General practitioner involvement in a group home

This paper describes the experience of a general practitioner employed to provide physical care to 12 highly dependent residents of a group home. In the first year after their discharge from hospital the residents required a mean of 15 contacts each, 90% of which occurred during regular twice-weekly visits to the home. Previously unmet needs for physical care were identified on screening, including visual, dental and footcare problems which were usually correctable. Smoking and obesity were common and resistant to intervention. Shared care policies are described which were developed together with the nursing staff and visiting mental health professionals.

Many long-term mentally ill people now live in staffed group homes in the community. General practitioners (GPs) should ideally provide their primary medical care. However, there are potential problems to be overcome.
First, a GP who takes on all of the residents of a group home faces a significant workload. The long-term mentally ill suffer increased cardio vascular and respiratory problems (Allebeck, 1989) and are often demanding of a GP's time. Horder (1990) surveyed three staffed hostels in north London. Two of the three had difficulty finding practices willing to take on the resi dents, who were subsequently registered with a number of different GPs. In these two homes visiting psychiatrists provided some care for physical problems. Despite this, the residents made frequent demands on their GPs, with con sultation rates two to three times higher than average.
The second potential problem is poor com munication between the hostel staff and the practice. Horder found that staff had concerns about medical cover, particularly out-of-hours, and wanted clear policies to cover psychiatric and physical emergencies as well as minor physi cal problems. Having separate records for psychiatric and physical care was a potential source of confusion and duplication of effort. The GP notes were usually kept at the practice and were not available to the psychiatrist, or to other GPs who might be called out-of-hours. She suggested each resident should have a record kept in the home, available to all staff. Allen (1992) interviewed hostel staff in Gloucester, and the GPs who looked after their residents. The staff felt the GPs could improve the accuracy of their prescribing and be more welcoming to the residents. The staff wanted meetings with GPs, receptionists and practice nurses to discuss roles and expectations. The GPs wanted long-life drug charts in the homes, with prescriptions ordered regularly rather than on an ad-hoc basis. They also welcomed the idea of meetings with staff.
Horder recommended that all the residents of a group home should be registered with a single GP, in order to develop consistent management policies together with the staff. She suggested that extra remuneration might be provided for such work, which is additional to the general medical services covered by capitation fees and other allowances.
I am the GP for 12 residents of a highdependency group home in my practice area. The residents present many behavioural problems and have spent many years in and out of psychi atrie hospitals. Previous attempts to discharge them had failed, including in some cases place ments in less well staffed community homes. The home has qualified mental health nursing staff on duty 24 hours a day plus visiting psychia trists, a psychologist, social worker, and occu pational therapist. I accept the registration of all the residents and provide general medical ser vices. Mypartners cover my absence in the usual way. In addition to this, I am employed as a clinical assistant for a number of extra duties, including developing policies for shared care with the specialist team.
This paper describes the GP workload in the first 12 months of the life of the home, after the residents were discharged from hospital in early 1993; the residents' physical needs, including unmet needs revealed by screening; and shared care policies which have been developed.

The study
To measure workload, I examined the residents' GP case-notes and extracted data on the frequency and nature of their GP contacts in the 12 months after their discharge from hospital.
To assess needs for physical care, I screened the residents within the first two months after hospital discharge, with a standardised medical assessment including a full physical examina tion, urinalysis, full blood count, thyroid func tion test and chest x-ray. Other tests were performed if they were indicated.
Management policies were developed with the staff both informally, as problems arose, and more formally in the weekly multidisciplinary team meetings. The areas covered were incor porated into a contract between the practice and the community unit managers. day the local psychiatric unit staff were available for any psychiatric emergencies. Out-of-hours, the duty GP was called initially, for psychiatric as well as physical problems. The local in-patient psychiatric unit agreed to admit patients urgently who could not be managed in the home.
The ordering, storage and administration of drags. The psychiatric staff remained respon sible for the prescription of psychotropic drugs, while I prescribed for physical problems. Regular repeat prescriptions were provided in synchro nised two-monthly batches of FPlOs. In addition I wrote up the drugs on the home's prescription charts.

Workload
The average annual consultation rate was 15.3 (range 4â€"46), compared to an average rate of 2.9 (range 0-18) among a random sample of 100 adults in our practice. Most of the residents could not be relied upon to get themselves to the surgery (two miles away, with no easy public transport) and over 90% of the contacts took place during my regular twice-weekly visits to the home. There were eight out-of-hours visits in the 12 months.

