Home visit delegation in general practice: Who is responsible now?

First posted on the RCGP website on 20 December 2019.

Last month, GPs in England voted to reduce home visits as part of their core contractual activities. The argument for this removal was cited as a lack of capacity amongst GPs to undertake home visits amid increasingly demanding workloads. These results were met with some opposition, but the vote means that the British Medical Association (BMA) will now lobby NHS England to revise the core services provided by GPs. However, the impact of this decision on both patient care and the wider workforce remains unclear.

For the past 18 months, the Evidence Synthesis Working Group (ESWG) has explored what home visit delegation may mean for the health service. The group produces high quality reviews that not only test what works, but also determine what works, in what situations, for whom; and identify clinical and methodology gaps that can inform future research, inform policy and develop robust practical interventions for primary care.

"Several factors need to be accounted for when considering home visit delegation"

By undertaking a review of published research evidence (both UK and international), policy documents and debate articles, researchers have developed an understanding of the conditions and processes of delegation and examined when (and when not) delegation of home visits might be appropriate.

Findings suggest several factors need to be accounted for when considering home visit delegation. A critical factor is that any healthcare professional (HCP) providing the home visit should be integrated into the general practice team from the outset. A GP may feel that delegation is suitable if they have previously established a degree of professional trust with the HCP. This trust will facilitate the appropriate and safe sharing of information and follow-up deemed relevant to a particular case.

"The delegation of tasks such as home visits can have implications for patient experience"

The HCP may benefit from an appropriate level of clinical autonomy linked to their skill set. Such consideration may also support the sustainability of the service. However, the impact on patient health (and long-term outcomes) is less clear. GPs supporting home visit delegation should be mindful that this may not, in the long run, reduce their workload. This may be particularly pertinent if the patient has complex needs or if the HCP requires extensive input from the GP.

Within primary care, the delegation of tasks such as home visits can have implications for patient experience. While patient satisfaction may be achieved in the short term, longer-term this may require a shift in communication and expectations about the nature of care being delivered. This comes at a time when patients are having to negotiate an increasingly distributed and complex primary healthcare system.

"Continuity of care and equitable access for all patients"

This shift also has implications for professionals and the organisations in which they work. This includes the variety of work experienced by staff doing delegated home visits. If home visits are removed from GP core contracts, broader more long-term considerations need to occur in terms of how to support sustainable training and retain a workforce employed to undertake the sole task of home visits. This also raises questions about how to maintain continuity of care and equitable access for all patients and ensure a feasible workload for GPs in the context of primary care networks.

Disclaimer:

The views expressed in this commentary represent the views of the authors and not necessarily those of the host institutions, RCGP, the NHS, the NIHR, or the Department of Health and Social Care.

Acknowledgements:

Ruth Abrams, Dr Kamal R Mahtani and Dr Sophie Park are members of the NIHR SPCR Evidence Synthesis Working Group [project number 390].