Practice Boundaries and Home Visits

I have an overwhelming sense of deja-vu. As part of the government's plan to scrap practice boundaries, the suggestion has been made that someone other than GP's could take over the responsibility for out of hours care - oh sorry, I mean home visits. This of course coming at the same time as GP's are being asked to take back control of out of hours care which was seized from us (albeit gratefully) just a few years ago. Unfortunately of course that grand plan has left a wake of debt, poor care and unnecessary deaths. But I'm sure it will be different this time...

The debate on practice boundaries is an interesting one. The idea of increasing patient choice is of course appealing, but is fraught with problems, none greater than how to manage home visits for patients who don't live locally. Never fear though, the Department of Health is going to resolve the problem with one of the four potential solutions:

1. Creating rules to identify which patients practices should arrange home visits for, and which PCTs should be responsible for.
2. Asking GP practices to continue to provide or arrange home visits for all patients.
3. Allowing patients to register with two separate GP practices.
4. Removing all home visiting obligations from GP practices, making PCTs responsible instead.

Here are my thoughts on the above:

1. Logistical nightmare which would exacerbate the 'postcode lottery' effect and be wholly unfair to patients living just beyond the boundaries set (who may previously have been covered by their practice).
2. Impossible. Should I pop out to visit my sick patient in Kent, in between consultations in Islington?
3. Potentially workable if we had an IT system to support it, allowing both practices up to date information on consultations and prescribing. We don't.
4. Ludicrous. Much as I grumble about home visits (home visit = no lunch break), they provide an essential service to the sickest patients. Imagine the dying cancer patient, requiring regular home visits, being seen by a different PCT doctor on each occasion? It has the out of hours fiasco written all over it. Can this government really make the same mistake twice?

It seems to me that none of the government's options are workable. Yet the push for it continues because at first glance, 'it seems like a good idea' (may win votes). Perhaps even more importantly, opinion polls show quite clearly that it is only a small minority of patients who would wish to register with a different local practice or with a practice close to work (18% and 6% respectively). Does the enormous expense that this re-structuring will incur provide the tax payer with value for money when it will benefit only a minority? With the rest of the public sector under immense pressure to cut costs, is it really as Andy Burnham would have us believe "the right move at the right time"?

The majority of patients can already choose between a number of local practices. In addition, it has always been possible to be seen as a temporary patient in any practice in the UK, giving easy access to NHS primary care services wherever you are. So my point is this, where exactly is the problem?

Love in a cold climate

At the end of a routine consultation, Mr Howard playfully announced that 'romance was in the air'. He said it with a wide smile, a twinkle in his eye and a wink. He is 85 years old. There was no hiding how delighted he was, and it made me grin from ear to ear to see it. How absolutely wonderful that this frail old man had found someone with whom to share his days at the ripe old age of 85. I couldn't have been happier for him. He offered to show me a photo. Reaching into his coat pocket he withdrew, not the gleaming photo that I was expecting, but a small white business card. A little unusual perhaps, but it did indeed include a tiny photo and he offered it to me with great relish. I was a little taken aback. I had, I'm afraid, been expecting a little old lady in a floral dress and sensible shoes. Instead I saw the face of a rather pretty Thai woman who I guessed to be in her late 40's. "She's only 48 years old" he told me proudly.

I hope that outwardly I managed to maintain my buoyant manner, but my head was full of worrying questions;

"What does she see in him?

Perhaps she's after his money?

Maybe a passport?

Does he know what he's doing?

Should I say something?"

I elected to keep quiet, but I have since been contemplating my reaction. Was I concerned purely because of the age gap, or was it because she was Asian? Would I have reacted in the same way if she had been British? Would I have felt differently if she had been French, or Indian? I had made an assumption, a judgement of her, based on a photo. A tiny photo at that. I now feel rather ashamed at the speed at which I had sized this photo up and placed her in a 'category'.

It's not the first time I've caught myself at this. Only a month ago I saw a rather grand lady, well spoken and well dressed, who had come in with an itchy rash. It looked like scabies, but it seemed so unlikely in this woman. As a result, I dished out the usual multipurpose, 'bit-of-everything-in-it' cream and asked her to return if it didn't improve. It didn't improve. After much procrastination, I reluctantly mentioned scabies, suggesting rather sheepishly that perhaps she might have been away somewhere where she could have picked it up? I was expecting to be met with outrage, but she didn't seem surprised at all. It made me wonder about the reality of her home life behind that grand exterior.

I've begun to realize just how many judgements we make about our patients from day to day. How intelligent is our patient, and how competent? How motivated, how sensible, how realistic, how honest, how vulnerable? When I think about it, nearly every clinical decision that I make is based on at least one such assumption.

Yet I am young, and my experience of this world is limited. All of a sudden I feel rather under qualified for the task.

Body Language

We are taught at medical school of the importance of communication, verbal and non-verbal. We are shown how to arrange a consulting room to best nurture the doctor-patient relationship, advised on what to wear (mini skirts out, sensible frocks in) and made to watch ourselves on video to see how we perform. It forms part of the new 'touchy-feely' approach to teaching medical students and whilst I acknowedge its importance, I don't think many of us took it very seriously at the time. I always believed that either you found it easy or you didn't.

Nowhere are communication skills taken more seriously than in GP training. You attend courses, (pretend to) read books on the subject, and swot up on models and theories put forward by learned professors who have dedicated a lifetime to consultation analysis. But here again, I couldn't help thinking that most of it was a waste of time and effort. I learnt a few useful tricks, but on the whole, I felt that I was lucky enough to find talking to patients pretty easy, with or without the help of Roger Neighbour et al.

I have learnt not to be so smug.

On Monday afternoon I met Mr Hussain. He turned up for the first appointment after lunch, ten minutes late. That made me cross. As a result when I called him in, I failed to give him my welcoming smile and left out the usual pleasantries. Instead I ushered him in to sit, and asked, in a fairly cool manner, how I could help.

"Oh" he said, "I was hoping to see Dr Jones."

I could feel the hackles go up. My initial mild irritation intensified as I explained that Dr Jones was not in today. I emphasized that I would be happy to make him an appointment with Dr Jones the next day if he would rather. More than happy.

There was a long pause during which Mr Hussain simply stared at me. More annoying still. But then I saw something in his eyes that I hadn't noticed before. He looked anxious and timid. I realised that in his silence he was weighing up whether or not he could confide in me, looking for the smallest sign from me to proceed. I felt ashamed of myself. I uncrossed my arms, sat forward in my chair, and met his gaze. It was enough.

"It's man trouble" he said.

Ah.

So I've been taught a valuable lesson. In being complacent about my perceived aptitude as a communicator, I have missed the fact that with this comes the danger of complete transparency. In essence, my communication can be a little too effective. I run the risk of communicating hostility as well as kindness, impatience as well as patience, apathy as well as sympathy.

My challenge therefore is not to communicate what I'm feeling. Not to let Mrs Smith know that I'm miserable because I've given up wine for lent; not to let Mr Jenkins see how distracted I am by his comb over; not to make Mr Hussain feel uncomfortable purely because I'm annoyed that he's late.

Perhaps a gentle word of warning then to those who believe, as I did, that they are born communicators. For you may be giving away rather more of yourself than you'd wish...