I have clear memories of our family GP when I was a little boy. His name was Iain Kerr. He was a marathon runner. He was an advocate for euthanasia which caused him problems latterly. He died a few years ago from skin cancer.
I can’t remember him visiting the house although I am sure he did or would if there had been something wrong.
That was back in the days in the UK when local GPs were on-call for their patients, either every night or one-in-three or whatever, depending on the numbers of doctors in the practice.
Later there were mergers then conglomerates and organisations took over the night-time with nationals employing GPs to call-handle and visit depending on the situations.
Recently my brother sent me an old air-mail letter he had found written by my mum in 1985. Mum described an illness I had, no one quite knew what, perhaps glandular fever, likely a virus. It had me as a 12 year old, off my feet and in bed for a couple of weeks. I remember the doctor, Michael Herz, visiting me. I was living in an absorption centre in Israel at the time.
In the early 90’s when I was planning medicine as a career, my brother, a GP in Cornwall would take me on house visits.
I found them the best aspects of the job. Better than sitting in a surgery.
Getting to see the inside of peoples’ houses, how they lived, how they greeted you at their front door, the stairs to the bedrooms, all that kind of thing provided an insight to who they were.
Before Covid GP house visits were still common although by then doctors had already split – some would never visit, even if a patient was in a bad way, even if they were very frail, couldn’t make it to the front door, even if they were dying, other practices would visit eight or nine patients a day depending on their population size.
Covid ended all this.
It brought with it home visiting services and remote consultation. This is when the phone or a video-call would substitute for driving down the street looking at house numbers, knocking on doors, or the local GPs would employ paramedics to visit their patients. Take their observations, make diagnoses and decide what to do.
I am a big fan of paramedics and many working as practitioners are skilled at all the above, diagnosing a urine or chest infection, prescribing antibiotics, reassuring.
The biggest difference between paramedics and GPs is something I have discussed before – it is a fundamental of health and social care that has been forgotten by those planning the future; continuity of care.
What makes a GP special is their knowledge of a patient, their insight over months, years, even decades into a person’s life. The bond that continues after the acute illness has passed, the person recovered, perhaps passed through school, left for college and returned, married then divorced, raised children.
This integrated continuity is more precious than any algorithm.
Paramedics work in an episodic fashion. They see you when you have fallen. Patch you up or take you to hospital. They are not privy to your family dynamics, which school you attend, where your parents live, who they are, your previous decisions or wishes relating to investigation, treatment or care.
They enter then leave. The GPs stick around.
Since Covid the number of GP home visits have fallen-off.
People have stopped asking for their doctor to come and see them.
In many instances doctors can’t visit their patients as the intensity of work in primary care has increased so much. Our nation’s health is deteriorating, despite all the progress made in technology and treatments, or, if not their health, their perception of health, their level of fear and anxiety, even their ability to self-manage.
And I still visit. It is a major part of what I do. I love it.
I saw two patients yesterday who hadn’t had a doctor visit in a very long time. They asked me enquiringly as to why I had decided to visit them (both would have struggled to come to see me). They were appreciative. I was privileged, allowed into their homes, allowed to listen, to hear the complexity of their health issues, provided an opportunity to disentangle the multiple conditions that were holding them back.
Reviewing the chest and heart problems, pain, dizziness, immobility, even their families anxieties.
None of this could be done by a paramedic visiting to treat a fall or a GP with a five-minute appointment slot.
And yet, I know I only see a tiny number of the people who would benefit.
I have one pair of hands and the hours are limited.
I wish I could do more.
And I feel that time is after me. The wheels of modernity are not turning in my direction.
What will be in five or ten years?
Where will house-calls sit in the madness of health and social care? The system is creaking, breaking in parts, and yet, our population is ageing, more people see the limitations of modern medicine, the futility of a passage through acute then general medicine where disease-specific pathways fail to consider all that is happening, fail to acknowledge, see or realise the person.
What will be?
Will I still visit?
I surely hope I am able to sustain these calls, even with the increasing costs of travel (my electric car helps) that are a disproportionate tax on other who drive around the community visiting patients in their capacity as nurses, therapists, support workers and carers.
It is such a time of opportunity, yet the uncertainty drives a lack of confidence that is inherently detrimental to wellbeing.
Let’s see if we can’t keep the visits going. Maybe chip a few percentage points off the cost of running hospitals and secondary care and take the treatment to the patient, let’s focus on patient-power rather than the disempowerment that comes from lying half-naked in a hospital gown of a dirty stretcher. Let’s keep reinventing, keeping what works and throwing-away the rest.