CORRESPONDENCE * All letters must be typed with double spacing and signed bv all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Domiciliary visits SIR,-Professor Liam J Donaldson and Dr Peter M Hill have questioned the appropriateness of domiciliary visits and suggested that in geriatric medicine they are used as a prerequisite for admissions.' It is my experience that even with a well publicised "age related" admissions policy, no catchment area restrictions, and a waiting list of less than two weeks for a routine outpatient appointment the domiciliary visiting service is perceived by general practitioners as being necessary and effective. Over the past three years I prospectively audited the outcome of 850 domiciliary visits that I performed. In all, 30% of the patients were admitted in a planned, organised manner, usually the day after referral-thus ensuring that they were appropriately placed, appropriate clothing was brought, and relatives were informed. Only 8% were admitted the same day and not all of these were strict medical emergencies, for which of course domiciliary visits would have been inappropriate. Subsequently 15% of patients attended the day hospital for investigation or treatment. In my series 47% received no further follow up, and the general practitioners were advised on appropriate home management. Dr Malcolm Forsythe has suggested that general practitioner fundholders will reduce their requests on grounds of cost. 2 I submit that the extra costs of ambulance provision and perhaps unnecessary tests performed by junior staff in outpatient departments may perversely render the domiciliary consultation the cheaper option even if a proportion of patients subsequently need to attend hospital. The nationwide reduction in the numbers of long stay geriatric beds, coupled with the massive expansion in provision of nursing homes, has led to an increased number of severely disabled people cared for in the community and may further increase the number of requests for domiciliary visits in geriatric medicine.
attend, and occasional circumstances where not even an urgent outpatient appointment would be soon enough or where there is genuine clinical doubt on the need for admission. For several years general practitioners have been able to arrange emergency admissions directly, and the availability of geriatric outpatient clinics was emphasised. The effect on the numbers of visits requested from this geriatric department in the four months on either side of the circular is shown in the table, with the preceding year's figures for comparison. Domiciliary referrals before and after circular 1989
Change (%)
1990
-48 (14) -62 (21)
April-July September-December
352 292
308 230
Change (%)
-60 (17) -78 (25)
There seems to have been a slightly greater fall than would have been expected from annual or seasonal variation. Reviewing my own visits for the four months on either side of the circular, I thought that before it 43 of a total of 76 (57%) and after it 24 of 49 (49%) met a criterion, usually the issue of disability. The guidelines therefore did nothing to improve the appropriateness ofreferrals, as seen by a consultant. It is fees that confound and may corrupt the question of domiciliary visits. In specialties like geriatrics, where community aspects are important, it would be preferable if visits were recognised as part of the job and time, but not fees, allowed for them. The system needs review-but in the interests of patient care, not of health authorities' (or doctors') pockets. E J DUNSTAN
Sells Oak Hospital, Birmingham B29 6JD I Forsythe M. Domiciliary 23 Februarv.)
visits.
BMJ 1991;302:426-7.
G PHILLIPS
Department of M,edicine for the Elderly, Broadgreen Hospital, Liverpool L14 3LB I Doiialdson LJ, Hill PMNI. The domiciliary consultation service: time to take stock. BAIJ 1991;302:449-51. (23 February.) 2 Forsythe Al. Domiciliary visits. BAi7 1991;302:426-7. (23 February.)
