Time to call for real NHS reform
Dr Jim Sherifi thinks that, though continuity of care for patients has not broken down yet, it is under threat, and the profession must be on its guard
Are GPs losing continuity of care for their patients or have they already lost it? If not, then is it important that it should be maintained? If it is, then how can that be done within the constraints of recent changes in primary care and in particular those changes brought about by the new contract?
General practice has evolved over the last century from a service where one doctor had total responsibility for a fixed number of patients for 24 hours a day, every day of the year, to the present day where that responsibility is shared between doctors within a partnership and with an independent out-of-hours service.
A clear divergence has taken place between daytime weekday care, provided by the patient's practice and thus with the patient's records to hand, and that which takes place evenings, nights, weekends and bank holidays where access to the patient's previous medical history is not available.
Dealing first with practice-based health care provision, pressures and innovative solutions have created and highlighted several issues, some problematic, which may directly impact on patient health (see table).
In my view, continuity of medical care for patients is under threat but has not, as yet, broken down altogether. There is greater fragmentation of primary health care delivery which will inevitably lead to less effective medical management unless issues of communication are urgently addressed.
Much depends on the successful implementation of a regional, comprehensive, accessible, computerised records system as envisaged by the NHS NFIT programme. Unfortunately that is still likely to be many years away.
The factors that present a threat to continuity of care
Lack of pre-bookable, long-term appointments in order to meet this requirement can lead to patients returning to see another doctor during an ongoing management plan.
There needs to be flexibility built in to the appointments system to ensure the same doctor can follow up the same condition.
Low GP recruitment
In order to address this problem, concessions have been made by successive governments on improving training, remuneration and job satisfaction, mainly through limiting hours of work. But recruitment remains poor with a knock-on effect on practice stability.
Practices need to make themselves more attractive to potential new doctors, whether partners or salaried. Doctors from the EU may need induction training and familiarisation with NHS and UK medical needs.
Nurse practitioner/practice nurse
Nurses are taking on a large number of 'traditional' GP duties including acute case triage and management of chronic conditions (asthma, hypertension, diabetes). Nurses need and welcome regular interaction with, and easy access to, doctors when undertaking their duties. Clear guidelines need to be laid out.
Paramedics are increasingly practice based and available to see and assess patients requesting acute home visits. Some also undertake their own clinics.
Like nurses, paramedics need easy access to doctors when undertaking their duties. Again, clear guidelines need to be laid out.
Locums are increasingly available and locuming is used as an alternative, flexible and varied career by doctors. As a form of 'contracting out services', using a locum can still work out cheaper than taking on a new partner. Locums need to be familiar with processes within the practice, initially through the provision of a comprehensive locum pack.
Again increasingly available and used as an alternative, flexible and varied career by doctors. Cheaper than taking on a new partner.
No problem with continuity. Need to be fully involved in the day-to-day activities and decisions of the practice. Ideally they should have the stability of regular sessions in order to efficiently manage their patients.
Computer records /NFIT
The wide use of different primary care software providers has created an environment where computers cannot 'speak' to each other. Patients' records are still being transferred on paper for data inputting by hand.
NFIT should rectify this discrepancy but when? In the meantime, the GMS contract has encouraged record keeping, including the maintenance of patient summaries.
Out-of-hours health care provision has lead to a different set of problems.
NHS drop-in centres
Currently, these are mainly located in city centres and are increasingly being used to treat minor, self-limiting illnesses. However, they are totally dependent on taking an immediate patient history, have no access to past medical records and tend not to pass findings back to the patient's GP.
In the short-term, there needs to be a more formalised transfer of information, by paper. In the longer-term, such centres should be included in the NFIT programme with 'real-time' data input.
NHS out-of-hours centres
Many include local GPs who at least have some familiarity with the area but still no access to past records. Again they have to depend on adequate and informed history taking.
Interchange of information with local daytime primary care providers is in place. Again, such centres should be included in the NFIT programme with 'real-time' data input.
Anonymous and generalised. Has robust protocols in place for handling advice on simple conditions or referring on to a secondary party for more complicated ones. Large volume of calls makes formalised transfer of information back to GP impracticable.
It is hard to see how this system could be altered without integration in to more locality-delivered health care.
Accident and emergency
Increasingly used, and abused, by patients seeking rapid access to a medical opinion. Predominantly staffed by less-experienced doctors who do not have access to patients' GP records (but do to hospital records).
Interchange of information with local daytime primary care providers is in place. Again, such centres should be included in the NFIT programme.
Jim Sherifi is a GP in Sudbury, Suffolk