GPs demanding fees from care homes must justify their charges to avoid provoking a scandal, says Stuart Shepherd

As some GPs continue to charge retainers for visits to residential and nursing homes, it’s essential for them to understand what services should be free of charge and which are “enhanced”.

The practice among a significant number of GPs of requesting retainer fees from care homes to secure primary care, rather than additional non-general medical services for their residents, was brought to the fore by the House of Commons Health Committee elder abuse report of 2004.

14% - PCTs aware of GPs refusing to visit residents not paying a retainer

61% - PCTs that agreed retainer fees should be banned

Wide variations in the costs of these retainers (from £897 to £24,000 per year) and the refusal of some GPs to retain all existing patients or accept any new registrations without them, were further highlighted in the 2008 English Community Care Association report Can We Afford The Doctor?

Yet, as a more recent report of a survey conducted by the ECCA called Post Code Tariff would appear to suggest, awareness of GP retainer fees across PCTs in England remains patchy and attitudes towards the practice are, perhaps, mixed.

Of the 29 primary care trusts that responded to the survey, just over half (55 per cent) said they were aware of the practice of GPs charging retainers for visits to care homes, 14 per cent were aware of GPs refusing to register or visit residents without a fee, only 10 per cent had guidelines or policies and, most interestingly maybe, that 39 per cent of PCTs did not agree that retainer fees to care homes should be abolished.

Recommendations within the report include PCTs ensuring their GPs keep to the terms of their contracts, national guidelines on enhanced services with guidelines on appropriate and transparent costings and, where retainer fees are paid, a fair tendering process.

A number of examples of best practice populate the report and demonstrate where strategic approaches have been implemented to support the provision of primary care services to residential and nursing homes. These include the services provided by NHS Wandsworth to the 200 bed Nightingale House on a personal medical services contract arrangement.

“The Nightingale Practice is, as far as we know, the only dedicated registered practice with a care home setting,” says Leon Smith, chief executive at Nightingale. “About 10 years ago, having paid a retainer to a local GP, we decided it was ridiculous. The local PCT supported our position and have been incredibly helpful in drawing up what is a complex contract.”

The British Geriatrics Society special interest group in primary and continuing care has been studying the demands that care and residential homes place on GP practices and primary care responses to them.

“The number of GP contacts that residents have - it can be dozens over a period of six months - is quite staggering,” says Dr John Gladman, co-chair of the BGS special interest group. “In County Durham they have set up a practice whose sole role is to look after the care home sector. Further afield, in Holland, nursing home medicine is a distinct discipline, separate from general practice and geriatric medicine.”

A dedicated practice at NHS Salford

Equitable Access to Primary Medical Care procurement provided NHS Salford with a timely mechanism to push through a strategy it had been formulating to respond to levels of “underdoctoring” across the patch and provide a city-wide GP practice dedicated to residential and nursing home patients.

“The practice has both a reactive service - responding to calls for urgent visits - and a proactive team that visits homes systematically to undertake care reviews,” says Richard Freeman, associate director of primary care commissioning. “It’s an effective way of ensuring a high-quality service to a vulnerable group while improving access all round. Mainstream GPs won’t be going out on daily time-consuming visits to several homes at a time.”

Open since July, registering for the service is a patient or family choice. A number of enhanced services have been written into the contract, quality of dementia care being one.

“With half of the care home patients having some form of dementia, we specified that the practice had to have at least one GP with psychogeriatric experience,” says Mr Freeman. “They will develop expertise in this area and go on to support the rest of the health and social care sector in Salford, training professionals to spot early signs of the disease and seeing patients from other practices to help with care planning.”


English Community Care Association

British Geriatrics Society

Nightingale House