Better continuity of care

We do not need any more research about the benefits of continuity of care. The evidence is clear; it is associated with improved preventive and chronic care services, patient and clinician satisfaction, lower hospital utilization, lower costs, and for elderly patients, lower mortality.

What we do need is better continuity of care. According to a recent BMA survey, enthusiasm for continuity of care exceeds that of any other aspect of general practice,

BMA survey

Continuity of care matters more to some patients than others, in particular those with long-term conditions, mental health problems, multimorbidity (several different conditions at the same time), during serious but hopefully shorter term conditions like cancer and during end of life care. Continuity of care makes care more person-centred because getting to know a patient as a person takes time. Continuity of care makes care more efficient because less time is spent repeating a medical history or trying to read it from the notes. Continuity of care makes medical practice safer- we identified lack of continuity as a contributing factor in delayed diagnosis of cancer and introduced changes in our practice which have improved continuity and since then have not had any delayed cancer diagnoses.

Continuity lost

Continuity has not been lost because research has shown that less continuity is superior. It has withered through neglect. Several factors have undermined continuity and these include, but are not limited to:

  • More GPs working part-time: the rest of the time they are raising children, teaching, commissioning, studying, doing specialist clinics like minor surgery, going on courses, appraising other doctors or being appraised/ revalidated, attending (often compulsory) meetings, etc.
  • An higher turnover of GPs. The traditional partnership model gave GPs a long-term interest in and commitment to their practice and they would usually stay there for the duration of their career. Nowadays there are fewer partners and more salaried/ locum doctors who change practice more frequently.
  • Lack of career structure. Practices vary in their commitment to their salaried GPs. Some encourage them to develop their career, take on more responsibility and join the partnership. Others see them as occasional labour and they come and go before patients can benefit from continuity of care.
  • A greater emphasis on access – instead of waiting to see a usual GP, policy-makers -who by and large don’t fall into the categories of patients who most benefit from continuity –have insisted that patients are seen quicker (by anyone) and have pushed for policies like 48 hour access at the expense of continuity.
  • Increasingly multidisciplinary primary care: Practice nurses are managing a lot of chronic disease clinics, pharmacists, nurse-practitioners, physician assistants, and others are seeing patients.
  • Insufficient numbers of GPs. In the UK we are several thousand GPs short of what we need to cover the population. This means that many GPs have more patients registered than they can effectively care for.

Continuity compromised

Several other factors limit the ability of an organisation to provide continuity of care. These include, but are not limited to:

  • High turnover of patients. In our practice in Hoxton we have a 25% list turnover every year. Many patients come and go too quickly to establish a relationship with a GP
  • High turnover of staff. There are far too few GPs and many practices have great difficulty recruiting and are left with short-term doctors filling in for days or weeks at a time.
  • Disease-centred incentives: We are paid for the management of disease, not the care of patients. The two are related, but can be in conflict for example, someone may be tired, anxious, stressed and lonely, but the incentives drive management around blood pressure, cholesterol, and a set of prescribed drugs and they may be sent to a specialist clinic for their disease rather than their GP.
  • Some generalist GPs have become specialists in particular areas, for example dermatology or women’s health and patients may see them instead of their own GP.
  • Some patients choose to see a different GP for particular problems, for example I do a fair few prostate checks on male patients whose usual GP is a woman.
  • Lack of commitment from the managers/ doctors in the organisation. While the large majority of GPs and patients value continuity of care, not all do. It may be that their practice demographic includes lower proportions of vulnerable patients or that they perceived the work involved in improving continuity not worthwhile. They may not believe the evidence in support of continuity to be sufficiently strong.
  • Perverse incentives. Payment by activity rewards a practice for every patient contact. A surgery that offers a walk-in service, where patients turn up and see the next available clinician may have little incentive to change.


Better continuity

First of all, better continuity needs commitment from the organisation. Everyone, or at least the majority of people in the organisation, including management, reception and clinical staff need to believe that continuity matters. Everyone has a role in ensuring patients meet with their own doctor or nurse. My practice made the decision to improve continuity after auditing patients who had a delayed diagnosis of cancer and found that a lack of continuity was a common contributing factor. Other practices may discover similar reasons or be motivated by their patient survey or patient participation group or the academic evidence, which I have summarised here.

