GP Contract Enhanced Services Primary Care Networks

Enhanced Health in Care Homes service– a summary of the requirements

The bulk of the new Enhanced Health in Care Homes service begins next month. Pulse Intelligence provides an overview of the service and its key requirements.

Practices have already implemented some of the core elements of this new service, in establishing the interim COVID-19 care home support service.

The full Enhanced Health in Care Homes (EHCH) service and contractual requirements are outlined in the Network Contact DES and associated guidance, while the EHCH Framework provides further details for its implementation.

The full service was to be implemented from 31 July 2020 but the bulk of clinical requirements come in from 1 October 2020.  

Which patients does the service cover?

The service covers all CQC-registered care homes, with or without nursing. It does not cover secure units for mental health or supported living environments.


PCNs will receive £120 per bed per year from October 2020 when the service starts in full (payment in the first year was at the rate of £60 per bed per year). The payment per bed is designed to reflect the difference in workload that could occur between networks, although inequities may remain among member practices depending on share of the service workload and staff.

PCNs are being paid for the service from October 2020 to end of March 2021 in eight monthly instalments, starting from 1 August 2020, at a rate of £7.50 per bed per month.

Changes due to Covid-19  

Both the interim service and the EHCH service in the Network Contract DES required Primary Care Networks (PCNs) to nominate a clinical lead responsible for ensuring service delivery. Originally this post was to be held by a ‘lead GP (or GPs)’, but under the interim arrangements this was relaxed to allow ‘any named clinician’ and NHS England has since revised regulations such that the clinical lead may be ‘a non-GP clinician with appropriate experience of working in care homes’.  The PCN remains responsible for nominating the clinical lead, and if the clinical lead is from a partner organisation such as a community provider, the PCN still remains responsible for all aspects of the delivery of the EHCH service requirements in the DES.

What does the service involve?

The EHCH service builds on pilots of enhance care home support and incorporates nine key ‘care elements’:

1. Enhanced primary care support

  • Each care home aligned to a named PCN, which leads a weekly multidisciplinary ‘home round’
  • Personalised Care and Support Plans (PCSPs)
  • Medicine reviews
  • Hydration and nutrition support
  • Oral health care
  • Access to out-of-hours/urgent care when needed

2. Multi-disciplinary team (MDT) support including coordinated health and social care

  • Expert advice and care for those with the most complex needs
  • Continence promotion and management
  • Flu prevention and management
  • Wound care – leg and foot ulcers
  • Helping professionals, carers, and individuals with needs navigate the health and care system

3. Falls prevention, Reablement, and rehabilitation including strength and balance

  • Rehabilitation/reablement services
  • Falls, strength, and balance
  • Developing community assets to support resilience and independence

4. High quality palliative and end-of-life care, Mental health, and dementia care

  • Palliative and end-of-life care
  • Mental health care
  • Dementia care

5. Joined-up commissioning and collaboration between health and social care

  • Co-production with providers and networked care homes
  • Shared contractual mechanisms to promote integration (including Continuing Healthcare)
  • Access to appropriate housing options

6. Workforce development

  • Training and development for social care provider staff
  • Joint workforce planning across all sectors

7. Data, IT and technology

  • Linked health and social care data sets
  • Access to the care record and secure email

What are the contractual requirements for PCNs?

By 31 July 2020

The PCN was required to:

1. Have agreed with the commissioner the care homes for which the PCN will have responsibility (referred to as the ‘PCN’s Aligned Care Homes’).

The commissioner is responsible for ensuring care homes within their geographical area are aligned to a single PCN, and may allocate a care home to a PCN if agreement cannot be reached. Where the commissioner allocates a care home to a PCN, that PCN must deliver the Enhanced Health in Care Homes service requirements in respect of that care home in accordance with this Network Contract DES Specification.

2. Have in place with local partners (including community services providers) a simple plan about how the Enhanced Health in Care Homes service requirements set out in this Network Contract DES Specification will operate

3. Support people entering, or already resident in the PCN’s Aligned Care Home, to register with a practice in the aligned PCN if this is not already the case.

4. Ensure a lead clinician with responsibility for these Enhanced Health in Care Homes service requirements is agreed for each of the PCN’s Aligned Care Homes. NB The clinical lead is expected to support the delivery of the service requirements, and strengthen links between care homes and PCNs, but is not medically responsible and accountable for the care of individual care home patients – the responsibility for the service delivery as described in the DES lies with the PCN.

By 30 September 2020

The PCN must:

1. Work with community service providers and other relevant partners to establish and coordinate a multidisciplinary team (MDT) to deliver these Enhanced Health in Care Homes service requirements.

2. Have established arrangements for the MDT to enable the development of personalised care and support plans with people living in the PCN’s Aligned Care Homes.

From 1 October 2020

1.  Deliver a weekly ‘home round’ for the PCN’s patients who are living in the PCN’s Aligned Care Home(s). In providing the weekly home round a PCN:  i) must prioritise residents for review according to need, based on MDT clinical judgement and care home advice (a PCN is not required to deliver a weekly review for all residents); ii.) must have consistency of staff in the MDT, save in exceptional circumstances; iii) must include appropriate and consistent medical input from a GP or geriatrician, with the frequency and form of this input determined on the basis of clinical judgement; and iv) may use digital technology to support the weekly home round and facilitate the medical input.

2. Using the MDT arrangements, develop and refresh as required a personalised care and support plan  (PCSP) with patients resident in the PCN’s Aligned Care Home(s). A PCN must: i) aim for the plan to be developed and agreed with each new patient within seven working days of admission to the home and within seven working days of readmission following a hospital episode (unless there is good reason for a different timescale); ii) develop plans with the patient and/or their carer;  iii) base plans on the principles and domains of a Comprehensive Geriatric Assessment including assessment of the physical, psychological, functional, social and environmental needs of the patient including end of life care needs where appropriate; iv) draw, where practicable, on existing assessments that have taken place outside of the home and reflecting their goals; and v) make all reasonable efforts to support delivery of the plan.

3. Identify and/or engage in locally organised shared learning opportunities as appropriate and as capacity allows.

4. Support with a patient’s discharge from hospital and transfers of care between settings, including giving due regard to NICE Guideline 27.  

By no later than 31 March 2021

The PCN must establish protocols between the care home and with system partners for information sharing, shared care planning, use of shared care records and clear clinical governance.

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