Intended for healthcare professionals

Letters

Continuity in general practice

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7288.737 (Published 24 March 2001) Cite this as: BMJ 2001;322:737
  1. George Taylor (g.b.taylor{at}doctors.org.uk), general practitioner
  1. GuidePost Medical Group, Choppington, Northumberland NE 62 5RA
  2. Mill Stream Surgery, Benson, Oxfordshire OX10 6RL

    Continuity is fine, but not for everything

    EDITOR—With reference to the article by Guthrie and Wyke,1 continuity in general practice is one of those obvious good things, but it is too complicated to be something with an easy answer, an all or nothing. In 1988 I wrote a personal view which proposed that patients might see a different doctor for acute illness than for their long term problems.2 They might even travel to see this personal doctor. This was met with some amazement by some of my colleagues.

    The changes in a society that now expects to be able to get money at midnight and shop in Tesco at 2 am (and I am as guilty as anyone else) means that, in places where general practice demand is high, systems have to be developed to cope. So we have walk in centres, triage systems, or duty doctors seeing all those strange things, social, medical, or just “I'm off work today,” that need to be seen now. In quiet places of low demand, general practitioners may disapprove of this development, but this is the only way that current demand can be met in some places.

    This is the only type of care that a government can expect if it wants you to see your general practitioner within 48 hours. Continuity in these situations is nice, but is a gold standard that is difficult if not impossible to achieve, perhaps valued more highly by politicians than by doctors or even patients. Non-acute problems that can wait (for example, hypertension, diabetes, and continuing emotional problems) will all benefit from an ongoing relationship and continuity of care—sometimes just from the general practitioner, sometimes from a team. This type of care demands commitment from primary care to ensure that those involved can provide it. Increasingly, general practice is an activity carried out alongside raising children, participation in NHS management meetings, clinical posts in hospital, or just the desire to work fewer hours in the week.

    Continuity also demands a culture change in society. I have to plan some weeks ahead to see my dentist, accountant, or solicitor, so patients will have to develop forward planning skills in order to have continuity with their general practitioner for their ongoing problems. Continuity is fine but not for everything. It is impossible in a “must be seen within 48 hours” system, but, at the right time and in the right place, it can continue to be a major strength of which British primary care can be rightly proud. Perhaps my 1988 musings are coming true?

    References

    1. 1.
    2. 2.

    1. Peter Rose (peter.rose{at}public-health.oxford.ac.uk), general practitioner,
    2. Karen Bateman, general practitioner
    1. GuidePost Medical Group, Choppington, Northumberland NE 62 5RA
    2. Mill Stream Surgery, Benson, Oxfordshire OX10 6RL

      Continuity of care is not all or nothing

      EDITOR—With reference to the article by Guthrie and Wyke,1 it is important that continuity of care in its original sense continues as a core value for general practice despite the considerable changes of the last 20 years. It is one of the main reasons why our service is both effective and cost effective.1 The concept, however, that continuity is an all or nothing phenomenon needs to be questioned in view of these changes and the expectations of patients.

      Firstly, with increased social mobility, patients can no longer offer continuity to their doctors. We practise in a relatively stable rural community, but only 47% of our current patients were registered 10 years ago and only 23% were registered 20 years ago.

      Secondly, patients increasingly exercise their right to make choices. An individual doctor cannot now be available at times that are convenient to all patients. Our experience is that many patients with acute problems would prefer to see any doctor if it can be at a time convenient to themselves. Patients often choose a different doctor on purpose according to the situation—a female doctor for a gynaecological problem, a doctor with manipulation skills for backache.

      We have developed the concept of continuity for an episode of care to acknowledge these developments. Patients in our practice are encouraged to see the same doctor over time for a single problem. A diabetic patient may see the same doctor over several years for their diabetic care but a different doctor for a sore throat. An audit showed that 98% of our diabetic patients and 95% of asthmatic patients had their routine checks with their usual doctor. This system does not prevent a patient from seeing the same doctor for all their care when the doctor is available. As ongoing care can be planned in advance, we have found that this system improves the management of our availability of appointments.

      Thus we try to ensure the best aspects of traditional continuity of care, but also offer the flexibility demanded of modern practice. One important aspect of this concept is that doctors may not get to know their patients and their families so well. Primary care professionals need to pay more attention to the exploration of a patient's health beliefs and cultural aspects of health in each consultation to ensure the continued effectiveness of general practice. We would welcome research into models such as ours so that they may be refined for the benefit of patients and primary care.

      References

      1. 1.