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At the heart of general practice since 1960

The case for continuity

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When I was a child, growing up in Southend in the 70s, one of my most enduring memories was of our family doctor. Dr F was a short, rotund character, rather like Norman Rockwell’s caricature in the ‘Doctor and the Doll’. He was clearly unhinged by the arrival of my parents and their nine young children, and even during those formative years, I could see the funny side of him telling us we were ill because we had not got used to the weather in this country yet. But in spite of his lack of worldliness and some quite spectacular medical errors, he was kind and held my mother’s hand after my father died. As he was single handed, he was the only doctor I ever saw until the age of 18 when I left home.

We are obviously not living in the 70s now but in a 24/7 world of impatience and instant gratification. My local Mall is now open until 10pm daily in the run up to Christmas and if I can go and buy my socks at 9pm, why can’t I also get my smear done then? Successive governments have fuelled this choice-led agenda and the irony is that those with the most health needs have had their choices restricted, with the bureaucratic issues of choose and book and inability to attend a practice during extended hours due to transport issues.

The government’s drive for round the clock routine primary care is detrimental to continuity of care. If my sanity only allows me to work six or seven sessions at the coalface and these sessions have to be spread over twelve hour days for seven days a week, how am I possibly going to develop a close relationship with patients who have multiple and often complex health needs?

The key to reducing unscheduled urgent care is to have continuity of in-hours care. The chaotic drug dependent diabetic, the personality disorder who frequently self-harms, the brittle asthmatic… how will some of these patients fare in a supermarket-style practice?

Instead of spending £50m on wider GP access, the Government should be investing in partnerships in smaller practices to allow them to deliver the type of service that doctors want and patients need.

We need to integrate IT systems with out of hours to allow continuity of care, whilst rejecting the consumerist agenda for health, to encourage continuity of care in core hours. It is this relationship with the patient that will reduce referrals and unscheduled admissions; not the pandering to the chattering classes. Unfortunately, as health is a political hot potato, the chattering classes will always win.

Dr Shaba Nabi is a GP trainer in Bristol

 

 

 

 

 

Readers' comments (8)

  • There will never ever be continuity of care as no doctor can be on 24 hours, 365 days a year. Logically, there will be times when a doctor is unavailable and the patient has to see someone else. Ergo. So then, how many hours can any doctor work in a year ? What happens outside these hours ?

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  • Dear Anonymous
    Just as medicine has moved on since the days of Dr Finlay's Casebook so has continuity.
    Every Doctor has personal experiences of developing a mutually trusting relationship over several consultations with a patient. That is the essence of continuity, not 24/7 availability. In the modern version patients at a GP practice who can achieve a consultation rate of 60% with the same GP are getting "good enough" continuity. The evidence is that this sort of continuity is liked by patients and doctors alike, provides higher quality of care than so called "taxi rank" medicine and is more cost effective. It is interesting that many of our senior GP leaders are beginning to talk about the importance of continuity - it is a modern achievable valuable objective, and to be honest, it is much more rewarding as well!

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  • Peter Swinyard

    People are confusing continual with continuous. Care is best provided by a patient's "own doctor". Continuity of personal relationship medicine reduces unnecessary investigations, hospitalisations and care costs and risk to and inconvenience to patients. Emergencies require continuity of record. Longitudinal care requires continuity of personal relationships.

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  • "The chaotic drug dependent diabetic, the personality disorder who frequently self-harms, the brittle asthmatic.."

    The way you refer to these patients suggests you are already practising "supermarket style" medicine.

    How about, the person with diabetes who has problems with substance abuse? The person our profession has chosen to label as having a personality disorder? The person with brittle asthma?

    Seriously, these are human beings, not diagnoses.

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  • Exactly, and if you have continuity of care these challenging patients become personalities to their GP.

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  • surely the biggest challenge to continuity is the fragmentation of the workforce with the increase in part time working

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  • I am afraid I do not understand continuity. Is it classified as 60% consultations with the same doctor ? Shaba refers to her GP as the only one she saw till 18. Single handed, 24 hour , 365 days or does she mean 60 % ?

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  • Harry Longman

    An important and timely piece. We see conflicting statements and actions from government with one policy ostensibly supporting continuity (only for 75+, bizarrely) while another undermines it, as you say. Let's take one crumb of comfort from this, Hunt is at least saying that continuity matters. Now we have to connect that to measures which enable it.

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