Local MP demands weekly home visits for his elderly mother
Three GPs share their approach to a practice problem
Three GPs share their approach to a practice problem
An elderly patient who does not seem to have that much wrong with her and yet requests a steady stream of visits is now demanding that you come and see her every week. She tells you she cannot cope with her pain and it is her right to be visited. Her son, who is the local MP, is backing her demands. However in the local paper, there is a picture of her helping out in a local charity shop. One of your partners wants to remove her from the list, while the other says you should visit whenever she asks for it. What should you do?
Dr Elizabeth Scott
'I am not going to be intimidated or bullied into routine home visits'
I am not going to be bullied by my partners nor intimidated by letters on notepaper bearing the famous on House of Commons Portcullis. The Portcullis used to be on the old threepenny coin and that is all it is worth. In a year or two her son will be grovelling to me to ask my patients to vote for him. Her insistence on weekly visits is no more than the next step of the ageing attention-seeker. She is also probably making her son's life hell, which is why he wants to offload her on me while appearing to be super-caring.
But behind her behaviour is a real cry for help that I should not ignore. She is afraid; afraid of illness and death creeping ever closer, afraid of loneliness, afraid as many older people are as they notice 'senior moments' – can't hear the television, can't see the bus numbers. So striking her off my list is not an option.
However, routine visits for no reason are poor medicine, carrying the risk of missing the weight loss, the depressed faces, the increased difficulty in getting about that are all such valuable pointers to early diagnosis. They also create a dependent patient who can't manage without the doctor. That is a rod for any practice's back and not worth risking.
I have faced this problem before and am not prepared to give in to her demands. I had a patient just like her, whose son owned much of the local property. Faced with a similar demand, I asked both of them in to evening surgery. I explained that the time I wanted to see the old lady was when she felt unwell. I also explained that I would prefer it if she could be brought to surgery in the morning as I could then do any tests I thought fit and get the results off to the lab. I also suggested regular visits to our well-woman clinic. I explained that I saw her out shopping by herself frequently so I did not think I was asking for much on her part.
Their response was to bridle a little and talk about long waits in the waiting room. I accepted this, apologised and promised to make sure she was seen on time. This apparent offer of special treatment cheered them both up and saved face on all sides. At her next visit she said she enjoyed discussing her problems with the nurse in the well-woman clinic, aware that I would be told anything significant.
I also ran a few routine checks – which seemed to reassure her more than any of the home visits. I then said that this regime was what I could offer and if they felt it was not what they wanted they should feel free to find another practice whose care they preferred. That stopped them both in their tracks and I sent away a very thoughtful pair.
I then explained my theory of good care and confessed that I too had been getting anxious because reliance on so many home visits was not allowing me to form a proper assessment of her condition since they were done by the doctor on call, thus preventing continuity of care. I told them that my preferred option would be a six-monthly booked surgery visit attended by both of them to air any anxieties they had. I reassured them that if the old lady was unwell, she would be seen promptly in surgery, if possible by me. I also mentioned the possibility of regular visits to our well-woman clinic whose nurse would pass on any concerns to me.
Dr Iain Mclean
'Weekly visits are not justifiable on clinical, ethical or practical grounds'
Every practice has its demanding 'worried contingent'. Such folk are characteristically self-centred and prepared to commit more time and effort to manipulate their practice team than the team can provide for their care. Practices need a consistent plan to deal with these situations.
Once a verbal or written modus operandum is agreed it should be impartially applied. Relatives, VIPs and friends should all be treated equally and fairly. Your response to this patient's demands is simple: the answer is no. Weekly visits are not justifiable on clinical, ethical or practical grounds. Where a crisis exists, a week is too long. Where chronic pathology preventing consultation at the surgery exists, a week is too short.
At my practice we would take the initiative. I would visit to establish the complaints, diagnosis and treatment and/or onward referral. The issue of visits would be raised with the clear statement that weekly visits would not be done. Such visits would be detrimental to her care and an abuse of NHS resources. Patients attend the surgery unless they are confined to their home.
Given her son's interest in doctors visiting his mum she should be told the practice will write to him explaining these points, and that if this is unacceptable to her we would understand if she chose to change practices but felt it likely that she would receive a similar response from other practices.
