Organising general practice for care homes: a multi-method study.

Background: General practice provides first-line National Health Service care for around 400,000 care home residents. Good primary care can enhance residents' health and well-being and optimise use of hospital services.

Objectives: This study aimed to explore the relationships between organisation of general practice and the perspectives and experiences of residents, general practice and care home staff, outcomes and costs.

Design: Survey of general practices (2018), qualitative study (2019), analysis of primary care data (2019-21).

Policy context: National Health Service England Vanguard funded innovation in services for care homes in five areas (2015-8); Enhanced Health in Care Homes introduces standardised care home healthcare processes in England (2020-4).

Setting: England: national survey; qualitative work in three areas (two Vanguards); analysis of national primary care data across early implementation of Enhanced Health in Care Homes and the COVID-19 pandemic.

Participants: One hundred and fifty general practice survey respondents; 101 interviewees (general practitioners, practice managers, receptionists, care home managers, nurses, senior carers, residents, relatives, commissioners) in three areas; 103,732 care home residents ≥ 75 years, registered with participating practices in Clinical Research Datalink Aurum 2019-21.

Results: Qualitative analysis identified three themes concerned with general practitioner services to care homes: relational processes, communication and organisation. Continuity of care, sensitivity to the skills of care home staff and routines of the home, along with a willingness to dedicate time to patients, are all crucial. Different structures (e.g. scheduled visits) provide opportunities to develop effective, efficient care, but flounder without established, trusting relationships. The way in which new initiatives are implemented is crucial to acceptance and ultimate success: telemedicine was an example that generated efficiencies for the National Health Service, but could be a burden to care homes, resented by staff and perceived as a barrier to overcome. One hundred and fifty practices responded to our survey, a majority staffed by ≤ 5 general practitioners. Larger practices were more likely to have a nominated general practitioner for care homes and make weekly scheduled visits. Analysis of primary care data found that in practices with a higher number of care home residents, patients had more contacts with primary care and fewer urgent referrals. Between 2019 and 2021, total contacts and estimated costs increased, and urgent referrals and polypharmacy fell.

Limitations: Sparse evidence of systematic change in Vanguard areas limited our conclusions about specific initiatives. Implementation of national policy during the COVID-19 pandemic complicates data interpretation.

Conclusions: Larger practices or those with higher numbers of care home residents were more likely to adopt ways of working that are associated with higher-quality care. However, trusting relationships between care homes and a motivated, adequately resourced primary care workforce may be more important than models of care, in enhancing primary care for care homes. General practices and care homes find creative ways around initiatives that are not perceived to offer any benefits, emphasising the need for local flexibility when implementing national initiatives.

Future work: Future work could address how best to promote ways of working that prioritise trusting relationships; the absence of care pathways specific to care home patients, and the impact of Enhanced Health in Care Homes on system-wide costs.

Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 14/196/05) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 11. See the NIHR Funding and Awards website for further award information.