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Our home visit service freed up GPs – and saved my practice

Dr David Chilvers describes how a dedicated acute home visiting service has freed up GPs from doing hundreds of home visits each month, helping to stabilise his practice for the future

dr david chilvers

The problem

We are based in Gosport, a small town in Hampshire with easy access to some of the best sailing in the world as well as miles of woodland walks in the New Forest and the vibrant city of Portsmouth. However, this is a coastal town with pockets of deprivation and our practice, like others in the area, has had serious problems with recruitment and retention.

Retirement of successive senior partners brought junior partners a step closer to being the last person on the 25-year lease of our premises, which made recruitment even more difficult.

Home visits were a major part of our problem, taking up an hour and a half of GP time each day, causing over-work and low morale, and leaving us little time to think about the rest of the business.

We realised we had to do things very differently.

What we did

We obtained funding from the Five Year Forward View to trial a new home visiting service, with the help of the CCG, our community provider and GPs from our local alliance of four practices, the Willow Group.

Initially we had one senior district nurse doing visits between 8am and 5pm, with GP support available – either telephone or in person – up until afternoon surgery each day. Calls were triaged by a GP at one of the practices, and appropriate calls forwarded to the district nurse. The service has since expanded and now employs two senior and two junior district nurses.

The CCG moved GP practices to a single IT platform that is shared with the community provider, so that the nurses have read-write access on mobile devices in the patient’s home.

Once the service got underway, it quickly became evident that GP support was rarely necessary. Furthermore, we still had two or more clinicians turning up to the same nursing home on a given day, so we are now working with a unified home visit list covering all the practices, which the visiting service oversees. Calls that are not suitable are then passed to the GP surgeries, rather than the other way round.

Results

The service has changed our working day dramatically. In the first month it had had already saved us around 157 home visits; now 13 months on we estimate we are saving 260 GP home visits a month, or 60 visits a week.

There are times when a problem has not resolved with the treatment plans arranged, and these calls get passed back to the GPs. However they are the exception – we might have to deal with one or two consultations a day. Indeed the community team nurses have often shown themselves to be superior in their knowledge of other services and reablement. In the uncommon event of a hospital admission being necessary, the patient will have been seen several hours earlier than they would have been when GPs were juggling visits – meaning they avoid the early afternoon rush of admissions, and helping the hospital to manage the workload. So the service is proving better for patients and the hospital as well as for GPs.

Challenges

Patients were initially sceptical about the service, mainly due to being resistant to change and wanting to continue to have access to their GP. The first week was difficult for the staff, with lots of questions, mainly about process. However this soon improved and the number of visits possible increased rapidly.

The future

Despite the initial scepticism, the service has subsequently had a hugely positive reception in the community.

I am delighted as well. I often have no visits at all, or just a single planned visit, so I can get on with pathology results and scripts in between surgeries. I am able to cope with the workload and I go home at night with much more confidence that we have been able to do a good job.

Moreover, the service has allowed me to stabilise the practice – I am in no doubt that without it, the practice would have folded. As a result, I am planning on staying on as a GP and partner for years to come, rather than taking early retirement.

The service is due to be reviewed in two months, and we are hopeful that the CCG’s Primary Care Committee, responsible for commissioning primary care, will recognise the enormous benefits we have seen and continue to fund it.

Dr David Chilvers is a GP partner in Gosport and chair of NHS Fareham and Gosport CCG

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Readers' comments (7)

  • 'We obtained funding from the Five Year Forward View to trial a new home visiting service'

    So more money and resources help!

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  • But the vicarious liability remains, borne on the shoulders of the dwindling number of GPs.

    Dealing with acts and omissions of others [still accountable as the registered GP] will exacerbate the feelings of burn out and encourage more to leave the profession.

