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Gold, incentives and meh

Should GPs stop doing home visits?

Dr Ellie Cannon and Dr Charlotte Alexander go head-to-head, as GP leaders at the England LMCs conference vote for a motion for home visits to be removed from core GP contract work

charlotte pic

 

YES - When was the last time your home visits genuinely helped patients?

I understand that this leads us further down the road of corporatisation and away from the Doc Martin model of care, but trying to do both is killing us. We all want to be the friendly local GP who knows the whole family, but when was the last time you attended a patient at home that you knew well and genuinely helped them?

Longstanding partners may know patients in their community well, but it’s often salaried doctors who do the visits, which are sometimes the first and last time they’ll see a patient before they die.

The subsequent work entailed to register the death, console a grieving family who they’ve never met, and conduct time-consuming visits feels mind-numbing, not rewarding. The feeling is one of resentment, not empathy. Is this how we’d want to die?

I don’t disagree with the home visit as a part of overall care, but it can’t continue as it is. It will have to be removed if it can’t be properly funded within the contract. The clause in the GPC contract which states that a GP isn’t obliged to visit, unless it’s clinically necessary, is just a way of underfunding it. Who can really judge this over the phone?

We often have to visit, as our goodwill and sometimes anxiety that this one may be serious overrides our sense that we haven’t got time. We often find that it wasn’t ‘clinically’ necessary, causing frustration and stress at not having done other work - but we must be careful here.

We often find that it wasn’t ‘clinically’ necessary

If we decide our workload on that basis, we write ourselves out of a job. If we forget the reassurance that doctors provide to patients, families and care home staff, we lose a sense of purpose.

My choice would be for a GP practice to bid for the funding to employ an additional GP to undertake home visits on the day and help with the duty list. This could be done in rotation throughout the week, giving support, continuity of care, variety of work. We know that the Government won’t fund this, though - a home visiting service with paramedic practitioners will be deemed more cost effective.

We’ll still have to do the paperwork, sign the prescriptions and liaise with the family - we just won’t have to get into a car.

To the public, this will seem like another example of lazy GPs who don’t want extra work. 

The rise in locum chambers, salaried doctors who’ll only do limited days, and the private sector tells us that we’ve had enough. We may not be brave enough to say it and we may feel a sense of heroism that we can still shoulder it, but illness, depression or long sabbaticals often prove otherwise.

Nobody wants to jeopardise the care of the frail, but we’re no longer in a position to fill the gaps from poor social care and a loss of the family network.

Dr Charlotte Alexander is a GP in Surrey

15 dr ellie cannon

NO - If we’re not giving healthcare to the most vulnerable, then who are we seeing? 

I don’t see how GPs can stop doing home visits, and I, for one, don’t want to. For patients who are terminally ill, truly bedbound and genuinely too unwell to leave the home safely, it's essential for them to be able to see their regular GP.

At the risk of sounding like an old romantic – if we’re not giving healthcare to the most vulnerable, then who are we seeing? Saving our time for QOF points and targets?

There are a myriad of ways we could improve efficiency to free up this essential time in general practice. Let’s reduce the DNAs, the viral URTIs, the inappropriate face-to-face appointments and form filling, so we can have the time for home visits.

I’m happy to Skype and text the digitally-enabled and savvy, to free up other clinic time for home visits.

It’s fair to say that home visits are a spectrum, and my experience may not be what other GPs face. I work within a large area of social housing in north London: it’s densely populated and most of my home visits are on foot.

It can often take me less than five minutes to get to a patient. When I'm on call, I can see three or four patients at home in an hour.

Sometimes, when I’m talking to an elderly patient on the phone, who may be hard of hearing or struggling, I say ‘don’t worry, I’ll just pop in’ - maybe it’s because my clinic room is a basement and it’s a good excuse to get out!

Losing home visits would knock out what it means to be a true generalist

Seriously, popping out to a home visit, even in a crazy, hectic day of 50 on-call patients to phone, is good for me too. Some housekeeping time, some fresh air - it’s no bad thing.

And there's a huge amount to gain from seeing a patient at home – how they're truly living, and who's supporting them. More often that not, it's home visits that prompt me to offer social care involvement and increased support that wouldn't have been apparent if I’d not seen a patient myself. The holism of general practice.

Community services do an amazing job for our practice – we're well served, particularly by palliative care, community nursing and frailty teams, but GPs still need to have the option to visit. It may not be the most efficient use of time - but that could be said about numerous areas of our work.

Not everything can be digitalised and delegated; losing home visits would knock out the essence of general practice and what it means to be a true generalist.

Dr Ellie Cannon is a portfolio GP in London and broadcast media doctor

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Readers' comments (34)

  • Vinci Ho

    ''The pessimist looks down, and hits his head. The optimist looks up, and loses his footing. The realist looks forward, and adjusts his path accordingly."
    Quote from The Walking Dead

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  • similar articles written re giving up night work. Think it will come. Not through choice but forced central underfunding. One more area that we lose control of and gradual erosion of current model over next 10-15 years. Costs will be astronomical and of great surprise to ministers.

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  • it would be helpful if those writing these articles could confirm how often they "actually" see patients. It would be useful to know if they see any patients at all. Some perspective is very important. If you do one sessions and a visit a month, you would love visits to remain on the contract. If you work full time and are fighting of visits daily, the real story of your jobbing GP is clear. Most who want to do visits see none or hardly any patients it doesn't affect them. Some Context please.

