for flu immunisation jabs because immunisation of people with asthma, diabetes and all people over the age of 65 is provided by the NHS.

Q: Are there any instances where a GP can charge a fee for providing services to a care home ?

A: A GP may enter into arrangements to provide professional services to any body or institution, including nursing or residential care homes. It is, for example, not unusual for a nursing or residential care home to contract for the services of a doctor for services that the NHS does not normally need to provide to patients on an individual basis.

Examples of service which are not considered to be those which GPs offer as part of their NHS contract are the safe management and control of medicines, occupational health of the staff of the home, management of patients with problems of mobility or on infection control. These are different from individual, direct patient services, for which GPs should not be charging their registered patients.

The British Medical Association's general Medical Services Committee has published guidance for doctors on the operation of retainer fees. Provision of Services to Registered Nursing and Residential Homes: Guidance for GPs, (BMA 1996). It should be clear to residents which services are provided under the GP's NHS contract and which are additional and might need to be paid for privately.

Q: Older people take up more of doctors' time and often require costly treatment. Aren't they at greater risk of being removed from doctors' lists as a result ?

A: GPs have the right to remove any patient from their lists, just as any patient has the right to leave the list. However, removal should only be considered as a last resort, when the doctor / patient relationship has irretrievably broken down. The General Medical Council considers it unacceptable for a doctor to remove a patient solely because of his or her age.

Q: Are there other ways in which GPs can provide healthcare to residents of care homes ? For example, I've heard of Personal Medical Services Pilots.

A: Patients still need to be registered with a GP, even if that GP is a member of a PMS Pilot. GPs in PMS pilots provide the same services free at the point of delivery as GMS doctors. The PMS core contract provides a framework which ensures the continuation of services to patients, but is built upon locally to reflect local needs and is therefore more flexible and sensitive to the needs of the particular population those GPs serve.

GPs who work under the GMS contract can also receive incentives from the health authority, Primary Care Trust or group to provide specially tailored health care to people in residential care homes. These are called Local Development schemes and reflect the additional effort needed to care for people who may have special needs.

Q: How can the managers of a care home influence the provision of health care to their residents ?

A: The first port of call is the health authority which is responsible for ensuring that everyone in the area has access to a GP. The health authority monitors the performance of primary care organisations against the objectives laid down in the health authority health improvement programme.

Primary Care Groups and Primary Care Trusts bring together doctors, nurses, community practitioners, social workers and lay people to plan and commission health care for their populations. Primary Care Trusts not only commission health care but also provide community services.

Care home managers should develop relationships with PCTs and become advocates for their residents. In this way you will have a chance to voice concerns and hop ensure that your residents get good access to health care.

Q: Where can I get further help ?

A: If the health authority or PCT is unable to help, your regional office of the Department of Health can provide further advice and guidance. Each regional office has a lead for primary care. These are listed below.

Finally, it is worth noting that the BMA's own guidance to GPs on charges to patients is as follows:

AGPs contemplating making any charge to their NHS patients must ensure they comply with the strict requirements of the terms of service and that they act in accordance with the ethical duty not to use, or appear to use, their position of trust to influence patients to follow a particular course of action which may offer the doctor some advantage, financial or otherwise.

GPs must bear in mind that their action, in making a charge, could be alleged to involve accepting remuneration for treatment, which might be a breach of the terms of service, or breach of the ethical duty not to abuse their position of trust. The consequences could be a complaint to the FHSA, with a possible finding of a breach of the terms of service, possibly a complaint to the GMC's professional conduct committee or, ultimately, criminal proceedings.

Conclusion

If members have any difficulties with regard to the provision of GP services to their patients they should contact head office.