The barriers I’ve described above are not insurmountable. I work in a teaching practice with  13,000 patients, 12 part-time doctors, 2-3 trainees and a 25% annual list turnover. We managed to increase continuity from 50% of all patient contacts to 80% between 2012 and 2014. It was only possible by involving everyone in the practice, especially the reception team. It is important to have on-going discussions about how it is working, especially for new doctors and patients who may not be sure what to do when they see somebody else’s patient. Two doctors have retired and 5(!) have got pregnant in the last 2 years, which has severely tested our efforts – but we haven’t given up!

Involve patients!

The majority of patients value continuity of care, and this blog written by Trudy, who has epilepsy and OCD is a great example. Every patient needs to know that the organisation values continuity and why. They need to be assured that a commitment to continuity will not bar them from urgent access when they need it. They need to know who is responsible for their care. I made business cards that I give to my patients, which really helps.


A commentary from the US by Reena Gupta in 2013 includes other suggestions for improving continuity of care. She begins by saying that if we want to improve continuity we need to be able to measure it and she explains that there is no single measure that is suitable for every organisation. Bristol University Centre for Academic Primary Care have come up with a continuity of care calculator that can be used with the EMIS GP operating system. Whatever system is used, what matters is that continuity is measured and the organisation (and their patients) can set goals and track progress. As we discovered when 5 doctors became pregnant, and 2 long-term partners retired, progress can slip.

Another suggestion is to maximise the numbers of days that part-time clinicians spend in their practice. Instead of working 3 or 4 sessions over 2 days, it is better to spread the sessions over 3 or 4 days.

For the last two years I have worked only 4 clinical sessions (half days) over 3 days a week. I make about 5-10 calls to my patients each day that I am in, in addition to my face-to-face appointments and I have managed to maintain continuity with about 90% of all routine appointments with my own patients. In Tower Hamlets, clinicians and academics are piloting microteams – where a patient has their own small team, rather than one specific GP.

RCGP Poster Can Micro-teams offer better continuity for multimorbidity in Tower Hamlets_Page_1

Policy makers and continuity of care

Policy makers need to be aware that continuity of care matters for the most vulnerable patients most of all. They need to be aware that continuity may be the price paid for access. Ill-considered policies like 48 hour GP access put forward by the Labour party undermine continuity of care, especially when so many GPs work part-time. Far better is to ensure that patients have on the day access for urgent problems – by phone in the first instance and face-to-face where necessary. An experienced GP can give advice and treatment or arrange for follow up with the patient’s usual doctor.

Providing continuity of care is hardest where there are high turnovers of patients and staff, where recruitment is difficult and patients are most anxious and chaotic. This is typical in deprived areas. Incentives should not reward practices for the good fortune of being situated in a well off, stable community.

Policy makers should help promote continuity of care. They can encourage patients to ask, ‘who is my doctor?’ or ‘who is in my team?’ Organisations can be incentivised to promote and measure continuity of care and show – to their patients – what they are doing about it.

As Gupta concludes, Few things in medicine have as much evidence supporting their effectiveness as continuity of care.

We should promote it, measure it, and do everything we can to make it better.

A Resilient NHS?

There was no shortage of self-confessed wounded healers at yesterday’s Wounded Healer conference. Professor Jill Maben, who gave the first keynote, confessed that she had to leave her first nursing post because of stress, and I met many doctors and nurses throughout the day who had their own personal stories. Several, like Jill Maben were presenting or leading workshops, and others were there to find better ways for themselves and their colleagues to cope.

In her research Jill followed up nurses from training into qualified posts and discovered that their ideals were sustained, compromised or crushed by the pressures of work [1]. The compromised idealists who were unable to provide the compassionate, patient-focused care they aspired to, were the most distressed and this resonated with everyone in the audience, whether doctors, nurses, managers or patients. In their excellent review of compassionate care, Cole King and Gilbert explain that whilst empathy gives us the capacity to understand another’s suffering, compassion gives us the motivation and desire to relieve it [2]. When the ability to relieve suffering is compromised, it is not only patients, but also health professionals who suffer. In order to protect themselves, Maben discovered that nurses who were suffering focused on ‘poppets’, patients who were less complex and more rewarding to care for.

Health professionals enjoy hard work. Professor Ivan Robertson, in the second keynote explained that demanding work is satisfying only if it is matched by adequate support, resources and control. I found it very helpful later in the day to apply this during a session about burnout and resilience in general practice. When GPs are feeling burned out we should ask, ‘what are we missing in terms of support, resources and control?’