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  • Who will undertake the review in 2 months?
    Can we have some details on what this review entails?
    What are the parameters which will define success?
    Are the visiting practitioners reviewing the problem list, the medications, investigation results, the correspondence pertaining to previous ailments as well as recent events thereby opportunistically identifying the full range of outstanding issues which could conceivably have a bearing on the "problem of the day"?
    Or is it an exercise in "patch the punter up", followed by self-gratulatory smugness for a job done "well" (and superficially)?

    The home visit, in my estimation, should be conducted in a similar fashion to that conducted by the hospital medical registrar who as been asked to review a patient on a ward, admitted under the care of any of the disciplines who has an acute problem which requires a comprehensive evaluation of these aspects in order to correctly assess the problem of the day and identify all the issues correctly.

    I have found it to be rarely done in this fashion by established GPs hence I am sceptical that the scheme described in the article above would do so.

    An example I recently saw- a patient who had been on prednisolone for a diagnosis of autoimmune encephalitis for a number of years. I found questionable evidence for this diagnosis and wrote to the consultant under whose care the diagnosis had been made seeking clarification.The consultant wrote back having reviewed the investigations and having found a normal CSF and no autoantibodies suggested tapering the prednisolone by 1mg/month to zero (from 8mg/day). The tapering commenced but it ended up being the case that the dose went from 5mg to zero due to what I would regard as shoddy practise with poor continuity of care.

    Unsurprisingly the patient had the typical symptoms (non-specific as expected) of adrenal suppression which resulted in a number of home visits, bulls~it diagnoses (UTI, chest infection- you know what I mean) and no improvement. A fully qualified GP "noted" her anemia and some bruising and made a 2WW referral to haematology.The anemia was longstanding and the patient was also anticoagulated.

    Whilst waiting for the appointment a further HV was requested for the same vague symptoms and it landed on my plate.

    By systematically looking at the aspects I mentioned above and the rest-homes drug chart the too rapid cessation of steroids was identified; a postural drop in BP found on examination and the resumption of prednisolone improved the patients condition. With a close eye kept on the rate of dose reduction after a period of stabilisation, the patient has remained well (for them) and the taper proceeds correctly.

    This is a complicated case but much of what we see these days is- if only the situation is looked at properly.

    Finally, the reply from the haematologist was very (and appropriately) scathing.

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  • 'I have found it to be rarely done in this fashion by established GPs hence I am sceptical that the scheme described in the article above would do so. '

    Bully for you IDGAF! Presumably the supply of trained doctors at your level of superior expertise is even lower than that of us lowly GPs so I'm not sure what your comment is adding!

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  • Big and Small @12.12pm.

    What it adds is the unpalatable truth that throughout the NHS (Consultants included) the trend is towards superficial medicine, and many practitioners lack the intellectual honesty to consciously identify and accept this. As GPs we are the last of the true Generalists but sadly, in name only because the training most have is lacking in the depth which is needed to replace the role provided by the General Physician. Having district nurses doing home visits I accept is a pragmatic move due to the lack of GPs and pressure upon us, but the point remains this is dumbing-down and the patients, who may be delighted with what they receive, are poorly placed to really understand the issues around their cases (ie investigations and their implications)which do not come to their attention.

    If you can sit back and honestly say that you would consider the patients casenotes in the way I describe before doing a home visit then you would be one of those GPs who as your quote of my words states is a rarity.

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  • When you have continuity of care in a practice, especially if you are a partner, it is in your interests to do a thorough review of the patient as it saves time later. Do it right first time.

    I suspect that if there is no continuity of care, then it is in the interest of the doctor just to get through their shift. This is why it is so wrong to destroy the partnership model. Sadly I gave up my partnership as I could see the direction of travel, and I am relieved I did so. That does not stop me missing my partnership and knowing it is best for patients and the majority of GPs.

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  • "Gosport, a small town in Hampshire with easy access to some of the best sailing in the world as well as miles of woodland walks in the New Forest and the vibrant city of Portsmouth."

    Sad that such a lovely town has a slightly tarnished reputation at present.

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