Choosing the right home visiting service model for your practice

Dr David Coleman outlines the pros and cons of different home visiting service models

Last November an LMC conference motion calling for an end to GPs being contractually obliged to make home visits caused quite a stir among the profession and in the wider mainstream media.  

If the response proved one thing, beyond the ability of many who should know better to willfully misinterpret events to advance their own cause, it was that home visits are an emotive issue. 

To some GPs, home visits embody all that is good about UK general practice. To others they are a source of frustration, an inefficient and anachronistic hangover from the past.

What most of us can agree on is that some home visits can be safely managed by advanced practitioners from different backgrounds, be they paramedics, emergency care practitioners (ECPs), pharmacists, advanced nurse practitioners, physios, or even social prescribers.

Broadly speaking, practices wishing to reduce their visiting workload have four options, based on the following approaches.

1. Traditional GP home visits

Some partners still feel that, despite the inconvenience, GPs should make home visits for their patients.

If you believe that only GPs can be trusted to provide home visits, then at least consider tightening up your approach. Consider introducing a home visit protocol and supporting the receptionists to implement it.

Better still, triage the visit requests yourself to filter out any inappropriate requests. I find speaking to patients directly and pointing out, for example, how they recently attended an outpatient clinic, is an effective way of suggesting that they could also attend the surgery. Lack of transport is not a reason for a home visit.

2. Practice based team

A more pragmatic approach is for the practice to create its own visiting team/service based on a combination of skill-mixes.

With this type of service, relying on the input of advanced clinical practitioners (ACPs) rather than doctors, robust triage and supervision is vital. This minimises the chances of allocating the wrong type of practitioner to the patient, which ultimately leads to duplication of work.

For example, an end-of-life patient who hasn’t seen a doctor for over two weeks should see a GP, not only because GPs are appropriately skilled to provide palliative care input, but also because this avoids complications with death certification when a patient passes away.

Alternatively, a patient requiring a medication review would benefit from a pharmacist’s input, whereas a frail elderly patient with worsening knee pain may benefit from seeing a practitioner who could potentially offer a joint injection.

If you know your patients, and know your staff, you will get things right 90% of the time with this approach. Yes, a doctor can generally manage most things (except boilers, although this is occasionally requested), but they are expensive, in short supply, and certainly in our part of South Yorkshire if you manage to secure a locum GP it is quite rare for them to offer home visits.

ACPs are flexible, competent, and have good awareness of their limitations. If you support them and give them appropriate cases, they can be safe, effective and – critically – cost-effective.

3. Networking opportunity

We all know that working at scale is de rigueur these days. So if you like the sound of option 2, you might want to consider its scaled up cousin and team up with your neighbouring practice, local federation or, in future, your Primary Care Network (PCN), to create a community based visiting service.

As this means visits are effectively allocated to an external team, it is even more vital to have robust triage.

Clearly some patients will not be appropriate for a community visiting service staffed exclusively by ACPs. Exactly which patients these are will depend on the clinicians making up the service, but it may include palliative care patients or complex mental health patients with well established relationships with a regular GP.

You need to define these patients clearly, and make sure all clinicians who are triaging are aware of which cases the practice will manage, and which patients it will refer.

Ideally, the service will have access to GPs post-visit for debrief and supervision. In addition, not all practitioners will necessarily be prescribers, so it may be necessary to have some prescribing support.

From a practical point of view, this type of service will need a host employer to handle HR issues and hold the contract; in order for staff to benefit from NHS pensions, this must be an organisation that holds an NHS contract.

A word of caution, though. Despite what we are told, especially in the utopian world of PCNs, skilled advanced practitioners do not grow on trees. It simply may not be possible to recruit enough of them to staff a robust service in your area.

Be realistic about what sort of coverage a visiting service may be able to provide and be prepared to put safeguards in place to ensure reasonable equity of work across practices sharing the service.

Even with the best will in the world, you will not eradicate home visits, but you will be able to reclaim a big chunk of your workforce during the middle of the day. If that gives you a fighting chance of completing your admin and escaping before 7pm then it’s surely worth exploring.

Dr David Coleman is a GP partner and trainer in South Yorkshire