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Home visits, the decline 
of the roving doctor

When I was training to be a GP, my tutor showed me a painting by Sir Luke Fildes called “The Doctor”. Its significance was lost to me in those fun-filled days of team-building exercises and group learning, however I remembered it again recently when I was asked to fill out an insurance report for one of my elderly patients.

In it, the underwriter asked what she could do by herself; could she dress unaided? Could she walk unaided? Could she climb stairs? Did she have carers? I felt guilty when I realized that I just did not know. Whenever I had seen her, a family member had brought her into the practice, led her dutifully to my desk and back out when her allotted ten minutes had elapsed. Would I have known her better if I had visited her at home?

Believe it or not, there was a time when you could see a GP in the wild. Far from the reclusive species we know today, GPs would regularly visit a large proportion of their patients at home and would revel in the opportunities that the house call provided. Seeing the patient in their daily habitat gave them a picture of their constitution: their interests, their families, their habits and their current mood. At inception, circa 1948, the role of the general practitioner was one of twenty-four seven, three sixty-five care. When the doctors’ charter of 1966 came into effect, more emphasis was placed on facilities and staff within a practice and one could argue that the focus towards centralised care began here. However the model was unsurprisingly fraught with difficulty and, in effect, was unsustainable.

Surprising then that GPs were held to this historic contract clause for round the clock care until 1996 when co-operatives made up of local practitioners started to take on the Out of Hours (OOH) work on a rota basis. This continued until the 2004 GP contract in which Primary Care Trusts (PCT’s) took the responsibility for organizing OOH care after the GP practices acrimoniously opted out. This in turn gave the opportunity for businessmen with newly organised limited companies to bid for the OOH contracts, making entrepreneurs out of some medics, but also making the idea of a home visit from your doctor an unlikely event.

"On leaving I was filled with a different kind of satisfaction, one that I had forgotten existed. I truly felt privileged to be her doctor."

Troubled by the unfamiliarity with my patient, I decided to audit my daily practice and it soon became clear why a home visit has become a rarity for me too. I regularly take ten or more calls after a saturated morning clinic, moving on to a hundred or more test results and a similar number of clinical correspondence documents. I then go about the task of liaising with various other healthcare professionals, sorting out one of the regular “situations” in the waiting room - one of our receptionists had a mobile phone thrown at her head recently – and if I’m lucky, taking on some calories in preparation for the afternoon. Then I do it all again in my second clinic which is usually followed by a final flourish in which I might be asked to deal with any ‘last orders’ that come up before closing time.

It seems it is not just me who has this problem. The pattern is reflected in national figures which showed a greater than 50% decrease in home visits between 1995 and 2009. GP consultations have meanwhile increased at a staggering rate: 220 million per year in 1995, 290 million per year in 2006 and 340 million per year in 2014. The way people are contacting their GP is also changing. The number of telephone calls per person per year has more than doubled whilst most doctors are completely untrained in the complexities of managing a telephone consultation.

Shortly after my attempt at her insurance form, I visited my patient at home. She opened the door to me and warmly welcomed me inside her immaculately kept bungalow. It was decorated with souvenirs from her travels all over the world and taking pride of place above her fireplace was a set of medals. I learned that she was a successful cyclist in her youth, one of the trailblazers for UK women’s cycling. She was planning a trip to see her old cycling friends who had since emigrated to Australia, hence the need for the insurance form. I joked that I might be joining her on the 22-hour flight down under to visit some of my medical school colleagues who have joined a flux of UK doctors looking for a better working life. On leaving I was filled with a different kind of satisfaction, one that I had forgotten existed. I truly felt privileged to be her doctor.

Looking at the painting again recently was a deeply moving experience for me. If I had to say why, I would probably attribute it to the journey: from idealistic doctor to exhausted firefighter. It could also be due to my other job as a father to a little girl. I can only describe what I see: another wearied father looking on in a helpless but prepared stance, ready to do anything to help, his pathetic attempts at nursing visible in the foreground. I also see a doctor sitting in a chaotic household, pensively poised next to a desperately ill child. A doctor, where he should be.

Jeetinder Khasriya
@gpdquk

Image Sir Luke Fildes, The Doctor, 1890, © Tate CC-BY-NC-ND 3.0 (Unported)

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2 Responses

  1. I wish to reiterate comments regarding the 'GP opt-out' from OOH responsibility in 2004: GPs did not opt to stop doing what we were doing. GPs were given a choice that did not include what we were doing OOH at the time - it included only 2 options: a) Opt out completely, but maybe work shifts in coops non-locally (for rural gps there were no local options, only regional ones) OR b) take on 'huge' numbers of additional permanent staff paid at unsocial prime rates AND invest heavily in equipment and vehicles and IT (not necessarily practice-compatible), to run a much greater service than currently was. Unsurprisingly, for rural GPs who might have continued own local 'on-call' care, the second option was prohibitively expensive, in other words it was an opt-out forced by the DoH, and the people need to realise this was forced, not GPs abandoning their patients. A fact the DoH would like forgotten - DO NOT LET IT BE.
    • Thanks for the insight into this David. I often find that research of what is supposed to have happened doesn't always tally with the reality of the position that GPs were put in. Very interesting to know that rural GPs felt they weren't allow to continue to provide the level of care they wanted.

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