This site is intended for health professionals only

At the heart of general practice since 1960

Read the latest issue online

Gold, incentives and meh

The value of visits

Dr Shaba Nabi

Last week, the Conference of England LMCs narrowly passed a motion to remove the ’anachronism’ of home visits from core contract work and negotiate a separately commissioned service for acute visits.

This motion has not only caused a public outcry with the Daily Wail going into overdrive on its front pages; it has also divided the profession, which is unsurprising as this motion was passed along the lines of Brexit, with a 54%/46% majority.

It is at this point; I must state two declarations of interest.

The first is that I am deputy chair for the Conference of England LMCs and was chairing this part of the debate. The second is that I dislike home visits for all the reasons outlined in this article.

But disliking something doesn’t necessarily mean it shouldn’t happen. I doubt many GPs would question the importance of home visits for those patients very near the end of life, to ensure the continuity of relationship so desperately required at the final stages.

Many of us would continue visiting this small group, regardless of any alternative commissioned plans.

But if we were to indulge in the popular pastime of risk stratification of patients, there are several cohorts of patients below the top of this pyramid.

The next layer down is those patients who are not dying but whose mobility issues mean they cannot get in or out of a car independently.

Many attend hospital appointments with the assistance of ambulance transport, so I can see no reason why this can’t be provided for attendances at GP practices.

Below this cohort are patients who can travel in a car for trips to the shops or hairdressers, but do not have a ready source of transport available at all times.

I dislike home visits... but disliking something doesn’t necessarily mean it shouldn’t happen

I think the majority of us would agree that GPs do not have the capacity to offer a taxi service for these people and alternative transport needs to be facilitated, either through self-funding or state assisted.

So, this leaves us with the truly housebound (think home ventilator) and those in the final stages of life.

If you were to read the North Staffordshire LMC home visit guidance, this is the only group of patients GPs should be visiting.

There are many GPs who feel outraged by this motion and consider it to be removing the core values of general practice.

Personally, I’ve long forgotten what the core of general practice actually is.

I no longer review people with diabetes, heart disease or asthma because my excellent practice nurse team do this for me. Soon, I will no longer see people with musculoskeletal issues, minor illness or perform medication reviews.

So, where does that leave me? I am thrown a motley crew of mental health, safeguarding and occupational health, with visits squeezed into this emotionally draining 12-hour day.

Let’s stop pretending we currently offer an equitable service to housebound patients who are not at the end of life – they are often managed over the phone or by the most junior doctors in the practice, because the rest of us are so busy fielding the on calls and attending meetings.

There is real value to commissioning a truly multi-disciplinary home visiting service, made up of pharmacists, nurses, physiotherapists and social workers, as well as GPs.

PCNs may have a role to play here, but not without the proportionate funding required to deliver this properly.

There is plenty of money in the system already, wasted on political gimmicks such as improved access and skype consultations.

And if the media paid attention to conference in its entirety, and not just clickbait, it would realise that LMCs also voted overwhelmingly in favour of scrapping the improved access scheme.

So instead of funding half empty weekend surgeries of verrucas and sick notes, how about moving this money to core general practice to fund a separately commissioned home visiting service? If you want seven-day access, then something’s got to give.

After all, consultant surgeons aren’t expected to pop out, between operating lists, to check on their post-op patients at home, so why are we?

Dr Shaba Nabi is a GP trainer in Bristol. Read more Dr Nabi’s blogs online at pulsetoday.co.uk/nabi

Rate this article  (4.36 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (8)

  • AL "4 TRIES IN ONE GAME" BUNDY

    i hear people justify that palliative care
    is always suitable for gp home visits
    However i feel that there needs to be
    a specific community palliative care team
    headed by experienced palliative care consultants and specialist nurses
    macmillan are wonderfull

    GP's vary in their skills and knowledge with palliative care
    the complexity is linked with much stress and adverse outcomes

    GP provided palliative care
    is the cheap option at best
    and dangerous at worst

    Unsuitable or offensive? Report this comment

  • AL "4 TRIES IN ONE GAME" BUNDY

    Complex palliative care patients need continuity of care
    Often It can be highly inappropriate to pass these on to a locum GP

