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Relational care

Ben Hoban is a GP in Exeter

It has become generally accepted that continuity of care is a good thing, and the discussion is currently more concerned with whether or not it is achievable. It is clear, however, that continuity arises more readily in some settings than others,1 and not without help: practices with a high degree of personal continuity tend to have systems that promote this, both by enabling patients to see their own doctor, and by making it more difficult for them to see someone else. The fact that these systems should be necessary makes sense in the context of changes that have been taking place in UK general practice over a matter of decades.

Continuity of care was originally part of a package which also included a high proportion of single-handed practices, 24-hour responsibility for patients, freedom for doctors to apply a limited medical knowledge base as they thought best, and a standard of care set by their professional colleagues. This landscape, in which personal continuity arose naturally, has now changed: group practices providing in-hours care only and including part-time salaried GPs and non-medical professionals are the norm, and care is standardized and judged against patients’ expectations. The government has gained control over the system; doctors have gained the freedom to have a life outside the surgery; and patients have gained – at least in theory – unlimited access to textbook medicine, regardless of who provides it.

In the light of all these changes, what sense does it make to pursue continuity of care in isolation from the other elements of practice that used to make it the norm?

…what sense does it make to pursue continuity of care in isolation from the other elements of practice that used to make it the norm?

Ask a patient which doctor they’d like to see, and the answer will tend to be: anyone; their usual doctor; a doctor suited to help with a particular problem; or a different doctor to the one they usually see. In practical terms, availability is often valued more highly than continuity for acute problems, especially among less affluent patients.2,3 So what exactly does seeing one doctor repeatedly bring to the table, and are there other ways of getting it?

Consider the stages of a model consultation. Connecting4 is easier if you know each other already and don’t have to worry about making a good impression. Summarizing, or agreeing what the problem is, will happen more readily if you can communicate effectively, based on a good understanding of the other’s perspective. Making and handing over a plan of action, and safety netting that plan, require trust and confidence on both sides in the other’s good will and ability to do what is required, hopefully based on previous successful encounters. Doctors and patients are both more likely to feel accountable to each other in carrying out the plan if they expect to meet again.

Connecting is easier if you know each other already and don’t have to worry about making a good impression.

All these things are fundamentally relational. Relationships tend to be built over time, but a long relationship is not necessarily a happy one, or a short one necessarily superficial. A longstanding doctor-patient relationship can lead to collusion, blind spots and resentment, while a new one can bring a fresh perspective.

Let’s consider, then, that personal continuity of care may be a good thing, not necessarily for its own sake, but because it enables a more relational kind of consultation. We may be moving away from the kind of general practice where such continuity is readily achievable. Instead of trying to turn back the clock, let’s be proactive in developing those skills that continuity nurtures, which are conducive to successful working relationships with patients and with each other, in both the short and the long term: listening, building rapport and goodwill, sharing uncertainty and decision-making and fostering accountability. In our current direction of travel towards ever-larger practices, we may also need to consider the upper size limit that would still allow patients to get to know even a few clinicians, so as to be confident of seeing at least one familiar face when they need to; and which would allow those clinicians to collaborate effectively in caring for them. If we simply hark back to a golden era of continuous care rather than learning its lessons, we may find ourselves doing the same again in another few decades.

References

1. Te Winkel, Marije; Slottje, Pauline; De Kruif, Anja; Lissenberg-Witte, Birgit; van Marum, Rob; Schers, Henk; Uijen, Annemarie; Bont, Jettie; Maarsingh, Otto General practice and patient characteristics associated with personal continuity: mixed methods study, BJGP 2022; DOI: https://doi.org/10.3399/BJGP.2022.0038
2. Ahmed Aboulghate, Gary Abel, Marc N Elliott, Richard A Parker, John Campbell, Georgios Lyratzopoulos and Martin Roland, Do English patients want continuity of care, and do they receive it? BJGP 2012; 62(601): e567-e575 DOI: 10.3399/bjgp12X653624
3. Richard Baker, Mary Boulton, Kate Windridge, Carolyn Tarrant, John Bankart and George K Freeman, Interpersonal continuity of care: a cross-sectional survey of primary care patients’ preferences and their experiences, BJGP 2007; 57: 283-290
4. Roger Neighbour, The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style, CRC Press, 2017 (2nd edition)

Featured photo by Everton Vila on Unsplash

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