Many GPs feel unsupported and isolated. The intensity of work, combined with every task being delivered to the computer in the doctor’s consulting room, means that it is possible for a GP to spend all day behind a closed door and have no interaction with anyone else in their practice. We discussed strategies like enforced coffee breaks, working duty or administrative sessions in shared offices, and meeting before surgery starts to ensure everyone could get together. We all agreed that narrative-based clinical supervision for all health professionals would help [3]. The importance of different members of the practice team understanding the lived experience of each other’s work mirrored Havi Carel’s concern that health professionals should try harder to appreciate what it is like to be a patient [4]. There was a lot of enthusiasm for Schwartz rounds where anyone involved in patient care, from secretaries to hospital porters, nurses and consultants share stories about the emotional labour of care [5–8]. I have a study group of six GPs, some of whom I did my postgraduate training with over 15 years ago, that meets every three weeks on a Sunday afternoon and has been invaluable in times of difficulty.


Lack of resources is a very common complaint. The lack of money hangs over almost everything. A blog from Professor Chris Ham of the Kings Fund the day before the conference accused the Treasury of denying the scale of the NHS funding shortfall. Many of us who work in the NHS feel a mixture of fury, dismay and despair at the cuts to NHS services over which we have no control. Human resources are a related concern and in nursing the very high turnover of staff, dependency on agency staff, reliance of under-qualified staff and under-staffing are all demoralising. There is also no chance that numbers of GPs will increase sufficiently in the near future so it seems that almost everybody in the NHS is expected to work beyond their capacity. Material resources may be in short supply and we need easy access to all the necessary equipment, which is too often missing or not fit for purpose, especially IT [9].


At first sight, there appears to be a contradiction because we enjoy, compared to many of our patients a lot of privilege and control over our working lives and yet are still at high risk of burnout [10,11]. In searching for the elusive resilience, it is helpful to think about the support and resources over which we do have some control and doing what we can. Nevertheless, as the imposed junior doctors’ contract with a 20% pay cut this week demonstrated, salaried state employees have little say over their terms and conditions. For GPs, who may be self-employed, the impact of our increasingly dense and numerous appraisals, inspections, compulsory trainings, care pathways and performance indicators, is tiring and demotivating [12].

Individuals and organisations

The first and perhaps most important point to note is that when healthcare professional is burned (or burning) out, they are akin a canary in a mine, they are a sign that the organisation is in trouble. Colluding with the idea that the problem lies with an individual removes the responsibility for the organisation to look at systemic issues. If we take the canary analogy, it may be possible to spot the early signs of an organisational problem before the canary keels over or the doctor goes off sick. GPs at the Wounded Healer conference bought up examples of early signs including – increased complaints about a doctor, increased referral rates, working unusually excessive hours, seeing patients outside of clinics – especially the same patient(s) frequently, failing to keep up with admin, etc. Changes to mood or personality especially cynicism and depersonalisation and physical changes like insomnia or weight change, or excessive drinking are common. Nevertheless there may be no signs at all, because when doctors are sick, work is almost always the last bit of their lives still standing. Severely depressed doctors are able to consult in ways that are not recognisably different to their patients and doctors use their ability to continue working to deny the reality of their illness. Sick doctors hang on very tightly to their resilient, healthy, cope-with-anything, professional identity [13]. Shame and stigma are felt very strongly by doctors who suffer with physical and mental illnesses and are a barrier to recognising illness and recovery [13–15]. There is a distinction between strength – to carry on regardless, and courage – to admit ones’ vulnerability – which is key to overcoming shame. Doctors who are at risk of burnout tend to feel shame acutely, deny their vulnerability and score very low on self-compassion [16].

The importance of group dynamics was bought up by Julian Lousada in the third keynote and was a recurrent theme. Bad organisations tend to scapegoat and locate their problems in an individual. We should ask ourselves, ‘what kinds of organisations have whistleblowers?’ There is a growing, if nascent interest in ‘enabling environments’ creating the organisational culture in which professionalism and resilience can flourish. One of the most important things organisations can do, and another strong theme from the conference, was to enable members to tell their stories. Accountability, according to safety expert Sidney Dekker, is to give accounts and a ‘just culture’ is one in which accounts are freely given and heard without blame [17]. If you want to understand terms like burnout and resilience, listening to stories told by those who have experienced it will teach you far more than turning to a dictionary or Wikipedia. Sharing stories and having our stories really heard is one of the most important ways we can prevent burnout and nurture resilience.

