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CAMHS won't see you now

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)

  • Why would govt ban home visits which are free. Gp pays for car expenses from pocket , popular and convenient for patient and banning them willl loose govt vote??
    Nothing will happen.

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  • Visits as a 'as well as the rest of the work' task are of course a chore, whereas if they are 'instead of the rest of the work' duty, they are usually both manageable and even enjoyable. Certain provisos of course - you have to be a big enough, (as in number of doctors) practice, and the designated doctor has to have enough to do. In our case, covering maybe 400+ square miles, 15,500 patients, including 4 homes and a minor injuries unit, the 'driver doc' usually is occupied all day. If the duty is quiet, she/helps out with the mobile sick in the surgery. Most doctors, partners and salaried, LIKE visit days, I accept that there is pressure of workload, but I would rather get rid of the things that I believe are a waste of time (in my case, almost everything to do with cholesterol and statins, mild to moderate hypertension, most of the ckd burden, and chasing stable asthmatics that don't want to have an annual review) and carry on doing things that the patients want and sometimes need, and that I mostly enjoy.

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  • Vinci Ho

    I suppose the truth could only become more apparent if we keep debating the subject .
    (1)This ballot result (54vs46) was certainly a close call by any stretch of imagination. It is a result that I hope everyone would respect ( clearly there is no Russian meddling involved!)
    (2)The issue of whether we should carry on providing home visits is neither about the ‘safety’ nor morality of doing home visits . It is all about terms and conditions appropriate to the workload we face everyday in the frontline. Hence , it is not even just about home visits. While I do not want to sound like a cynical coal-face grass-root GP , it is this type of GP the system needs the most . They need protection (I sound like a football manager now!).
    (3)The solution or answer is always somewhere between the two extremes of argument (no visit against unrestricted visits).
    There are undoubtedly patients who can only be safely managed at home (palliative care, dying patients etc ) . Notwithstanding this , we desperately need a well-funded mechanism to triage and then provide this service. If we are facing secondary care providers rejecting GP referrals as ‘inappropriate’ everyday, it is only logical for us to negotiate with NHS England and the forthcoming government for terms and conditions for ‘appropriate’ home visits.

    As I always insist the ‘right’ thing can only be done at the right time and right place in politics , I cannot see any better than this most extraordinary moment in our recent history shortly before this fortune-determining general election in our country.
    Richard , I am afraid we have to now rely on the hard-work and wisdom of you guys to deliver this mandate .

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  • @ carfentanyl GP Partner/Principal23 Nov 2019 3:04pm

    Rather enjoyed your little rant about ‘secret Santas’ ‘merely pleasuring themselves’. Might I add ‘narcissistic xxxx’s bolstering their own plinths’.

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  • As we struggle to find something tangible we can take out of our day that will make a difference removing home visits is an obvious choice as everyone immediately knows they would have a much shorter working day.
    No other proposed plan over the last 5 years has shown any evidence of doing the same.
    I would rather retain the variety of the job which includes home visits and have time limited surgeries but it appears impossible to do this.
    Maybe we could offer to take them back when the 6000 extra GPs are in post-that would be a government incentive!
    Removing home visit by GPs to care homes may be a compromise as it is possible to commission models around this.

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  • I heard that Matt Hancock is working with CERN to devise a scheme which will slow down the velocity of the Earths rotation thereby making each day longer than 24 hours to help us get time to ensure we can fit in home visits.

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  • Vinci Ho

    No , I think the Babylonians can use quantum computing to manoeuvre particles so that the patients asking home visits , no matter how far they live away , can be cured as their own body particles will be influenced accordingly through entanglement.
    🤓🤣

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  • Home visits are too time consuming. Parking fines if you can find a space, cars scratched, hunting for poorly signed houses and numbers. Personal safety at risk from being trapped to dog bites.
    Look at other more attractive countries with better health care that do not have home visits. Our new GPs are flocking there.

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  • The issue here is not that we do not want to do Home Visits it is that we lack the capacity to do them properly or safely.

    Our GMS contract needs to evolve into one that is based primarily on activity. Then the more home vistits you do, the more you get paid, the more pts you see the more you get paid. In such a system you don't need the maligned Car-Hill Formula. This way when the next pressure group starts shouting about PSAs, we can welcome them will open arms and its beholden on the Govt to stem the flow not us evil doctors.

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  • Has anyone considered the safety issues with doing home visits alone?

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