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Losing continuity may mean fewer Xmas gifts – but it will be worth it

Dr Zoe Norris

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Yes, I know Christmas is coming earlier every year, and we haven’t even had Bonfire Night yet. But having festive cheer rammed down our throats from autumn gave me an idea for a research paper: ‘Higher workload in general practice results in fewer bottles of wine for clinicians at Christmas.’

Because it seems to me the gifts of wine and chocolates have dwindled in recent years.

Maybe not being showered with pressies is a good sign. It seems it’s the insatiable heartsinks who bear the most gifts, perhaps a tacit admission of the angst and work they have brought – or an advance on next year’s woes. A box of Ferrero Rocher is scant consolation for 12 months of grief.

But there is a wider point. As workload goes up, continuity of care goes down. Even in that rarest of beasts, the fully staffed practice, the sheer volume of workload makes always seeing the same doctor a challenge. So either we don’t end up with regular patients – the ones likely to send cards and gifts – or the patient who always sends a nice bottle of whisky comes in on a day when our efforts are diverted elsewhere.

I don’t need something wrapped up in shiny paper to understand a patient’s gratitude

The loss of continuity of care is a shame. It can give you a warm, fuzzy feeling inside and doing a full clinic of patients you have seen before and know well is a hell of a lot easier than starting from scratch every time. Ten minutes becomes a lot longer when your opening question isn’t ‘how can I help you today?’, but rather ‘so did the tablets I gave you work?’.

But the reality is the traditional concept of continuity has partly led to the situation we are in by stoking unrealistic demand. We may need to ditch it for our own sakes. Until the magical 5,000 new colleagues and £20bn in the global sum appear (ha!), we have to find a way of doing things that, sadly, doesn’t involve the same GP seeing the same patient.

But we can still provide a form of continuity. Finishing a consultation with a new patient in 10 minutes is damn hard – hats off to you if you can do it well. But managing that appointment, keeping good notes that include the fact you don’t know what’s going on (‘Unclear clinical picture? Viral? Stress? Dengue fever?’) gives the next person who sees that patient a starting point.

Some practices have started a ‘follow-up’ register for patients who have a condition that really needs seeing by the same person each time. When these patients ring for an appointment, they are prioritised to that same GPs clinic. Once that episode is over, they come off the register, and someone else can be added if need be. An eminently sensible idea.

Adapting traditional continuity of care may make our lives a bit easier. In the festive seasons when I was locuming, my side of the Christmas tree was definitely bare compared with my teacher husband’s. But I also had some flexibility. Besides, I don’t need something wrapped up in shiny paper to understand a patient’s gratitude.

So the chocs and booze might not have our name on them, and we might drop the annual ‘who is the most popular GP’ game. But letting go of traditional continuity of care may make the other 50 weeks of the year a little easier.

Dr Zoe Norris is a GP in Hull

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Readers' comments (13)

  • ‘A box of Ferrero Rocher is scant consolation for 12 months of grief.’
    So true!

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  • I really don't mind about the presents:- but loss of continuity is a huge loss. Overall, for workload, the extra time used each visit by a new Doctor to catch up on previous transactions is a huge and underestimated burden! Occasionally one needs fresh eyes on a presentation, but generally to be able to start where one left off is worth a huge amount, not only to the doctor, but also to the patient, and our loss of continuity is an under-appreciated risk to health.

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  • you seem happy to ditch one of the aspects of primary care most valued by patients. I find that sad

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  • Continuity doesn’t matter unless you’re old or sick.

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  • Peter Swinyard

    Zoe doesn't expect me to agree. I don't. Personal relationship continuity in medicine has proven benefits to reduction in morbidity. Yes, we have the data, it's incontrovertible. If you need the full story, contact the Family Doctor Association office. It's not just about the fuzzy feelgood factor. It is truly appreciated by patients who indeed do not have to start from scratch each time and hear yet another differing opinion on their management - please don't say we all do the same thing - we don't.

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  • zoe have to disagree with you on this one too. but I have total respect for you and you are a giant in my view . continuity leads to trust and so much better. I think that when a problem becomes chronic and complex, palliative, requiring secondary care input, polypharmacy etc. then to know the person that you are seeing is invaluable. really in my view it is the jewel of general practice. it is the part that can't be privatised or replaced by AI.

    - anonymous salaried!

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  • I don’t understand the people disagreeing with Zoe. The article states that she feels loss of continuity is a shame, and then lists a number of ways that continuity is better. It seems Zoe is just being practical about accepting that continuity is completely untenable with today’s resourcing, and thinking about how to adapt to try to maintain some semblance of it. I regularly tell my patients, “yes, continuity is not possible in the manner it used to be, you don’t like it, your doctors don’t like it.” I then say that we try to create some continuity now through good note-keeping, and I then advise them to try to get to know a couple of the GPs well in order to try and create a collaborative continuity of sorts. Adaptation. I don’t find Zoe saying that loss of continuity is alright, so what’s to disagree with? This is just realpolitik.

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  • Lots of good opposing opinions but Shh who’s saying continuity doesn’t matter unless you’re old or sick? Clearly it seems to matter less to you which is a bit tragic. Let’s have a full population vote on this which will take our attention away from Brexit!

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  • A brave article, sad but true. We would all love continuity but when continuity is pushed too much you develop dependence, you end up with a small case load of the same regulars. I once looked in on a colleagues clinic that was booked will all reviews and most mental health reviews. So the low acuity patients got 15 min chat and a tweak of antideps, they saw the same GP and the same MHT but the acutely unwell were seen as extras in 5 mins -- wrong way round. I suspect sometimes continuity is a way of staying in our comfort zone and can blunt us.
    As I say good article with good insight.

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  • So good note-keeping, a brand new innovation, is the answer to the lack of continuity issue? I despair. Good note keeping is as essential to good practise as reading the notes properly. And yes, this does take time, but without making this investment the patient will almost always get a pi~~ poor evaluation.

    Sometimes I think that the RCGP and its penchant for mindfulness is reflected in the practise of most GPs irrespective of whether or not they are fans of this august body. It is like the GP consultation is only conscious of "the present" without realising how the past has a clear role in producing what is evident today, and "managing risk and undifferentiated presentations" is a glib cop-out because a close analysis of the notes demonstrates a greater degree of differentiation than would seem apparent- if the past notes are read and thought about.

    I certainly value continuity of care because I make a point of investing time in properly evaluating the notes, so subsequent visits build on what has gone before, not an imagined evaluation based on the symptom the patient has on that day.

    I think rubbish training compounded by time pressures are making the cracks in primary care impossible to not notice.

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