‘A thing of the past’
The RCGP suggests that computerised records should be consulted prior to a home visit being made, with specific attention paid to: ‘Data on consultations spanning the past year; investigation results; medication; details of referrals; major alerts; quality and outcomes framework reminders and even hospital letters.’ This relatively new reliance on technology paints a rather different picture from the traditional perception of GP home visits. As Carmel Loughlin, practice manager at Three Spires Surgery, Omagh, Northern Ireland, explains, “The historical view of the local doctor popping in and out of houses, having a cup of tea whilst visiting sick patients, is almost a thing of the past.”
Under severe time pressures, GPs are finding it increasingly difficult to remove themselves from practice-based responsibilities. “The morning surgeries are now lasting into the afternoon and the demands on GP time means that the home visit is now reserved for absolute emergencies,” Carmel says. “In my practice the doctors now ‘phone patients who are requesting house calls in order to individually assess their illness and decide if a home visit – or hospital care – is appropriate.”
Breeding confidence in patients
Due to a clear need for additional help to support home visits, Carmel’s practice has turned to other clinicians to support patients requiring care at home and she says that the implementation of a new triage system has also reduced the number of home visits requests. “We often call for help from district nurses to measure blood pressure and do blood tests and we may seek assistance from the community-based respiratory and palliative care teams.” This relationship with community teams is one that has created better lines of communication between primary and tertiary care – a relationship that is currently thriving and breeding confidence in patients.
“The value patients place on their GP encompasses the local knowledge that the GP has. Often a GP will say, ‘If that patient is requesting a house call they are ill!’ The GP knows their patient and can often assess quickly if a visit is required or not,” Carmel says. In a practice serving an increasingly elderly population, house calls can be a demanding business which relies on well-rehearsed strategies to manage patient care effectively. And these mutual support strategies work in both directions. “Often the community-based teams need the input of the patient’s GP. The teams in place to try to ensure that patients are discharged early often require the co-operation and assistance of the local GP to ensure that those patients stay out of hospital,” Carmel explains.
In Carmel’s practice specific attention has also been afforded to housebound patients – a group which has tended to go largely unnoticed until they are acutely unwell. “This is because housebound patients order medication regularly and don’t attend the surgery. We are also faced with the difficulty of identifying the truly housebound group because some of those we know as ‘housebound’ will, for example, attend church, the hairdresser and hospital appointments but demand that a GP visit them at home.”
Video technology limitations
The great video call debate is ongoing within primary care; can this approach really enhance the patient experience in general, and what impact might this technology have on the care of housebound patients, in particular? “Skype has serious limitations and older patients are slow to – or indeed don’t have the skills to – embrace the technology,” Carmel says. “Internet coverage is still poor in some areas, which makes this type of consultation impossible. A Skype connection will not measure blood pressure or allow for a hands-on examination of a patient; it’s no better than a telephone call. There are few technological advances or expert teams that will replace the examination and diagnosis of an experienced GP.”
The many advantages of creating high-performance clinical teams are clear when implementing a home visit strategy within practice settings. For the elderly and the housebound, being treated in a timely manner is an expectation that can often go unmet; a team effort can help to avoid particular difficulties and enhance service delivery.
Case-study: Pollok Health Centre, Glasgow
To support their home visit strategy one practice in Glasgow has recently decided to use a bicycle for making the rounds! Marie McMenamin, practice manager at Pollok Health Centre, Glasgow, says that the decision to use a bicycle was originally inspired by the surgery’s community links practitioner, Gerry Mitchell.
The bike isn’t intended for all home visits but is used at the GPs discretion – particularly when travelling shorter distances – as Lindsey Morley, GP at Pollok Health Centre, points out. “The bike access gives GPs a feel-good-factor along with a bit of exercise. If there’s a house call request just before GPs start surgery it’s quicker to use the bike. Our links practitioner also uses the bike for any visits to patients needing his help to leave their house and access community services.”
Lindsey adds that the surgery uses a clearly-defined home visit strategy. “GPs vet each house call and try to encourage younger patients to attend surgery. However, if patients say they can’t come down, doctors don’t push the issue and will go out to them; GPs would never refuse a request.
As winter approaches the thought of arriving at a patient’s house on two-wheels perhaps doesn’t bear thinking about for most GPs but, when the seasons change, fair weather cycling has a tempting fitness appeal!
Assessing worst case scenarios
A search of the National Reporting and Learning System identified 11 incidents relating to GP home visits reported with a degree of harm equivalent to death or severe harm in a recent two-year period. Some of the incidents suggested that there were gaps in the process for deciding if a more urgent response was needed. When a request for a home visit is made, it is vital that general practices have a system in place to assess whether a home visit is clinically necessary and the urgency of need for medical attention. NHS England Patient Safety Alert – March 2016