‘The price of greatness is responsibility’

Emilie Couchman is an academic GP currently undertaking a PhD with the Mesothelioma UK Research Centre at the University of Sheffield and working as a GP on a part-time basis in Wiltshire. She is on Twitter: @DrEmilieCouch

I have recently been challenged on my belief that the 20th century ‘family doctor’ is unachievable in 21st century NHS primary care. Relational continuity, the unique selling point of the ‘family doctor’, alone is not enough.¹ It is not enough because our society is now completely different; unrecognisable even. I am reminded of this daily through my encounters with people (patients and staff alike) who cannot understand or adapt to the new ways of working. And is it fair to ask them to do so? Our convenience culture, our impatience, our healthcare system’s multidisciplinary complexity, our seemingly unending degree of choice exacerbated by privatisation and constant competition; mean that strategies to further a single relationship between a doctor and his/her patient just isn’t going to cut the mustard.

We know that continuity has therapeutic value. The evidence base is substantial enough now that it is widely accepted that benefits tend to outweigh the few disadvantages that continuity might incur in certain circumstances. Continuity affects both sides of the coin: it supports factors such as staff satisfaction and retention, while also positively influencing patient outcomes.² Ultimately, continuity affects how people feel. Is this not at the root of how people relate to their own health and to others? Is making people feel better not the supreme aim of all healthcare? Policy documents continue to focus on access and triage, and still do not advocate strongly enough for continuity, despite unequivocal evidence demonstrating its worth.^{3, 4}

The ever-diversifying complex multidisciplinary healthcare system has created both challenges and opportunities for continuity provision. The renowned triad of components defining continuity, developed by Haggerty et al., perhaps require revision, particularly because of the significant overlap between managerial and informational continuity.⁵ Resources are of course important, but creativity is arguably imperative if we are to develop workable solutions for the current continuity crisis. There is fantastic research being done which demonstrates how people are challenging existing concepts and structures. For example, Ladds et al. recently proposed a new framework for continuity based on ‘what is to be continued’; consisting of four domains: Therapeutic; Disease episode; Distributed work; Commitment to the practice community.⁵ We need more of this novel thinking, and we need to study its application within primary care.

In a system where new job roles seem to be cropping up left, right and centre; whose responsibility is it to provide continuity? Labelling it as ‘everyone’s responsibility’ comes with risks. ‘The “collusion of anonymity” was a phrase used by Balint to describe the taking of important decisions, without anyone feeling ultimately responsible for them.’⁶ Recently, Dr Phil Whitaker wrote ‘no one seems any longer to hold responsibility for an individual’s care’.⁷ As Sir Winston Churchill once said, ‘the price of greatness is responsibility’.⁸ It seems that healthcare professionals constantly practice against a background threatening low hum of litigation, especially given the apparently huge burden on them of patient expectation, that seems to have smashed the glass ceiling. Does this mean that healthcare professionals are less and less keen to take ownership of patients, and how might this societal shift in attitude, and its profound negative impact on the clinician-patient relationship, be counteracted or absorbed?

Given the increasingly multidisciplinary system we work in, perhaps no one individual can be expected to take responsibility for championing continuity. Clearly, we need a (multidisciplinary) team effort. The chasm between members of society who remember ‘the good old days of the family doctor’; and those who have never experienced this version of primary care, seems to be widening. Resources need to be used innovatively if we are to reframe society’s thinking of the ‘family doctor’ as the ‘family practice’.

References

1. Kemple T. Bringing back or taking forward the ‘Family doctor’? BJGP Life. 2023.
2. Couchman E, Ejegi-Memeh S, Mitchell S, Gardiner C. Facilitators of and barriers to continuity with GPs in primary palliative cancer care: A mixed-methods systematic review. Progress in Palliative Care. 2023;31(1):18-36.
3. The future of general practice: Fourth Report of Session 2022–23. In: Committee HaSC, editor.: House of Commons; 2022.
4. The future of general practice: Government Response to the Committee’s Fourth Report. In: Committee HaSC, editor.: House of Commons; 2023.
5. Ladds E, Greenhalgh T. Modernising continuity: a new conceptual framework. British Journal of General Practice. 2023;73(731):246-8.
6. Edgcumbe D. But there are no QOF points for Balint work!: its place in modern practice. Br J Gen Pract. 2010;60(580):858-9.
7. Whitaker P. What is a doctor? A GP’s prescription for the future. Edinburgh: Canongate Books Ltd; 2023.
8. Churchill W. Never Give In!: Winston Churchill’s Speeches: A&C Black; 2013. p. 292.

Featured photo by Kristina Gadeikyte on Unsplash