Mother asks for weekly home visits

A mother of three children regularly requests home visits that you do not believe are necessary. What should you do?

THE PROBLEM 
A mother of three small children requests a home visit at least once a week for herself or for one of the children. She lives about a mile from the surgery, but says it is too difficult for her to get to the building because there is no bus nearby and she does not have other transport. How do you address this?

Dr Fola Olaleye’s view

Attempting to balance home visit requests against the patients’ health needs is always a delicate issue. In this case, I would want to know how she reaches the supermarket, the school or nursery and other social amenities.

I would gather evidence of inappropriate home visits she has had in the past and discuss it with colleagues at the next clinical meeting.

We should be able to identify possible patient issues such as a lack of awareness of limited health resources, poverty, domestic violence, child protection issues, poor parenting skills, unmet health needs, inappropriate expectations and physical or mental disabilities.

I would suggest the practice write a letter informing her of our concerns regarding the inappropriate requests for home visits, and suggesting sources of help such as the Citizens Advisory Bureau, benefits agency, support from the health visitors, or parenting classes.

Communication is vital. An exploration of her ideas’ concerns and expectations would help uncover underlying health issues, and I would attempt to encourage a shared responsibility.

- Dr Olaleye is a GP Medway, Kent. He qualified as a GP in February 2006

Dr Sujaya Mankragod’s reply

This is a difficult but common problem. More information is therefore required about whether the health concern is genuine and, if on further investigation, there are significant health problems.

If there are significant health problems, then probably her request for home visits is reasonable, but thought would have to be given about possible hospitalisation of the ill person or persons. However, if it was consensus that her requests were unreasonable, the next step would be to speak to the mother and find out her concerns and expectations.

I would ask her about her real concerns and explain the symptoms and signs of the disease in question and discuss the likelihood of this being the problem.

If it was a minor ailment that she was seeking attention for, then I would give her patient information leaflets.

I would explain to her that it was unreasonable for her to expect home visits just because she has no transport and that it is up to the doctors to decide if a home visit was necessary depending on the clinical need.

If I thought underlying depression or anxiety was the problem, then I would tell her so and refer her to a counsellor and suggest some self-help books.

I would make her understand that, though we are there to help her, she must take responsibility for her health and that of her children, rather than be totally dependant.

- Dr Mankragod is a freelance GP in Cardiff. She qualified as a GP in February 2006

Dr Tillmann Jacobi’s reply

It is likely that in this case there is an underlying social problem, which might have been going on unnoticed for many years.
 
Also, consider that a variation of Munchausen’s syndrome by proxy might be displayed in the mother’s behaviour. Action is therefore necessary to prevent possible significant harm over time.

Liaise with other healthcare professionals in your practice — GPs, nurses, and health visitors — and seek their advice. Bring the case up in a practice meeting.

Whatever advice and approach from the surgery the family experiences, it needs to be a consistent message from the practice, rather than confusing different messages and actions from individuals.

- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005

LEARNING POINTS 
  • How to decide if repeat home visits are necessary
  • Gather evidence of inappropriate previous home visits.
  • Suggest other sources of support, for example the Citizens Advisory Bureau, benefits agency or parenting classes.
  • Enlist the help of other GPs and the health visitors in your practice.
  • Explain that it is unreasonable to expect home visits without a genuine need.
  • Consider underlying depression or anxiety, or a variation of
  • Munchausen’s syndrome by proxy.

 

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