The Housebound Service

Claire Kaye, GP, Schopwick surgery


Our surgery, Schopwick, is set  in a beautiful  part of  leafy  Hertfordshire on the borders of  North London. We have a large elderly  population and despite the fact that our clinical  team were trying to provide the very  best  care to  all  patients, we felt that  our  housebound population was not  receiving as much time and attention as we would like. I  am a salaried  GP at  the practice and the partners asked me to devise a mechanism for  providing  better care to this vulnerable population.

In January 2015 I  set up  the ‘Housebound service’ in close consultation with the rest of the surgery  and community team and I  am pleased to report it  has been a great success.

The problem

In general, housebound patients find it  difficult to  access medical and social support.  As GP’s we are often limited for time on home visits.  As a result we commonly  manage  the immediate acute problems when we visit a patient  at  home but  we find  it  difficult to  sort out  wider issues. This, in my  opinion, contributes to  patients going in to  crisis at  some point. For example, a patient  who  has had a fall  may not  just  need their lacerations and head injury assessing. The cause of  the fall  is vital. They may have fallen because they  have undiagnosed  memory issues or underlying  pathology such as polymyalgia rheumatica or  arthritis. They  may  be struggling to  look  after themselves and need more social support.

If  we can  make small  changes early then in theory patients should have better outcomes. This was a hypothesis which I  hoped to  prove. Patients had also reported to us that  they  often didn’t  know how to or  who to seek  help from if  they had a more of  a chronic issue, such as becoming  frailer, and they often didn’t want to ‘bother the GP’ if  there was no  specific acute issue.

The solution

The aim of  the service is to  provide holistic care of the housebound population. It  focuses on continuity of care so  that  patients know who  and how to  get help, with more chronic issues, when needed. The service is ‘in-house’ and so  patients have said  they  feel  reassured that  their GP practice  is their  point  of  contact.

Each housebound patient  has a one hour holistic consultation with the lead GP  at  home at  least  annually. Patients also  receive at  least one follow up  telephone consultation approximately  one month  later with the lead GP. If  necessary they  have more face to  face or  telephone consultations throughout  the year. A template was created based on the Comprehensive Geriatric Assessment which is used during the face to  face  consultation and a user friendly  computer version of this template was also  produced to  enable all the information to  be entered correctly  on  our  IT system. The  template covers  all  medical issues, medication review, falls risk assessment, mobility, nutrition, memory and mood  assessment, resuscitation status and social  issues.

Continuity is vital to  the success of the service and so the  lead GP  can be contacted, at the GP surgery,  by the patient  when needed, however the patient still continues to  see their usual  GP for  acute issues.

We also wanted to ensure that we work closely with the multi-disciplinary team, including the  practice ‘carers champion’, CCG navigator  and local  allied health professionals including OT, physio, social services and memory clinic to  provide joined up  care.

The other important part of the service is that  any clinical  or  non clinical member of the surgery team can refer a patient to the Housebound Service. There is no paper work  involved and no  criteria except that  the patient must be housebound.

The impact of the service

Anecdotally the patients and relatives seemed to  really value the service.  Comments included things such as ‘ this service is heaven sent’, ‘we have been desperate and didn’t  know where to  turn’ and ‘at last I know that  someone cares’. A Survey Monkey was conducted retrospectively interviewing  69  patients about their experience of the housebound service. The outcome were very  successful. Patients and relatives felt that the service was useful and accessible. Patients said that they valued time and continuity with  their GP. They  felt  reassured and that the surgery  cared about  their overall wellbeing.

Also multiple new diagnosis have been picked up  including  breast  cancer, PMR, OA, depression, dementia and severe AS. A lot of this patient group either didn’t realise anything was medically  wrong or they didn’t want to ‘bother the doctor’.

An audit was also carried out looking at a time period before and after the Housebound Service was started. It showed that this project has contributed to  reducing home visits  by  29 visits in a one month period when looking at 2 comparable points in 2 consecutive years.

Interestingly, staff have also reported that they  have found the service helpful. Practice staff, (including  non-clinicians) who have concerns about a patient have direct  access to a more in depth consultation from the lead GP and patients can be discussed easily, when required, in practice meetings. It also helps to  give clinicians an idea of  a patient’s baseline which is useful  when assessing  an acutely unwell housebound patient.

One of the joys of this service is that  there is virtually no red tape. There is no referral paperwork  to fill in and no discharge system. It is simply  an extension of the usual service provided by the patient’s GP. The project has improved housebound patient diagnosis, follow up and overall care to a vulnerable population group. It  also  allows for  careful  care planning aiming to  reduce falls and provide better patient care.
We have now extended the model  to involve our community matron which includes a weekly  ‘ward round’ type discussion of  current  patients. The lead GP sees patients on alternate weeks but  is available for messages on a weekly basis. Our community matron also  sees patients on an alternate week basis. This development  is providing  even closer links with  the community team which is in turn benefiting our patients.

Useful resources

 If you would like more information on implementing this Bright Idea in your practice, please email

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