General practitioner Practice manager GP practices

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NHS primary care medical services in institutions and care homes in the UK

NHS GP practices are increasingly being asked to provide primary care medical services to patients residing in institutions or care homes where the types of services expected may not fall under their contractual obligations; accordingly the BMA is receiving increased queries from practices and LMCs as to the requirements to register and provide services to such patients.

This guidance outlines the responsibilities of practices in deciding whether they need to register such patients, and if so, what services they are required to provide.  

When GPs provide services to patients residing in institutions and care homes, there is often confusion over who is clinically responsible for their care, which may present a risk to patient safety. GPs must not be forced to accept clinical responsibility for aspects of the care of patients in secondary care institutions, nor for those in any setting where the clinical needs of the patient fall outside the normal skills and contractual requirements of GPs.

Care for patients in intermediate care can also present problems caused by a lack of clarity about the professional responsibility of GPs. This is important in the light of the trend to discharge relatively high-dependency patients from hospitals to other institutions, with GPs increasingly being asked to provide care which is likely to be beyond that which most GPs are trained, or contracted, to provide.

With this in mind, and following legal advice, this guidance outlines the responsibilities of practices in deciding whether they need to register such patients, and if so, what services they are required to provide. References to the CQC and NHS England should be read as including the relevant bodies in the four nations (e.g. Health Inspectorate Wales, NHS Scotland etc.) and members should also ensure they refer to the relevant regulations for their jurisdiction.

 

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If you have any queries or concerns, please contact [email protected] or your LMC.

 

Guidance for GP practices

  • Registration of hospital inpatients

    There are limited grounds by which a practice may refuse to register a patient who is a (temporary or permanent) resident of an institution within the practice boundary, under Part 2 paragraph 21 of Schedule 3 of the GMS regulations (2015).

    Decisions need to be taken on a case by case basis, taking into consideration the needs of the patient, the services provided by the institution and any other commissioned services that may be available to the patient.

    If a hospital is providing a full range of medical services e.g. acute care and is not a single speciality (e.g. a psychiatric hospital), then it is very likely the practice will have reasonable grounds to refuse registration.

    If adequate primary medical services are provided by the institution (as commissioned by the Commissioner) or if alternative commissioned arrangements are available to the patient, then it may not be necessary for a practice to register a patient who is resident in that institution, but again any decision needs to be taken on a case by case basis.

    However, where it is known to the practice (remembering that the assessment and decision rests with the GP) that adequate primary medical services are not provided, current legal advice suggests there are unlikely to be reasonable grounds for refusing to register such patients.

  • Provision of services

    Regulation 17 (5) (b) of the Regulations provides contractors with discretion (which must be exercised reasonably) to decide the scope of the treatment or investigations that are necessary or appropriate; but again a decision must be taken for each individual case. The fact that certain services may be provided within the institution is a factor in deciding the extent of any supplemental services which it is necessary or appropriate for the GP to provide.

    The view of GPC, based on our legal advice, is that GPs are entitled to refuse to provide care of a kind which the patient already receives or can receive from the institution where they reside; or that would be beyond the scope of normal primary medical services as defined by the GMS contract.

  • Obligation to carry out a visit

    If a GP is requested to carry out a visit to an institution to provide services to a registered patient, a clinical decision should be taken on a case by case basis in the same way as any other registered patient would be assessed for a home visit.

    Under the GMS Regulations, where in the reasonable opinion of the contractor attendance outside of practice premises is required due to the medical condition of the patient, then primary care services must be provided in the most appropriate place. Therefore a request to visit a patient in a psychiatric institution under the schedule will not be appropriate unless the medical condition of the patient requires it.

    The fact a patient was detained under the Mental Health Act, lack of staff or lack of transport would not be factors to consider if such a request was made.

  • Indicators of whether GPs are responsible for patient care

    When assessing institutions to determine who is responsible for patients, it is appropriate to consider several points which will help indicate whether GPs should be providing services:

    • is there a consultant or other non-primary care doctor with clinical responsibility for the patients or residents?
    • does any consultant or other hospital doctor act for the patients/residents, and is this at the GP's sole invitation?
    • what are the historical care arrangements?
    • are there often instances where the level of care required is above that which would normally be provided by GPs?

    GPs are likely to be responsible for patient care if:

    • the residents fall into the practice's geographical area and
    • the institution is registered as a care home by the Care Quality Commission (CQC) and is not registered as providing hospital services (in England).

    These characteristics indicate that GPs may be responsible but they need not all be present, nor is this an exhaustive list. Moreover, even if these points apply, the GP may not be responsible if other factors outweigh these characteristics.

    Even where GPs are required to take responsibility for residents or patients, there is no requirement to provide any services beyond those set out in the GP’s primary care contract and GPs should decline to work outside their normal clinical remit.

    GPs are reminded that the definition of essential services in the GMS/PMS regulations refers to services being provided in a manner that is determined by the practice and are "necessary and appropriate". If a GP is working outside their expertise and training they put patients at risk as well as their own registration.

     

    GPs are unlikely to be responsible for patient care if:

    • the institution is registered with the CQC as a hospital (in England)
    • the institution provides a full range of medical services e.g. an acute hospitals setting, rather than being a single specialty or psychiatric institution

    GPs should not be responsible for clinical care for patients that is routinely provided by secondary care professionals who are NOT:

    • directly clinically responsible to the GP and
    • directly managerially responsible to the GP and
    • acting for the patient solely at the GP's invitation

     

  • Providing primary care services to patients in secondary care institutions

    GPs need to be aware that some services simply do not fall within the normal competencies of the average GP and should be provided only by a doctor with the appropriate specialist skills and training.

    GPs who are being pressured into providing care in hospitals or are not clear whether an institution is a secondary care establishment and are unclear in respect of their responsibilities for both patient registration and the provision of care should contact their LMC and their medical defence body for advice.

    GPs should also raise concerns with the CQC (in England) over the care in any institution should they feel that safe and appropriate medical arrangements are not being adequately commissioned or provided and are putting patients at risk.

     

  • Providing care to patients in non-hospital institutions or care homes

    The provision of services beyond those covered by the GMS contract or PMS agreement, or beyond the clinical skills of the doctor, cannot be forced upon a contractor. If a GP determines that such a service or assessment is required, a referral to a specialist service should be made.

    Practices that are providing care to residential patients or to patients in intermediate or continuing care institutions should ensure that the level of service required by the institution is not greater than that defined as essential services. If practices are concerned, they should raise the issue with their commissioner and LMC. If this is the case, then on an entirely voluntary basis, the practice may seek to enter into a contractual arrangement over and above the normal GMS/PMS one through negotiations with their commissioner.

    Practices may also enter into private arrangements to provide administrative services to institutions, for example regular ward rounds, completion of institution medical records and drug charts, providing advice to the institution management etc. but must not charge for any services which would constitute the provision of treatment to individual registered patients.

    GPs should not allow themselves to be coerced or contractually threatened to provide services beyond their contractual obligations or the level of primary medical services they normally provide.

    In providing care GPs must always:

    • recognise and work within the limits of their professional competence
    • consult colleagues if they have any concerns (e.g. LMC Officers, colleagues in practice, MDO advisors)
    • be competent when making diagnoses and when giving or arranging treatment, this includes requests to prescribe medication that is out of their usual clinical experience
    • ensure they are properly indemnified for the services provided
    • consider the case for raising any concerns with their CCG, NHS England or the CQC

    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 commissioners 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.