Luke Allen is a GP academic clinical fellow at Oxford University.

A coffee-break conversation about flexible part-time working and relational continuity

Sam (early-mid career GP): Hey, can I grab you for a minute to talk about my hours?

Charlie (senior GP partner): Of course, in fact I was hoping to discuss something with you too – about trying to ensure that our patients see the same professional at each visit.

Sam: Right, that ‘relational continuity’ seems to be a hot topic right now doesn’t it. And I totally get it too. Seeing the same patient each time helps as you get to know the back story, and the patient doesn’t have to repeat themselves all the time. That’s the worst thing about locum shifts and mega-practices.

Charlie: Right, there’s some new research that shows what we already know intuitively; continuity improves health outcomes, and it is what doctors and patients often value most about general practice.

A lifelong connection with a community, providing all aspects of their care

Sam: It is sad that those relationships have been eroded over time, I‘ve just finished reading A Fortunate Man and was struck by how completely alien the 1960s community GP role was. With doctors and patients moving around more, and the fragmentation that comes from team working, we’ve worked ourselves into a corner where we are basically specialists in complex geriatric multimorbidity. Not to be cheesy, but I found myself yearning for elements of the general practice depicted in that book; a lifelong connection with a community, providing all aspects of their care, and really knowing them and their goals and aspirations.

Charlie: I guess the longitudinal relationship used to be with a single GP, but now it’s with a practice team, and the locus of continuity has shifted from the doctor’s hippocampus to the electronic patient record.

Sam: It sounds so dehumanising when you say it out loud. But that has been the price of vastly improving the efficiency, equity, and in some areas technical quality of care offered to patients. Think how much more a multi-disciplinary team can offer. And the other side of the access/long-term relationship coin is being called-out at 3am on a Sunday to a complex delivery. That brings me back to talking about my hours…

Charlie: Sorry, of course.

Sam: As you know, Alex and I are trying for another baby, and my community work on social determinants is really taking off. I know that stepping up to eight sessions really helped the practice as you tried to hire the new partners, but I’m actually thinking of dropping down to less than my original three days.

Charlie: Er…

Sam: I can feel your heart sinking from here… I was a bit nervous about broaching this with you.

Charlie: I…er…of course…

Sam: I’m so sorry, I know that this is a bit of a bombshell for the practice. I’m still committed to staying here long term; I love the team and I love the patients. Well, maybe love is a bit strong, they drive me crazy sometimes, but I certainly don’t want to work anywhere else.

Flexible working is the new normal and us dinosaurs just have to get used to it.

Charlie: No no, it’s fine. We just need to work it through. Of course, you have to do what’s right for your family. Flexible working is the new normal and us dinosaurs just have to get used to it. But I would like to try and work through what this means for the continuity of care we offer our patients.

Sam: That’s something I’ve been thinking about too actually – although it may sound like having my cake and eating it – I’d love to find a way back towards working as a family doctor rather than what often equates to being an in-house locum.

Charlie: Well, for a while I’ve been thinking about giving each GP their own list of patients. I’ll ask Amanda to divide them up then we can use a practice meeting to make sure that the allocations are fair. We would also divide the patients between the practice nurses. Ideally the same person would see the same patient for every encounter.

Sam: Lots of other practices already do that and it seems to work ok. They partner up and coordinate leave so that the same doctors always cover each other – including bloods and admin. But hang on, I can’t make my patients wait potentially four days to see me if I’m down to six sessions, and no-one works ten sessions here anymore…

Charlie: Well yes, I was hoping that we might retain you on seven or eight sessions, but with fever days it is still possible to provide better continuity than we currently achieve. We just have to segment the patients.

Sam: *quizzically raised eyebrow*

Charlie: Well younger patients and those with acute minor illnesses don’t tend to mind who they see for those discrete time-limited problems, as long as the person seeing them is professional and technically qualified to deal with the problem. We could up-skill our advanced nurse practitioner to take on some of the duty doctor triage and minor illness work, freeing up more time for you to see patients with chronic problems.

Sam: I’d still like to get a mix of issues. I find that patients often disclose valuable information in those seemingly minor encounters – this morning Mrs Begum was in for a pill review and she mentioned that she’s bought a new dog and her daughter recently got married and is moving away. Those nuggets really advance the relationship, and they provide so much context for subsequent issues.

Charlie: OK. I’m glad you’re on board with the dedicated list idea. We need to get the most bang-for-buck out of you, so the majority of your appointments should still be for patients with long-term care needs as that’s where you add the most value. We’ll keep a smaller number free for acute work – although we are drawing up plans to shift a lot of this work to nurses, along with reviewing results and some other admin – and then I wondered how you felt about having some walk-in slots as well?

Calling the surgery between 8:30-8:31am for an appointment is actually a high barrier of entry for… basically all of the groups with the highest care needs.

Sam: Let me stop you at ‘less admin’! I’m 100% on board with having someone else go through my letter and bloods. I know some places use nurses, pharmacists, or doctor’s assistants to review results. They seem to be able to independently deal with the lower-order tasks and feed back important positives or negatives. I guess you need good protocols and regular discussions. Bromley-by-bow do that with pharmacists don’t they? Sorry, I’m getting carried away here, and I’ve got a patient in two minutes and I still haven peed today. You said something about walk-in slots?

Charlie: We’ll discuss it later, but yes. Something that came out of your community engagement work was that calling the surgery between 8:30-8:31am for an appointment is actually a high barrier of entry for single mums trying to do breakfast, people on benefits, patients with mental health problems, our small homeless and substance misuse population, and some of our older patients: basically all of the groups with the highest care needs. To improve access I’m thinking about offering walk-in appointments at the start of each day. To continue the ethos of continuity, each doctor and nurse would have the first hour or so free for walk-ins, and we will train receptionists to triage the babies and elderly etc ahead of the worried well.

Sam: That sounds completely crazy, although I’ve heard of practices that do it and it seems to work in some. Given that you’ve been so understanding with me I’m willing to give it a go.

Charlie: Well I haven’t committed anything yet, but of course we’ll do everything we can to accommodate your three-day week. Another thing that will help you to keep continuity with your list would be advertising your working days on our website, and under your photo by the front desk. Ideally we would stick to the same three days each week and, if you’re ok with it, also let patients know your annual leave dates in advance, and who will be covering you.

Sam: Thanks again, I know how difficult it’s been to go from a handful of full-time partners to a huge collective of part-time partners, salaried docs, and fringe locums in a relatively short period of time. I’ve never known the kind of continuity that you had – working with the same families for decades. But I’m really excited to work towards your ideas about how we can preserve that essence of family medicine within the confines of 21st century care. See you at coffee.