GP and PCN clinical director Dr David Coleman describes how to set up the new Enhanced Health in Care Homes service, based on the approach at his PCN covering a large suburban area across the south of Doncaster.
Our PCN covers a large, suburban area across the south of Doncaster, encompassing a number of former mining areas and some semi-rural villages. There are 10 member practices and the patient population is 66,000.
The average list size is slightly lower than the national average, reflecting the tendency for smaller 2-3 partner practices. The PCN has a larger than average care home population, however, with 400 patients in a range of settings including learning disability establishments, residential and nursing homes.
There are three practices in our PCN area that belong to a neighbouring PCN, all of whom have patients in care homes. This has prompted some discussions about alignment.
The vision for the Network DES is that ‘each care home will be aligned have to a single PCN (and its MDT)’. Meetings are ongoing to determine a solution, guided by the DES document. Should an impasse be reached we hope the CCG, perhaps with LMC support, can step in to broker an agreement.
It is worth looking at existing staff resource in your area before drawing up your multidisciplinary team (MDT). Our PCN met to discuss the requirements of the DES and the staffing options afforded by the Additional Roles Reimbursement Scheme (ARRS). There was a strong consensus for developing a team defined by its skill mix – with physician associates, pharmacists, a pharmacy technician, and a care co-ordinator to tie everything together. Our CCG has already commissioned another provider to provide additional care home support, which comprises physiotherapists, district nursing services, podiatrists, dieticians and speech and language therapists, and we didn’t feel a need to reinvent the wheel.
Staff members will be employed by the local GP federation, who will handle all the admin, training and HR costs at a competitive rate. The federation already holds some NHS contracts, enabling the new staff to access the NHS pension scheme, and has an existing HR infrastructure, so the PCN feeling is that this simplifies matters. HR costs could be averted if employment was shared across the practices, but steps would need to be taken to ensure consistency in approach.
A clinician from the practice with registered patients at the care home will act as the clinical lead for their patients; our practice has a dedicated nurse practitioner for proactive care, who will cover our patients in the four homes we look after ourselves. If a home has patients from multiple practices in a PCN, which is the case in around half of our homes, the relevant leads will attend for the relevant section of the ward round. This improves efficiency, as clinicians from each practice can be getting on with implementing the outcomes, rather than sitting through discussions about another practice’s patients.
Our ward rounds are currently being conducted remotely via Microsoft Teams. Digital meetings have become the norm during the pandemic, but given the number of participants and the geographical size of the PCN, this is probably ideal for delivering the weekly ward rounds.
Patients can be identified by the MDT or care home staff for discussion; patients who don’t have an up to date Personalised Care and Support Plan (PCSP) are prioritised. Indeed, these should be completed within seven days of admission to a home.
Our goal is to cover all residents at least once a month (the DES does not mandate weekly reviews for every patient), with review dates being set to facilitate this. Input should be sought from all stakeholders prior to discussion. The care coordinator can ensure communication with all relevant parties occurs following each MDT.
PCSPs should be based on the principles and domains of a Comprehensive Geriatric Assessment. A universal document should be used across the whole PCN to ensure consistency of approach across the homes. We are looking at customised template software for practices, as we have both EMIS and SystmOne users in our patch. There are several resources available to support creation of a bespoke local solution; the British Geriatric Society offer some excellent guidance.
Our PCN is still in discussions about the funding related to this service and equity of funding for practices.
All practices have care home residents, but some have significantly higher numbers and proportions than others. The feeling is that we will attempt to balance any inequities by allowing greater access to staff members employed via the Network DES
ARRS to other practices. This would ensure that a practice that doesn’t benefit as much from care home support still obtains some benefit from, say, a clinical pharmacist.
Our recruitment for the ARRS staff is ongoing, however we have a significant underspend from last year which we are hoping to utilise to further support our work on the Enhanced Care Home work. This may be direct support/staffing, such as employment of further administrators, or indirect – for example, funding additional practice nurse capacity to reduce in-house workload at practices, which in turn can free up established clinical staff member’s times to contribute to MDTs. First, however, we need to see what staff are appointed via ARRS.
Dr David Coleman is a GP partner and trainer in Conisbrough and Clinical Director of South Doncaster PCN
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