Title: Organising general practice for care homes: A multi-method study
Funder: Department of Health and Social Care

Abstract: General practice provides first line medical care to care homes, but in recent years, innovative commissioning and service development have increased the variation in how general practice is organised for care homes. In this study, we will identify areas where commissioners or providers have worked to enhance GP services for care home residents and evaluate the impact of the organisation of GP care on residents, general practice and care home staff. Aim: To identify effective and cost effective ways of organising general practice for care homes and evaluate the impact on residents, general practice and care home staff. Research Questions 1. In what ways is the organisation of general practice for care homes associated with better resident outcomes and experiences? 2. What are the implications of different models of GP involvement for residents’ service use and costs? 3. What are the perspectives of residents and relatives, commissioners and staff in general practice and care homes on different ways of organising general practice for care homes; which are acceptable and associated with positive experiences? Plan of investigation: Multi-method case study approach Prior to the start of the funded project the following will be completed: Email survey of practice managers in case study areas (CCGs) to describe GP service organisation to care homes, cluster (or latent class) analysis to develop a simple typology of service organisation for use in the following analyses. WP1. (Research question 1) Comparative analyses of chronic disease management, patient and system outcomes for care home residents in case study areas. Three sites will be selected; two with innovative, contrasting ways of organising general practice for care homes and one where there has been no systematic change to services (usually multiple GPs for each care home). At each case site, patient level data from GP records in the ResearchOne database will be analysed to compare achievement on selected measures, before and after the introduction of changes to GP organisation in the innovation areas and over similar time period in ‘usual care’ areas. Outcome measures will include: hospital admission and readmission rates, potentially avoidable (ambulatory care sensitive) admissions, measures of prescribing quality, GP and practice nurse contacts (in person and by telephone), measures of relational continuity and chronic disease management. Comparisons will be made within and across case studies, controlling for resident characteristics. WP2.(RQ 2) Economic evaluation – Costs will be assigned to the service utilisation identified in WP1, and comparisons conducted within and between case sites and typologies WP3. (RQ 3) Qualitative research - Individual interviews in the case study sites with residents, relatives, GP and care home staff and commissioners, to explore perceptions of the context, structure and processes of service delivery to care homes, positive and negative consequences of different ways of working for staff and residents. Participants will be drawn from sites with particularly effective care and others where resident data point to worse care. This study will provide empirical evidence to a) inform organisational change in general practice, b) support commissioners and providers to make best use of resources, and c) ultimately help residents, family and staff influence and choose the primary medical care services they would like to receive.

Lay abstract: General practitioners provide front line medical care for care homes, and the people who live there are often a GP’s most complicated patients. Most residents are old; many are frail and living with at least one medical diagnosis, including dementia. Information on the health of care home residents is not collected routinely, but some research suggests that the quality of health care provided for care home residents may not be as good as the care given to older adults who live in their own homes. Organising GP services for care homes is important now, to make sure residents get appropriate, high quality care. With the number of people in care homes predicted to rise rapidly over the next twenty years, it will be more and more important that services are well organised and good value for money. In many parts of the country, GPs look after their individual patients in care homes, so that the home has to work with many general practices. (This is what we mean by usual care). In recent years, the authorities that plan local health services have worked with GPs to find new ways of organising medical services for care homes. For example, in some areas, there are GP practices where all the patients live in care homes. Other new ideas include telehealth linkage connecting care homes directly with the NHS, or GPs working in partnership with community geriatricians. Having one GP practice working with one care home is becoming more common. There are also differences in the way GPs look after their patients; some plan routine visits every week, and make sure health promotion and preventive care are a priority. Other GPs may not visit until problems arise. Some of these ways of working may be better for residents. They may have different consequences for care home and GP reception staff. Costs may differ, too. This study aims to identify ways of organising GP services for care homes that produce good health outcomes for residents at lowest cost. We will also take into account the views of residents, relatives and staff in general practices and care homes. We will select three areas in England. Two of them will have introduced new ways for GPs to work with care homes, one will not have had any new initiatives. The main part of our study involves analysing data from anonymised general practice patient records in the three study areas. We will look at a range of issues, such as how GPs manage chronic illness, how often residents are admitted to hospital for conditions that could be looked after in the community, and the quality of prescribing. The costs of different models of GP care will also be calculated. We will make comparisons within each area, between GP practices and care homes, and between areas with different ways of working. Interviews with frontline staff in general practice and care homes will give us insights into the impact of any changes on staff. Interviews with residents and relatives will provide an understanding of their experiences and perceptions of GP services when delivered in different ways. At the end of this project, we will have a better understanding of which of the different ways that GPs work with care homes are better than others for residents, staff and the public purse. We will work closely with stakeholders and policy makers to make sure that our work influences what happens at a local level. Improving the experiences and outcomes of care home residents is our overall goal.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE