Delegating home visits in general practice: a realist review on the impact on GP workload and patient care

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p>UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs’ workload and hospital admissions, and improving patients’ access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances.</jats:p></jats:sec><jats:sec><jats:title>Aim</jats:title><jats:p>To explore how the process of delegating home visits works, for whom, and in what contexts.</jats:p></jats:sec><jats:sec><jats:title>Design and setting</jats:title><jats:p>A review of secondary data on home visit delegation processes in UK primary care settings.</jats:p></jats:sec><jats:sec><jats:title>Method</jats:title><jats:p>A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.</jats:p></jats:sec>

Identifying evidence for five realist reviews in primary health care: A comparison of search methods

“…In four of the five included reviews, data extracted from published, academic research papers dominate. However, in one review (Review A), only 51% of included papers fell into this category, 44 and in one other (Review E) these documents made up only 24% of included documents 46 . All of the reviews included data extracted from numerous other types of document, in varying proportions.…”

“…The lead reviewers on each project agreed to contribute their data to this study. The detailed methods employed in each review are reported in their own study protocols and published reports (where applicable) 39–48 . For this study, we collected data from each review team relating to the final list of documents included in each review.…”

Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK

“…The initial uncertainty described by GPs was mitigated by practices having the opportunity to define the scope of the ECP's work, such as triage decisions and interdisciplinary learning, which is also an important feature of integrating nurse practitioners into primary care teams [10]. Collaboration between GPs and ECPs was another essential factor that mitigated the potential for professional role boundary conflicts [10,11,20]. As previously described for interdisciplinary working between physician associates and GPs [13], ECPs and GPs worked together to define their roles and reframe their professional boundaries at the GP practice level.…”

Home visits for vulnerable older people: journeys to the ‘Far End’

“…11 As the delegation of home visits develops, practioners will need clarity around boundaries and understanding of roles. 12 Therefore, a blended model of home visits may be appropriate with acute presentations being delegated to paramedics or advanced nurse practioners. Long-term conditions or more complex Far End cases may be best retained by the GP until the evidence base and ways to implement recommendations have been established.…”