GPs to stop providing care to residents in care homes

[hiddenhome2]

Guardian link here

I work in a care home and I'm finding this quite shocking.

Our residents retain their own GP unless they have moved from another practice area.

Care homes are taking on increasingly fragile residents with often complex needs as well as more palliative care cases. We absolutely need medical cover.

We take NHS intermediate care patients too who stay with us for some rehab before either being discharged home or going into residential care.

We have a great team of advanced nurse practitioners who visit each morning to see if anybody needs anything and they're also on call up until 8pm and over weekends too. They're often better than the GPs because they view things from a nursing perspective and they get to know the residents in the way only a nurse can.

I'm not sure what this has to do with sticking up for junior doctors?

SsargassoSea most people in the care home I work in have dementia or Parkinsons or have had a stroke and few of them would be safe to be left to just snooze in a chair at the home of their retired children, and for the most part the only ones who would do so need a lot of lifting as part of their care because they simply can't get out of their chair alone! Most of them fall easily and it takes 2 adults even to pick up a fairly light adult from the floor, and is much better to have lots of eyes about the place to notice if they have forgotten to use their walking frames or are about to try to use the stairs, which they will fall down, or if they are taking down their trousers somewhere inappropriate thinking they are sitting on the toilet... the ones who physically can't get out of their chair need lifting on and off the toilet, into and out of bed, and it is physically demanding to dress them etc. too - many children of people in their 90s are not in a physical state themselves to lift their parent on and off the toilet multiple times a day - and where that parent can't weight bear at all it takes two relatively fit and healthy people to do the whole process, including cleaning them up etc. without hurting the person.

Many of them have no living children, some never did, in other cases the children themselves are dead (one poor lady of 96 has a photo of herself from the 1940s on her room, with two toddlers in between her and her husband and with her chubby baby on her knee - the baby died the week after the photo was taken, and one of the children died as a child, the other was her carer for ten years but died before her mother and never married or had children) and where they do have children they are often "only" in their late 50s and 60s and still working... We also have a few residents in their 50s and 60s who have had strokes and cannot physically care for themselves, and have nobody else to care for them at home.

hiddenhome we have nurses on staff - there are usually 3 in the "house" at any one time, one on each floor (the floors are fairly self contained for day to day living) as well as professional carers who have done 4 year apprenticeships including studying and exams, and then helpers/ unqualified carers as well.

I agree the nurses are often better than the visiting GPs and catch their prescription mistakes sometimes - it seems a pity they can't prescribe as a lot of the time they do know a lot more about the specific cases and situation - but the good thing is they sit down with the GPs and discuss what would be appropriate. One of the GPs is notorious for always suggesting the same treatment whenever he doesn't actually know what the problem is, and its a skill in itself for the nurses to make him think that prescribing something more appropriate was his idea

Well I know a care home owner and they are minted
Some of the fees charged are ridiculous and I do wonder what happened to the profits
Not the case for many homes I know however these have been very profitable for some in the past and perhaps the profits could have gone towards providing some GP cover

The problem is if care home owners have to pay for GP call outs, they just won't call them out and people will suffer. The nurses will be instructed to just deal with whatever problem presents

Lulu good luck trying to persuade most people in their 90s to shower daily - at least 80% of the residents of the care home I work at are highly averse to showering more than once a week, and a significant majority still hold with something akin to "shed nerry a clout til May is out" and feel that we are putting them in mortal danger of chills by showering them as quickly as reasonably possible (in the very warm care home with lovely warm water) once a week, and then carefully drying them, hair drying their hair and dressing them in the 2 vests and 2 tops and 2 jumpers they ask for :o

GPs desperately would love to give excellent care to Care Homes and Nursing Homes.

What they can't do is clone themselves, and do a full day of surgery, audit, QoF and meetings, as well as teaching, and look after themselves and their kids, and provide a good enough service to Care Homes on top.

The question is: do you want GPs to continue to struggle to provide a shit service, paid for by thin air?

Or, do we want to fund a decent service that our elderly and vulnerable deserve?

GPs are stretched to the absolute limit. Where I live, they cannot recruit doctors to even train as GPs. Since this government is doing all it can to send decent junior doctors abroad, this is only going to worsen.

GPs are a finite resource- either fund and resource them appropriately, or they're going to have to drop some of those plates they keep spinning.

It's better to be honest when you can't take anymore- GPs can't take anymore.

It's not just about money, it's about there being a recruitment crisis, low morale (thanks, Jeremy Cunt) and exhaustion.

