GP Contract Enhanced Services Primary Care Networks

Setting up the new Enhanced Health in Care Homes service – an urban PCN’s approach in South Liverpool

Dr Rachel Disley and colleagues Julia Hyde, Jane Fradley and Gayle Rook explain how their Primary Care Network is building on a pilot care home scheme to implement the Enhanced Health in Care Home Framework in an urban area covering South Liverpool.


  • Name: SWAGGA Primary Care Network
  • Number of practices: 17  
  • Total patients: 92,186
  • Care home population: 552 beds
  • Types of homes: nursing residential, specialist and learning disability

SWAGGA (Speke, Woolton, Aigburth, Gateacre, Garston, Allerton) Primary Care Network (PCN) covers an urban area across the south of Liverpool and is served by 17 GP practices with a population of 92,186.

There are 15 care homes aligned to the Network with a total 552 beds across all CQC registered nursing residential, specialist and learning disability homes. Based on SWAGGA’s weighted list size this equates to 5.25 per 1,000 population in a care home.

The proportion of older people in SWAGGA is significantly higher than the average, with 18% aged over 65 compared with 14% for Liverpool. There is also a high proportion of moderately or severely frail in this age group – of those with a frailty score recorded, 58% are categorised as having moderate frailty followed by 34% with severe frailty. Hospital admissions from care homes are also significantly higher in this network, with a rate of 34 admissions per 1,000 population compared with 22 per 1,000 reported for Liverpool as a whole.

As a consequence, practices in SWAGGA have been involved for a number of years in testing approaches to the implementation of the Enhanced Health in Care Homes (EHCH), under the Care Home Advanced Model of Provision (CHAMP) pilot, with some excellent outcomes in a number of care homes.

Care home alignment – a systematic approach

Under the Network Contract DES, each care home should be aligned to a single PCN, which will deliver the EHCH service for that home. This is to achieve consistency of care for people living in that home, and help care homes, PCNs and providers of community services to build the strong working relationships and integrated care arrangements that are crucial to the success of the model.

SWAGGA has worked with Liverpool CCG to support the alignment of each care home taking into account: where the home is located in relation to practices/PCNs; the existing GP registration of residents; what contracts are already held between the CCG and practices to provide support to the home, or directly between the home and practices; and existing relationships between care homes and practices.

To achieve optimal alignment:

  • Each home was contacted and asked for their current residency status and registered GP alignment of those residents.
  • Bed totals were based on the data held in a ‘Care Home Alignment Tracker’.
  • Where multiple PCNs had registered patients in one home, the PCN with the highest number of residents was highlighted as the best alignment.
  • Communication was then sent to all PCNs highlighting the methodology and initial draft of alignment of care homes to PCNs for discussion. We plan to register any new patients to the aligned practice where possible, while respecting patient choice.  A couple of care homes will be split across two practices, where registrant numbers are similar in each. 

Adapting to deliver the EHCH Framework

During the unprecedented situation with the COVID-19 pandemic, primary and community services have already had to repurpose support for all CQC registered care homes (with or without nursing). Alongside this some elements of the EHCH Framework have been expedited, such as:

  • Identifying named clinical leads
  • Weekly ‘check ins’
  • Process for developing personalised care and support plans
  • Clinical pharmacy support, including structured medication reviews to care home residents.

Practices in SWAGGA are moving towards a named responsible GP for each care home and are already conducting weekly ward rounds. Each practice will be responsible for their own patients and will not be involved in ward rounds unrelated to their registered patients. Where a care home has more than one practice, ward rounds are being established with individual practices.

Shaping the team around care elements

We have been reviewing the service requirements to determine which health professionals would be best placed to meet the criteria, using results from the CHAMP initiative to decide how to best use the existing staffing resource, and identify any gaps and roles that the PCN can look to fill.

The existing staff in our multidisciplinary team (MDT) include the community matron, care home staff, Medicines Management Team, primary care clinicians and allied health professionals who attend when patients are referred to them. To develop the team we have discussed moving to a more proactive model, taking on roles from the Additional Roles Reimbursement Scheme (ARRS) that will be best placed to meet the care element needs of the EHCH Framework. From this, we have decided to aim to recruit a dietitian, a care co-ordinator and two physicians associates in the coming months to work with the existing team.

  • Dieticians review prescribing of oral nutritional supplements, as well as ensure optimal nutrition and hydration which is key to preventing frailty and falls, and improving quality of life – a key element of the EHCH framework. The dietician will also promote a food first approach and support appropriate prescribing, which we hope will lead to significant clinical and cost benefits.
  • Physician associates will work with the community matrons to assess and examine patients and link in with the lead GP where appropriate. They will help develop care plans, and provide health promotion and disease prevention support and management of long-term conditions.
  • The care coordinator role will provide necessary additional administrative support.

Developing proactive care through the weekly ward round

Our ward rounds are currently being done weekly using video consultations, due to Covid-19. This has proved time saving for all involved but network connections can be unreliable so this will require further investment to embed as routine practice, using the £120 per patient EHCH service funding. We do aim to resume some face-to-face reviews once the new team is in place, in particular to enable physical examinations, depending on the pandemic situation.

The lead GP at each home is encouraged to link in with the care home matron to do a joint ward round. We use a comprehensive template, developed locally, to summarise and standardise key information for each patient and keep it readily available on electronic records. This includes an advanced, personalised care plan for end of life care and/or long-term conditions care. With weekly support from the GPs, the care is becoming more methodical and proactive, with initial anecdotal evidence suggesting fewer sporadic queries throughout the week and care homes feeling well supported.

To help to prioritise patients for the ward round, we are building on a ‘tiers of need process’ developed under the CHAMP pilot.  Care homes are contacted each week by a community matron or pharmacist from the community Intermediate Care Team, who work with the care homes to identify patient needs as ranging from tier 1, where needs can be met by care home staff with no MDT input, through to tier 4 for advanced complex care and referral on to the MDT as appropriate, for further input from other health professionals – for example, social workers and geriatricians. The practice requests some information about patients prioritised that week ahead of the ward round – for example, queries or concerns, baseline observations and medication issues. This helps with key information whilst enabling a focus on delivering care elements of the EHCH.  

GP leads ensuring staffing equity

Discussions around distribution of funding to member practices are ongoing. Some practices have a greater proportion of care home patients and staff than others; the plan here is for the named GP in each practice to work with ARRS staff to ensure adequate care for their registered patients.  

Dr Rachel Disley is a GP partner and Clinical Director at the SWAGGA PCN; Julia Hyde is Integrated Care Lead for SWAGGA PCN and Nurse Clinician in a South Liverpool practice, Jane Fradley is Senior Programme Delivery Manager CCG and Gayle Rooke is CHAMP Project Manager and Integration Delivery Manager CCG

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