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Independents' Day

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

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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

    PM and S
    You have nothing less than respect from myself 🙏😑

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  • 58yo, 10 sessions. We have experimented recently with various ideas - one doctor who does the majority of the visits - usually 8 but depends on how many others in to pick up some of the rest - also depends a bit on who is visiting doctor. We have just appointed a paramedic who has taken on this role but we will be protecting him from calls which would not be suitable. We triage calls from those who are not coded as housebound and we have a fairly strict cut off of 11.30 after which they are triaged by the two doctors running the acute service that sees the on day demand.
    I still do my own palliative care patients as much as I can and they are able to call or message me whenever. We also do weekly visits to 5 care homes which reduces the numbers of visits substantially.
    I think removing the visiting would continue to erode the bond between the public and Primary Care. We need to be strict about visiting - the days of visiting children with chickenpox is long gone - but to remove it completely means we should probably pack up shop and live in the hospital.

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  • “ pop out!”
    Oh dear God

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  • Yes. "pop out" - the old cutesy chummy diminutive. It takes no time at all, does it? Just "pop in" while I'm "on my rounds". Only 5 minutes away after all. Really? Must be the smallest of practice areas. Who else remembers the famous article many years ago by Dr Cuddly ( not his real name) who almost hugged himself to death so pleased was he to "pop in" delivering "piping hot fish and chips" to elderly patients? Maybe some doctors are would rather be Secret Santa to patients all the year round, maybe some think they are a uniquely comforting guardian angel to the sick and dying. They aren't - unless they are available 24/7/365, they are merely pleasuring themselves with their arrogance, and what they deliver is just a matter of a few degrees greater than all their overburdened peers. If they love it so very much, let them publish their home address and personal telephone numbers online, then they can enjoy true unlimited access like in the good old days. What's not to like?

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  • Visiting a UK GP is for many patients a Social ritual akin to going to the post office. Many people just want a “bit of a chat” Or a “moan” with a trained intelligent professional. It makes them feel better about their lives. No wonder so many “home visit” Requests are 95% complete BS and a complete waste of Valuable time. Doctors don’t have any time to waste on wild goose chases around town in their cars at lunch time going to see people’s legs that are “swollen” or people who are “chesty”. That’s what district nurses should be for

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  • At the moment we have a visiting paramedic service supplied by the CCG but I think it will end next year . It works very well. The paramedic can visit about 8 patients per day for about 40000 patients. The GPs don't pass on all the visits . We keep the palliative care and ones where the paramedic has been before and there is no improvement. Once the paramedic is booked out for the day then GP has to decide if to visit any further requests. The number of home visit requests is definitely going up because people are getting older and more housebound/ residential homes. What would really help would be if NHS England would fund a visiting paramedic per PCN. It would probably pay for it self in reduced ambulance call outs.

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  • Harry, thank you, for typical examples of reasons for (home visits) requests. Few years ago, we agreed a policy that in our practice reception and triage nurse discussed requests for visits with duty Dr before it was offered to patients. It has cut numbers of home visits by some 90%, just asking if patients are really housebound or had real medical need. Like someone said, grow a spine and decide where you are needed most...but work would be better if this unnecessary distraction (visits) was completely removed.

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  • What bothers me is that people who can just pop out are happy to impose their model on everyone else. I last worked in a rural practice where 10 mins face to face was often more than an hours round trip. If this is taken out of the core contract someone else can do it and get paid.

    In the end I moved to Canada, and patients shudder... make friends with neighbours and get a lift in.

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  • ‘Housebound’ is not a binary state.
    Many patients could be brought to the surgery with accessible transport and an escort but the NHS or social care have not commissioned this, preferring ‘free’ GP time.
    Some patients could travel if well but not when ill.
    In the UK we, and our housing and benefits system, also encourages patients to stay living at home alone when they should be in residential or nursing care with people who can help them.
    This all contributes to requests for visits that, without being reckless, still need to be done after triaging.
    And for those practices that smugly say they have no visits - you are either taking clinical risks or you have unwritten working and reception practices that push those patients to your neighbouring GPs.

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  • ‘Doctors don’t have any time to waste on wild goose chases around town in their cars at lunch time going to see people’s legs that are “swollen” or people who are “chesty”. That’s what district nurses should be for’

    That’s what DNs request GP home visits for!

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