General Practitioner

I am an NHS GP and recently completed population health fellowship, hosted by BSW primary Care Training Hub. I had been increasingly aware that as workload pressures increased as did the challenge of serving my patients who were homebound. It was headline news in 2019 when 54% of delegates at the England LMC conference voted to remove home visiting from the core GP contract due to capacity issues.  As institutional priorities such as efficiency and digitalisation are advanced homebound residents were a group vulnerable to becoming excluded. I was also interested in the holistic health needs of homebound residents and the benefits of non-medical prescribing in promoting health and wellbeing in homebound residents with minimal risk of iatrogenic harms.

Literature modelling identified two key clinical antecedents to becoming homebound, immobility or physiological instability, both closely associated with frailty markers such as multi-morbidity, medical complexity and symptom burden. However, social, economic and environmental inequalities were shown to influence which members of our society were more likely to develop the prerequisite conditions that produce home-boundedness. It is also known that despite homebound persons having amongst the highest healthcare costs, they had some of the poorest health outcomes, with home-boundedness being an independent risk factor for disease. Studies have found that even when correcting for age and health baseline characteristics, homebound people experience poorer physical and mental health outcomes, and higher annual mortality rates than their peers.

BSW health data searches were limited: the number residents coded as homebound varied widely depending on the clinical database searched, and the majority of identified residents had missing demographic and care data. That said we did find that the likelihood of being homebound increased for female residents, Irish and also black ethnic and racial groups, and those experiencing higher levels of socio-economic deprivation. Locally home-boundedness was strongly linked to multimorbidity (54% had 3-6 chronic health conditions) and older age (90% aged >60 years; 60% aged >80 years) yet 63% of homebound residents had no coded frailty care.

With the support of VirginCare and DHI, we completed a retrospective audit identifying 288 homebound residents who had accessed the social prescriber link worker (SPLW) service between December 2020-2021. The clients were younger on average than the typical BSW homebound resident (mean age 62 years), the majority of these contacts were remote telephone consults (83%), and were generated by GP referral (73%). The most common reason for accessing the SPLW service in this group for mental health needs (36% of referrals). While numbers were admittedly small, 100% of those responding to Friends and Family Test  responded as “likely” or “extremely likely” to recommend the service, with 0% negative feedback received from this client group.

The scope and ambition of my initial fellowship project plan was significantly curtailed by the pandemic and service pressures. However I had many opportunities to meet with local service planners and commissioners, and also to work alongside social-prescriber and personalised care colleagues across BSW. I hope that my work, and the connections I made in my fellowship year, are the beginning of a conversation of how we better design holistic and personalised care options for homebound residents, but also how we might be able to support those at risk of becoming homebound to delay this milestone health event.