Visiting patients in their own home is a time-consuming business. Understandably, GPs prefer to see patients in the surgery where they can make more efficient use of their time and facilities. However, it is not always easy for a patient to get to the surgery, because of lack of transport or poor mobility for example, or, especially in the case of young children, fear of making matters worse.
So what are the doctor's obligations when faced with a patient who insists on a home visit?
GPs are accountable to the health authority (or equivalent) under the their Terms of Service, to the General Medical Council (GMC), and to their patients in the civil courts if sued for negligence.
The doctor's Terms of Service are the terms of the contract between a GP and the health authority governing the provision of medical services to patients.
In England and Wales, paragraph 13 was amended in 1995 in an attempt to clarify when a doctor is under an obligation to visit a patient at home.
First, it deals with services provided during normal surgery hours, stating:
'A doctor shall render the relevant services during the hours for which he is normally available in the case of a patient whose condition is such that in the doctor's reasonable opinion it would be inappropriate for the patient to attend at the practice premises at whichever is appropriate of the places set out in sub-paragraph (5)' (previously defined locations, including the patient's own home).
Out of hours, the wording of paragraph 13 is slightly different:
'Outside normal hours the doctor shall consider, in the light of the patient's medical condition, whether a consultation is needed, and if so, when.'
If a consultation is required, the GP must form a reasonable opinion as to where it should take place.
However, the basis on which the reasonable opinion is formed is not confined to the medical issues, and the wording certainly leaves scope for social factors to be considered.
Judging what is reasonable
How should the reasonableness test be applied to the following?
A 20-year-old man with 'a raging sore throat' who is 'feeling really rough' asks for a home visit. He cannot, he says, come to the surgery because his girlfriend has taken the car to work and he has no money for a taxi. He insists that he needs to be seen as he has never felt so ill before, but it seems that he is up and about.
Most GPs would be extremely reluctant to visit such a patient but, in the event of a complaint, is the doctor vulnerable to criticism?
In responding to any complaint, the doctor would first have to set out the facts about the patient's medical condition and then justify the decision not to visit. Justification might include having given advice to try home treatments for a period before review or having made arrangements to see the patient at the surgery when his girlfriend had returned from work.
The key here is demonstrating that there was no reason to believe the patient's position would be jeopardised by not seeing him at home. In other words, the reasonable opinion must be based upon an assessment of the facts; a doctor who failed to make sufficient enquiry could be vulnerable to criticism.
Take another example. The mother of a 15-month-old child telephones the surgery obviously anxious. All she is willing to say is that the child is ill and needs to be seen. She demands that a doctor visit straightaway. Is this situation any different from the problem posed by the 20 year old?
On the face of it, perhaps not. An unreasonable young man has been replaced by an unreasonable young mother. But there are crucial differences.
First, the mother's refusal to give any details about what is wrong with her child means that the doctor is not in a position to reach a reasonable opinion about anything other than the mother's attitude.
Second, the patient here is the child, not the mother, and one way or another the GP needs to obtain more information about the child's condition.
The danger is that the mother and GP will dig themselves into entrenched positions with the GP being none the wiser about the child's illness, the assessment and management of which must be the paramount consideration. Ultimately, that may mean visiting to assess the child despite the probability that it is a self-limiting or trivial illness.
If the doctor refuses to visit, the mother refuses to come to the surgery, and the child turns out to have meningitis resulting in death or serious handicap, the doctor's position will prove difficult to defend, notwithstanding the unreasonableness of the mother.
What the GMC says
The GMC's guidance in Good Medical Practice1 does not address this specific scenario, but does make the following applicable points.
It states that:
'Good clinical care must include an adequate assessment of the patient's condition, based on the history, clinical signs and, if necessary, an appropriate examination.'
'Successful relationships between doctors and patients depend on trust and to establish and maintain that trust, you must listen to patients and respect their views, treat patients politely and considerately, and be readily accessible to patients and colleagues when you are on duty.'
It also states:
'You must not refuse or delay treatment because you believe that the patient's actions have contributed to their condition, or because you may be putting yourself at risk.'
In addition to complaining to the health authority and the GMC, aggrieved patients may also attempt to recover damages through a negligence action.
To succeed, the patient must prove that a duty of care existed (which would clearly be the case in both examples cited here), that there was a breach of that duty, and that harm was suffered as a result of that breach of duty.
The test of whether or not the doctor delivered an adequate standard of care would be whether the doctor put himself in a position to make an adequate assessment of the patient and managed the patient appropriately thereafter.
That in turn would depend upon the history elicited over the telephone and the further advice given about management and the need for follow-up.
The fact that the doctor did not visit would not in itself amount to a breach of duty, but failure to make sufficient enquiry to form a reasonable opinion would amount to a breach of duty.
Finally, compensation is recoverable for the harm that would have been avoided but for the breach of duty.
In the first case, if the patient recovered from a simple upper respiratory tract infection, no harm would have been suffered and no compensation would be payable even if a case for negligence could otherwise be made.
In the second, if the child did develop meningitis, expert evidence would be required to determine whether, on the balance of probabilities, death or serious handicap would have been avoided had earlier assessment and referral been made.
When paragraph 13 of the Terms of Service was amended, it was hailed by some as a substantial change which made it clear that it was up to the doctor to decide whether a visit was necessary.
That is true, but to be justifiable the decision must be an informed one, not a blunt refusal to visit.
- Good Medical Practice. 2nd edn. London: GMC, July 1998.