GP Contract Enhanced Services Primary Care Networks

Delivering the Enhanced Health in Care Homes service – a collaboration of three coastal Networks

GPs Dr Katharine Bhatt and Dr Trevor Avis describe how three Primary Care Networks (PCNs) in their coastal area are adapting their established collaborative Care Home Visiting Service to deliver the new Network DES Enhanced Health in Care Homes service at scale.


  • Three PCNs: Baywide, Paignton and Brixham, Torquay
  • Number of GP practices: 10
  • Total population: 150,000 patients in three coastal towns covering 25 square miles
  • Care home population: Over 2,100 residents in nearly 100 homes – nursing, residential, mental health and learning disability

Torbay has one of the highest ratios of care home beds per head of the population in the UK; however, these are dispersed over a relatively small geographical area.

Our team created an innovative and collaborative service at scale to fulfil the medical needs of care home residents. This began as a collaborative pilot providing early visiting to the busiest homes during the peak winter weeks in 2017-2018. The pilot’s impact on unplanned admissions, practice home visit demand and end of life care enabled the creation of the Torbay Care Home Visiting Service (TCHVS) which has now been running since November 2018.  We have operated as an acute, proactive and early visiting service for the 26 homes who are the highest users of Primary and Urgent Care services across all three PCNs, funded by Transformation at Scale monies from GPFV funding, then extended by Winter Pressures and Better Care Fund support.

Our outcome data show reduced unplanned admissions, hospital bed days, individual practice workload and significantly reduced GP out-of-hours contacts.  Keys to success (see below) identified in qualitative feedback included: improved communication and relationships between care homes and healthcare teams; improved continuity of care and advance care planning for patients; and significantly reduced workload and stress levels for GP practices.

Keys to success
Trusted relationships with Care Home staff
Clinician continuity
Enhanced relationships with community teams
Expertise in Care Home medicine
Additional Capacity for proactive care
Capacity for Advanced Care Planning
Use of Technology Enabled Care

Keys to success as identified by clinicians, care homes and community teams

Evolving the established service to fulfil the EHCH framework

We plan to use our established team, community relationships and processes to develop the Enhanced Health in Care Homes DES at scale with our three PCNs and Integrated Care Organisation (ICO). This means expanding to support almost 100 care homes.

Although we are three PCNs, there are only two community teams covering the same footprint.  This, combined with the established nature of the current TCHVS and Torbay’s small geographical area, means we can operate an at-scale EHCH while maintaining the localism that is inherent in the framework.

We anticipate resourcing an expanded TCHVS by pooling the three PCNs’ EHCH DES funds, applying for additional Winter Pressures funding and using Additional Roles Reimbursement Scheme (ARRS) and GP time supplied equally by each PCN. 

Achieving care home alignment

The PCNs have undertaken  a ‘soft-realignment’ of care home patients, identifying which PCN the majority of each home’s residents are registered with, and asking the remaining residents to re-register with a nominated practice at the same PCN. This fulfills the EHCH requirement of one home to one PCN and ensures each PCN has equivalent numbers of care home patients and EHCH funds, allowing equitable contributions to a collaborative service. We are lucky to have a history of collaborative working for wider benefit for the whole primary care community, which has helped practices be on board with this approach.

Our TCHVS lead GP and lead nurse will be the named clinical leads for each of our care homes, but we may spread this role to other members of the team as it expands.  Their responsibilities will be to chair the multidisciplinary team (MDT) and facilitate communication between care homes, community teams and practices.

Adapting our referral service to deliver the weekly ‘home round’

Our care homes currently refer to us using a using a standardised ‘Situation, Background, Assessment, Recommendation’ (SBAR) referral form emailed to a single point of access. The SBAR contains a brief explanation of the acute problem as well as clinical observations and details of advance care plans already in place.

The TCHVS team triages and actions all referrals the same day. We now plan to incorporate a proactive weekly contact to any homes who have not already referred to us through this acute SBAR pathway in the previous 7 days. This ensures all homes have guaranteed weekly clinical contact, and allows the most appropriate member of the TCHVS team to deal with the concern acutely in a virtual home round, or triage it in to the MDT if necessary.

Setting up a virtual MDT

The TCHVS is staffed day to day by two GPs supplied by local practices on a rota, with the same daily nurse and trainee ANP providing clinical continuity throughout the week.  In total there are 18 GP and 13 nursing sessions per week.  We also have a dedicated administrator and operations manager, and lead GP oversight. 

Our nurses focus on the acute and minor illnesses while the GPs focus on complexity, frailty and advance care planning.  We work one-to-one with our nurses which gives them an excellent training opportunity to enhance their skills – we are planning to support them with prescribing and Treatment Escalation Plan training in the coming weeks, to support the need for personalised care plans within the framework. 

We already have regular contact with the Older People’s Mental Health Team, Medicines Optimisation in Care Homes pharmacist and the community teams.  This enables us to discuss complex patients, share decision making and hold risk more safely in the community.

We have now formalised this multidisciplinary input by establishing a weekly virtual community MDT (see table, below) using Microsoft Teams.   All teams and care homes can refer residents to be discussed at the MDT using a specific MDT SBAR form.

The MDT list is compiled and shared before the meeting so all teams can review it.  Involvement from secondary care geriatricians and the hospital discharge team means the MDT can support safe discharge planning and improve communication between the hospital and community teams. Having a single MDT meeting across three PCNs is more efficient for all of the community teams, so maximising attendance.

The MDT list is compiled and shared before the meeting so all teams can review it.  Involvement from secondary care geriatricians and the hospital discharge team means the MDT can support safe discharge planning and improve communication between the hospital and community teams. Having a single MDT meeting across three PCNs is more efficient for all of the community teams, so maximising attendance.

Community Teams  
GPs Speech and Language
Community Nurses Therapy teams
Pharmacist Older People’s Mental Health Team
Dieticians Quality Assurance and Intervention Team
Hospital Discharge Team Care of the Elderly Consultants
Community Palliative Care Team Community Service Managers

Teams involved in our MDT

Embedding remote working

Remote consulting opens up the option of collaboration between practices and PCNs even if they work in a wide geographical area that would have previously made this impossible. Digital transformation and remote consulting has already significantly reduced our face-to-face visits and the associated travelling time and footfall into care homes. We now do over 90% of our clinical contacts via email, telephone or video consultation, giving us maximum flexibility to expand and fulfil the home round requirements at scale.  It has already released sufficient clinician capacity to expand our service to 34 care homes (1,000 residents) without increasing our staffing.

We use AccuRx and Microsoft Teams as secure platforms freely available to us via our CCG.  They have been simple to use for both clinicians and care home staff.

We have supported homes to become confident in taking clinical observations and encouraged them to sign up to Restore2 and other training packages from local training providers to facilitate safe remote assessment of residents. We are about to start a pilot of electronic stethoscopes where care home staff can examine and record heart and lung sounds for us to assess remotely.

We are also supporting homes to sign up to accounts meaning they can send patient data securely and access Microsoft Teams for MDT and video consulting.

Dr Katharine Bhatt is Lead GP, Torbay Care Home Visiting Service and Dr Trevor Avis is Clinical Director, Paignton and Brixham PCN and Chair, Southern Primary Care Collaborative Board

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