Relationship-centred care

As the conference drew to a close I found myself sitting next to Pip Hardy from Patient Voices an organisation that uses video, audio, still images and music to convey patients’, carers’ and practitioners’ own stories in a unique way. I had just seen a headline on the BBC that the new junior doctors’ contract would put patients first. ‘Putting patients first’ is a powerful rhetorical statement that carries the assumption that someone (junior doctors?) or something (the NHS?) is not putting patients first. The rhetoric serves a political purpose which is to undermine public confidence in the institution of the NHS, which is necessary if it is to be dismantled and privatised. The government will deny this intention at the same time as they portray healthcare professionals as being opposed to the interests of patients as, for example, they push for routine, 7 day services. The Francis report into failings of care at Mid Staffordshire hospital made it clear that the focus on patients was being lost because of the demands of financial control and inspections. Throughout the NHS the dead weight of market bureaucracy; finance, inspections, regulation, contracts and commissioning -imposed by government, not health care professionals – has put considerations other than patients to the fore. Government is to blame for this, not healthcare professionals.

What Pip and I concluded was that we could counter the divisive rhetoric if we could find ways to share patient, carer and professional narratives to show how intertwined and interdependent and complex healthcare can be. In his review of a book written by a doctor, Arthur Kleinman wrote of the need for writing that centres on the moral and emotional exchange in the doctor-patient relationship [18]. I sincerely hope that we have time to facilitate this. A mutual appreciation of the experiences of care can support resilience; a study of resilient GPs working in challenging, deprived areas found that they were sustained by a deep appreciation and respect for the population they served [19].

In conclusion

The conference concluded with Jon Ballatt and Penny Campling – the husband and wife team who wrote the wonderful book, Intelligent Kindness [20]. When healthcare professionals are treated with kindness and compassion, when they have sufficient resources, support and control over their work, then patients benefit and if not, patients suffer. The evidence is indisputable.

For more on The Paradox of the Wounded Healer, I recommend this essay by David Zigmond

My related blogs:

The Wounded Healers

The Emotional Labour of Care

When Doctors become Patients


1            Maben J, Latter S, Clark JM. The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nurs Inq 2007;14:99–113. doi:10.1111/j.1440-1800.2007.00357.x

2            Cole-King A, Gilbert P. Compassionate Care: The theory and the reality. J Holist Healthc 2011;8:29–37. care ACK and PG.pdf

3            Tomlinson J. Using clinical supervision to improve the quality and safety of patient care: a response to Berwick and Francis. BMC Med Educ 2015;15:103. doi:10.1186/s12909-015-0324-3

4            Carel H, Kidd IJ. Epistemic injustice in healthcare: a philosophial analysis. Med Health Care Philos Published Online First: 17 April 2014. doi:10.1007/s11019-014-9560-2

5            Point of Care Foundation. Point of Care Foundation – Schwartz Rounds. 2013. (accessed 20 Oct2014).

6            Theodosius C. Emotional Labour in Health Care: The Unmanaged Heart of Nursing. 1st ed. Routledge 2008. (accessed 11 Aug2014).

7            Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med 1996;5:71–5. (accessed 7 Aug2014).

8            Luu S, Patel P, St-Martin L, et al. Waking up the next morning: surgeons’ emotional reactions to adverse events. Med Educ 2012;46:1179–88. doi:10.1111/medu.12058

9            Caldwell G. The RCPE response to Mid Staffordshire. J R Coll Physicians Edinb 2013;43:188–9. doi:10.4997/JRCPE.2013.222

10          Launer J. Power and powerlessness. Postgrad Med J 2009;85:280–280. doi:10.1136/pgmj.2009.081885

11          Zenasni F, Boujut E, Woerner A, et al. Burnout and empathy in primary care: three hypotheses. Br J Gen Pract 2012;62:346–7. doi:10.3399/bjgp12X652193

12          Zigmond D. Doctors have always been over-worked, but that’s not what’s causing the recruitment crisis. OpenDemocracy. 2015. (accessed 16 Sep2015).

13          Tomlinson J. BMJ Careers – Lessons from ‘the other side’: teaching and learning from doctors’ illness narratives. BMJ Careers. 2014. (accessed 19 Jan2015).