And still... People vote Tory. What did we expect?

Families can't always 'step up to the plate'. My DM ended up on anti depressants and blood pressure medication trying to take care of my grandma, (all at yet more cost to the NHS). It's not always as realistic as it seems.

I'm a GP and we have recently discussed opting out of providing cover the care homes. This is not because we're lazy and we don't care.

There are two issues.
Firstly, the sheer volume of work is unmanageable. There are far more elderly people than there used to be, and care homes are being built at a phenomenal rate. We have had to cancel 2 surgeries per week to do regular rounds of the care homes we look after. So, every week, 30 appointments that could have been offered to other patients have been lost. In addition to the weekly routine visits to care homes, we do almost daily ad hoc visits to residents who can't wait until the next round.

Secondly, the residents of care homes have complex medical problems, that we are simply not qualified to manage. These are people who, 10 years ago, would have been on long-stay geriatric wards, being looked after by specialist geriatricians. GPs cant magically generate skills and knowledge that specialists train years for. It's akin to a GP having a go at an appendicectomy!

What we really need are community geriatricians, who could be in charge of several care homes, offering residents the level of care and expertise that they deserve. But that costs, and the government won't pay, as long as us GPs carry on muddling through. So maybe it's time we stopped...

Well, obviously something has to change due to the ageing population. It'll be interesting to see how this will be organised and paid for over the next 10-20 years.

Exactly what CPtart and Schwabischeweihnachtskanne said.

Due to the state of her dementia, she would have had some of her care funded. This wasn't the issue. She was so difficult to look after (no better way to say it) that they wouldn't take her in.

This is indeed shocking and upsetting, but part of a bigger picture.

Primary Care is collapsing.
The amount of unresourced work being transferred (usually unilaterally, with no discussion or agreement or, see above, additional resources) from Secondary Care in to the community is an absolute fucking disgrace. And yes, those most vulnerable are the most likely to suffer .

I am a GP, semirural/suburban practice, we look after 120 care home bed, visit twice weekly as a matter or routine and whenever required if something happens acutely. The mix is about 40 beds residential care, 40 nursing care and 40 specialist dementia beds. The homes are private enterprises and v nice, but chronically understaffed, particularly with experiences and appropriately trained nurses - they are expensive of course, and cut in to profits… . So, very dedicated and incredibly caring carers are left to look after people with chronic complex needs, co-morbidity, polypharmacy and of course, usually, declining health.
It IS unsustainable for a GP, jack of all trades, master of none (which is what I LOVE about my job), to provide the care that this subgroup of our 8000 patients needs.
We fight for them, we spend a lot of time of doing Advanced Care Planning, discussed Preferred Place of Care/Death, making sure everything is communicated to OOH/ambulance service - and when it comes to the crunch and somebody is actually dying? 999 get called.
I am not blaming the carers or the distressed families, I am blaming a wider societal ill of not talking about death/dying/terminal decline. I am blaming a culture in which everything has to be measurable - if a box was not ticked, it did not happen. Holding a dying person's hand has no value in that context. Filling in a form is what will protect an under supported member of staff against any come back - equally not having filled in said form will make it all alright, no matter what actually happened.

I had not realised that things were quite as bad in England, so thanks for that link, hidden. I salute you and your colleagues.
It usually takes about 5 years before things happening in the NHS in England arrive here in Scotland, but it is dire here too.

Primary care is dying - under the pressure of demand (both reasonable and unreasonable expectations), media slagging, pressure from government.
So few junior doctors want to become GPs anymore - certainly v few men. We cannot fill our training spaces (5 applicants to 18 spaces - that is applicants, whether they are suitable or not is a whole other question).

I am really quite pessimistic about the future - it is all about resources. Not just money, but staff, training, time, facilities.
I am almost 50, I have made sure I will have enough put by to be able to buy in care, because I don't think that the NHS or even private care providers will exist as they currently do when I need them.

I also think that families will have to think long and hard what it is they want for their older family members and what they can contribute.

It is all frigging frightening.

Sorry about the essay

But here is more:

The integration of Health and Social Care is in its infancy here. It all sounds great on paper: people being looked after at home or 'in a homely setting', cared for in a way that they wish.
All the planning and diverting of funding is based on the principle of robbing Peter to pay Paul. There are no NEW resources.
All the planning is done via social services, the health service has been allowed v little input.

