Re:Response to Iona Heath's article from the independent panel of The King's Fund's inquiry into the quality of general practice
Sir Ian Kennedy and colleagues' response to Iona Heath's commentary
on the recent King's Fund GP report does not address her criticism in the
case of continuity of care.
As Heath mentions, I had the privilege of contributing to the Inquiry
paper on continuity of care. One of our conclusions was that 'many
developments in practice and national policy have had the unintended
consequence of making relationship continuity more difficult to achieve'.
And a principal recommendation was 'ensuring better understanding of the
importance of continuity and the need to prioritise or incentivise it
alongside other developments in health care' (1).
I was naturally curious as to what emphasis the final report would
make on continuity. As Heath reports, I was present at the initial launch
of the report, giving me a chance to quiz the authors. In the few minutes
available to scan its 150 pages I was delighted to see Continuity of care
given prominence: - 'as a priority for GPs and patients alike. There is
evidence to show that in recent years it has become more difficult for
patients to see a preferred GP...' and: - 'Greater priority needs to be
given to continuity of care...' So I looked on eagerly to see what
recommendations there would be to preserve/enhance continuity in future.
But in vain, there were none. But there was reference to 'evolving skill-
mix', a 'wider range of professionals', 'GPs should be empowered to take
on a more expert advisory role'. These things may have merit, but they
will not improve the continuity of therapeutic relationships.
There is sensible coverage on continuity of care in the body of the
report (pages 83-88), but the key points on pages 88 and 99 are non-
specific, omitting any mention of what is already possible in continuity
of care measurement. Crucially, the three final chapters on 'Developing an
environment for quality improvement', 'The future of general practice',
and 'Conclusions' do not mention continuity of care at all. I cannot
follow Sir Ian's saying that 'The vision it sets out for the future of
general practice clearly has this theme at its heart'. Nor do these
sections show awareness that moving to a complex system of multiple
primary care providers risks losing the personal element that has been
inherent in general practice and is perhaps one of the reasons GPs have
retained the trust of patients in spite of the many shortcomings rightly
highlighted by the report.
I also suggest that Sir Ian and colleagues have misunderstood Heath's
commentary if they think she is 'blaming the patient'. She merely points
out that the report reads as lacking 'understanding that patients, as well
as reasonable and rational, can also be abusive, manipulative and self
destructive'. Until we can all agree and understand that the world in the
consulting room can sometimes be messy and difficult, I fear we will not
make the progress we all desire towards improving care and reducing
excessive variation in quality.
One small point that Heath kindly omitted is a surprising error in
the 'historical timeline' of general practice on pages 13-15 of the
report. Here the creation of the RCGP is said to have been in 1972. This
is no typographical slip of a digit, for the entry is in apparently
appropriate sequence in a paragraph headed '1970s - Professionalisation'.
Rapid Response:
Re:Response to Iona Heath's article from the independent panel of The King's Fund's inquiry into the quality of general practice
Sir Ian Kennedy and colleagues' response to Iona Heath's commentary
on the recent King's Fund GP report does not address her criticism in the
case of continuity of care.
As Heath mentions, I had the privilege of contributing to the Inquiry
paper on continuity of care. One of our conclusions was that 'many
developments in practice and national policy have had the unintended
consequence of making relationship continuity more difficult to achieve'.
And a principal recommendation was 'ensuring better understanding of the
importance of continuity and the need to prioritise or incentivise it
alongside other developments in health care' (1).
I was naturally curious as to what emphasis the final report would
make on continuity. As Heath reports, I was present at the initial launch
of the report, giving me a chance to quiz the authors. In the few minutes
available to scan its 150 pages I was delighted to see Continuity of care
given prominence: - 'as a priority for GPs and patients alike. There is
evidence to show that in recent years it has become more difficult for
patients to see a preferred GP...' and: - 'Greater priority needs to be
given to continuity of care...' So I looked on eagerly to see what
recommendations there would be to preserve/enhance continuity in future.
But in vain, there were none. But there was reference to 'evolving skill-
mix', a 'wider range of professionals', 'GPs should be empowered to take
on a more expert advisory role'. These things may have merit, but they
will not improve the continuity of therapeutic relationships.
There is sensible coverage on continuity of care in the body of the
report (pages 83-88), but the key points on pages 88 and 99 are non-
specific, omitting any mention of what is already possible in continuity
of care measurement. Crucially, the three final chapters on 'Developing an
environment for quality improvement', 'The future of general practice',
and 'Conclusions' do not mention continuity of care at all. I cannot
follow Sir Ian's saying that 'The vision it sets out for the future of
general practice clearly has this theme at its heart'. Nor do these
sections show awareness that moving to a complex system of multiple
primary care providers risks losing the personal element that has been
inherent in general practice and is perhaps one of the reasons GPs have
retained the trust of patients in spite of the many shortcomings rightly
highlighted by the report.
I also suggest that Sir Ian and colleagues have misunderstood Heath's
commentary if they think she is 'blaming the patient'. She merely points
out that the report reads as lacking 'understanding that patients, as well
as reasonable and rational, can also be abusive, manipulative and self
destructive'. Until we can all agree and understand that the world in the
consulting room can sometimes be messy and difficult, I fear we will not
make the progress we all desire towards improving care and reducing
excessive variation in quality.
One small point that Heath kindly omitted is a surprising error in
the 'historical timeline' of general practice on pages 13-15 of the
report. Here the creation of the RCGP is said to have been in 1972. This
is no typographical slip of a digit, for the entry is in apparently
appropriate sequence in a paragraph headed '1970s - Professionalisation'.
(1) Freeman G, Hughes J. Continuity of care and the patient
experience. Report for the King's Fund Inquiry into the Quality of General
Practice in England 2009-10. King's Fund London. June 2010.
http://www.kingsfund.org.uk/current_projects/gp_inquiry/dimensions_of_ca...
(accessed 1st May 2011).
Competing interests: No competing interests