14          Bynum WE, Goodie JL. Shame, guilt, and the medical learner: ignored connections and why we should care. Med Educ 2014;48:1045–54. doi:10.1111/medu.12521

15          Henderson M, Brooks SK, Del Busso L, et al. Shame! Self-stigmatisation as an obstacle to sick doctors returning to work: a qualitative study. BMJ Open 2012;2:e001776 – . doi:10.1136/bmjopen-2012-001776

16          De Zulueta PC. Suffering, compassion and ‘doing good medical ethics’. J Med Ethics 2015;41:87–90. doi:10.1136/medethics-2014-102355

17          Dekker PS. Just Culture: Balancing Safety and Accountability. Ashgate Publishing, Ltd. 2012. (accessed 7 Aug2014).

18          Kleinman A. Medical sensibility: whose feelings count? Lancet 2013;381:1893–4. doi:10.1016/S0140-6736(13)61146-0

19         Stevenson AD, Phillips CB, Anderson KJ. Resilience among doctors who work in challenging areas: a qualitative study. Br J Gen Pract 2011;61:e404–10. doi:10.3399/bjgp11X583182

20          Heath I. Kindness in healthcare: what goes around. BMJ 2012;344:e1171–e1171. doi:10.1136/bmj.e1171

Patients as people and liminal medicine

Bill had booked to see me ten days ago and was here for a standard 12 minute appointment. He was the third patient in my afternoon surgery. When I scanned the names of those booked in to see me I recognised twelve immediately, two were new patients and Dr Brown had booked one of her patients in with me for a joint injection. I was ‘only’ running five minutes late.

“Couldn’t you let me finish this chapter?” Bill joked, folding up his book as he walked in.

I smiled and shook him warmly by the hand as I led him in from the waiting room. Other patients looked up. The greeting though sincere, is nevertheless consciously a public act, it’s not just for Bill, but is intended to show that this is the kind of place where doctors and nurses get to know one-another.

“You’re looking well” I commented as we walked together to my room.

I have learned to make such general observations about physical appearances, for example when someone is walking or breathing with less effort than the last time we met. In matters of psyche my patients often wear stoical and cheerful masks which they don’t take off until the sanctity of my office, and often not, even then. I probe a more cautiously there.

“Gout’s a lot better since those new pills you gave me, touch wood” he said, tapping his head.

“Would you like to stick with them?”

“Oh yes please, you said I could if they worked.”

I had made a note in his record and added the Allopurinol to his repeat prescriptions before we were comfortably seated.

“How have you been, and what can I do for you?” I began, trying to be familiar, curious and business-like all at the same time.

“How long have we got, doc?” Bill was only half joking.

“Tell me what you’ve got and we’ll see what we can do.” Healthcare is teamwork; ideally and wherever possible, we patients and professionals aspire to work together. We use the pronoun we, instinctively in general practice.

“Can we start with the pills?”

I had his medication screen already open, “Sure”.

“Not mine, it’s Pauline, she’s had dreadful diarrhoea since the hospital started her on them – remember we talked about them last time?”

Without looking at her records I knew what he was talking about. Pauline his wife had been prescribed medication for dementia, and was suffering one of the commonest side effects. Bill’s colitis causes similar problems and I imagined them hopping up and down waiting turns to get into their tiny bathroom.

“You can imagine what it’s like with the two of us”

Bill and Pauline look after each other so the side effects from Pauline’s medication affect them both. Individual autonomy may rule medical ethics, but in medical practice, autonomy is relational – serious illnesses and treatment decisions also affect families and carers.

“Oh yes, I can! Did she try some Loperamide?” I asked

“She did, but it was no good. She wants to know if she can stop them, she’s on enough pills as it is.”

I guessed she had stopped them already and he was just checking out of courtesy.

“Has she tried stopping?” I asked, suggesting in the tone of my voice that it would have been OK if she had.

“She hasn’t taken them for the last week, and she feels a lot better without them. The diarrhoea settled down in a couple of days. We’re not long for this world doc, and we don’t want to spend our last days on the loo.”

“That’s fine, I don’t blame you.” I had sensed when Pauline first agreed to try the medication that she was not keen.

“And we don’t want to try anything else, thanks, before you ask. We’re managing all right for now”

“Are you sure?” I suspected they were, but wanted to give him an opportunity to let me know if they needed anything else.

“Yeah, don’t worry, we’ll let you know.”

“Now, have you got time to take a look at my shoulder?”

