GP home visits: essential patient care or disposable relic?

GPs DEBATE HOME VISITING

The requirements of the current GP General Medical Services (GMS) contract in relation to home visiting are broad.³ The contract is not prescriptive about who should visit or where the visit should take place, and states that the decision to visit is dependent on the opinion and agreement of the GP contractor. In November 2019, the Local Medical Committee (LMC) conference debated the current contractual requirements and a motion was narrowly passed to instruct the General Practitioners Committee (GPC) (the negotiating arm of the British Medical Association) to ‘remove the anachronism of home visits from core contract work’.⁴ The majority backed a motion to negotiate a separate acute service for urgent visits.

Reporting of the LMC debate in the national press and social media highlighted how emotive the issue of home visits is, and the diversity of views among GPs that exist around their value. They were described by some as a service that is regarded by patients as an entitlement, available for purposes of convenience.⁴ It is likely that GPs working in practices that are short-staffed and overwhelmed by workload pressures are more likely to view home visits as an inefficient use of their scarce resources. Others considered home visits a vital component of general practice, arguing that when patients are unwell at home it is generalist doctors who are best placed to assess them. There were concerns that removing home visits from the GP contract would compromise the values of general practice, sending a message to patients that their doctor no longer cares for those who may have pressing clinical needs but wish to be treated at home.

WHAT DO WE KNOW ABOUT GP HOME VISITING?

In a healthcare system where it is expected that contracts are informed by robust evidence-based medicine, the lack of evidence regarding GP home visits, including out of hours, is striking. There has been relatively little research to understand the circumstances in which patients request GP home visits, when and why GPs undertake home visits, and how outcomes can be optimised within a resource-constrained health service. What is known is that over the last 50 years there has been a steady decline in the extent to which GPs visit patients in their homes in the UK and internationally,^2,5,6 and that not all GPs are convinced of their benefits.¹

Some GP consultations with patients at home are reactive when there is an acute and sudden deterioration in their health, including out of hours. The visiting professional must skilfully balance the risks of continuing care at home against admission to hospital. Others are more proactive, to monitor and plan care for those with long-term health conditions that may prevent them from attending the surgery. Research suggests that GPs do not tend to dispute visit requests for vulnerable, older people.¹ For patients who are dying, there is a positive association between GP home visit rates and achieving home as the preferred place for end-of-life care.⁷ GPs who gain experience of home visiting during their training are more likely to undertake home visits post-qualification.⁸ GP visits to residential and nursing care homes, and the quality of care delivered, have been described as particular areas of concern.⁹ Little is known about responses to other patient groups who may benefit, including: those with mental health concerns; physical disabilities; complex care needs; or those who are unwell with potentially infectious diseases, such as children who may be advised not to attend the GP surgery. Patients appreciate home visits and feel that their relationship with their GP improves as a result.¹⁰

Although GP consultations in patients’ homes are likely to require different consultation skills from those that apply within the surgery setting, the requirements for training in the conduct of GP home visits are ill defined and are largely left for the trainee and their trainer to negotiate. For many trainees, there may be limited opportunity for their home visits to be observed, because of logistical and time constraints.¹¹ Formative assessment tools (Clinical Observational Tools) for home visits are lacking, and summative assessment of a simulated home visit (within the MRCGP Clinical Skills Assessment) occurs in only half of exams.

Many types of home visit have already been subsumed by other services, such as specialist community teams, early visiting services, and care home teams. Although this can be seen as relieving pressure on overstretched general practice, an unintended consequence is the fragmentation of care associated with multiple specialist teams providing care in the patient’s home. It also calls into question the role of general practice in the management of such complex patients. Obtaining timely information, communicating with each visiting specialist team, and overseeing such care risks adding to the GP workload.¹² As Abrams et al highlight in their realist review of delegated home visiting services in this issue, there is more to be done to understand how such services can be implemented effectively.¹³ Research is needed to inform delegation processes, and effective system implementation is needed to support such services and to understand the impact on patient satisfaction, long-term health outcomes, and cost.¹³ A pertinent issue is the need for clarity around roles and responsibilities, so that the professional status and autonomy of all involved are understood and valued. This is most likely when trusted professional relationships are developed over time and where the facility to share information effectively exists.¹³

WHAT NEXT?

‘Good general practice will always consist of patients feeling at home with their doctor and of doctors feeling at home with their patients.’¹² In the context of burgeoning demand and underfunding of workforce and resources, there is a need to listen to the diversity of views among GPs and primary care colleagues concerning the future of home visits. Robust research is needed to provide understanding into the value of GP consultations in patients’ homes, both through visiting and using telemedicine, and how best to optimise the delivery of primary medical care, particularly for housebound patients, 24 hours a day, 7 days a week. Increased understanding into the nuances and impact of GP home visits on patient care and the wider healthcare system would form an important evidence base to inform NHS policy and the training and development of the primary care workforce, and is necessary before changes are made to the GP core contract.