GP home visits: more evidence is urgently needed to inform debate

This article is written by Drs Sarah Mitchell, Sarah Hillman, David Rapley, and Professor Jeremy Dale from the Unit of Academic Primary Care based at Warwick Medical School.

The general practitioner (GP) home visit has long been regarded core to general practice in the UK and Western Europe (1). However, at the recent Local Medical Committee Conference in November 2019, after heated debate about GP capacity to deliver home visits, a motion was passed with 54% of the vote, 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”. 74% of voters backed a motion to “negotiate a separate acute service for urgent visits”. Health Secretary Matt Hancock immediately rejected the outcome of the vote, promising extra resources for training and funding for more GPs and practice staff.

The ensuing debate in the national media, GP press and social media, highlighted a remarkable diversity of views around the value of home visits. Some propose that patients should not be able to “demand” home visits as an entitlement or alternative to a surgery appointment. For others, home visits are considered core to general practice and there are concerns that removing them from the GP contract would “sell the heart and soul of our profession away”, sending a message to patients that their doctor no longer cares for them.

What is unclear is the extent to which the debate about home visiting is intended to highlight the pressure that primary care is under, or whether it is truly about the value of home visits. The building pressure and demand on primary care is well documented and forms the basis of a number of high profile campaigns. The growing complexity of the aging population, with highly complex multi-morbidity, and diverse family and social situations, plays an important part. So do many other factors, many of which are eloquently listed by GP Dr Margaret McCartney on Twitter following the LMC vote; managing the problems caused by drug shortages, missed hospital appointments, supporting patients with troublesome symptoms when hospital outpatient appointments or surgery is delayed, and writing letters of support for employment tribunals and housing applications. Perhaps by addressing some of these, as Dr McCartney suggests, GPs would have more time to visit housebound and highly vulnerable patients, including those approaching the end of life.

In a healthcare system where it is expected that contracts are underpinned by evidence-based medicine, it is striking that the GP home visit has practically no evidence base to enhance understanding of its purpose or role. The scant amount of research evidence that is available suggests that there is unwillingness amongst younger GPs to provide home visits (2), but GPs who gain experience of home visits during their training are more likely to undertake home visiting post qualification (2). There is also a positive association between GP home visit rates and achieving end of life care at home (3). However, there is little evidence about the outcome of home visits, the impact on patient care or the role of the GP, or other members of the primary care team, during those visits.

Furthermore, current training in home visits is limited. For GP trainees, their home visits may not be observed or monitored and they receive little guidance or feedback on how best to conduct the visit. Barriers to assessment include logistical constraints, staff and safety concerns (4). Summative assessment of home visits (within the MRCGP Clinical Skills Assessment) occurs in only half of exams and not in a realistic setting. Formative assessment tools (Clinical Observational Tools COTS) for home visits are lacking.

GPs undertake home visits for a range of different reasons. Some are reactive when there is an acute and sudden deterioration in a patient’s health. Others are more proactive, involve the development of relational continuity of care between GPs and patients, which is especially important for patients who are unable to travel to the GP because of chronic disease, palliative care and other serious debilitating conditions. Assessing a patient in their home differs to a surgery setting. While there is potential to understand how a patient functions in their usual environment, and the effects on their health, there are also significant challenges in undertaking accurate clinical assessments of a patient’s condition, particularly when they are acutely unwell. The lack of point of care testing in general practice compounds the problem (5).

In 2003 when the last major reorganisation of the GP contract occurred, 24/7 care was removed. Such changes in out of hours care provision have been associated with compromised continuity of care and subsequent increased rates of admission to hospital during out of hours periods. Given that those whom GPs visit are among the most complex and frail in the community it is likely that removing home visits may result in a higher hospital admission rate, overburdening an already over-stretched secondary care system.

If GPs retain home visiting in their core working day, then they can (and should) decide who does them. Visits to patients living with medical and social complexity, and those needing continuity of care, must be carried out by GPs; the less complex and perhaps those for nursing homes can be delegated to advanced nurse practitioners or physicians’ assistants. GPs are used to managing uncertainty and risk, abrogating this responsibility risks diluting patient care.

More research is required to inform debate about home visits and the GP contract, particularly taking into account the diverse views that seem to exist amongst GPs. However, robust research will be challenging because the home visit is a complex, multifactorial process, rather than a discrete intervention. Research is needed to provide increased understanding into the nuances and impact of the GP home visit, who it provides benefits to, how, when and why. This would form an important evidence base to inform not only the debate about contract decisions but also the future training and development of the primary care workforce to deliver timely and effective care in the community, and should be considered an urgent priority by research funders and academics in primary care.

 

References

1. Aylin P, Majeed A, Cook DG. Home visiting by general practitioners in England and Wales. Br Med J. 1996;313:207-10.
2. Magin P, Catzikiris N, Tapley A, et al. Home Visits and nursing home visits by early-career GPs: a cross sectional study. Fam Pract. 2017;34(1):77-82.
3. Tanuseputro P. Beach S, Chalifoux M, et al. Associations between physician home visits for the dying and place of death: A population based retrospective cohort study. PLoS One. 2018;13(2):e0191322.
4. Mui E, Pham TT, McMurren CE. Family medicine training in house calls: Survey of residency program directors across Canada. Can Fam Physician. 2018;64:e498-e506.
5. Lasserson D. Interface medicine: a new generalism for the NHS. Br J Gen Pract 2017;67(664):492-3.