“Of course” That’s what I always say. When patients say “Have you got time …?” or “Just one last thing …” it frequently introduces the symptom they are most afraid of or ashamed to talk about. They come in to test us with something safer – a sore throat, back pain or a medication query, before deciding whether we’re sensitive, serious or empathic enough for them to trust us with what’s really worrying them. Mandating only one problem per consultation has always seemed absurd; you made the appointment for pain in your breast, but vertigo – the first time you had ever had it, started a day before the appointment and when will you ever get round to talking about the bouts of inexplicable tearfulness? Sometimes the problem might be better looked at in another appointment and usually something can be negotiated. But first we need to know what it is.

“Tell me about it” I said, whilst gesturing for him to stand up and remove his shirt so I could see and examine his shoulder while we worked systematically through a clinical history and examination. He was getting dressed again barely three minutes later.

“Just one last thing”, he said, slipping off his shoe and sock and pointing at his toe. “That Vicks you said I should try for my toenail was bloody useless! Have the results come back and is there anything else I can try?” His toenail looked exactly as it had a month ago, if anything slightly worse. I looked up the mycology result and we talked about the options briefly and decided on a topical treatment.

We left my room together. “Would you like me to come round and see Pauline?” I asked. “Thanks for asking doc, no need for now, I’ll get her here, but if I can’t, don’t worry, I’ll let you know”

You can’t take a serum stoicism level. In general, older people, whose health is more precarious, tend to be more reluctant than the anxious young to visit their GP. Perhaps it is a self-reliance learned from wartime hardship, or perhaps a perfectly rational fear that new symptoms are more likely to be something serious which they would prefer to ignore. I’ve noticed an increasing fear of hospitals – fear of medical errors, hospital acquired infections and nursing neglect, fear of being a burden and a bed-blocker and of course, the fear of death. The discourse of austerity and just deserts is internalised by the elderly poor who sense that they are not worthy and it is their duty to suffer quietly. Collectively we’re abandoning them by failing to provide sufficient tax-funds for care.

The depth of relationship between a GP and his/ her patients is linked to greater efficiency as the description above shows and was confirmed by a study published last year. The study showed that more problems and more emotional issues were raised and discussed when relationships were deeper. Primary care is already adapting to a future in which GPs are responsible for much larger numbers of patients than they have previously managed. There are not, and almost certainly will not, be enough GPs in the future and the more patients we have, the less we will be able to get to know them. Ex-editor of the British Medical Journal Richard Smith appears to be looking forward to a future in which the average GP is responsible for 3000 or more patients instead of the 1,167-2,237 average full-time list we presently have or the 1000 or less, I think we should be caring for. Primary care teams will be more diverse than ever before. For the problems described above, Bill could have seen a pharmacist, a nurse, a physiotherapist and a podiatrist -perhaps three or four separate appointments and another one for his wife. Could they have spotted his easier gait? How long would it have taken them to understand why Bill and Pauline were not keen on her dementia medication? Would they know about Bill the husband and carer? Would they know about Bill’s stoicism and coping strategies, honed after caring for a daughter with Down’s syndrome for thirty years before she died? Who would know how long Bill and Pauline want to live and how they want to go?

I have begun interviewing medical students about their experiences on GP placements. One of the strongest impressions they had was about the ways in which GPs know their patients and their lives. There is an implicit assumption that shared-decision-making, self-management support and better organisation will make healthcare more patient-centred but almost nothing in the literature about the importance of knowing patients as people. Adapting primary care to a future in which ever larger, more complex teams are responsible for ever greater numbers of patients, carries the real danger of further fragmenting care, transforming patients as people who need to be known over time into problems that need to be solved as quickly as possible.

GPs are specialists in liminal medicine. In anthropology a liminal zone is the intermediate state of a rite of passage. When we travel, liminal zones occur when we are stateless, between one passport control and another. In contrast to our hospital colleagues who specialise in medicine where thresholds have to be crossed for patients to enter their field of expertise, we work in the liminal spaces between thresholds where patients as people hold dual passports for the kingdoms of the well and the sick. In these spaces biology mixes with biography, science with mysticism and a straightforward presentation offsets a precariously balanced life whose foundations are undermined by trauma and loss. Iona Heath describes GPs as gatekeepers in the liminal zones between suffering and illness and between illness and disease. The human complexity of treating patients as people in general practice is an enormous intellectual challenge, equal at least to any of the biological sciences. We should be proud of what we do and invest in it – for the sake of our patients.

