Collaborating with the resident’s own GP

Weekends and out-of-hours periods expose the cracks in continuity of care. When the person who knows a resident best (their own GP) is out of the loop, small problems (a change in mobility, a new symptom, a missing medication) can escalate into ambulance calls and hospital admissions.

This post explains why collaboration with the resident’s GP matters, shows the real risks when it’s missing, and gives practical, evidence-aligned steps care-home managers can use tomorrow to reduce avoidable admissions.

Why the resident’s own GP matters

• Continuity of clinical knowledge. The resident’s own GP holds diagnostic context: frailty baseline, prior investigations, code status and what has worked before and all of which improves remote decisions and avoids unnecessary transfers.
  

• Safer medicines management and reconciliation. Accurate medicines lists and reconciled prescriptions on transfer avoid omissions, duplications and harmful interactions which is a frequent reason for escalation.
  

• Faster, proportionate decision-making. When the GP is engaged, clinical queries can be resolved in situ (advice, short-term prescriptions, anticipatory meds) rather than defaulting to 999. Primary-care led interventions have been shown to reduce unplanned admissions.
  

• Regulatory and governance alignment. CQC and NICE expect clear medicines processes and documented clinical oversight where working with the resident’s GP supports those standards.
  
  

What goes wrong when the GP isn’t involved

• Poor medicines reconciliation after discharge - missing or changed prescriptions increase risk of adverse events and re-presentation.
  

• Default escalation to hospital because staff lack confidence or access to clinical directives. Studies link stronger primary-care continuity with fewer emergency admissions.
  

• Fragmented advance care planning without access to prior ACP/DNACPR records or frailty notes, staff may be forced into risk-averse decisions leading to conveyance.
  

• Repeated assessments and duplicated diagnostics which is time-consuming for staff and stressful for residents; avoidable when the GP shares clinical history.

Practical steps to strengthen collaboration (actionable, inspector-friendly)

Use these as a standard operating procedure for each resident and for transfers.

1. Named GP contact on every resident file
   

   • Record the patient’s registered GP practice, named clinician (where available), phone and secure messaging route. Put this on the shift handover board.
     

2. Standard transfer pack (digital + paper) sent at every transfer (to and from hospital)
   

   • Minimum data: current meds (dose/route/frequency), latest MAR, allergies, last BP/HR/frailty summary, recent blood results (if relevant), DNACPR/ACP status, reason for transfer and expected follow-up. Use a one-page template and require sender signature. (Medicines reconciliation guidance supports this practice.)
     

3. Pre-weekend GP check-in for high-risk residents
   

   • Every Friday: identify residents with <7 days supply, time-critical meds, recent instability, or planned hospital discharge and proactively contact the GP for prescriptions/anticipatory plans.
     

4. Shared decision templates for out-of-hours queries
   

   • Create a short script staff use when contacting the GP or an out-of-hours clinician: include baseline, current concern, observations, current meds, what has been tried, and the resident’s expressed wishes/ACP.
     

5. Agree roles and escalation pathways with the GP practice
   

   • Define when the GP will accept clinical advice calls, when the care home should use an out-of-hours service, and how follow-up will be recorded. Document the agreed response times and what constitutes a handover back to the GP.
     

6. Medicines reconciliation within 24 hours of transfer
   

   • Ensure reconciliation is completed, documented in MAR and communicated to the GP if changes were made. (This is consistent with national medicines-safety guidance.)
     

7. Weekly governance summary shared with the GP practice
   

   • Short report of incidents, near misses and learning outcomes builds trust and demonstrates joint quality improvement.
     

How out-of-hours GP services (RTCGP) bridge gaps

When the resident’s own GP is unavailable, a doctor-led out-of-hours service can act as a safe bridge, but only if collaboration and information flow are designed into the pathway:

• Triage with access to the resident’s records (or a concise transfer pack) enables clinicians to make proportionate decisions without default hospital referral.
  

• Same-day prescribing and coordinated medicine delivery avoids admissions driven by simple supply gaps.
  

• Documented short-term plans and weekday handback ensure that any temporary measures are reviewed by the resident’s GP, protecting continuity and governance.
  

• Clear escalation protocols for controlled drugs, end-of-life care or frailty crises keep care in the home when appropriate and safe.

(If you have a named GP practice partnership, agree in advance how a third-party weekend service will communicate decisions back to the registered GP where a short daily summary reduces duplication and risk.)