Fiona Dalziel
MA(Hons) CIHM FIHM
Independent Consultant in Practice Management
Fiona is an experienced primary care trainer and facilitator. She is the national RCGP QPA Adviser and has advised on both the original and the review of the Quality and Outcomes Framework of the 2004 GP contract
Occasionally, we become aware that a patient seems to have somehow slipped through the net. It happens in most practices from time to time and sometimes the patient is caused harm as a result. The harm may be in the form of a late diagnosis and it is often hard to say that it was the fault of any individual.
The patient has often consulted several different GPs over a period of time. The symptoms described may contain no “red flags” and may be a continuation of a condition with which they have consulted before. They may have been seen by a mixture doctors in training, locums, salaried doctors and partners.
There have been lots of opportunities to identify what is going on with the patient but the opportunities have been missed, and eventually an emergency situation develops. The practice undertakes a significant event review and identifies that there was not much evidence of continuity of care.
Complaints about missed diagnosis in practice often involve seeing multiple practitioners and this is sometimes termed “collusion of anonymity”. Having said that, a potential downside of continuity can be that a new set of eyes may see a patient differently and lower the risk of assumptions being made.
But continuity of care does matter.
What is continuity?
Both the Royal College of GPs (RCGP) and The King’s Fund have recently published papers researching, defining and promoting the values of continuity of care.(1,2)
Key to general practice in the UK is continuity of care, where the GP takes overall responsibility for co-ordinating different aspects of a patient’s care. Patients generally remain registered for as long as they can (often for life) with a practice, and a profound relationship of trust may develop with an individual GP. Patients with this kind of relationship with someone who knows them are more able to manage their illness independently, and patients who do not benefit from this relationship or experience a lack of continuity are more likely to miss appointments or not comply with their medication.
This type of continuity is defined as “relationship continuity”. The RCGP’s policy paper on continuity of care says that this type of relationship is “longitudinal, personal, continuing and care: it implies knowledge of each other within the context of the therapeutic relationship, commitment and trust. Both doctor and patient contribute to its creation and maintenance. It does not necessarily involve only one clinician and it should be flexible over time, responding to the patient’s changing needs and social context. It is experienced by patients as care over time from a known and trusted clinician.”(1)
Continuity of care under threat
Since 1948 and the days of Dr Findlay, general practice has gone through a massive amount of changes, and more are on the way. GPs started in the NHS in mostly single-handed practices. This was followed in later years by the introduction of group practices. The new GMS contract in 2004 changed registration with the individual GP to registration with the practice.
Some practices have prioritised the maintenance of a system of personal lists but most practices have moved away from them as they became more difficult to administer. GPs do not now have 24-hour responsibility for their patients.
Political pressure and the access standard of being seen by a GP within 48 hours led to the introduction of “Advanced Access”, with the emphasis being on seen within the target and a reduction in emphasis on seeing the doctor of choice.
Practices put various strategies in place to manage this requirement and there was an increase in the number of salaried doctors employed to meet the target. Many of you will remember an episode of the BBC’s Question Time in 2005 when Tony Blair was informed that many practices now would not let patients make an appointment in advance. Patients were forced to choose between getting seen quickly and continuity of care.
Several other trends also now make the fight to preserve continuity more onerous. Many new GPs prefer to work part-time. The advent of extended hours also means that some GPs’ work is spread more thinly across the week. NHS Direct, NHS 24 and walk-in centres add to the mix, along with polyclinics.
An unintended consequence of the nGMS contract has been the trend to replace retiring or leaving partners with salaried doctors, who are a more mobile population.
Reduced profits have meant that a great deal of practices try to ensure that patients are seen by an appropriately qualified and trained team member who is the most cost-effective person for that patient contact. The input to patient care of all the members of the expanding team are very highly valued.
However, continuity with these team members must be reinforced alongside reinforcing continuity with the GP team. Recent moves by primary care trusts (PCTs) and community health partnerships to reorganise community nursing teams away from being practice-attached also contribute to this problem.
