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At the heart of general practice since 1960

Continuity is dead. Now what?

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I have been a full-time, nine session GP sqaudie for nearly 25 years. Clinical practice suits my skill set; practical and pragmatic.

This work made me value the importance of continuity. I knew the patients and the families. I understood that certain families were in every week with a new symptom of health introspection, and the health anxiety being passed from generation to generation.

I didn’t do many investigations or referrals. Firstly, because I had limited access to tests like ultrasound and CT, but more importantly, I knew the probability of disease was very low. Those tingling fingers, headaches, abdominal pains and chest pains were a complex of health-seeking behaviours and beliefs.

We need to think how we might substitute continuity

We used magic, misdirection and time as test. We simply reassured many of these patients; complex symptoms dealt with without investigation in under 10 minutes. And I realised that referrals did harm by feeding the monster of health introspection. In any case, patients would wait six months to see some inexperienced snotty SHO.

Very occasionally you might be wrong and you always had to be alive to this possibility. All GPs were good at playing these probabilities based on extensive experience and continuity. These days we define these symptoms as ‘medically unexplained symptoms’ (MUS).

But the culture has changed. Occasional delays in diagnosis are no longer acceptable. GPs are fearful of being sued, being splashed across the Daily Mail or even losing their registration. So we refer more and investigate more. We do this even when we know that there is virtually no probability of illness. Even as our hospitals have got bigger, with increased numbers of referrals it still takes six months to be seen by some inexperienced snotty SHO (unless, of course, you go privately,  when a consultant will see you yesterday). Continuity is less important in new culture of relentless early investigation and referral.

The generations are different too. Most Pulse readers are grizzled old GPs who spent decades on-call and worked full time in the same practice. They understand about continuity and value it, like me. But now, for many full-time general practice seven sessions a week. Part-time is the ‘new normal’. No-one wants to work out of hours and a large number GPs have never done a single out-of-hours shift.

We old GPs made too many sacrifices and work broke many. So the working experience of many Pulse readers is so far removed from current working patterns, that general practice is a different job compared to 25 years ago. Doctors want more balance in their lives and refuse to work as we did. The current generation of GPs does not value continuity and fails to see its value as a previous generation did. Also, the hospitals have already been a continuity-free zone for decades.

This new reality is a post-continuity age. And this is OK; reduced continuity can be a good thing. Sometimes patients manipulate us into doing things we shouldn't. Put bluntly, having less personal contact makes it easier to say ‘no’ when we need too. Also some patients can be emotionally draining and dilution can help prevent burnout. Practice policies on things like the prescription of red drugs are much easier to implement when we are less personally involved. There is more oversight of clinical practice when more doctors involved. This will ultimately harmonise clinical care with less potential for clinical outliers. 

If we stop railing against the loss of continuity then we can move on. We need to think how we might substitute continuity. Better clinical summaries, better note taking and read coding of MUS. Most importantly, better teaching and recognition on MUS (which represent a third of all contacts across primary and secondary care) and more resources to teach medical students in the community. The unpopular truth is that continuity is dead, long live continuity. 

Dr Des Spence is a GP in Maryhill, Glasgow, and a tutor at the University of Glasgow

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Readers' comments (25)

  • Vinci Ho

    Respect you sticking to your argument.
    I will leave you guys to comment : Is this capitulationism finally giving up our identity and telos OR is this pragmatism to be practical and realistic?
    On another tone , if I am correct , Julian Tudor Hart will be ninty years old tomorrow, happy birthday , Julian . We all know what you stand for.......

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  • TBH, continuity had a role in the days when GP's stored all patient informatjon in their heads and only put a line down on their paper notes.

    I'm not so sure if it is as important now.

