Continuity of care and other old fashioned values

“Old fashioned general practice restored” scream the headlines as the new variations to the contract for general practitioners for 2014-15 are agreed between the Department of Health and the BMA’s General Practitioners Committee.

Key to the government’s proposal for the public face of negotiated success is the implementation of a plan to give every patient over the age of 75 a named GP. This specified doctor will also be key in coordinating the care plans of a practice’s most vulnerable patients.

Newspapers hailed this as a victory for the common man in rolling back the era of decadent general practice to those good old days of avuncular Dr Findlay (when the management of an acute stroke was to put you to bed and receive a daily visit as you slowly succumbed). In spite of this political bluster, continuity of care is as sacred to those working in general practice, and probably to all in clinical practice, as it is to the politicians—in fact, probably more so.

To my mind, there is little more satisfying than the potential long term relationships offered by a career in general practice. It is these relationships that bring incredible gain to both patients and doctors and are the bedrock of efficiency in healthcare.

This is in spite of a societal trend for contact to become more and more anonymised. You may have given “Susan” at the call centre a detailed and helpful description of the fault with your broadband, but it is as certain as destiny itself that you will never be able to speak to her in your increasingly frustrated subsequent calls.

Yet patients, in the main, still have their own GP. It may just be the one preferred by the patient, or it may be a formally allocated and nominated one (as it is in our practice, where the concept of personalised lists and responsibility is fundamental to the way we provide care). Yet I wager that if you ask patients they are far, far more likely to know the name of their GP than their member of parliament or even the Secretary of State for Health.

Continuity of care allows the fruition of the doctor-patient relationship, and at its best it is imbued with trust and a level of commitment that are difficult to replicate elsewhere.

For elderly or chronically ill patients, it is even more important. Continuity provides historical knowledge that allows a greater understanding of patient and disease. It focuses attention on the new or the different, and it avoids repetitive or unnecessary investigation. The onus of responsibility rests with the doctor who “owns” that patient, and this minimises buck passing or filibustering care.

It is not just in general practice that this is important. Colleagues in surgical specialties face the rather lamentable situation where patients coming back for postoperative outpatient follow-up will rarely, if ever, see the surgeon who actually did the operation. Trying to answer questions or second guess someone else’s actions can make such consultations unsatisfying for both patient and doctor.

Continuity has a value and this is capitalised on by the private sector, which highlights that their health insurance buys the ability to get continuity of care and avoids the “you never get to see the same doctor twice” situation so common in the NHS.

However, such continuity of care comes with a price and a cost to deliver. It faces growing obstacles whatever the political will of the government or even the profession.

To start with, there is a diametrical balance between continuity and access. The drive to deliver instantly accessible care whenever and wherever has many intrinsic disadvantages.

Yet political expediency has seen successive governments make this promise to the population. They have almost enshrined it as a right to be seen rapidly on request, however appropriate or inappropriate that demand is. A plethora of pathways compounds the problem so that patients may go straight to a walk-in centre after seeing a GP and not getting the outcome they want. If foiled there, they may try their hand at an out of hours centre or accident and emergency department. This accessibility devalues continuity of care as well as making it impossible to provide.

Then there is the recent intention to expand general practice access to 8 am to 8 pm, seven days a week. Whatever the advantages and disadvantages of this plan, it cannot avoid spreading the availability of each individual doctor on any one day or any one slot and, if anything, decreasing individual doctors’ accessibility to patients.

Just as difficult is the new world of medical education and training. Shift systems have replaced team working in firms, so that the ethos of continuing responsibility has been diluted and the named doctor for the patient has been lost. Similarly to call centres, histories, problems, fears, and questions have to be repeated at each encounter with a new doctor on shift.

Medical staffing is also changing, with more people wishing to work part time, with reduced hours, or in a job share with the inevitable reduction in hours of availability. This has many advantages in maintaining a breadth of workforce and ensuring that there is employment flexibility, but such advantages do not come without a cost.

Politicians may preen themselves on the introduction of an obligation to provide a named doctor with individual responsibility for a patient. But this is just restoring values to general practice that the recent move to tick box targets threatened with extinction. The challenge now is how to nurture these values back to full strength.