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  • I think a better system would be a register of people eligible for home visits. They would need assessing for this and part of the eligibility would be that they haven’t left the house for 3 months and can’t get to hospital appointments either. If you are so acutely unwell you’re need an unanticipated home visit, you need hospital

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  • I am glad that some of us enjoy the support of community nursing, palliative care, frailty teams, as evident from Dr Cannon's article. But what about areas that do not have such support? Where I work, in Wiltshire, there is no functioning social services or district nursing team. We don't know who our palliative care nurse is and local Hospice ignore our referrals. Acute services are so crap that patients choose not to bother with attending AE even with barn door obvious life threatening symptoms like collapse/bradicardia or cardiac chest pain. We spend endless hours seeing these patients and trying to magic up some safety nets around them. I simply don't have time to drive half an hour each way any more.

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  • dear Anonymously GP partner - that's a catchy name - why not use your own? How often I actually see patients is 4-5 sessions a week and that is every week. Did you assume differently because of the pretty picture and the TV appearances - perhaps you didn't look for evidence before jumping to a wrong conclusion. So yes I do see patients, just like all other GPs in a very deprived part of London where I have worked for the last 11 years. You write "If you do one sessions and a visit a month you would love visits to remain on the contract" - well maybe, but that's not Dr Cannon who wrote this article is it? I wrote this based on my experience of life weekly in my GP surgery. You also wrote "Most who want to do visits see none or hardly any patients it doesn't affect them" - this is quite the hyperbolic comment - do you have evidence to cite for this? Perhaps Anonymously you need to give us all some Context please.

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  • If home visits were funded and resourced properly , I'm sure most GPs would be happy to continue doing them, although there are still issues around suboptimal enivrionemnt to work, lack of record etc and safety issues.

    before I became I GP, I genuinely thought home visits would be rare, for end of life dying at home. I was astounded with all the "cough, dizzy, Gen unwell " crap

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  • Visits to those in clinical need should really not be a problem, do we really want our most crumbly old folk with acute on chronic problems waiting for hours in A and E, what would be very useful would be a service for acute/unscheduled visits that can be so disruptive, particularly in the afternoons.

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  • Vinci Ho

    Looking at the final result of this ballot, 54% versus 46% for the motion . This is a Brexit-like scoreline , isn’t it ?
    I would only say that I am humbled by this result , no matter what . As I wrote today , I fully understand that many would feel we had , perhaps , betrayed one of the traditional virtues of general practice . One of my local LMC colleagues even called this result shooting an own goal on ourselves. I disagree :
    (1) This is no longer about morality and virtues , it is down to terms and conditions. The culmination of year after year underfunding and underinvestment in general practice(with disproportionate workload)has convinced many of us that ‘enough is enough’ . That explains the early exit of many colleagues, hence the retention arm of the GP crisis . Many colleagues are burnt out needing help and our younger colleagues have chosen to work less than full-time-equivalent or elsewhere(other than frontline) to protect themselves. Totally understandable . That represents the recruitment arm of the crisis .
    (2) I am currently working six clinical sessions weekly ,plus one administrative(Sunday morning) for my practice and reluctantly takes on the Clinical Director for our PCN as my predecessor resigned for personal reason while absolutely no other colleague in our PCN is willing to step forward . I think there is the need for many of us to wake up and see the reality situation sitting right in front of us . Some colleagues up and down the country had to give up their beloved practices simply because they had no other choices .
    (3) As I wrote today , if this result could represent a benign version or virtual industrial action , so be it . I put this as a scorched earth policy where ‘enough is enough’ . And there is no better time to call this three weeks before probably the most important general election of the country for decades. Call me belligerent , otherwise .

    Now , I hope BMA/GPC will take this forward sensitively and intelligently onto the negotiation table with any forthcoming government , which undoubtedly needs our continual existence to score with their political football .

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  • Like the author I work 2-2.5 days a week (4-5 sessions) and having done 20 years of up to 11 sessions per week I can tell the difference. I’m in the transition to retirement and winding down. If I felt the same every day I work now than I did when working FT then it wouldn’t be sustainable but it isn’t - every day there is a bigger light at the end of the tunnel - a 4-5 day w/e. The less I work the more I enjoy it and I’m sure having the variety of something else tomorrow keeps me and I’m sure those with portfolio careers going. What I see from those around me doing stuff other than GP work is that they in the main choose roles without the uncertainty of having 5 mins of duty left and 3 visits come in. That’s the issue - whether it be family time, lunch or just being there for a pm surgery - it’s OFF - dealing with uncertainty was the great strength of the old GP as we seldom had much else in our lives - work life balance has improved and not working w/e makes life a lot better despite the fact I often had only a handful of visits from Friday night to Monday morning. I lived in the area and a visit on foot or a 5 minute drive makes the choice to visit much easier than knowing a visit will take up the best part of an hour or more. Who do I blame? Everyone. Us old GPs with visit books filled by reception whilst we worked. How to turn around a ‘request’ for a visit is in my experience almost impossible and is often the cause for a complaint - “It’s my right! Are you REFUSING’ to visit?” ((Patient expectation is key - it took us years but now patients don’t expect a home visit so when they get one it’s appropriate and gratefully recieved - tell them it’s so much easier and we have all the kit in the surgery - send a taxi if needs be - yes been there done that! Often visits are requested as children need looking after - is this OUR problem? Maybe it is and if so it’s yet another job for the GP(The patients - Jeeze you pay £5 for a taxi and it saves me an hour to do other stuff for other patients - and by the way that’s less than the fag packet in your pocket. Government - it’s just too easy to push everything onto GPs and maybe home visits WERE part of that - it’s all the other 2y care work that has come our way as well as patient expectation exploding.

    A local surgery has a driver and dedicated GP - I suspect this just makes more and more work - a paramedic able to triage and deal with 90% would be more efficient and probably involve more continuity of care.

    There is no doubt that younger GPs see home visits as a stress and for this reason alone will drive away those we are trying to recruit and retain. Not rocket science is it?!

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