Physical problems
Nine of the 12 residents smoked, in each case more than 20 cigarettes per day. Attempts to persuade them to stop, including offering nico tine replacement therapy, were universally un successful. Four were obese (defined as a body weight more than 10% over desired weight) which seemed at least in part to be due to the side-effects of neuroleptic and antidepressant medication, which could not be stopped safely. Six residents had neglected foot problems requir ing chiropody, which significantly improved the mobility of two. Four were found to have reduced visual acuity, one of whom had not previously been provided with spectacles. Six were found to be in need of dental treatment. Table 1 shows that a high proportion of the other physical problems found were either previ ously unrecognised or in need of further treat ment. It also shows some of the difficulties encountered in providing care.

Shared care
The following areas were addressed: Division of responsibility between GP and psychi atric staff. An experienced psychiatrist visited the home three times a week. In addition, during the Equipment needed Jor physical care to be pro vided in the home. This included a stethoscope, sphygmomanometer, auroscope and ophthalmo scope, scales, urine testing sticks, urine and blood specimen bottles, syringes, needles, swabs and request forms.
General medical records to be kept in the home. Each patient's problems were recorded on a summary card which was placed prominently in the front of the medical record. This is to be replaced annually. The card enables any GP called to the home out-of-hours to grasp quickly the patient's past history and main problems.
Availability to speak to residents' relatives. Rela tives were seen at my regular twice-weekly visits to the home, and could telephone me at my surgery at prearranged times.

Comment
This study confirms that providing good quality GP care to a group home can be very timeconsuming. It demonstrates some of the advan tages of having a single GP primarily responsible for all the residents, and some of the issues which should be addressed in order to share care appropriately. The model of care described, with regular visits by a single GP, is particularly suited to very dependent residents who cannot be relied upon to attend surgery premises, and who need a high level of continuity of care. It is not the only possible model, however. Less dependent residents might be better able to attend surgery, if and when they decide them selves that they need attention, which might help to encourage a more normal and perhaps less institutional existence.
Physical screening of such disabled mentally ill patients seems worthwhile, at least on one occa sion after they leave psychiatric hospital. Previ ous studies of screening long-term mentally ill  (Brugha et al, 1989;Honig et al, 1989). However, some problems, particularly smoking and obesity, are not very amenable to intervention.
Providing primary care to a high-dependency group home is a challenging task but one which I have found rewarding and never boring. The difficulties in providing a high level of care to such disabled residents and support to the staff should not be underestimated, and should be recognised by way of remuneration in addition to the usual fees for general medical services.
Tony Kendrick,General Practitioner,Health Centre,Stepgates,Chertsey,Surrey KT16 8HZ and Senior Lecturer,Division of General Practice and Primary Care,St George's Hospital Medical School,Cranmer Terrace,London SW1 7 ORE Links between fund-holding general practices and mental health professionals

T.I. R, Mutale
A postal questionnaire was sent to a random sample of 300 fund-holding general practices. Respondents were asked to indicate if they had links with a psychiatrist, community psychiatric nurse or psychologist; 210 (70%) general practitioners returned completed question naires. Out of 210 practices 161 (77%) had links with at least one specialist mental health professional. Com munity psychiatric nurses had links with more practices than psychiatrists or psychologists. Problems with time or space made it difficult for practices to form links.
Patients with psychological disorders make up one fifth to a quarter of the workload of the average general practitioner (Shepherd et al, 1966). The recent shift of mental health re sources to community-based care has led to a greater need for specialist input at primary care level. Some GPs have responded to this need by establishing links with mental health profession als (Thomas & Corney, 1992). Fund-holding practices, who are direct purchasers in their own right, are in a powerful position to influence such links.
This study set out to determine the extent and quality of links between fund-holding practices and a broad range of specialist mental health professionals. Previous studies have determined links between GPs and mainly one type of pro fession (Brown & Tower, 1990). Those that have looked at links with a wider range of profession als have not determined the quality of the links found, or made a distinction between child and adult mental health practitioners (Thomas & Corney, 1992). This study remedies both these shortcomings. In addition, it is the first survey to study the impact of fund-holding on working relationships between mental health professionals and GPs.

The study
In May and June 1993, 300 general practices were chosen from a list of first wave and second wave fund-holding practices in the United Kingdom, using a random numbers table. One