SIR,-As Dr Malcolm Forsythe states, we need to identify the domiciliary visits worth doing.' In August 1990, to control the domiciliary workload and make it more appropriate, guidelines on when a geriatrician's visit was justifiable (irrespective of eligibility for a fee) were circulated to local general practitioners. In addition to medical inability to attend hospital, grounds included the issues of disability and environment, consistent refusal to
BMJ VOLUME 302
16 MARCH 1991
SIR,-Professor Liam J Donaldson and Dr Peter M Hill note that certain specialties, such as geriatrics and psychiatry, have a high rate of domiciliary consultations and seem to assume that this is because a domiciliary consultation is used as a prerequisite for admission in these specialties. ' We suggest that there are other reasons for this pattern. In our specialty of psychogeriatrics many patients referred to our service have dementia. It is almost impossible to make a meaningful assessment of these people in an outpatient clinic. When they do come to a clinic they are usually bundled into ambulances several hours before their appointment time and then driven around the town for some time before finally reaching the clinic. By the time we see them they are distressed and more disoriented than usual and no realistic assessment can be made. In contrast, a domiciliary
consultation allows patients to be seen in their own home with no inconvenience to themselves. In addition, the environment can be assessed as well as the patient. The state of the home often gives far more information about how the patient is functioning than the cognitive assessment. It is surprising how many members of the local community appear with useful information when a doctor visits. Another advantage of domiciliary consultations is that the patient is actually seen. The psychiatrists for the elderly in east Leeds recently audited one year's referrals to our outpatient department. Only 60% of those referred were seen in the clinic, patients often needing two appointments before they turned up. In contrast, 99% of those referred for domiciliary consultation were assessed, with 25% of them being admitted. If the geriatric and psychiatric services in the Northern region are using domiciliary consultation as a prerequisite for admission, then by admitting less than 50% of the patients referred they have saved the NHS thousands of pounds and should be congratulated for this cost saving exercise. W K BURN J K LAYBOURN J P WATTIS
St James's University Hospital, Leeds L29 7TF 1 Donaldson Lj, Hill PM. The domiciliary consultation service: time to take stock. BMJ7 1991;302:449-51. (23 February.)
SIR,-Professor Liam J Donaldson and Dr Peter M Hill suggest that donmiciliary consultations have considerably departed from the original concept and many are performed outside the criteria delineated in the terms and conditions of service.' We can provide direct evidence to support this contention. An audit of 97 domiciliary visits performed over eight months by one of us (JR) showed that 31 patients were admitted and 35 were seen as outpatients. A general practitioner attended one visit. This engendered concern that the admission of seriously ill patients was being delayed by previous home assessment. As delay in admission adversely affects outcome2 a structured referral system was instituted. Requests for domiciliary consultations in which admission was desired were declined and the admission was arranged immediately. Patients unable to attend hospital were visited in the usual manner, whereas those capable of attending were seen in the rapid assessment clinic for elders. The clinic is held daily in the day hospital, and patients are seen by the consultant usually within 24 hours after referral. In the 21 months after the scheme was introduced 288 patients attended the clinic and 61 domiciliary consultations were performed, a fall in the monthly rate from 12 to three (p
Domiciliary visits SIR,-Professor Liam J Donaldson and Dr Peter M Hill have questioned the appropriateness of domiciliary visits and suggested that in geriatric medicine they are used as a prerequisite for admissions.' It is my experience that even with a well publicised "age related" admissions policy, no catchment area restrictions, and a waiting list of less than two weeks for a routine outpatient appointment the domiciliary visiting service is perceived by general practitioners as being necessary and effective. Over the past three years I prospectively audited the outcome of 850 domiciliary visits that I performed. In all, 30% of the patients were admitted in a planned, organised manner, usually the day after referral-thus ensuring that they were appropriately placed, appropriate clothing was brought, and relatives were informed. Only 8% were admitted the same day and not all of these were strict medical emergencies, for which of course domiciliary visits would have been inappropriate. Subsequently 15% of patients attended the day hospital for investigation or treatment. In my series 47% received no further follow up, and the general practitioners were advised on appropriate home management. Dr Malcolm Forsythe has suggested that general practitioner fundholders will reduce their requests on grounds of cost. 2 I submit that the extra costs of ambulance provision and perhaps unnecessary tests performed by junior staff in outpatient departments may perversely render the domiciliary consultation the cheaper option even if a proportion of patients subsequently need to attend hospital. The nationwide reduction in the numbers of long stay geriatric beds, coupled with the massive expansion in provision of nursing homes, has led to an increased number of severely disabled people cared for in the community and may further increase the number of requests for domiciliary visits in geriatric medicine.
