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The value of visits



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

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