Home visits – a risky business? Featured
At the end of March 2016 NHS England issued a patient safety alert on ‘Risk of death from failure to prioritise home visits in general practice’. The alert tells of a practice which while having a system to mange visits did not have a system for prioritising potentially urgent calls requiring an early response and rapid clinical intervention. The GP made other visits and did not have time to see this patient until the evening but before the GP arrived the patient had collapsed and had to be taken to hospital by ambulance and subsequently died.
Cases like this are unusual but on looking back at the National Reporting and Learning System, NHS England found another 11 incidents resulting in death or severe harm over the last two years. There may, of course, be others that were not spotted and reported.
This is an issue that the Primary Care Foundation specifically picked up in our 2009 report for the Department of Health, sent to all practices, on ‘Urgent Care in General Practice’. We developed a system and process to help practices become better organised to respond to all requests for care - not only urgent requests.
We have now worked with over 1,500 practices across the UK looking broadly at access and giving information to practices to help them identify how to improve. Often we find that the issue is that patients are coming back more frequently than would be expected and the question becomes how to address this.
But we also look specifically at how requests can be assessed and if necessary spoken to by a clinician within a reasonably short period of time - thereby avoiding the practices running the same risk identified in the patient safety notice.
So what practical steps can you take, particularly when most practices are feeling under increasing pressure to manage a rising workload? Practices have come up with a range of different solutions but they tend to combine a better system for spotting urgent cases with a reduction in the overall workload. So scanning all home visit requests – or finding a way that suits you of rapidly calling people back – can both identify that up to half of the home visit requests don’t really need a visit at all and can be managed in other ways while also spotting the very few that need a really rapid response.
Many practices use the duty doctor to screen home visit requests and make sure that they also have capacity to carry out the visit, while other practices build in a gap in the morning (so perhaps a couple of 10-minute appointment slots) to allow a GP to review requests that have come in and to carry out any telephone assessment of other cases too. Smaller practices find this works for them, but that visiting the patient is harder. But there are a number of examples of single-handed practices working together to set up a home visiting scheme with a GP able to cover a number of practices (see the case study in our report from Halton & St Helens).