Our people on palliative care do die in the home (as is their preference) ... a lady died in the home on Monday night (totally expected, and peacefully), and I had to go into her room to retrieve her former roommate's belongings, she looked very peaceful... her clothes were laid out on a chair by her bed as her daughter wanted to be the one to dress her for the funeral... surely 999 is not called for people on palliative care?

It does sound a big mess though!

Kanne, sometimes (not always, of course) relatives/carers panic when the dying person starts breathing funny/looks terrible/gets agitated or whatever. So yes, with the best preparation, sometimes 999 gets called inappropriately.
Of course good preparation helps to prevent that.
Also, for relatives (if the expected death is at home) to know who to contact should the death happen in the middle of the night: call the OOH dr, NOT 999.

It is a mess, indeed.

Yes, there's a huge taboo surrounding death

The relatives often insist upon hospital right at the last minute. It takes weeks of planning ahead to get an advanced care plan agreed to by them and some just don't want to talk about it, then are shocked that we have to call 999 when their relative becomes very ill and begins to die

Do you have a Nurse Practitioner system? Pacific ours visit the home each day and are fantastic. The system totally frees up the GPs to do their surgery work. We're really getting along well with this new system. No more 111 calls either as we can phone urgent care directly too. Whoever has been involved in setting these systems up deserves a medal it's helping us so much.

It's worrying about resources though

I wonder if attitudes to death are a bit different here in Germany, as people come back from hospital to die, and when there has been a death a memorial notice goes up, and all the residents who can/ want to go to the little service in the chapel on the ground floor (not the actual funeral) and a lot of them put the little memorial card with photo up in their rooms and those who are medically capable often talk about the deceased ... The children of the parents on palliative care usually seem more peaceful and thoughtful than distraught when they come to visit - its usually pretty clear that the palliative route is for the best, by the time it is decided upon...

Yes, it's less traumatic for the relatives if things are planned for prior to them happening, but they often don't trust us.

The cradle to grave idea of the NHS sorting all our health problems might have contributed to the lack of planning or thought we give to ageing and death here in the UK.

My DM who had been a nurse, including having worked in a geriatric hospital and a care home, didn't discuss any plans or arrangements for her death, other than to change her mind from cremation to burial a few years before her death.

For my DCs' sakes I hope to have things decided well before hand.

Hidden, it is bit confusing with the different info so I wonder how it will pan out.

I was also under the impression that care homes make a huge profit and that paying staff a decent wage shouldn't be a problem if the bigwigs are prepared to lose literally pennies a week, they won't notice it!

I have one friend in a care home so I'll be interested to see how it turns out. They are all so lovely there, the daily staff not paid enough in my view.

Our care assistants are on minimum wage. The nurses aren't paid particularly highly for the amount of responsibility and experience we have.

I don't know what the profit margins are, but providing decent care isn't cheap and I don't think the fees are high enoughtbh, not considering how much we struggle to get the work done.

I believe a lot of for profit care homes ARE run by consortiums of doctors. This doesn't sit well with me - especially considering how much care workers are paid.

My dp's are in their late eighties - DDad in the process of being diagnosed with dementia, along with many other problems, DMum has physical and mobility issues. They live at home, I spend a couple of hours a day with them, but they are struggling.

Their local surgery have been amazing and the staff KIND, which makes such a difference - nurse visits twice a week for physical problems, doctors visiting when required. They have a care package in place and a carer for 15 minutes every day, longer once a week for bathing (we tried to suggest that DH and I could help with washing but DDad wouldn't entertain it ).

I don't know what the future holds, I dread the middle of the night phonecalls and I hate to see them struggling so much.

I dream of properly run not for profit care homes where couples could be together in little bedsits perhaps, with medical, hygiene and household tasks taken care of by staff and with family input. M&D have been married for 65 years, and the thought of them being separated into care is harrowing for all concerned. End of life should not be this way. There is no point in all the wonderful medical advances which cure disease and allow people to live longer if we don't have the capacity to ensure those longer lives are actually worth living and elderly people don't feel as if they are being a burden.

Hidden, my understanding was that profit margins are quite high and will be pocketed by the entrepreneurs who set up the home. I'm not against private enterprise at all, I just think the pay is skewiff and people doing vital work are underpaid.

I am constantly puzzled why so much effort is put into medicines that extend life but that's a separate thread.

Many care homes groups are owned by private equity firmswhose primary purpose is to make profit. Several have had problems with this and have due to debt restructuring etc come to the brink of bankruptcy. There was a big issue with this a few years back and the problem surfaced again at the end of last year with southern cross.