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How to... Improve treatment in care homes

Dr Teresa Griffin explains how the Gold Standards Framework for end-of-life care works in practice.

Dr Griffin (left) and Mandy Thorn, owner of Uplands nursing home, work together to improve care
Dr Griffin (left) and Mandy Thorn, owner of Uplands nursing home, work together to improve care

A recent report commissioned by the DoH revealed that for seven out of 10 care home residents, mistakes are made with their medication.

Professor Nick Barber of London University who led the research says GPs, care home staff and pharmacists all have a role to play. But the greatest responsibility lies with GPs. However, with the right systems in place it is possible to deliver high-quality care without draining practice resources.

Practice workload
The Shrewsbury practice where I am a partner looks after 80 patients in the nearby Uplands nursing home that includes 40 dementia patients as well as palliative and intermediate beds.

The PCT pays the practice to look after the intermediate care beds and Uplands pays us for an additional session for the dementia patients.

Some patients understandably want to maintain a relationship with their lifelong family doctor, but the benefits of continuity are outweighed by the potential for inconsistent care, poor co-ordination and strained lines of communication.

Gold Standards Framework
The financial arrangement is not the glue that binds us. My practice has adopted the Gold Standards Framework (GSF) in primary care programme for end-of-life care. Uplands has been through the GSF Care Homes training programme and was awarded beacon status.

GSF is about organisational change, so in practical terms this means that all the staff in the home have a part to play in the end-of-life care of the patients, from the owner to the cooks and the manager to the cleaners.

Clinical sessions
We conduct three clinical sessions at Uplands each week. All the sessions are influenced, but not dictated by the coding of all patients.

We code patients ABCD - 'A' meaning the patient has years to live, down to 'D', only days. Our visits predominantly focus on 'D' patients. Before the session, the home faxes over a list of patients to be seen. On arrival I discuss those patients with the unit managers and will try to include some others. Medication plays a key part in our discussions.

Regular review
The GP undertaking a regular review of patients is perhaps the biggest difference the GSF makes as to use the GSF really well you need to proactively assess patients.

This constant dialogue means that together we maintain control of the patients' symptoms and medication. With this review procedure in place, even when there is a significant change in the patient's condition, what might be an emergency possibly followed by a decision to admit, could be prevented by a quick phone call to one of the GPs.

Out of hours
If an out-of-hours (OOH) doctor has to visit, they are given all necessary information, including the patient's advance care plan, another core element of GSF.

This enables them to make informed decisions about medication and other serious issues such as where they wish to die and whether the patient wants to be resuscitated. Without this level of co-ordination the out-of-hours GP could be vulnerable to inappropriate prescribing and might send patients to hospital against their wishes.

Research shows that care homes that have been through the GSF programme have cut the number of residents dying in hospital by 50 per cent and inappropriate hospital admissions by 40 per cent.

Over 90 per cent of GP practices now have a palliative care register and a planning meeting. Almost two-thirds have adopted a deeper level of GSF and 1,000 care homes have done GSF care homes training.

Care home staff
Uplands' staff have also developed a good professional relationship with their local pharmacy. Speedy and efficient prescribing by our practice would be of little use without this other critical link.

Mandy Thorn, owner of Uplands, and vice-chairman of the National Care Association sees our working relationship as a model for care homes.

'Mistakes can happen. But where GPs have access to medical records, as they have here, and there is a close working relationship between care home, GP, pharmacy and patient these incidences become very rare.'

Ms Thorn adds that NHS Shropshire County and NHS Telford and Wrekin PCT have a very good medicines management programme that has made a huge difference.

'The real message is that good quality training, motivated staff, access to real time information and true partnership working makes all the difference to care,' she says.

  • Dr Griffiin is a GP in Shropshire

The framework Involves

  • Advance care planning discussions for all residents from time of admission to care home.
  • Identification of residents' levels of need and stage of illness, using coding assessment.
  • Improved documentation using special templates and assessment tools.
  • Improved collaboration and consistency with visiting GPs and out-of-hours doctors.
  • Fewer crisis hospital admissions, leading to more residents dying peacefully in the home.


  • Do maintain constant dialogue with care home staff.
  • Do establish a good working relationship with a pharmacist.
  • Do regularly and proactively assess patients.
  • Don't 'crisis prescribe'.
  • Don't leave out-of-hours doctors to flounder without important patient information.
  • Don't overlook the important role played by all care home staff.



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