Medical Matters/Dr Charles Daly: Mary, an elderly housebound patient, rings me once a month to remind me to visit when I am doing my "rounds" after surgery.
This quaint phrase evokes an era of leisurely, unhurried home visits when doctors travelled by pony and trap, fees were paid in guineas and tea was served in china cups after the conclusion of business. It is unlikely we will ever adopt the North American attitude that if you are ill enough to need a house call you should bypass your doctor and go straight to casualty, but GPs' rounds are in danger of becoming a thing of the past.
There are certain insights and advantages to be gained by seeing patients in their own environments, learning how they adapt to their illnesses in the domestic context and understanding how family dynamics may influence the outcome of illness, but one visit is often enough. Doctors who were practising 20 or 30 years ago recall doing up to 20 routine house calls after a busy day's surgery. Today 10 house calls a week would be considered unusually high, even in the busiest practices.
What has happened in a relatively short period to reverse this situation so dramatically? Cynics might point out that the decline in house calls accelerated rapidly after 1989, when the method of payment in the GMS medical-card system changed from a fee per item to capitation, meaning there was no longer a financial incentive to visit people at home. There may be an element of truth in this, but the full answer is more complicated. There are several reasons why house calls are less common than before, and most have to do with time, or the lack of it.
It makes sense and saves time to encourage patients to attend the surgery if possible. Better examination rooms, better records and more use of modern diagnostic equipment mean it is much easier to examine someone properly in a bright modern surgery than in a small, dimly lit boxroom where you might have to clamber over a bed or chest of drawers merely to get to the patient.
These days a house call may mean a round trip of up to an hour; the same consultation in the surgery might take 10 minutes. Previously, many house calls were done because patients had no transport. There is very little justification for this today. Most people have access to somebody with a car. Doctors often find that if they react to a request for a house call by implying that it may be several hours before they can call, transport materialises miraculously to deliver the patient.
On the other hand, it is very annoying to arrive at a house with three cars in the driveway and to have the door opened by a relatively able-bodied patient. I once worked in an urban practice where the official policy was that bad weather, poor social conditions and lack of transport were not valid reasons for demanding a house call. This policy was so stringent that a house-call request almost merited an in-house inquiry.
Security is another reason why doctors are more reluctant to visit homes in some urban areas or on housing estates where there is a real risk of violence, assault, robbery of doctors' bags (which may contain drugs), car damage or threats of car damage by youthful blackmailers, especially at night. Female doctors are especially vulnerable and, quite rightly, will not subject themselves to such dangers. This means some places become no-go areas for house calls, even for those in genuine need. It is not entirely an urban phenomenon; in my relatively tranquil semi-rural practice I have been thumped several times - and floored once - by violent patients of both sexes.
The one area where there has been an increase in house calls is terminal care. The development of the hospice movement and advances in pain relief and symptom control in patients dying from cancer mean patients can spend more of their remaining time at home with regular medical input. Although these calls demand intense time commitment and effort, they are generally positive experiences for patients, carers and doctors alike, and by definition the time span is short. Calls will also continue to be made to nursing homes, welfare homes and other institutions where patient mobility is compromised and where it is logistically easier to see a number of patients on the same visit, in familiar surroundings and with nursing staff who know them well.
I used to go to a retired colleague every few months, for treatment for a slow-growing cancer. Afterwards we would repair to the patio for coffee and carrot cake and talk of matters of mutual interest while the Atlantic breakers pounded the rocks below. This was the idyll and ideal of house calls, but such experiences today are limited, sacrificed on the altar of expediency and time management.
Dr Muiris Houston returns next week