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A faulty production line

Is general practice giving up on continuity of care?

Maintaining continuity is a growing challenge in the face of polyclinics and the out-of-hours opt-out. Emma Wilkinson reports

Maintaining continuity is a growing challenge in the face of polyclinics and the out-of-hours opt-out. Emma Wilkinson reports

General practice is more than just a job.

Unlike, say, accountancy or marketing, it has a clearly defined and cherished set of values shared by most of its members.

One of those is continuity of care, which 96% of GPs still believe is central to the profession, according to Pulse's survey.

But whether general practice can continue to deliver on its commitment to continuity is open to question, given the opt-out from out-of-hours responsibility, the increasing tendency for doctors to work in large practices and the devolvement of care to nurses.

Perhaps in part it is about the definition of continuity – whether it is seeing the same person each time, members of the same practice team or simply access to a shared medical record.

Professor Chris Salisbury, professor of primary care at the University of Bristol and a GP in a deprived area of the city, insists continuity is still a defining feature of the profession, but that changes such as giving up out-of-hours responsibility raised the question of how much it still matters to GPs.

‘It's really important, not just to patients but to GPs – one of the reasons people go into general practice is because they want to have a relationship with people,' he says.

But he adds that continuity does not have to mean a cradle-to-grave relationship, or one with a single GP. ‘I used to be a full-time GP in a practice that did personal lists, then I job-shared with another GP, so people saw one or the other of us.

That can work quite well – small groups of doctors who make sure one is always there.' He says he often has young mothers coming to see him who do not know who their health visitor is – and would hate that also to be true of their GP.

‘I think polyclinics will try to do things at minimum cost – employ salaried doctors who are just doing sessions. As a GP once said to me, "without continuity, general practice is just crap casualty".'

Valued by the vulnerable

Dr Matthew Ridd, another GP researcher at the University of Bristol, has published work showing continuity is still valued among GPs – particularly for vulnerable patients with complex or psychological problems.

More commonly, continuity is being provided within teams, but as yet it is unknown whether this provides the same benefits, he says.

‘If you compare general practice today with that of 20 years ago, there are a lot more GPs working part-time in order to do other things or because of family commitments.

Our concern was whether continuity was still a contemporary value, whether it still matters to GPs, and we found it does matter – but there's a balance to be struck with personal boundaries and increased professional demands.'

He adds: ‘Continuity is much more at a practice level these days – and that might be okay, but it depends how the practice is organised.

If you've got 20 doctors and five or six nurses, one model would be to have two or three teams of doctors working at opposite ends of the week so they provide continuity between them.'

Dr Ridd believes continuity is beneficial even for younger patients with acute minor problems, who may not be bothered about it.

‘What might appear to be minor when seen by one or two doctors over a month or two might be more complex,' he warns.

Professional development

One more rarely mentioned danger of the move away from continuity is that it could hinder professional development.

‘If you don't know the outcome of your decisions how can you reflect on them?' asks Dr Ridd.

Under the new contract, much routine chronic disease management is done by nurses and other members of the practice team.

This drive to improved efficiency means GPs are increasingly seeing only the most complex patients – potentially further disrupting the personal relationship.

Professor Tony Avery, head of general practice at the University of Nottingham, believes this is challenging but not necessarily a negative change.

‘It's rare for me to have a straightforward consultation like in the old days.

Some would say that's how it should be – we're relatively well paid for doing that. But there has to be an acceptance that it is complicated.

One of the challenges we face is getting the balance right between what the QOF is telling us to do, and what is best for the patient and what the patient wants.'

Those challenges are starkly exposed in our survey, in which 85% of GPs said their work had become more complex and 89% said it had got heavier since the 2004 contract.

But Professor Richard Baker, professor of quality in healthcare at the University of Leicester, believes that while general practice may be changing, patients' needs remain the same.

He worries it is the most vulnerable people who will be disadvantaged by changes in healthcare.

‘People who have complicated illnesses want to see someone they know and trust.

'Most people can negotiate the system to get what they want – tell the receptionist they always see so-and-so – but where we need to concentrate are people who aren't good at getting what they want.'

He adds: ‘Information continuity is not a substitute for relationship continuity. For patients who want quick access that's fine, but that doesn't apply to those with complex chronic conditions and the evidence from our studies is they really do want to see someone they know.'

Strongly held beliefs

Dr Peter Swinyard, honorary secretary of the Family Doctor Association, is typical of many GPs who told Pulse they have strong views on continuity.

‘I believe firmly the best way to provide quality of care is for the doctor and patient to build a relationship over the years,' he says.

Although now working in a medium-sized practice, Dr Swinyard says working as a singlehander was the most fulfilling part of his career.

‘Continuity is achievable and it's not always defined by the size of the practice but it's harder to achieve in a large practice. About three doctors is probably optimum – after that there are communication problems.'

Dr Nick Brown, a GP in Chippenham, Wiltshire, works in a practice of 16,000 patients but the doctors all have individual lists – which is one possible solution to protecting the doctor-patient relationship.

‘We're very strict about that. The majority of patients we see are the elderly and those with chronic conditions. These are the people the Government doesn't seem to care about.'

The Government, of course, argues it does value continuity, and that this is precisely why it is pushing through plans for electronic care records – to ensure patient details are accessible to a range of health professionals.

But for some GPs, no amount of virtual continuity will ever be a substitute for the real thing.

GP views on the continuity challenge GP views on the continuity challenge

Dr Russell Thorpe, St Annes, Lancashire

‘I feel it's much better for patients to be seen by a small number of practitioners.

'And I worry about the trend for people to be triaged by nurses because very serious conditions can present as minor illnesses. I'm very concerned.'

Dr John Ashcroft, Ilkeston, Derbyshire

‘Patients have their own dentist and they should have their own doctor.

'It should be in the QOF, with a target payment if the registered doctor is seen more than 80% of the time – that should give the private sector something to think about.'

Dr Dermot Ryan, Leicester

‘I make no apologies for not being open all hours – I work bloody hard.

'The Government is ratcheting up patient expectations and promising something completely undeliverable. There just aren't enough of us.'

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