    Unsuitable or offensive? Report this comment

  • AL "4 TRIES IN ONE GAME" BUNDY

    Why cant the LMC NEGOTIATE Directly
    with NHS ENGLAND??
    like the brexit analogy
    lmc vote = referendum to leave
    but good luck getting it done
    lets get "no visits" done

    Unsuitable or offensive? Report this comment

  • DrRubbishBin

    "AL "4 TRIES IN ONE GAME" BUNDY | Hospital Doctor26 Nov 2019 9:43am

    Complex palliative care patients need continuity of care
    Often It can be highly inappropriate to pass these on to a locum GP"
    I doubt you actually know much about locum GPs, many practices use the same people over long periods who get to know the practice population well. With the move towards 10,000 + practice lists it's unlikely even employed GPs have met more than a small % of the patient list. Whilst I totally agree continuity is very important for this group the reality of general practice as we are forced to work today makes this often very difficult. Your comment isn't helpful

    Unsuitable or offensive? Report this comment

  • What a lovely, balanced article, Shaba. I think the title sums up the issue - there are lots of patients and politicians who think they value home visits, but not enough to pay (directly or via taxation) what they actually cost. And the under-valuing is probably what causes a lot of GP frustration about visits: patients expect us to visit when they manage to get, albeit with some effort, to the hairdresser. I think some patients do have the attitude of "well, you're the one with the car" - I actually had someone ask me to collect a prescription for them for exactly this reason last week.

    Home visiting is a service that does have a value, and a future, for patients and doctors, I think; but it needs to be better funded, clinically safer, and more responsibly and efficiently used. Which is why I was happy to see this issue on the agenda last week (as a member of the Conference Agenda Committee) and spoke in favour of the motion. However, if General Practice continues to feel the financial squeeze, we continue to dash out to visits with a 2 page print out whilst inhaling lunch, and patients continue to request visits because their walking isn't so good and they haven't got the cash to hand for a taxi - then I'm not so sure about it having a future.

    Unsuitable or offensive? Report this comment

  • I'm an old fart GP aged 58. The 12 hour day is too much but trimming it by ending the requirement for home visits is as bad a mistake as ending the responsibility for out of hours. That does not mean I want to go back to doing my own on call, just that the profession needs to retain the responsibility and so control over how it is done.
    I value hugely the team around me, community nurses, social care and social prescribing colleagues, third sector and so on. However there is a qualitative benefit from seeing someone with complex problems in their own surroundings, particularly when there are mental health problems for patients and or carers. GPs are expected (and are paid) to be care coordinators, so how can we do this if we have not set eyes on the patient at least occasionally.
    I'd far rather all the developments in GP teams free me to go and do visits when. needed, rather than just be Dr Fixit in the practice.

    Unsuitable or offensive? Report this comment

  • When I do a car shift I enjoy the home visits. In surgery I hate them as I am time poor. Enormous time is wasted on admin. Remove the admin and we would have more time to see the patients-wherever that might be.

    Unsuitable or offensive? Report this comment

  • @ Merlin: I agree 100%. I also do daytime GMS and OOH Car Visits. Nothing wrong with visits: a big opportunity to turn things around for our most vulnerable patients, BUT in hours(like most of a GMS day)it is not prioritised and the time allocation has become really stupid and inappropriate. Please don't ditch this valuable insight into the full perspective of being someone's GP.
    If we lose this, we will be running out of reasons to exist. I know I am a dinosaur and I voted against dropping OOH. We played a big part in the collapse of A&E depts as a result from Nov 2004 onwards and lost a lot of professional standing at the same time. Yes, I know: on call was unpleasant and tiring but we made hade it crappy for ourselves by loading our on-call by joining up with local practices for the maximal denominator for nights-off. All we needed to do was to price-in a full day-off the next day. Hate to quote Donald Trump but "really dumb". We have stumbled blindly into undermining our status and can only blame ourselves! I'm 55 and now have a very happy portfolio career to make up for the damage you voted for along the way. I apologise to my successors now: you will never know the real (and sometimes exhausting) joy of being a family doctor. Unless you are "in this zone", you will be contstantly thinking: "well never mind, only 69 minutes before 111 take over.." :(

    Unsuitable or offensive? Report this comment

Have your say