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Home Visits

Coalface tales

James Booth

Friday, 06 December 2019

AdobeStock_216247291_home_visit.jpgI’m not sure there are many aspects of our job as GPs that are as emotive in so many ways as home visits. They seem to be a touchstone for so many things; both the nostalgic view of the family doctor and a burdensome, archaic practice. 

It’s certainly true that patients love them, and indeed see them as an expected part of primary care. I once did a talk for the local council about primary care pressures and began with a screenshot from Dr Finlay’s Casebook1; I wanted to make the point that the starting point for so much debate about modern primary care rests on an image from two generations ago, and moreover a fictional series set a generation before that. That fictional GP grappling through a stormy night with a Gladstone bag and brogues is certainly seen as appealing as an ideal, though, and it’s really notable to me that when people speak of experiences of erstwhile colleagues, it’s disproportionately often that they refer to a home visit rather than an encounter at the surgery. 

Yet for doctors, they are equally emotive, but as something burdensome, old fashioned, and often unwelcome. A cursory look at any GP forum will see tales of ridiculous requests, and debates about the safety and appropriateness of this type of care. It’s also a frequent request for advice and reassurance by new colleagues: was I right to visit? Was I right to say no? I think all of us have an anecdote or two about a particularly egregious call-out request – mine being the gentleman who wanted me to visit him to check he was well enough to fly to Jamaica that Friday. I’ve become highly alert to the phrase “pop round” as a marker that someone is about to devalue my time.

So it is perhaps no surprise that the debate at the LMC Conference this month ended with a vote in favour of calling for the practice to end. The wording of the motion, perhaps hinting at that nostalgic view, called them an “anachronism.” It is certainly true that many other nations – perhaps most other nations – get by without this service. The response has been much as we’d expect; Matt Hancock tells us it’s not possible, other professional associations3 express dismay, patient groups dislike it…and frankly, as normal, more heat than light is generated. Personally, I am unsure about the wording of the motion, but I think the role of home visits in a context of an under-resourced, understaffed service facing increasing demand is very much necessary. 

My own practice sees me taking a rather contrary view about home visiting. In fact – and I feel that this is a bit like making some sort of shameful admission, oddly – I quite like them, when they are the right ones. I saved some routine ones up a few weeks ago and spent a morning doing them with our two medical students, and it turned into one of the more stimulating sessions we’d had. They were shocked to see how poor the living conditions for one elderly patient were, and unhappy that another had been rendered housebound by simply being on an upstairs floor as her rheumatoid arthritis flared. They also got to see how a man with quite marked dementia was able to cope surprisingly well in the home familiar to him for so many years. Certainly, palliative care at home is something I feel is core to our work, and with my safeguarding hat on, there is something to be said to seeing a home environment and reflecting on the experience of being there for everyone in it. There is something about the visiting doctor being plugged into their community in a unique way.

And yet: they are also a burden. It’s the most time inefficient way to see patients, and over my quite dispersed practice area, more than a couple of visits can result in me spending a lot of time in my car over a lunchtime. Whilst I accept that there is a cohort of patients who become housebound when ill but not otherwise, I do a number of calls where the reason for visiting is more about a lack of support for the patient, rather than clinical need. There’s a safety issue too – in my time, I have had to provide end-of-life care to a man who, whilst frail, was also a convicted sex offender, and I wouldn’t allow female colleagues to visit him alone. I also would like to make it a legal requirement for people to illuminate house numbers and for keysafes to be painted bright yellow so I can find the wretched things.2 So, in common with so many surgeries, I now employ an ANP who does a large proportion of mine for me, and – in many cases – does them better with her experience as a community matron. Which has felt both completely necessary and faintly hypocritical.

I think, to be honest, that my attitude to them is probably not dissimilar to that of most of us; the problem isn’t the visiting per se, but the fact that there is such an expectation around them, and that it impinges so much on daily practice. I’d have rephrased that conference motion: something like, “Primary Care is not resourced to provide the visiting service expected of it.” I hope that there is always a place in my job for seeing the housebound and the dying in their own homes; I want it there, and I want future generations of GPs to want it too. But: we are camels that have a large number of back-breaking straws now, and this one feels especially heavy. 

  1. Dr Finlay’s Casebook for those who don’t know it was a TV series based on a series of novels about a dashing young GP caring devotedly for the folk of the small Scottish town of Tannochbrae, assisted by a crusty superannuated curmudgeon of a partner called Dr Cameron.  Any suggestion that my own partnership with my father made me think of this comparison is of course nonsense.
  2. Quite literally, I have a patient with a keysafe that is actually behind a bush, at ankle level.  I wonder that they feel the need to even lock the bloody thing.
  3. Peart L. Care England slams GPs vote to remove home visits from core work. Care Home Professional, 29 November 2019.

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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