Continuity of care is becoming ever harder to provide, but Labour’s proposal for patients to be able to request a particular GP is not the way to go about it, argues Dr Zoe Rog
Early one morning a few weeks ago, I found myself kneeling on the cold, hard tiles of our practice reception area tending to one of my patients who had collapsed as he approached the desk.
The patient has a complex history, and my colleagues were relieved that I was in the building as I know him well, which was helpful in dealing with the acute situation. When the paramedics arrived, I was able to give them a summary of the important details of his medical history and a brief sense of the person he is.
In his semi-conscious state, he started worrying about his sick note and that his benefits would be stopped, so I was able to reassure him about this and persuade him to focus on his recovery. I was also able to extract a promise from him not to discharge himself from hospital before he had been assessed and treated, as I had an inkling he may think about doing this as soon as he felt able to get off the trolley.
We have even reached a point recently where he will agree to take medication consistently that he was previously reticent about because I have suggested it’s a good idea. Sometimes continuity of care is fantastic, and sometimes it is achievable.
Early in my career, I remember finding out that a patient had sadly died. The patient was well known to the senior partner and we had both been seeing her. She had been taken to hospital and died suddenly of a pulmonary embolus. The news had been conveyed to the surgery by her devastated family.
The senior partner was at a meeting in London that day, but I knew he would want to know what had happened. Unsure whether I was doing the right thing, I phoned to let him know. He thanked me and told me that he would call in to see the family that evening when his train got back from London. I offered to give him the family’s address.
‘I know the address,’ he told me. ‘I delivered their youngest daughter; she was born at home soon after I started at the practice.’ He visited the family that evening and cried with them, sharing their communal grief. I will admit I was quite envious of the relationship the senior partner had with most of his patients. He was the epitome of the British cradle-to-grave family doctor, and it was the kind of career I aspired to when I was drawn to the profession.
But even then I knew that this model of care was unlikely to be sustainable. All the partners in the practice previously had been able to work full-time and with personalised lists. Even then GPs were beginning to need to reduce their sessions to accommodate the demands and complexity of their work.
Over time, more work has been pushed back from secondary care, mental health services and social care. And in the absence of promised extra GPs, our teams comprise many other highly skilled healthcare professionals, not just doctors. It is surprising and laudable that we manage as much continuity of care as we do, and much of this comes from our personal drive to go above and beyond for our patients.
Shadow health secretary Wes Streeting suggested that the Labour party will give GP practices financial incentives to let patients see the same doctor every time to boost continuity of care, because patients like this, and because it will motivate more GPs to stay in their jobs. We know that this means trying to take money away from practices that they are earning in some other way.
My grandparents used to like it when their local bank branch had a manager who knew them by name. The bank is now a coffee shop and the closest customers get to a personal experience is having their names written on their takeaway cups. Mr Streeting needs to understand that financial threats are not the way to motivate and retain GPs, and that continuity of care with the same GP isn’t as simple as writing someone’s name on their coffee cup.
Dr Zoe Rog is a GP in Runcorn, Cheshire
“And in the absence of promised extra GPs, our teams comprise many other highly skilled healthcare professionals, not just doctors.”
Are we sure about this? Is there really an “absence” of GPs?
Maybe I’m hallucinating but wasn’t there a recent article in the Pulse talking about significantly reduced demand for Locum GPs due to the much more skilled and highly qualified ARRS staff being hired in their place?
Rukhsana Hussain what are you talking about?
@Just My Opinion …
As someone who likes to give people the benefit of the doubt, I will assume that this question is coming from a place of genuine curiosity.
I am talking about hundreds, if not thousands of Locum GPs who are out of work right now, worrying about how they will pay bills and keep a roof over their heads.
We cannot claim a shortage or absence of GPs when there is availability of extra resource that we choose not to use.
Here is the link to the article I was hallucinating about :
https://www.pulsetoday.co.uk/news/lost-practices/gp-locums-asked-to-reduce-rates-to-compete-with-arrs-staff/?
“One GP told Pulse that locum work has ‘literally disappeared overnight’ and that after four years as full-time locum they have had to contact a charity for financial assistance.
They said they felt this is ‘because of the additional role recruitment scheme which has seen general practice flooded with ANP/ACP/PAs resulting in no need for highly qualified doctors’.”
There is certainly an absence of GPs wanting a permanent role in a practice. The work is certainly there (my practice is keen to recruit a GP if not two) maybe just not in the format people desire personally and so other professionals take that place left behind instead of being truly additional sadly 😢
@Adam Crowther
I understand that there may be practices that are struggling to recruit permanent GPs but hiring non-GPs is not the answer as you rightly point out that they are not truly additional.
As GPs we are the equivalent of Secondary Care Consultants. Would any of us be happy for our local Hospital Trusts to hire a PA or ACP with 2 years training in the place of a Consultant because they struggled to recruit a permanent Consultant?
I think the resounding answer will be NO! Absolutely not! We would not accept even an experienced Registrar in their place.
If we truly want GPs to be valued the same way as Consultants, we shouldn’t be allowing the same in General Practice either. And yet what we are seeing is the opposite.
Many Trusts hire Locum Consultants on longer term contracts and many locum GPs accept long term work. Where there is a will, there’s a way!
Let’s be honest. There is a way to get all GPs into work and negotiate with System Partners to provide funding etc but it requires everyone to put their biases aside and to focus on the bigger picture.
Devaluing our GP colleagues will ultimately result in devaluing ourselves as a Profession. Sadly, this has already happened, but it’s not too late to reverse the situation.
