Primary care arrangements for elderly people in residential and nursing homes

EDITOR—McCormack highlights variations, inequities, and problems in care for elderly people discharged after short stays in hospital.1 Declining long stay provision in the NHS and shorter acute inpatient stays have increased pressure on community services, exacerbating perverse incentives between health and social care.1 As long term care of elderly people is redefined as social care general practitioners have become responsible for the health care of increasing numbers of frailer residents of residential and nursing homes. Evidence on the effect of this is scarce.2

We conducted preliminary research by examining residents' arrangements for general practitioner consultations. We approached two samples of homes in the independent sector: a 20% random sample of nursing homes in Kent and 12 residential homes chosen from a study of social services organisation3 in Kent (n=4), London (n=3), and Sheffield (n=5). Letters to home managers were followed by telephone interviews (December 1997 to February 1998).

Few homes dealt with only with one general practitioner; typically they dealt with four or five (table). Regular clinics, held in half of the homes (usually weekly), were open only to patients of the general practitioner organising the clinic. For other residents, general practitioners visited only when asked to do so by home staff. Arrangements varied: one general practitioner did a weekly “ward round” to 85 residents, but most visits were to individual patients. Overall, the reported number of contacts with residents was high, albeit mainly in the winter.

Payments under the general practitioner contract seem small for these levels of activity and provide a poor incentive for quality care. Some home staff reported difficulties getting general practitioners to visit residents, while many homes that did not have regular clinics wanted them. One nursing home with regular clinics and good reported liaison between staff and the general practitioner paid the general practitioner £3000 quarterly, further blurring both the boundary between health and social care and professional accountability.

Although our data come from uncorroborated telephone interviews with a small number of homes mainly concentrated in southeast England, they are consistent with issues raised by McCormack. They show that the boundary between health and social care is further complicated by the division of primary and secondary healthcare funding and responsibilities. The role of general practitioners and their professional responsibilities need to be clarified.4 Primary care groups have potential,5 but details must be clarified.