attend, and occasional circumstances where not even an urgent outpatient appointment would be soon enough or where there is genuine clinical doubt on the need for admission. For several years general practitioners have been able to arrange emergency admissions directly, and the availability of geriatric outpatient clinics was emphasised. The effect on the numbers of visits requested from this geriatric department in the four months on either side of the circular is shown in the table, with the preceding year's figures for comparison. Domiciliary referrals before and after circular 1989
Change (%)
1990
-48 (14) -62 (21)
April-July September-December
352 292
308 230
Change (%)
-60 (17) -78 (25)
There seems to have been a slightly greater fall than would have been expected from annual or seasonal variation. Reviewing my own visits for the four months on either side of the circular, I thought that before it 43 of a total of 76 (57%) and after it 24 of 49 (49%) met a criterion, usually the issue of disability. The guidelines therefore did nothing to improve the appropriateness ofreferrals, as seen by a consultant. It is fees that confound and may corrupt the question of domiciliary visits. In specialties like geriatrics, where community aspects are important, it would be preferable if visits were recognised as part of the job and time, but not fees, allowed for them. The system needs review-but in the interests of patient care, not of health authorities' (or doctors') pockets. E J DUNSTAN
Sells Oak Hospital, Birmingham B29 6JD I Forsythe M. Domiciliary 23 Februarv.)
visits.
BMJ 1991;302:426-7.
G PHILLIPS
Department of M,edicine for the Elderly, Broadgreen Hospital, Liverpool L14 3LB I Doiialdson LJ, Hill PMNI. The domiciliary consultation service: time to take stock. BAIJ 1991;302:449-51. (23 February.) 2 Forsythe Al. Domiciliary visits. BAi7 1991;302:426-7. (23 February.)
SIR,-As Dr Malcolm Forsythe states, we need to identify the domiciliary visits worth doing.' In August 1990, to control the domiciliary workload and make it more appropriate, guidelines on when a geriatrician's visit was justifiable (irrespective of eligibility for a fee) were circulated to local general practitioners. In addition to medical inability to attend hospital, grounds included the issues of disability and environment, consistent refusal to
BMJ VOLUME 302
16 MARCH 1991
SIR,-Professor Liam J Donaldson and Dr Peter M Hill note that certain specialties, such as geriatrics and psychiatry, have a high rate of domiciliary consultations and seem to assume that this is because a domiciliary consultation is used as a prerequisite for admission in these specialties. ' We suggest that there are other reasons for this pattern. In our specialty of psychogeriatrics many patients referred to our service have dementia. It is almost impossible to make a meaningful assessment of these people in an outpatient clinic. When they do come to a clinic they are usually bundled into ambulances several hours before their appointment time and then driven around the town for some time before finally reaching the clinic. By the time we see them they are distressed and more disoriented than usual and no realistic assessment can be made. In contrast, a domiciliary
consultation allows patients to be seen in their own home with no inconvenience to themselves. In addition, the environment can be assessed as well as the patient. The state of the home often gives far more information about how the patient is functioning than the cognitive assessment. It is surprising how many members of the local community appear with useful information when a doctor visits. Another advantage of domiciliary consultations is that the patient is actually seen. The psychiatrists for the elderly in east Leeds recently audited one year's referrals to our outpatient department. Only 60% of those referred were seen in the clinic, patients often needing two appointments before they turned up. In contrast, 99% of those referred for domiciliary consultation were assessed, with 25% of them being admitted. If the geriatric and psychiatric services in the Northern region are using domiciliary consultation as a prerequisite for admission, then by admitting less than 50% of the patients referred they have saved the NHS thousands of pounds and should be congratulated for this cost saving exercise. W K BURN J K LAYBOURN J P WATTIS
St James's University Hospital, Leeds L29 7TF 1 Donaldson Lj, Hill PM. The domiciliary consultation service: time to take stock. BMJ7 1991;302:449-51. (23 February.)
SIR,-Professor Liam J Donaldson and Dr Peter M Hill suggest that donmiciliary consultations have considerably departed from the original concept and many are performed outside the criteria delineated in the terms and conditions of service.' We can provide direct evidence to support this contention. An audit of 97 domiciliary visits performed over eight months by one of us (JR) showed that 31 patients were admitted and 35 were seen as outpatients. A general practitioner attended one visit. This engendered concern that the admission of seriously ill patients was being delayed by previous home assessment. As delay in admission adversely affects outcome2 a structured referral system was instituted. Requests for domiciliary consultations in which admission was desired were declined and the admission was arranged immediately. Patients unable to attend hospital were visited in the usual manner, whereas those capable of attending were seen in the rapid assessment clinic for elders. The clinic is held daily in the day hospital, and patients are seen by the consultant usually within 24 hours after referral. In the 21 months after the scheme was introduced 288 patients attended the clinic and 61 domiciliary consultations were performed, a fall in the monthly rate from 12 to three (p