ARR positions fulfil a political agenda of falsely reassuring the public that staffing within the NHS is increasing while in collusion with PCNs and offering monetary incentives to Clinical directors to pursue this agenda , they simultaneously lower quality and standards across and greatly increase risk to the public at great cost.
The ARR roles fool patients into believing their problems are being fully resolved while in my experience, ARRs frequently miss important aspects of a patients care simply because they do not have the knowledge or experience to recognise subtle cues.
The CVs of some of the ARR roles have incredibly poor qualifications, yet due to financial incentives, Universities will accept them on to courses.
I have seen candidates admitted with 3 A’ Level grade E’s to physician associate courses and their capability reflects them(we have not employed any PA’s) but PCNs/Clinical Directors continue to push these roles. Yet in some practices they are replacing doctors. Maybe the public should be allowed to see their qualifications so they can make an informed rather than forced choice.
Clinical Directors and PCNs are motivated solely in my opinion by monetary gain , avoiding frontline care by paid meeting attendance and will continue to drive the destruction of the NHS we are all currently witnessing and in some cases enabling.
I did not know one can be a PA with 3 grade Es. No wonder they need so much hand holding because it is the GP that is actually doing the job.
If I or a member of my family was having major surgery, I would certainly want the surgeon to have the full set of training, required qualifications and experience. I don’t see how it should be any different for General Practice
They want us to go. They think we’re overtrained and too expensive, oh, and argumentative (except the GPC). New money for everything except GP partners, pay rises for everyone except GP partners. Death threats from Mail readers whose attitudes are dictated by their Tory paymasters. Public “shaming” of high earners (… fuck of if you think I’m complying with THAT shit). Government stooges the CQC tasked with punching down hard on us. They WANT us to go. They must be laughing their arses off that we still haven’t got the message. Haas it ever been worse? And yes, I know 32 years of GP now. It’s never been worse.
Continuity of care is what I valued most about being a GP. But I worked 9 sessions a week and every third weekend. On call one night a week, getting up in the night and early morning, and at weekends I was on. We visited after surgery usually doing three home visits but up to six or seven. We also had open surgeries in the earlier days before it was forbidden by ‘the authorities’. So access too wasn’t a problem.
We dealt with today’s problems, today.
We knew all our patients, their families, their homes and environment.
I also did home deliveries, the most satisfying and positive aspect of being a GP.
We were part of the family, in good times and bad. That’s what continuity of care was.
Today you’d be hard pressed to find a GP willing to commit that much to continuity of care, notwithstanding the assertion of, particularly academic GPs, who never did it anyway.
Continuity of care provides immeasurable rewards, but it comes at a cost. It is hard won and requires sacrifice.
Modern GPs just aren’t willing to offer true continuity, for all the lip service they give to it as a concept.
So GP no longer offers proper continuity, so stop imagining we do or might (of course there are still rare exceptions).
Instead then let at least offer access. Without access, any pretence of continuity of care is a delusion.
At the moment there seems to be neither access nor (proper) continuity. Indeed modern GP is not and never will be how it was when I was a young fellow. It needs modernising, it is no longer fit for purpose.
We need more GPs, smaller list sizes, longer consultation times. We also need a broader Primary Care team, longer hours of access to Primary Care, and more investment in Primary and Community Care services designed to meet the needs of the population rather than GP partners.
The independent contractor no longer works, General Practice is dead, long live Primary Care.
Dear Ivan
Much that I respect your commitment and hard work, you do realise you sound like a dinosaur, right?
It is easy to base your opinions on your personal experience, rather than evidence. But without looking at evidence, we are as lost as Daily Mail readers.
All the evidence shows that good continuity of care can happen without the self flagellation you are describing. And definitely without working 9 clinical sessions – what would you even advocate someone working more than full time?
There are many practices offering excellent data for continuity when some of their GPs work only 3-4 sessions per week – Horfield Health Centre in Bristol is an example of one with personal lists.
And in certain that Sir Denis Pereira Gray – the grandfather of general practice, and a lifelong researcher into continuity- would not advocate your method of acquiring it.
As for the independent contractor model needing to end – that is an opinion not reflected by the majority of GPs or the GPC. Perhaps you are overly reliant on emotion to form your opinions, and not data.
Bring back seniority but have it only accrued for what is the hardest part of the GP job (doing a surgery)
This should be the most rewarded role in primary care.
It would encourage additional sessions and aid continuity
it could even be shared by true job sharing GPs who cover the full monday morning till friday afternoon.
Yes, for decades I did the 9 sessions a week weekends on call , back in on Monday morning etc etc. When we had the chance we gave up 6k for getting out of the out of hours commitment. There are 6,000 out of hours hours ( if you follow me) in a year , so we were doing it for £1 (ONE) / hour . Ok , so we were in a rota which made it £5/hour. Christmas morning the lot.
I am still working ( part time ) now and trying to offer continuity of care. I have known some patients for over 40 years. I was (still am ) extremely stupid !
Dear Shaba Nabi
‘you do realise you sound like a dinosaur,’ yourself?
The GPST3’s have never heard of AJ Cronin/Dr Finlay etc and ‘continuity of care’ is a ‘foreign country’ to almost all. Few GPs consider returning to ancient service provision as a viable option but our ‘so called leaders’ have not come up with a practical plan (besides ‘get a gong and take gardening leave’). We have been abandoned by the ‘smarmy mouthed’!