A short letter to the MP would then be required. Keep it simple and leave out the humour. Politicians and the media are masters of distortion. The following points should be made. First – practice policy is to treat all patients equally and appropriate to need. Second – a demand for weekly home visits is an abuse of the NHS. Third – while the patient is fully protected by the health service code of confidentiality, any correspondence with the MP is in the public domain and attempts to abuse the system will be robustly resisted.
I've always been surprised by these types of patients. Often they are the 'worried well' with little experience of ill-health, who come to a working agreement when the issue of 'right to regular home visits' comes up. I've also been intrigued by those who leave the practice. Each practice will have its own historical method of providing care in the home and the approach to this woman will be informed by this.
Dr Julian Randall
'Play safe – set aside the situation and your reaction and be objective'
It's a Hippocratic first principle that the patient's social standing must not affect your judgment, for good reason. VIP patients have a reputation for developing bizarre complications, because of our primate instincts to recognise status. We manage them differently out of false courtesy. Then, already on unfamiliar territory, we can't recognise the early signs of deviation from normal progress when things go wrong.
So play safe. Set aside this patient's VIP relative and your emotional reaction, and be objective. Are you sure there's nothing wrong with her, or is it infuriated presumption? Have you done everything necessary to find out, or begrudged the effort? Study the notes for clues and omissions, and, this once, yield to her demand for a visit.
Take the history, do the examination, and then decide. This family has started with the conclusion that it's dreadful how GPs don't do house calls any more, a potential cause celebre, and they are setting you up as consistent with that assertion. So frustrate them. Visiting once more will deny them the opportunity for righteous indignation.
However, you are still heading for a confrontation, because even if you aren't acting unethically, the other party is. They may not be throwing physical weight around, but they still have power that others lack, and are abusing it. There's a good reason why we don't make unnecessary home visits: we owe an equal duty to each and every one of our patients, in limited time. When one is favoured, others must be denied.
You must explain this to the family clearly. Telling it straight is enough for the reasonable man; if he's unreasonable, nothing you say will do. If the family still tries to wrongfoot you and appeals to authority, then you must too. You have the right to remove this patient from your list, but will need to give them written notice. Whichever way you decide, don't go it alone. Involve the proper channels and inform your PCT. If your politician knows he's not taking on an individual but a trust he may back down – he knows it could rebound on him. Demanding preferential treatment on the NHS offends voters and brings the party into disrepute.
What does this teach us?
A routine follow-up
- May be justified during an acute illness but detailed advice to patients about when and why to consult again is usually safe, more convenient to patients and safeguards appointments
- Is necessary for chronic disease management – for example, in diabetes or mental ill-health
- Can often be achieved by telephone, or safely delegated to the practice nurse, community psychiatric nurse and so on
- Should be carried out at home only if the patient is truly housebound
- Has its own risks – the GP may fail to seek or recognise the significance of new symptoms or information; the patient may become disempowered or dependent on the doctor
- Is not justified by a patient saying they have no transport to surgery – but it may be safer to go and argue later
Encourage patients to visit the surgery
- It is safer for patients as they can be offered the full range of care in an optimum clinical environment, with full access to records, other health professionals and chaperones
- It is therefore safer medicolegally
- It is more efficient – the consultation can often be wrapped up in one go, and GPs can see three patients in the surgery in the time it takes to do a visit
- Very few patients are truly housebound – but again it might be safer to make the home visit and argue later, when you will be on firmer ground
- A home visit is not a right – patients have a right to a consultation, but at a time and place deemed appropriate by the GP
- Be flexible – offering to see a patient when a relative can bring them or enabling them to see their doctor of choice is often less disruptive than a home visit, and establishes the principle of surgery consultations
- But remember a surgery appointment is not always appropriate or necessary. The patient may be better managed with telephone advice, referral to another health service, social services, A&E or occasionally dialling 999
Treat patients equitably
- This is an ethical requirement
- Patients should not be removed from the list without a warning that repeated difficult behaviour may lead to removal (but violent patients can be removed without a warning)
- Relatives may have their own agenda and should not be assumed to be speaking for the patient. You should not act or divulge information without the patient's informed consent
Melanie Wynne-Jones is a GP in Marple, Cheshire