The dilemma
Mr and Mrs Jones are a lovely couple in their 80s who have been with the practice for decades. Recently, when, because of Mrs Jones’s cognitive impairment, they moved into a private residential home just outside our area, we agreed to keep them on our list. However, their carers call us out to see either Mr or Mrs Jones at least twice a week, always for trivia. We have tried to triage the calls by telephone, but the residential home staff know that if they use expressions such as ‘really concerned’ and ‘very poorly’ we have to visit to make an assessment. Mr and Mrs Jones are both in good physical health, so this could go on for years. What should we do?
A GP’s view
Dr Vasa Gnanapragasam is a GP in Sutton, Surrey
Having decided as a practice to permit this couple to stay on the list, the practice now has to deal with this problem sensitively.
It is important to ascertain who is initiating these calls.
You should try to ascertain the following: is the couple struggling to settle in the home and somatising their unhappiness; is Mr Jones concerned about his wife’s cognitive impairment and how advanced it is; are friends and family transferring their anxiety and concern to the staff, who in turn are passing it on to the practice; and, finally, do the home staff know how to attend to people with cognitive impairment.
You could consider discussing telephone consultations with the home staff.
Try to speak to a GP from a practice closer to the care home as they will be able to tell you about any recent staff changes or significant events which might explain a perceived high call-out rate.
If the home can allocate a named carer who can liaise with a named clinician at the practice, it will help to develop a good working relationship. This would create an environment of mutual respect and trust where issues can be discussed and enable the home to rationalise their referral behaviour.
Hopefully the practice can keep its promise to the couple.
A medico-legal view
Dr Angelique Mastihi, medico-legal adviser at MPS
Mr and Mrs Jones are registered on the practice list and the terms of service of the practice’s contract with the primary care organisation still apply, even though they no longer reside inside the practice area.
While leaving the practice area is an accepted basis for removal, you have agreed to allow them to remain on the list. You cannot now remove them because of the high input required.
Under the standard terms of GMS and PMS contracts, you must provide home visits where clinically indicated. Although it may be possible to triage requests, it is important to ensure you adequately assess the patient’s condition and requirements.
You may wish to consider meeting Mr and Mrs Jones and their carers to discuss the frequency and appropriateness of requests for home visits. Perhaps the carers feel unable to deal with their needs and this is the reason for the calls.
It may be possible to arrange a regular visit time so that non-urgent issues can be dealt with more efficiently and staff at the residential home have the reassurance that assistance is available if they really need it.
Hopefully agreement can be reached so that inappropriate requests for visits stop. If they continue, the practice might have to consider removal.
If the carers feel that the practice is unable to provide the care Mr and Mrs Jones require due to the additional distance, the couple may, of course, choose to move to a surgery closer to their home.
A patient’s view
Ian Semmons, Patient Partnership Group
Mr and Mrs Jones are two elderly patients with whom the practice has had an excellent doctor–patient partnership over many years. The quality of that is demonstrated by their desire to stay on your list when they moved into residential care.
Concern over the frequency and relevance of calls is totally justified and needs further urgent investigation.
The first step should be for you to arrange a meeting with the management team of the residential home to discuss your concerns. It does appear that questions need to be asked about the quality of care, given the number of calls you are receiving. If the home is registered with the local authority it would make sense to involve a representative in the discussion.
It needs to be established whether Mr and Mrs Jones are generating some of the calls, perhaps to gain reassurance after the uncertainty of the move.
The conclusion must be a care plan that ensures Mrs Jones receives the level of support that she needs, and that the staff in the residential home are competent to deliver it. If this can be achieved then the practice can continue to provide medical care without putting unreasonable demands on your staff.
