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CAMHS won't see you now

Is continuity all it's cracked up to be?

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Increasingly, our workforce is made up of a greater proportion of less than full time GPs. This is clearly an issue for practices, whose rotas were stable and straightforward for years when nine sessions was the norm.

Now, GPs in a practice may work anything from four sessions to full-time. Debates are had about workload, what constitutes a ‘half-day’, and whether working Mondays is a must.

But there is also a huge implication for patients: many don’t necessarily feel an allegiance to a particular practice, they just want to see ‘their’ GP. And when the delightful Dr Parte-Thyme doesn’t work on Tuesdays, Thursdays or Fridays, patients get grouchy and complaints start pouring in. Clearly, many still value patient-doctor continuity.

And GPs like continuity too: whilst we’re drowning in work, consultations with familiar patients can be hugely satisfying.

The recent work of Ridd et al. in the BJGP fuels the debate. Analysing data from the records of over 18,000 patients, the researchers evaluated whether patient-doctor continuity reduced the waiting time for patients from presenting symptom to diagnosis for breast, lung and colorectal cancers. The results may be surprising: seeing their favoured GP time and again will not win patients an early diagnosis.

If they have a high-risk symptom – breast lump, rectal bleeding, haemoptysis – they may as well see the miserable sod who everyone tries to avoid. The GP may never have met the patient previously, but is as likely to refer them as that delightful partner whose wine stores they regularly replenish.

For vague symptoms, the plot thickens. GPs who are familiar with a patient may attribute ‘tiredness’ or ‘fatigue’ to a personality trait or family issue. In knowing their patient well, it seems they may lose the gift of objectivity and a referral may be delayed. Presenting with the same symptom to a doctor with a fresh pair of eyes – perhaps a locum GP – actually expedites diagnoses in colorectal cancers by up to a week.

Now, a seven-day delay in a bowel cancer diagnosis is hardly a matter of life and death. On the contrary, though they’ve taken a slightly scenic route to the two-week clinic, patient satisfaction is still far higher in those who experience continuity of care from their GP.

Parties have offered all sorts of political policies in the most recent election: 8,000 new GPs, seven-day opening, same-day appointments for over-75s. All headline grabbing vote-winners, but all of them resulting in disjointed and discontinuous patient care.

We need to think seriously about our roles. Is doctor-patient continuity an antiquated has-been in a target-driven world where patient outcomes must take primacy?

Or, given the deep satisfaction both patients and GPs derive from continuity of care, despite moving to part-time working, do we need to make it an absolute priority?

A week is a long time in politics, but if your GP is worth their weight in gold, it may well be considered a small price to pay.

Dr Tom Gillham is a GP in Hertfordshire and specialty doctor in A&E. You can follow him @tjgillham.

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Readers' comments (12)

  • Harry Longman

    An important piece for the debate. Purdy et al (2014) showed continuity is linked to lower emergency admissions and Baker et al (2012) linked it with lower referrals. So there is huge value if not for cancer diagnosis. We have found that, offered a choice of named GP online, 22% of patients make one. This is good. If it were 0% we'd say the concept is dead. If 100% it would be impossible. So we can say it's important for some, some of the time. Treasure it.

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  • I would work full time if 'fulltime' was a reasonable number of hours.

    Each day is about 12 hours so after three of them I fell drained. Yet I only get a 'part-time' income despite working what most people think is a full working week.

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  • In the CCG no one cares about continuity. The small practice's do an amazing job at grassroot general practice, avoiding admission and polypharmacy script squiggles en masse. But that is not reinvested into their practices in the slightest. Instead the winners are the disjointed Tesco like surgeries who are ploughed with £££ to do incentive schemes based on their inefficiences. Small practices beloe budget never get a whiff of a pat on the back. So why be continuous???

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  • Hear hear to 'anonymous 6:45pm' - in the majority of industries 37.5hrs per week is full time. I think a lot of us would say a 3 hour clinic produces roughly another 3 hours of paperwork (if you include reading & actioning hospital letters, writing referrals and checking results etc), that equates to just over 3 x half day clinics a week (3x6 = 36 hours). I've never actually worked that out before, and even as low as 3 clinical sessions surprised me!

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  • The voters are demanding 8/8 7/7 and since very few doctors can tolerate an 84h week for any length of time beyond their 20s, it seems that the concept of continuity is already dead in the water.

    To make matters worse the MDOs are beginning to cotton-on to the fact that there's been some discrepancy in what exactly constitutes a 'session' and are tightening up on their requirements to bring us in line with the rest of high risk industry. This is pushing doctors more towards clocking on and off shifts because old-fashioned working habits will become uninsurable.

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  • It is not surprising that time to bowel cancer diagnosis may be longer with ones regular GP than with an unfamiliar one:

    Surely it simply reflects the fact that GPs tend to order more investigations for unfamiliar patients than for familiar ones?

    For the minority of patients with serious disease this may be a good thing and lead to early diagnosis.

    For the majority without serious disease it may lead to harm through overinvestigation, (and subsequent overdiagnosis & unnecessary treatment).

    Ultimately whether continuity is "better" depends on how we weigh these benefits and harms against each other.

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  • Recently I resigned from a small boutique practice with supurb continuity of care because they cant, wont or are just not able to pay me for the 2-3 hrs extra admin outside seeing patients. 5sessions, I'd effectively work 35 hrs and paid for 20. i was offered five jobs before I resigned from this heartwarming little practice - Im now paid for 30 hrs / week by the bigger centre and make over twice the takehome pay. primary care is doomed, because student loans mean we cannot work for free, no matter how charming the continuity, staff or rooms.

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  • I recently qualified and am an 8 session salaried gp. every week is 50+ hours solid work, i eat my sandwich on the way to visits, don't really get to talk to anyone except patients and I'm finding it pretty awful to be honest. next year I plan to locum as I have many friends who don't have the heavy paper work load and get home at 6pm. continuity is a sinking ship, and it will be the least of our problems in a few years anyway

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  • Continuity is a luxury that the country cant and doesn't want to afford as as a previous commentator has stated it will be the least of our problems in the very near future,I agree sadly.

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  • Even with a high risk symptom I would not attend/delay attending if couuld not see my GP. I personally am sick of reading about best clinical outcomes I want the best outcome for me as an individual. I do not want the best clinical outcome for whatever the latest the target is.

    Some years ago I did see the first availble GP for a red flag symptom which led to me having an operation and tests which put which not needed and put me at considerable risk. Never ever again.

    I just will not attend even in an emergency if it is not my GP.

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