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Rethinking continuity

Ben Hoban is a GP in Exeter.

Life is change, and the same current that brought our profession where it is today will most likely carry us somewhere else tomorrow. The recent focus on continuity of care is welcome in that it demonstrates the positive evidence-base for what has always been a central part of our role. If we look at continuity without considering the wider context of general practice, however, we may find ourselves being swept out to sea as we gaze longingly back at the beach.

The context here is that a patient’s care over the course of their lifetime now necessarily involves more people than before, as GPs work fewer clinical sessions and change their job more often,1 other healthcare professionals take on traditionally medical roles, practices become larger and the pressures in the system keep rising.2 How could it not become more difficult for someone wanting an appointment always to see the same named doctor?3 It is worth considering too that patients don’t always get on with their nominal GP, and would sometimes prefer to see someone else.4,5

The focus on personal rather than organisational continuity also means that we tend to neglect what happens outside our consulting room…

Given the relational foundation of general practice, it would be remarkable if all doctor-patient pairings were equally harmonious or effective. A certain amount of movement within a practice is to be expected before a patient finds the doctor they can work with best, and the danger of trying too hard to prevent this is that the pursuit of continuity ends up becoming a barrier to good care.

The focus on personal rather than organisational continuity also means that we tend to neglect what happens outside our consulting room, when by the time a patient sits down with us, they will probably already have spoken to several of our colleagues, whether receptionists, doctors or other clinicians, all of whom will have formed an impression of them and their situation. Only a small part of this will ever make it into the medical record, but imagine if we could integrate these impressions with our own: we would not just be better informed, but have a broader view, based on a number of different perspectives. Where it happens, this integration takes place in clinical meetings as well as less formal professional encounters, circumstances allowing, around the kettle, in the office, or at reception.

Players in a team carry out their individual roles in a way that is mutually enabling in pursuit of a common objective.

Although it’s become commonplace to refer to any organisation as a team, it’s worth asking how accurate this is. Players in a team carry out their individual roles in a way that is mutually enabling in pursuit of a common objective. Sitting in our room doing our thing while everyone else is sat in their room doing theirs is not teamwork, and yet this is often what happens, especially when it’s busy. Chatting with the receptionist over a cup of tea or setting aside time at the end of surgery for clinicians to discuss cases can feel like a luxury, but I would argue that they’re actually vital to ensuring that we function as a team, and that losing these moments of interaction makes us less effective and less resilient. There’s been a healthy shift in professional thinking from push-through-or-burn-out-trying to look-after-yourself-to-look-after-your-patients, but we may need to widen our perspective to include our colleagues too. The danger of thinking just about how we can protect our own wellbeing is that it quickly turns into a zero-sum game or a race to the exit. The bigger picture is that by working well together and looking after each other, we will find that we are also taking better care of ourselves and our patients.

It’s easy to think of continuity as a treasure chest buried on the desert island we have left behind us, which we must choose either to abandon forever or recover at any cost, but this is a false dichotomy. The current is carrying us forwards, and by allowing ourselves to follow it, we have the chance to move towards a richer kind of continuity based not on the contributions of just one individual, but on those of the whole team. We have always acknowledged the importance of the doctor-patient relationship, but by looking at the relationship between patients and the practice as a whole – and the relationships within the practice – we can ensure that in a changing healthcare context, continuity of care becomes multi-faceted rather than fragmented.

 

References

  1. Parisi R, Lau Y, Bower P, et al Rates of turnover among general practitioners: a retrospective study of all English general practices between 2007 and 2019. BMJ Open 2021;11:e049827. doi: 10.1136/bmjopen-2021-049827
  2. NHS Digital, General Practice Trends in the UK to 2017 Technical Steering Committee (TSC) Archive – NHS Digital
  3. Peter Tammes, Richard W Morris, Mairead Murphy and Chris Salisbury, Is continuity of primary care declining in England? Practice-level longitudinal study from 2012 to 2017, British Journal of General Practice 2021; 71 (707): e432-e440. DOI: https://doi.org/10.3399/BJGP.2020.0935
  4. Changing doctors without changing address, Journal of the Royal College of General Practitioners, 1986; 36 (285): 185 185.full.pdf (bjgp.org)
  5. B Billinghurst and M Whitfield, Why do patients change their general practitioner? A postal questionnaire study of patients in Avon, British Journal of General Practice 1993; 43 (373): 336-338.

Featured photo by Frank Mckenna on Unsplash

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