Home visiting in a rural practice

Abstract

The merits and demerits of home visiting in primary care have been debated for 15 years or more, and several studies have shown a definite decrease in home visiting by family doctors. Most studies were made in industrial or suburban practices, though McGregor1 reported on a largely rural practice in 1973. In comparing the decades 1949–58 and 1959–68 he noted a moderate change in emphasis from home visits to surgery consultations in 1959–68, though the absolute number of home visits increased marginally despite a fall in practice population. It is impossible to estimate an annual visiting rate per patient from his figures. Fry’ recorded a fairly steady rate of home visiting of between 0.6 and 0–8 visits per patient a year between 1951 and 1963, with a steady and progressive fall to a rate of 0–1 visits per patient a year in 1971. Marsh’ described a similar fall from 18 visits a day for a six-day week in 1960 to nine a day in 1967. In a mixed urban and rural study in 1968 Eimerl and Pearson’ showed that the urban doctor spent 40% of his time travelling to and face-to-face with patients at home and the rural doctor 56%. The city doctor saw 17% of his patients at home, the rural doctor 35%. They noted a trend showing that older doctors saw proportionately more patients at home than younger doctors. The case for less home visiting and more consultations taking place in the surgery is well rehearsed. The time spent in the car is largely time wasted and the availability of equipment and other resources argue strongly in favour of the piuient coming to the doctor rather than the reverse. A powerful note of caution was struck by Pereira Grayy in 1978, however. He recorded a fall in his own personal visiting rate from 0–5 visits per patient a year in 1974 to 0–35 visits per patient a year in 1976. But he questioned the wisdom of permitting this rate to fall too low, saying that if the family doctor was to know the patient in his entirety the doctor should see and study him in his own environment and not just when he is a nervous visitor to the consulting room. Furthermore, Pereira Gray offers evidence that when the family doctor abdicates his role as a home visitor and thus creates a clinical vacuum (clinical = at the sick-bed, Oxford Dictionary), others— workers, hospital-based paediatric nurses, hospital-namely, social based community mental nurses, or community geriatricians—will move in and take over his role, and the total responsibility for family care by the family doctor is put at risk. I have studied home visiting in our rural practice in Wales between the years 1953 and 1978. © 1981, British Medical Journal Publishing Group. All rights reserved.