Authors' objectives: 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. 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. General practice provides the point of first medical contact within the healthcare system for residents of UK care homes. Good primary care may enhance residents’ health and well-being and optimise use of hospital services. Yet there has long been a widely held view that care home residents do not receive high-quality primary care. Care homes are challenging settings in which to implement the vision of dignified, person-centred care outlined in government policy. General practitioners (GPs) are tasked with working in partnership with residents, helping them to find their voice, while working more efficiently, and integrating with other community and secondary care services. There has been great heterogeneity in the organisation of general practice services for care homes, both in the number of practices providing services to an individual care home, and in nature, frequency and regularity of primary care contacts with a particular home. NHS England funded the Vanguard initiative (2015–8) to identify and support innovative ways of working with care homes in five areas. This was followed by the introduction of a new policy [Enhanced Health in Care Homes (EHCH), implemented 2020–4] to standardise aspects of health care for residents. This report will address the question of how the organisation of GP services impacts on care home residents’ and staff experiences and examine selected aspects of care over time as the new policy is first introduced. The overall aim is to identify effective ways of serving this important group of patients. The aim was to identify effective ways of organising general practice for care homes and understand the experiences of residents, general practice and care home staff. Research questions In what ways is the organisation of general practice for care homes associated with better resident outcomes and experiences? What are the implications of different models of GP involvement for residents’ service use and costs? What are the perspectives of residents, relatives and staff in general practices, commissioning organisations and in care homes, on different ways of organising primary medical services for care homes? Which are acceptable and associated with positive experiences for staff, residents and relatives?

Authors' results and conclusions: 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. 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.

Authors' recommendations: Research into promotion of relational practice between care homes and primary care Promotion of ways of working that prioritise helpful relationships in health and social care (relational practice) has potential to enhance outcomes for care home residents. Previous work has established the importance of an atmosphere of respect and trust, a purposeful focus on relationships; and a physical environment that supports nurturing of relationships and individual autonomy. Our work identified additional factors that may be influenced by general practice – continuity of care, sensitivity to the expertise of care home staff and a willingness to dedicate time to patients. How to foster and sustain these attitudes and values, in the dynamic and pressurised environment of English primary care, is an important concern.

Authors' methods: Survey of general practices (2018), qualitative study (2019), analysis of primary care data (2019–21). 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. 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. 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. Methods: survey of general practices working with care homes A fixed-response e-mail survey was designed for completion by practice managers, administrative staff or GPs in England. The survey collected data on practice and care home characteristics, GP staff visits to care homes, and ways of working. Seven items were closely aligned with the organisational changes that occurred in the areas where NHS England Vanguard care home initiatives were introduced. Information about the survey was distributed to Clinical Commissioning Groups (CCGs) who circulated to practice managers by e-mail. Individuals who were interested in participating were sent an information sheet and consent form, followed by an electronic copy of the study questionnaire. The data were aggregated and analysed using frequencies and percentages. Hierarchical clustering analysis was used to classify practices into groups based on their responses. Interviews were conducted with GPs, practice managers and receptionists, care home managers, nurses, senior carers, residents, relatives and service commissioners. Interviews explored perceptions of the different models of general practice care, positive and negative consequences of different ways of working, how different models of care influence staff experiences, job satisfaction and resident and family experiences, and the underlying structures, processes and values that perpetuate these models. Fieldwork was conducted in three contrasting areas of England. Two had recently implemented new models of GP care for care homes, and the other had had no recent innovation. We used information collected in the survey to target care homes of a variety of types (residential/nursing/mixed), area-level social disadvantage and local GP practice size. Commissioners were recruited via existing links with the research team, public CCG/local authority staff lists and snowball sampling (where participants suggest another potential participant working in a similar commissioning role). The interviews were audio-recorded, transcribed and analysed using a thematic approach. Line-by-line coding generated an initial thematic framework that was refined as data collection progressed. The finalised framework was then placed into a wider structure of context, organisation, individual and system to ensure consistency of coding and agreement/refinement of themes. Our approach was both iterative and inductive; we interrogated the data to answer our research questions and also identified new themes. QSR international NVivo 11 (Warrington, UK) software was used to manage the data. We analysed data from Clinical Research Datalink Aurum, which contains longitudinal primary care records of 14.8 million individual patients. Residents aged 75 years + who contributed person-time for all or part of 2019 or 2021 were included. Data on contacts, referrals and prescribing were extracted. Analyses were completed using R version 4.2.2 (The R Foundation for Statistical Computing, Vienna, Austria) and IBM SPSS 29.0.0.0 (241) (IBM Corporation, Armonk, NY, USA).

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/14/196/05

Year Published: 2025

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/YNDV6358

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: United Kingdom

DOI: 10.3310/YNDV6358

Organisation Name: NIHR Health and Social Care Delivery Program

Contact Name: Rhiannon Miller

Contact Email: rhiannon.m@prepress-projects.co.uk