Fears that nursing home referrals to GPs and A&E wards were excessive and inappropriate were not borne out by a health authority study. Ali Zaatar reports

The roles of the acute sector, primary care and nursing homes in the care of older people are constantly changing. The past few years have seen substantial change in arrangements for continuing care. Changes in policy have moved the long-term management of chronic conditions away from secondary care settings.

1 These changes have an impact on the independent care sector and primary care.

It is well known that we are moving towards an ageing population. The over-75s are the fastest growing sector of the population and, by 2030, an estimated one-third of people will be of pensionable age.

2Sefton in Merseyside has a population of 283,723 across all ages, 9. 5 per cent of whom are over 75. This group is expected to make up 11. 8 per cent of people in the area by 2021.

These over-75s live either in their own home, or in residential or nursing homes.

Evidence suggests that older age groups have more contact with GPs than younger ones. A 1996 study showed that the number of people over-85 consulting their GPs increased by 30 times on the previous year.

3These findings were echoed by later research looking at older people with complex needs in the Sefton borough of Southport.

4Sefton has many nursing and residential homes. A 1999 survey showed that there were 176 nursing and residential home places per 1,000 people aged over 75.

5This was the third-highest figure in the North West. It was divided among 170 homes: 105 residential, 58 nursing and seven dual-registered.

These varied in size from four to 121 beds, with 70 per cent having between 16 and 40 beds.

The same survey showed that, between 1995 and 1999, the North West experienced a reverse in the nursing home growth trend. In this period, 27 nursing homes have closed, with a loss of about 525 beds. Nevertheless, the continuing increase in older age groups and the still relatively large number of nursing and residential homes in Sefton has implications for primary care services.

In June 1999, as a result of GPs' concerns about the increasing numbers of referrals from nursing homes, Sefton health authority commissioned the healthcare practice research and development unit at Salford University to carry out a nine-month research project. The project aimed to establish:

the level of emergency/unplanned referrals from nursing homes to primary care and accident and emergency departments;

whether these referrals were 'appropriate', from the perspective of the GP, A&E department staff, the nursing home, the resident and relatives;

the reasons for the emergency/unplanned call-outs.

Results Interpretation of 'emergency or unplanned' referrals to GPs varied greatly, but there was consensus on what constituted an emergency referral to A&E.

The initial retrospective census questionnaire to all nursing homes attracted a response rate of 66 per cent. No differences were found between responding and non-responding nursing homes in terms of location, number of beds or type of nursing home.

The level of emergency/unplanned referrals to GPs in the seven-month retrospective survey period (January-July 1999) totalled 807 for 47 nursing homes, an average of about 2. 45 referrals per home per month. The comparable figure for the three-month prospective survey (November 1999-January 2000) was 160 for 12 homes; that is, an average of 4. 44 per home per month.

This difference, although probably because of the time of year when the data was collected, could also be a result of different practices, skill-mix and/or training. As for referrals to A&E, in the retrospective census there were 124 referrals (about 0. 38 per home per month compared with 0. 44 per home per month in the prospective survey).

Both retrospective and prospective surveys showed similarities in the main reasons for referrals, with chest infection the most common one, followed by change of medication. GP alteration of medication was also the most common action resulting from the referral, occurring in 65 per cent of cases.

Although there is a moderate correlation between the number of beds in the home and the number of referrals, this did not seem to be affected by whether or not the home had a GP on retainer or the occurrence of routine visits.

Appropriateness of referrals The interview data did not indicate that inappropriate referrals were a significant issue.

Focus lay rather on the time of day when the referral was made. The researchers felt that, instead of exploring whether a referral was appropriate or not, it might have been more relevant to explore what action could have been taken to prevent and/or delay a visit being made, and what extra training and support the nurse might need.

Nursing home matrons drew attention to a number of things that the nursing staff did before calling for medical advice and intervention. At the same time, some GPs noted that a number of referrals related to 'the nursing role', in particular, pressure ulcer and wound care. This has implications for the education and training of nurses working in continuing care. Nevertheless, the interviewed residents were satisfied with the GP's response and action after a request for an unplanned visit.

GPs we interviewed pointed to a range of factors affecting the level of nursing home referrals. These included the training and confidence of nursing staff, staffing levels and continuity, the use of agency staff and their levels of experience. Other factors were the relationship and trust between GP and the nursing staff, their own familiarity with the resident, use of on-call service and provision of advice by telephone, prescribing arrangements and family or resident wishes.

Similarly, there were no differences in the factors highlighted by nursing home matrons. They pointed out that accepting GP phone advice could prevent a visit being made. Nursing homes that received routine visits from GPs thought this represented 'good continuity of care'.

Nursing home staff perceived that there were fewer unplanned referrals for residents whose GPs made routine visits. But the survey data did not bear this out.

Implications for homes and primary care This research has implications for the services provided by nursing homes and primary care. A set protocol for classifying, and thus prioritising, emergency referrals should be considered. This would help consistency.

The value of routinely recording the number of and reasons for emergency GP referrals should also be examined, along with what appropriate action nurses could take to prevent or delay an emergency referral. Benchmarking staffing, training and other support profiles are other potential solutions.

HAs should examine the potential role and contribution of a nurse specialist in meeting client needs and supporting the work of GPs within the continuing-care area.

The costs and time for training need to be addressed in a supportive manner, both within and for the independent continuing-care sector. Training for GPs in the needs of patients in the continuing-care sector should also be looked at.

Finally, the link between dependency, referral patterns and GP workload may be worthy of further examination as part of an audit of care.


1 Department of Health. The NHS & Community Care Act. Stationery Office. 1990.

2 Richard T. Aging Costs. Br Med J 1998; 317: 896-900.

3 Aylin P, Majeed F, Cook D. Home visiting by general practitioners in England and Wales. Br Med J 1996; 313: 207-220.

4 Furnish S. Towards Managed Care: meeting the needs of older people with complex needs in Southport and Manchester. University of Manchester, 1998.

5 Ball P, Miller J. Managing The Community Care Market: surveys of nursing and residential homes for older people, Sefton 1993-99. North West Business Management Working Group, 1999.