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  • This article taken alongside the recent one by Dr.Phil Peverley 'Eloi and Morlocks'could be combined and re titled 'RIP-the rise and fall of Uk general practice in the past 25 years'.No less an achievement than you would expect from 2 of Pulse's most incisive and critical thinkers.
    What has replaced the NHS of old is a 'Healthcare Government/Industrial complex',where Gp's are just a tiny cog in a massive 'machine',where the outcome pleases no one and the only motivator becomes survival within the system.
    The 'new normal ' of part time working or being a 'Morlock'(ie doing some kind of Admin job far removed from clinical practice ) are just survival mechanisms for the current generation,whilst the 'older Dr's ' drift off into semi or full retirement .
    Any organisation so weighed down by its own contradictions(as the NHS now is for eg) will eventually fail.We have seen this before eg the State Tractor industry of the old USSR.
    The workers knew they were better off than those without such a job and so did 'just enough'to keep that job but also realised that the 'final finished product' was unique in so much that it was worth less than the Raw materials that had gone into it!
    As a profession we have been slow to realise that we have been drawn into such a 'farrago',aided and abetted by 'our negotiator's,who have been out whited at every turn.
    It need not be like this but like anything that's worth having,you will probably find that you've got to 'fight for it'.

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  • Shall we just push to become "Community General Physicians" now and get it over with? Nobody likes GPs anymore including themselves.

    This gross tabloid-post shipman-appraise every turd you pass- run in the middle of the curve thing is here to stay. We couldn't turn the clock back even if we wanted to!

    Baa Baa

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  • Thought provoking article, thank you. AS a rural GP I can confirm that continuity is very much alive and kicking and thriving in my practice as well as in neighbouring practices. I struggle with the concept of society allowing something to fold which clearly works and is so cherished. I suspect that in the long term, continuity will be available to those who can afford it.

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  • Dr. Spence your opinion piece is interesting but please do not attempt to speak for the new generation of GPs. How do you know whether I value continuity? There is a not subtle implication in your piece that the new generation are work shy and somewhat less professional than previous generations. I finished my training in 2015 and I am taking partnership soon. The majority of my training group have become partners or aspire to become a partner if they can find a functional practice. We all value continuity. As you and I both know, we are seeing more patients than ever to try and meet ever increasing demand. This demand is due to a complex number of reasons which you have alluded to, from an ageing population, complex comorbidities, a consumerist society and modern GP training which encourages doctors to take a patient-centered approach. We are all trying our best in extremely difficult times. Please do not patronize the new generation. It only plays in to the hands of the Daily Mail etc.

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  • Vinci Ho

    Please send in more comments, especially our younger colleagues

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  • Continuity is important but may have to be targeted at higher risk groups at the head of a team of people rather than the sole practitioner model. It's mathematically impossible. Des Spence isn't arguing for or against something as responders have suggested. He is describing an inescapable truth based on demographics of both patients and GPS and all that that entails.

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  • Healthy Cynic

    Des
    I agree wholeheartedly with some of your points, slightly less so with others. The biggest truth here is the drift towards over-investigation and over-treatment, not only in the hospitals but also in GP land. This is what is making the NHS unsustainable. The gold-dust resource that we are losing is that experienced clinician (more properly known as a risk manager) who knows when to do nothing, and who has lots of tricks up his sleeve to get the 'patient' to accept that.

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  • Once again, this article raises some useful points about the impact of a consumer culture and over-investigation, but the message is lost by the lazy criticism of your equally over-worked and under-resourced hospital colleagues.

    You were an SHO once, why should they all be labelled snotty? Its very unkind. The ones I know are hard-working, caring and ambitious (and never allowed to come to clinic because the wards are too busy).

    You know perfectly well that all hospitals must achieve a maximum 13 week wait for new patient referrals, and that these are seen by consultants. Your consultant colleagues work extremely long hours, as you do, and we should offer each other mutual sympathy and respect for trying to prop up our failing health service together.

    Pulse is becoming as bad as the Daily Mail for vindictive criticism of doctors – just targeted at your hospital colleagues. Only last week, Copperfield wrote “And normally it’s just consultants I want to punch in the face”. This is a completely inappropriate thing to say. I would like to see the Pulse Editors take a stronger stance about this from their regular contributors.

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