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At the heart of general practice since 1960

Is continuity of care overrated?

Dr Tony Gu argues continuity puts too much pressure on overworked GPs while Professor Martin Roland says seeing patients we know leads to safer care

YES

For years, continuity has been an unimpeachable tenet of general practice. And yet, the more I practise, the more disillusioned I am. Yes, continuity has its positives and I am not advocating its total abrogation. However, general practice has changed. Altered workloads and demographics mean that portfolio and part-time careers are becoming the norm, seven-day working is here to stay and federating seems to be the answer to everything. With all these changes, the only way to maintain continuity is to give more of ourselves, and risk burnout.

This often-overlooked, but crucial argument is most strongly illustrated by a study of 564 GPs in BMJ Open, which singled out having multiple patients identifying the clinician as their ’usual doctor’ as the biggest risk factor for depersonalisation and burnout. Conversely, part-time workers have the lowest level of burnout.

Continuity is not even necessary – medical records with shared care planning should be enough. Those unplanned admissions DES care plans must have some use? A common argument by proponents of continuity is the perceived benefit in managing the elderly with multiple, complicated problems that records are not good enough to describe. So let us take an imaginary patient we can all relate to – 75-year-old Elsie with multiple medical problems. How often have we seen someone like Elsie delay consulting about her crushing chest pain because she wanted her own GP?

This shows how continuity can give patients worse outcomes. Continuity of care has other dangers: if you have developed a relationship with the patient won’t it be more difficult for you to refuse unreasonable requests, like that letter bending the truth about why Elsie cannot pay the ‘bedroom tax’? What if Elsie is fiercely independent and needs to drive to see her grandchildren, but is showing signs of early dementia – could you be objective for a DVLA report? Conversely, Elsie might feel she cannot say no to a GP’s advice – could this affect decisions about end-of-life care?

Finally, continuity begets complacency. The closest thing we have to peer review is our patients seeing another doctor. Without this, how easy is it to keep giving Elsie omeprazole for that unusual dyspepsia? How thorough are your notes compared to a locum’s?

We need to have less continuity and be more selfish to survive a career in general practice.

Dr Tony Gu is a portfolio GP in Manchester

 

NO

We know that patients value continuity, but it’s got so difficult in many practices that many patients now think we don’t care about it. But we should care, and we can do it.

First, seeing patients we know makes the job of being a GP more enjoyable. We can deal with problems more effectively if we know the person we’re seeing, and we can certainly deal with things better if we’re not starting from scratch in each 10-minute consultation. It makes it much easier to sort out which of the patient’s problems really need dealing with at that consultation and issues like ‘just checking up on your depression’ can sometimes only take 30 seconds if they’re part of an ongoing relationship.

Second, seeing patients we know makes for safer care and reduces the chance of making a mistake. In theory, good records alert the GP to all the patient’s problems. But all GPs know that having time to look through the notes properly before each consultation becomes more and more difficult as patients get older and more of them have multiple complex problems. Not to mention looking through the hospital letters to discover yet another follow-up test that the specialist has asked for. The risk of making a mistake, or at least feeling that we’re skating on thin ice, is only going to increase as our population of elderly patients increases.

Of course it’s difficult, with more GPs working part time, and with the Government’s obsession with access. But just telling patients it matters can improve continuity – they need to understand that GPs do care who they see. Similarly, you can encourage online booking and include a screen that advises patients that it’s often better to wait a bit longer to see a GP they know, change receptionists’ behaviour and prompts on booking systems so that the patient’s ‘own doctor’ becomes the default choice, and identify and flag the records of the small number of patients with complex problems who should be seen by a restricted number of doctors. You may need to adjust the appointment system and explain to these patients that they may have to wait longer. But they will get better care.

It’s not impossible. We could start to turn the clock back. And then we’d have happier GPs and more satisfied patients.

Professor Martin Roland is professor of health services research at the University of Cambridge. He was a practising GP for 35 years

 

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Readers' comments (33)

  • Harry Longman

    I'm with Martin and he knows the literature on the safety and quality of continuity far better than me. Specifically what makes the difference is relational not only information continuity. It's also labour saving as Martin points out, but further, there is not a trade off between access and continuity in a well organised demand led system. We've shown this in dozens of practices of all sizes.

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  • Doctor Dog

    The hard truth vs the touchy-feely argument.?
    Both arguments have merit- some patients prefer a service centred approach, some prefer a personal centred approach. The way things are going, I'm not sure that the latter will prevail.

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  • Hmmmm, which one of the two is the cardigan I wonder?!

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  • Continuity of care is a thing of the past.

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  • "Continuity of care" is nothing more than cardigans compensating for lack of medical know how. I hate cardigans with a passion.

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  • Knowing the patient is of little value if it 'all goes well'.

    A reasonable long term relationship with the punter (and the punter's daughter or wife) is all that stands between you and a great mound of s!!! if things go pear shaped (and this will happen from time to time).

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  • I can see both arguements;
    - Evidence has shown delays from a familiar face on 2ww.
    - LTC management is far more efficient and hospital is avoided more by someone who knows the patient and prevents protocol-driven admission.

    The killer for me is that the argument against continuity is in support of mega-practice, depersonalised care - and I don't think patients want that or benefit from it. Disjointed care has been at the heart of every major case review undertaken in health and social care for some time.

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  • Care of the service user in general is overrated!

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  • When patients have a choice and use the private option, do they opt to see a different doctor each time or find one they trust and stick with him/her? Moreover, one of the common complaints when patients report back from out-patients that they never see the same doctor twice and have to start from scratch each time.

    I disagree almost entirely with Tony Gu, including his assertion that "seven-day working is here to stay" - it isn't and needn't be but some areas have taken the temporary money (which I think could be better used supporting emergency OOH care) to create demand - but wonder is there actually any hard data, rather than supposition, regarding continuity and outcomes?

    Continuity of care doesn't mean always seeing the same doctor but having one or two doctors in the practice who know your medical history, whose opinion is valued (based on past experience) and to whom one would choose to turn for the serious concerns and when continuity matters.

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  • I would favour "cellular structure" of teams caring for patient groups of 3000-4000, this could be 2-4 doctors, dedicated nursing, reception, admin to the team and Separated or shielded from "urgent care". These cells could function inside of the 50,000 mega practices we see developing. These doctors would be encouraged to have another string to their practice, to give a balanced career which is sustainable.
    I cant imagine a new generation of doctors signing up for more than 6 sessions of list based GP or to commit to 2000 patients until they retire.

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