Visiting patients at home is a part of the GMS contract.
The GMS contract states;
7.6.1 In the case of a patient whose medical condition is such that in the reasonable opinion of the Contractor attendance on the patient is required and it would be inappropriate for the patient to attend at a place where services are provided in normal hours under the Contract, the Contractor shall provide services to that patient at whichever in its judgement is the most appropriate of the following places:
(a) the place recorded in the patient’s medical records as being his last home address;
(b) such other place as the Contractor has informed the patient and the Board is the place where it has agreed to visit and treat the patient;
(c) some other place in the Contractor’s practice area.
7.6.2 Nothing in this clause or clause 7.6.1 prevents the Contractor from:
(a) arranging for the referral of a patient without first seeing the patient, in a case where the medical condition of that patient makes that course of action appropriate; or
(b) visiting the patient in circumstances where this clause or clause 7.6.1 does not place it under an obligation to do so.
In other words, GPs should visit patients at their homes, or other places within their practice area, if the patient’s medical condition makes attendance at the GP surgery inappropriate. A good rule of thumb could be that if a patient could be reasonably be expected to travel to an outpatient hospital appointment, either with or without hospital transport then they could reasonably be expected to travel to the GP.
The LMC thus recommends that GPs should visit patients in their homes if they feel that they are medically unfit to travel to the surgery. It is important that practices triage requests for home visits for necessity and urgency, so that they can be appropriately managed. CQC has noted that it is a risk when practices do not have a method for assessing urgency of home visits and NHS England issued a patient safety alert in March 2016 regarding this issue. It is not acceptable, or safe, for home visits to be phoned in over the morning, and not looked at till lunchtime, for example. It may be that some visit requests are inappropriate because the patient is too unstable e.g. current chest pain and in fact it is more appropriate for a 999 ambulance to be called rather than wait for hours for a home visit.
Practices may want to consider phoning the patient or carer in advance to be able to triage effectively and signpost appropriately if a more urgent response or a surgery appointment is more appropriate.
However, there are a number of reasons why home visiting may be detrimental to patients;
- It can delay clinical assessment, as visiting cannot be carried out on an emergency basis, whereas assessing patient in the surgery can be
- Traveling to and from home visits can delay clinical assessment as the doctor may not be able to locate the patient’s address as quickly as the patient can attend the surgery
- Traveling to and from home visits, when clinically not needed, could prejudice the care of patients in the surgery, as the absent doctor will not be able to treat routine or emergency patients whilst away from the surgery
- Equipment for assessment and treatment by a GP which is portable to a patient’s home is not as effective as the equipment in the surgery
- The environment in a patient’s home is not ideal for clinical examination and assessment eg lighting may be suboptimal
- Medico legally it is not easy to justify inappropriate visit resulting in suboptimal examination of the patient and resulting poor decisions
Home visits are often carried out by a lone worker, which does need risk assessment
It is usually far more time efficient to bring patients to surgery rather than take the doctors to the patient, as in the same time period of a single home visit, usually multiple patients could be seen at the surgery. In the context of chronic under staffing and excessive workload across the whole workforce, making sure that only essential home visits are agreed to is vital.
Thus, the LMC also advises practices that reasons other than being medically unfit do not constitute a reason to perform a home visit. These reasons may include;
- Transport issues for the patient.
- It is not the GP practices responsibility to arrange transport, or to perform home visits because the patient has difficulty arranging transport. In these circumstances patients should seek transport help from relatives, friends, or taxi firms.
- Childcare issues for a patient – If a patient has difficulty arranging for someone to care for their children whilst attending appointments, patients are welcome to bring their children to the surgery.
- Poor mobility – whilst it is understood that having poor mobility is inconvenient and unpleasant, GP surgeries are designed to cater for patients with restricted mobility. If patients are able to attend appointments at other healthcare settings, then they should also be expected to attend appointments in GP surgeries.
The Unwell Child
Children with a fever will not be made worse by transporting a child to a place of care. It is in the best interest of the child to attend the surgery where they can be properly assessed and treated.
If a parent believes that the child is too unwell to travel to a surgery, then it would be advisable for them to seek help from the emergency services by calling 999. If the GP feels that attending the child at home, based on the clinical history, may prevent delay in treatment because of distance from available ambulance services, then they should attempt to do so.
Residents of Care Homes
Care home residents are no different to patients in their own homes. The need to visit should be based upon clinical need, not the availability of transport or staff to attend the surgery. It is the responsibility of care facilities to make transport available for residents so that they can get to medical and non-medical appointments.
The LMC encourages GP practices to use this guidance to generate a home visiting policy for the practice, which should be shared with patients and PPGs.
Patients Who Move to Outside of the Practice Boundary – Process for Removing Them From the List
The regulations state: http://www.legislation.gov.uk/uksi/2015/1862/schedule/3/paragraph/27/made
Removal from the list of patients who have moved
27. (1) Subject to sub-paragraph (2), where the Board is satisfied that a person on the contractor’s list of patients has moved and no longer resides in the contractor’s practice area, the Board must—
(a) inform both the person and the contractor that the contractor is no longer obliged to visit and treat that person;
(b) advise the person in writing to either obtain the contractor’s agreement to that person’s continued inclusion on the contractor’s list of patients or to apply for registration with another provider of essential services (or their equivalent); and
(c) inform the person that if, after the end of the period of 30 days beginning with the date on which the advice mentioned in paragraph (b) was given, that person has not acted in accordance with that advice and informed the Board accordingly, that person will be removed from the contractor’s list of patients.
(2) If, at the end of the period of 30 days mentioned in sub-paragraph (1)(c), the Board has not been informed by the person of the action taken, the Board must remove that person from the contractor’s list of patients and inform that person and the contractor of that removal.
Patients Who Move to Outside of the Practice Boundary – Requesting to Remain on the List
This is sometimes requested by patients who want to keep the same GP. Practices are able to agree to this,
- either accepting the new address and thereby agreeing to provide full GMS services including visiting (this can clearly be very impractical and will impact greatly on the time of the team, should home visits be required)
- or by changing the registration to an Out of Area registration (see further guidance on this at Out of Area Registrations and In Hours Urgent Primary Medical Services)
Please click here for “Improving Safety for Lone Works – A Guide for Managers”
Wessex LMCs would like to acknowledge the kind assistance of Lincolnshire LMC for letting us use their comprehensive guidance in producing this document.