Why set up a home visit policy?
Home visits play a traditional role in UK primary care. The image of a rural GP on a pleasant drive to see patients between quiet morning and afternoon surgeries is an archetypal media portrayal of English general practice.
Times are changing and ‘quiet’ general practice is a thing of the past. We have to make changes to ensure that precious resources are utilised to serve the needs of many rather than the convenience of a few.
The increase in workload and the effect on GP morale have been well documented by both the BMA and The King’s Fund recently. Patient numbers are rising, leaving GPs facing an ageing population and managing more medical complexity in the community.
Despite these mounting pressures, general practice continues to engage in some activities that take a disproportionate amount of the dwindling manpower; one of these practices is that of the home visit.
In the time it takes one practitioner to perform a visit, many more patients could be seen face-to-face in surgery. With pressures mounting, surgeries need to look at their workload and make tough decisions in the interests of their entire practice population. Having a robust home visit policy is one way that practices can manage patient expectations and thus workload.
What are we contractually obliged to provide?
The GMS regulations 2004 (Schedule 6, Regulation 26, Part 1) make it clear that it is the reasonable opinion of the contractor’ as to whether attendance on the patient is required and it would be inappropriate for them to attend the practice.
It is therefore for the clinician to determine where it is ‘most appropriate’ to see the patient.
It is fundamentally important to assess a patient in the safest environment; this is rarely a patient’s home. In the context of increasing medicolegal claims against GPs, it is difficult to justify clinical decisions made after assessing a patient in less than ideal surroundings.
Improving technology means we are capable of performing more investigations and initiating more complex treatments at the surgery than at home – sometimes because it would not be safe to do so in a patient’s home, sometimes because the equipment is not readily portable. A home visit could potentially delay important diagnostics and definitive treatment.
Importantly, there is nothing within the regulations that prevents a doctor referring a patient directly to hospital without first seeing them, providing ‘the medical condition of the patient makes that course of action appropriate’.
It is worth checking your local LMC’s website to see if they have a home visit policy or guidance which could reasonably form the blueprint for your practice’s own policy. Many policies are based on the excellent South Staffordshire LMC guidelines.
How do we decide which patients we should visit at home?
There are cases where a home visit is obviously the most appropriate way to assess a patient. These include visits for:
– Terminally ill patients
– Bed-bound patients
In the vast majority of cases where a patient is usually mobile they should be expected to attend surgery. There may be situations – for example, an infective exacerbation of COPD where the patient has a care plan including home treatment – where a home visit is deemed reasonable. These cases remain at the clinician’s discretion.
Children are generally portable; they can be most accurately and safely assessed in surgery and given emergency treatment if required.
A good benchmark is: ‘Would the patient reasonably be expected to attend a hospital outpatient appointment, with or without transport?’ If the answer is ‘yes’, attendance at a GP surgery is most appropriate.
This advice includes patients in residential care; the onus is on the private provider to properly address staffing and capacity, and not for general practice to fill the gap.
How should we explain the policy to patients?
The first step is to engage your whole practice team in the reasons for any policy change and its proposed implementation. Once the practice team is on board, we would suggest involving your Patient Participation Group. Explain changes are being made for the good of all patients and most importantly in the interests of patient safety.
With the PPG on board, you can discuss communicating changes with the rest of the patient population.
There is some good advice on the wording to use in patient education material on the GANFYD website.
What about complaints?
The main way to avoid complaints, or manage them effectively, is to ensure you have a policy that all members of the team understand, agree with and adhere to. Engagement of your patients early on in the implementation of a new policy should help reduce the number of issues once the new policy is established.
If you decline visits, make sure they have been triaged thoroughly (according to the GMC’s Good Medical Practice), you explain your reasoning clearly and document your decision.
When answering any complaints, include information on why the policy was introduced and how you engaged patients in this process.
What if our out-of-hours service differs?
The ideal would be to have a uniform local policy for in and out-of-hours general practice provision. This should improve patient understanding and lead to a cultural change ensuring appropriate use of home visits. However, this can be practically difficult.
If you update your home visit policy it might be prudent to inform your local out-of-hours provider and/or meet with them to discuss it.
Where there is a clash of policies and a non-medically trained call-handler triages a patient and believes a visit may be necessary, it still remains at the discretion of the trained clinician as to whether a visit is deemed necessary.