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
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
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