Doctor, my husband will see you now. Home visits, and why we should fight for them.

There’s a point you reach, I guess now, well into the Christmas Holidays and far enough away from the election to decide what next? You see, I had stopped. I couldn’t write any more after I became embroiled in the madness of political parties and all that stuff.

Well. Let’s move on.

Where to?

I though house visits would be a good place to start.

You see, a significant part of my job involves visiting people at home, sometimes when they are unwell, on other occasions because the effort required for the person to get out of their house is so great that it only happens on rare occasions.

Anyway, I like visiting people at home.

It is what used to happen on a far more regular basis back in the day, when the image of ‘doctor visits’ was formed in my imagination – probably when I was a small boy.

Sick – get to doctor; too sick to stand – ask doctor to visit. That was the kind of thing.

Now, saying doctor is as always, particularly when describing health or social care only a tiny nubbin of the reality; for every doctor there are 100 other people doing very similar jobs in different roles – therapists, nurses, dentists, opticians.

As I am one, I will get back to the doctors.

You see, there is a massive effort to discourage people from visiting A&E; well, let’s say, unnecessarily visiting A&E which in the mind of someone who feels ill is a conundrum. The notion of ad hoc rationalisations such as, ‘Am I sick enough for A&E, the doctor to call, to wait until Monday morning GP receptionist, 111 or 999?’ is beyond the abilities of many.

Some ironically wait until they are very sick before calling 999 which can result in critical illness – in these instances the message can be a little too explicit.

Recently I have spoken to some patients and their relatives who have been through the A&E experience.

No one has said it was fun.

Most describe prolonged trolley waits, delays in ambulance arrival and transfer, increased confusion amongst older people, harassed staff and so on.

Sure, I don’t doubt that some very ill people have been too out-of-it to relate their experiences of high-tech clinical care, but for those unfortunates who either didn’t really need to be in hospital or who needed to be in hospital but arrived at a point of over-stretched capacity, it didn’t work.

This I guess makes me think of a component of management-speak I once learned; the difference between ‘wicked’ and ‘tame’ problems. The essence is that ‘tame’ problems are those which are potentially very complicated, demanding significant resources and coordination but which are ultimately solvable. The sine qua non, at least back in the day was the Channel Tunnel, another might be the International Space Station. Success is easy to determine – Frenchman and Englishman shaking hands through a hole in the mud, and, well, failure is somewhere in the North Sea.

For ‘wicked’ problems, the solutions are often either poorly understood or impossible to define. Even the challenge itself if complex, with many partners or stakeholders all of whom potentially have different interests and opinions; classic examples here are the War on Drugs, Social Inequality or obesity.

Well, I would classify many aspects of 21^st Century Health and Social care as wicked problems, with acute care, or, the battle to stop people attending A&E departments who should either self-care, go somewhere else, or wait for Monday being a prime example.

No one quite knows how we can stop people turning-up at A&E and no one really knows what success looks like – the occasional person bleeding to death at home after a slip of the carving knife would be seen as a failure.

Back to the home visits.

For all the problems of A&E are opaque, there are some solutions which are probably not unreasonable, for example, education – teaching people in primary school what to do to avoid catching a cold or the flu (wash hands, get a vaccine).

Well, I see home visits as one of these strategies.

Part of the downside is that they are potentially inefficient.

It takes me at least 40 minutes to visit someone I have not met before at home and with travelling time this is more than an hour. In that time, in the hospital I could have seen perhaps six patients.

You could translate this into an economic/utilitarian argument and say, leave the old guy at home, see the six in hospital; this wouldn’t necessarily help the old guy. In this situation you are at risk of the inverse care law; also called the Matthew Principle – those who have (ability to get to hospital, a car to transport them to the GP) shall be given more – better access to clinical care, medicine, diagnostics, treatment.

I guess this wouldn’t apply if you were one of the six in hospital, equally, if you were the person at home, in bed, unable to get up because of a chest infection, low blood pressure and falls, you might see things differently.

The equation is therefore complicated.

For all the six I whittle through on a standard medical ward round, many will not actually need to be in hospital, many could be treated at home and most will go home in a day or two, begging the question as to whether they needed my review in the first place; the inverse of this is the person I visit at home who perhaps requires two or three paramedics to transport them from house to hospital and who, because of issues relating to mobility, capacity, insight or delirium end-up staying in hospital for weeks.

And it is this side of the equation that is awry.

Once a ‘housebound’ person is in hospital they inevitably stay for a long, long time. That is just the way our system operates (unless they are already in a nursing home and many of these people don’t benefit from acute hospital admission in the first place).

You might save half an hour of a doctor or nurse’s time by bringing the patient to them (ignoring the fact that many people don’t want to be ‘brought’), yet in the long-run the trauma or upheaval to that person, the delays either in transportation or being stuck on a hospital ward are hugely disproportionate.

I had wanted to write a little about home visits and the special circumstances that arise when you open a door and walk into the living or bedroom of someone you have never met before; that will be for another day. For now, I felt this necessary, as I know not everyone gets it. Not everyone sees the value of taking time to support the most needy and vulnerable; yes, I am treading on delicate political territory again and I know that doesn’t always work.

For today, I hope to keep popping out, spending quality time with patients, understanding what is important to them, their preferences, hopes, fears and aspirations, and supporting them to stay outside acute care.