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
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
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