If primary care is to be truly patient-centred, holistic, humane and efficient, we should be thinking seriously about what it would take to help GPs and patients get to know one-another, especially the elderly and those with long-term conditions, mental illnesses, and lives marked by poverty, tragedy and trauma whose biography is intimately bound up with their biology.

We need more GPs, not fewer, better continuity of care and more emphasis on knowing patients as people.

See also:

Relational autonomy as an essential component of patient-centred care

Supporting patient autonomy: The Importance of Clinician-Patient Relationships

Do we need academic primary care?

A few weeks ago I took part in a debate in which I attempted to defend the motion,


I enjoy debating and public speaking and accepted the invitation to speak without hesitation. As the day of the debate approached I grew increasingly apprehensive and unsure that I could convince myself, much less anybody else that I believed what I was supposed to say. When my turn came to speak I froze, I could barely speak, my heart pounded, I stumbled over words and phrases and I panicked and prayed for the ground to swallow me up. I’ve had a handful of panic attacks in my life, usually related to getting lost or driving, but this was the most public. It was awful.

And so with this still in mind, I attended the Society for Academic Primay Care Annual Scientific Meeting SAPCASM hoping to be inspired and convinced of the motion I had failed to defend.

The conference began for me with a session about becoming an independent researcher. Working in small groups we thought about how to sell our research ideas to an enlightened philanthropist (Bill Gates). It forced us to think about why our research mattered and why we were the best people to be doing it. An overarching theme was that young researchers are often not good at selling our ideas, much less ourselves and we need to practice this. I left wondering whether it was more about a good act than a good idea.

The first plenary from Frank Sullivan was about whether antivirals should be used in the treatment of Bell’s Palsy. Early in his presentation he told us that even though we have known for years that steroids are effective (NNT=9) they are only prescribed in 50% of eligible cases. If there was a meta-theme to the conference it was this – why are we researching new avenues (like antivirals, which by the way, don’t work) when what we already know to be effective is not yet done routinely? Why isn’t that the major focus of academic primary care?

My poster was up for the first session. I spent the full 25 minutes listening to an enthusiastic delegate and barely had time to talk about it to anyone else. Then I had to take it down. A few hours work and £18 printing costs for what?

In the next session I learned that patients don’t like to criticise their doctors too much. Of course, I didn’t learn that there, because as a GP, this has been obvious for as long as I’ve been in practice, and is obvious to most patients too.  The question, ‘what do we need reliable measures of patient satisfaction for?’ Is a good one and whether you want to help me be a better GP, or turn patients into consumers will probably influence the measures you use. I lamented the lack of politics here.

I was fortunate to see a prize-winning systematic review of GP recruitment strategies from Puja Verma. If only Jeremy Hunt and the RCGP had seen it too. The only thing that works is to change undergraduate education. Keele have got it right, Oxford has got it wrong and there’s not a snowman’s hope in hell that we’re going to get the 5000 extra GPs the government have promised in the time required.

Head of NHS England, Simon Stevens gave the afternoon plenary. He said he wants to make primary care more multi-disciplinary, offer more alternatives to face-to-face consultations and nurture diversity of primary care provision. It was as if he had read my blog for the Centre for Health and the Public Interest. The problem is that I don’t think he realises how efficient GPs are. For almost 40 consecutive face to face consultations I documented who else could have seen my patients. Typically, instead of seeing me (a doctor they knew) they could have seen 2 or 3 other people such as a pharmacist, psychologist, physiotherapist, nurse practitioner or nursing assistant. But instead, in 10-12 minutes I was able to review their medication, listen to how they were coping, take a look at their arthritic hands, inject their thumb and give them an information leaflet. Despite what I wrote in the blog, I think his ideas will mostly lead to higher costs, more fragmentation and loss of continuity. Patients who can manage remote consulting should be enabled to do so, and this might free up time for those who cannot, but we need more GPs! And policy makers should read The Mystery of General Practice to help them understand what we do.

