Covid 19: a fork in the road for general practice

Dear Editor,

We are grateful for the interest our editorial has attracted.

It is good that Longman from “Ask my GP” is so strong on the importance of continuity of GP care and we hope his system will promote it. Roberts, from a GP Federation, dismisses personal lists without reason or evidence and we suggest he links with some of the important minority of general practices now using them, perhaps including Temple in the adjacent response.

We agree with Ahmed that many patients are fearful of leaving home in the UK as well as India.

McAnea underlines the importance of the doctor-patient relationship and finds remote consulting lacks the personal touch. Recent research (1) suggests he is right that remote consulting may lead to increased GP workload.

Heer-Stavert paints a grim picture for patients: “continuity of care has been replaced with continuity of record, an informal home visit by a scheduling book. A kind word with a text reminder.” This illustrates the impersonal care we fear and is why we wrote our editorial. But it is not inevitable and there are general practices, post-Covid, with more than half their GP contacts with patients by their named/personal GP. General practice can follow the new insights from research. Personal lists remain a real choice for practices (2) and with judicious use of 15-minute consultations GPs can still provide personal care.

Denis Pereira Gray, George Freeman, Catherine Johns and Martin Roland

1. Salisbury C Murphy M and Duncan P (2020) The impact of digital-first consultations on workload in general practice J Med Internet Res 2020; 22 (6) :e18203 doi:10.2196/18203
2. Sidaway-Lee, K. Pereira Gray D and Evans, P. A method for measuring continuity of care in day-to-day general practice: a quantitative analysis of appointment data. Br J Gen Pract 2019; 69(682): e356-e362. doi:10.3399/bjgp19X701813

Dear Editor
Periera Gray et al make important points in their article but I feel there is a sense of "go back tide" about the whole paper. How we got here is salutary. The lack of investment in primary care with the inevitable concomitant deleterious effect on GP workforce is now playing out. GPs are survivors in the Darwinian ecology of the NHS. As a result of both these factors we are witnessing the emergence of larger, more diverse and part time teams working within a milieu created by a centrally driven policy of bigger is better. Continuity is important, but a victim of circumstance.

There are potential solutions which could mitigate this. The paper refers to some, such as personal lists and longer consultations. I don't see the former being workable, but thinking in terms of Dr Who's famous TARDIS, a structure that appears small on the outside (with two or three contact points for any individual) but which is actually very big on the inside might be a compromise.

The point the paper misses is the potential use of IT to replicate (imperfectly) some elements of continuity. In my experience a practice computer record will contain very few of the small facts, behaviour and relationship descriptions and indications about what is contextually important for any individual. Continuity is the co-creation of a subjective narrative which includes this latter data set. Patients (I contend) when confronted with bigger teams, assume that elements of this richer story are contained in the computer record being perused by the health professional they are currently consulting.

I would envisage an entirely different data screen available within and before a consultation which would include the opportunity for an individual to be able to provide detail on what they feel a health professional supporting them needs to know about them as well as the elements alluded to above.

Dear Editor
GPs should be careful what we wish for: the shift to the majority of consultations being remote initially appeared to ease some strains in primary care but this is an illusion. Demand has returned with a vengeance and I fear that our current model of working exacerbates the frustrations of both doctors and patients. Whilst a telephone consultation can be entirely appropriate for some patients with certain presentations they can often be more time-consuming and ultimately generate more work. The absence of a patient from the consulting room means so much nuance and important information are lost, for the patient and the doctor. We have to ask more questions over the phone, there is less scope for showing empathy via non-verbal communication and the artificial nature of these interactions invariably lack the personal touch. I chose to become a GP because I wanted to be part of a community and offer continuity of care within a varied population. The last 5 years in my job have felt increasingly unsustainable in terms of workload and complexity. The 10 minute consultation is not fit for purpose. Some patients need longer consultations with a regular GP who knows them. This benefits patient and the GP much of the time. Our system increasingly mitigates against this as work feels unsustainable, GPs work longer days and burnout rates increase. For our service to survive it needs a radical rethink - longer consultations as standard, a limit on daily patient contacts (for safety) and an expanding workforce able to meet the need. The PCN DES has gone some way to address meeting need by expanding additional roles and this is to be welcomed, but at the heart of what makes General Practice so effective and efficient is the doctor-patient relationship. This is lost by a majority-remote consulting model. Matt Hancock sees an opportunity here to have all primary care contacts as remote, at least initially - I didn't become a GP to work in a call centre and we risk losing our skills, our status and our independence if we allow this to happen. More importantly, we lose what makes this job a special one - the link with our patients over a lifetime. Beware.