Columnist Dr Shaba Nabi says continuity of care has fallen victim to the proliferation of additional roles and access routes in primary care
I was fortunate to complete my specialist training in a busy district general hospital, where I was responsible for admitting a wide range of patients without the need to shunt them off to local centres of excellence for cardiology or neurology. You could argue that as a non-specialist I was offering suboptimal care, so I can accept the use of specialist centres in secondary care.
It is harder to accept the splintering of generalist care, where traditional GP work is now being split between us and other healthcare professionals. In primary care, the rationale is not the need for the clinician with most expertise, but simply for a patient to be seen amid a growing GP workforce crisis. But this argument only worsens the GP retention issue.
Decades of underfunding the core contract have inevitably led to workload and workforce problems that push practices to use more allied healthcare professionals. GPs are left to see more complex patients, carrying greater risk without the buffer of continuity of care.
This slicing up of care risks becoming formalised, with last year’s Fuller Stocktake advocating a separation of planned and unplanned care. This has echoes of the 2004 contract, this time with in-hours urgent care decommissioned rather than out of hours. I fully understand the attraction of this as GPs are trying to cap daily contacts while drowning in same-day demand, but it would be as irreversible as that last big contract change.
So, let us look at the costs of splintering healthcare, which are both financial and emotional. First, the financial cost. Before my contract fell victim to yet another NHS restructure, I was CCG prescribing lead for four years. I developed numerous PGDs, for example to enable community pharmacists to treat tonsillitis and urine infections. I was helping local practices with demand/capacity mismatch. But I knew that pharmacies were receiving the equivalent of 20% of my global sum for treating each of these patients, for a condition I could manage in five minutes. If that investment went instead into core GP funding, I’m certain it would reverse workforce shortages.
The emotional cost is trickier. GPs have always prided themselves on being the last generalists, when all around us we see consultants specialising in the left thumb. But since our first-contact physios arrived, I can’t recall when I last examined a back or a shoulder. Similarly, I rarely see a mole since we trained up our PA in dermatology. This isn’t a major issue for me as I’ve spent 20-plus years doing those things, but newer GPs may never gain enough experience in such aspects of the role.
Aside from the obvious deskilling, I mourn the loss of continuity; I may see a patient for the first time for breast cancer, having missed out on simpler consultations earlier in her life.
This emotional cost is compounded by the profusion of transactional care, especially on call. The digital explosion lets us manage presentations without even speaking to the patient. We fire off antibiotics, fit notes and questionnaires based on emailed images. Patients can join and leave the practice without me ever setting eyes on them.
As practice clinical lead, I’m aware I am embracing these access solutions. But in a deprived area with major GP workforce shortages, what choice do I have?
Dr Shaba Nabi is a GP trainer in Bristol. Read more of her blogs here