Last, and by no means potentially least in terms of impact, is the introduction of GP commissioning for all practices in England. Experienced GPs risk being sucked into commissioning work and away from patient contact. Their knowledge of the patient community will be invaluable and they will be strong advocates for their patients’ care at a public health level, but continuity in the practice may be put at further disadvantage as a consequence.
The introduction of federations, and an increased likelihood of moving care to different “units”, can lead to the risk of fragmentation when patients move between different parts of the service to receive care. I am sure many of us often wonder: how would an elderly, confused patient, whose first language may not be English, deal with this complex and changing situation, while ill, unless they had strong advocacy from family members and, of course, their GP?
What is management continuity?
Practices can and must manage the risk to patient continuity from all of the above, and this can be done through management continuity.
The RCGP policy paper describes this as “the seamlessness of care: perhaps better thought of as tailored care where the seams are strong and invisible – and fit the wearer. It involves co-ordination and team work between care givers and across organisational boundaries. It depends on good communication in the timely and accurate sharing of information, good records and helping the patient navigate round the healthcare system as smoothly as possible. Information continuity is part of this, and the completeness, readability and availability of the clinical record is of great importance.”(1)
The role of the manager
Practice managers are able to contribute significantly to improving management continuity in the practice and therefore to reducing risk to patients. What action should we be considering?
Strengthen policies and IT systems that help with the identification of the “usual doctor”. IT systems should help practices identify the GP with whom a patient usually consults, if the patient does so. Systems of doctor/nurse/receptionist triage or patient “routing” should incorporate a step that encourages patients to see whomever they saw last for that condition. It is important however, of course, still to leave flexibility for the patient to choose. Different GPs with different specialities in the practice should be advertised to patients.
Use IT systems to maximise fast receipt of information on patients seen outside the practice. This would include out-of-hours contacts, discharges, clinic follow-up letters and other correspondence or communication.
Problem listing/summarising should be undertaken as quickly as possible on receipt of the record of newly registered patients.
Think differently about communication for hard-to-reach parts of the community. Consider whether it would be appropriate to use telephone, text and email communication, including email consultations, to supplement face-to-face contact. Hard-to-reach groups, including teenagers, could benefit from this.
Introduce “buddy groups” to help cover gaps and absences. GPs with complementary working hours and skills can work in teams and cover incoming mail, results etc, and become familiar with each other’s patients. Consider how to use buddy groups when directing patients asking for an appointment or advice if the “usual doctor” is not available.
Have an access policy that allows adequate access for unscheduled/emergency care but also allows and encourages patients to see the same GP at least for an episode of care. This is, of course, limited by capacity. If the practice uses a system of delegating care to minor illness nurses and other team members, could perhaps the length of pre-booked GP appointments be increased? This is a good example of the constant difficulty of balancing quality with quantity.
Use part-time staff, doctors in training and salaried doctors in ways that enhance continuity.
Involve and train receptionists. Reception staff are often very familiar with patients, know whom they normally consult, and are in a position to help patients take advantages of good continuity of care. Many receptionists pride themselves on this kind of familiarity with patients’ allegiances with specific GPs and with their reasons for moving from one GP to another. They may often be more familiar with reasons for moving from one to another than GPs themselves. Front-desk staff could play a significant part in promoting continuity.
Find out how well you are doing. Look at a particular aspect of care where continuity is especially significant, eg, depression, hypertension or cancer, and audit how well you are doing.
These suggestions are only an introduction to the ways in which continuity could be enhanced and patients protected.
The RCGP policy paper and the associated Continuity of Care RCGP Toolkit offer more detail and suggestions, including suggestions for commissioners as well as managers.
References
1. Hill A, Freeman, GK. Promoting Continuity of Care in General Practice. London: RCGP; 2010.
2. Freeman GK, Hughes J. Continuity of Care and the Patient Experience. Research Paper. London: The King’s Fund; 2010.
