Jobbing Doctor explains why he has a love-hate relationship with visiting patients at home
I have a love-hate relationship with part of my work.
I’m talking about visiting people at home.
When I first joined my practice, aeons ago, I was shown the practice archives – a collection of large diaries that contained the home visiting list of the practice in the 1960s and early 1970s. It was very instructive, as the numbers of home visits were enormous. Quite frequently doctors had to do up to 15 visits each a day. The names and addresses were there, kept in meticulous detail.
For many people the image of the family doctor from their childhood is of a man (it was usually a man in those days) dressed in a long overcoat and carrying with him a Gladstone bag. These images are rife in the writings of A J Cronin and Francis Brett Young, to name but two doctor-writers. Even newer fictions, such as the TV version of Doctor Finlay’s Casebook (Cronin again) and ‘Peak Practice’ do focus on the relationship of the doctor to people in their own houses.
Over the intervening years, the visiting load has become less onerous. Certainly, for me, it is unusual to have to do more than two visits per day, despite the population ageing, and the proliferation of residential homes.
I miss the pleasure of visiting people in their own homes, but I don’t miss the inefficiency of travelling around the area. I reckon I can see two or three home visits an hour if they are uncomplicated. I could see six to eight people an hour in my surgery in that time.
GP registrars get very anxious about home visits. They feel that they are pretty much on their own, without any senior help to assist them, and with only the basic equipment to support them. But that is a vital part of helping them towards independent practice. They really have to rely on their own clinical judgement.
Some of my partners hate doing home visits. They say that they are an ineffective use of time, achieve little and there is no real way to keep a cap on the numbers of requests. I suppose I am a little more sanguine about it, having known the way it was.
So why do people want to be visited at home? Sometimes they are genuinely housebound (the disabled, the severely agoraphobic, for example) and they might be temporarily bedbound with influenza or with fractures. We don’t mind those.
Sometimes they are very elderly or confused or demented, and that can be difficult. I suppose that is likely to account for around one third of visit requests. Quite a few people could come up to the surgery, and we get the slightly laughable situation where they say that if they can’t ‘have the doctor out’ then they will go up to Accident and Emergency, thereby destroying the logic of their request.
I would say, however, that a sizeable proportion of visit requests come because people do not want to take responsibility for those in their care – be it nurses, social workers or care assistants. The current jargon is to refer to these visits as CMA requests. This does not mean Considering Medical Advice; nor does it mean Caring for My Aunt.
This is, as the Americans would say a ‘Cover My Ass’ visit. Presently, nursing homes do not have to pay for home visits, so it is easy for them to ring through ‘just to be on the safe side’. And they do. All the time.
Last week on my on-call day I had five of these requests after I had completed my rounds.
The Jobbing Doctor is a general practitioner in a deprived urban area of England.
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