Katherine Yon gave a presentation and Rona Moss-Morris gave a keynote about Medically Unexplained Symptoms, perhaps better described as ‘persistent physical symptoms’. Doctors, educators and medical students are all afraid of what they don’t (and probably cannot) know, and so they tend to avoid it. Only 6 out of 53 medical schools provide training on MUS even though MUS accounts for 18% of GP workload and up to 50% of out patient workload. Most GPs will tell you that an enduring theraputic relationship is vital and most patients will accept that stress can cause physical symptoms, if assured that their symptoms are not imagined. There is evidence that some medical students avoid general practice on the grounds that it is not intellectually challenging enough. Medically unexplained symptoms and the patients who suffer them are as challenging as medicine gets, but it is a human challenge as much as an intellectual one and we might do well to celebrate the human challenges of general practice as one of its greatest attractions.

Christine Cabral gave a presentation about communicating with parents of children with a respiratory tract infection. When I summarised some of the qualitative literature last year, I came to the conclusion that parents wanted confidence, not reassurance. We need to do more to reassure parents that their concern is appropriate and then give them the confidence to cope after the consultation. Carol Sinnot, who presented some wonderful work on multimorbidity suggested I did a study to look at whether giving confidence reduced re-consultation rates. For a while I thought this was a good idea, but on reflection I thought, why not just do it because it’s the right thing to do?

There was a lot about multimorbidity including Bruce Guthrie’s wonderful plenary, ‘Multimorbidity: New paradigm or emperor’s new clothes?’ We learned that the main determinant is deprivation: people in the poorest areas have the equivalent health of people 15 years older in the wealthiest areas and the most debilitating morbidities are depression and chronic pain. This is most of what I deal with as a GP in one of the most deprived parts of Hackney. What do we need? Time and continuity of care in part, but most of all we need political action on the social determinants of health! Why isn’t there more political advocacy from academic primary care? So much downstream research and so little upstream action.

There were a range of papers about patient-centred practice and patient involvement, but as far as I could tell, no actual patient involvement, except for the fact that in one way or another we were all actual or potential patients. It is worth noting that many primary care researchers are not clinicians. But most primary care research is published in pay-walled journals and out of reach of the average (or even above average) patient or non-academic GP. This is a problem. I try on my blog to share research in a way that makes sense for these audiences, but this isn’t academic research and so won’t do anything for an academic career.

One of the best presentations of the conference was from Lesley Wye from Bristol about ‘Evidence based policy making and the art of commissioning’. This ethnographic study looked at how commissioners used evidence when making decisions. Unlike researchers who like to read and write, commissioners are social animals who like to stroll across the office and ask a colleague. Commissioners view ‘evidence’ as hard to find, hard to interpret, hard to apply and too slow. They tend to think that evidence is for healthcare but not commissioning. Researchers need to work with commissioners in the same space. Lesley’s work – undertaken with Chris Salisbury reminded me of the other highlight of the conference, a workshop on co-creation in research from Claire Jackson, Trish Greenhalgh and Judith Smith. Their message was that co-creating research takes place in the swampy lowlands where politics and personalities collide and inevitably requires compromises between research purity and practical utility. This is where I found the inspiration I needed for my debate.

Don’t judge me! Reflections on reflection

Few things seem to irritate doctors and medical students so much as mandatory reflection. Compared to bullying bosses, the lack of sleep and an unstoppable tide of human suffering, the amount of bitterness harboured at being forced to write down ‘reflections’ may seem crazily out of proportion, but I share their frustration. I say this because I am enthusiastic about reflection, but dismayed by the ways it has been handled in medical education and clinical practice.

The assumptions underlying medicine and reflection

To justify any kind of reflection we need to begin with questions like, ‘What is medicine (for)?’ The philosophical foundations of our practice are rarely examined in the formal medical curriculum, but in the hidden curriculum of real-life experience we learn that medicine is a moral practice, guided by science and shaped by culture. It is impossible to escape from the inherent moral ambiguity, scientific uncertainty and cultural conflicts that arise.

These conflicts result in cognitive dissonance – a state of internal inconsistency that some people thrive on, but most are left feeling anxious and uncomfortable, especially when their own values and beliefs are challenged. It may be possible to ignore or suppress the dissonance, but without serious thinking, it can lead to anxiety and burnout or an entrenchment of attitudes, and a lack of critical self and social-awareness.

This brings me to the first problem with mandatory reflection. The dissonance that is frequently the trigger for reflective writing often requires the author to acknowledge their anxiety and reveal their vulnerability. If they are going to do that, then they need to be confident that their writing with be treated seriously and sensitively. In reflective writing problems are identified and explored and though there may be resolution, resolution is not the aim and is rarely the outcome.

Reflection as a supervisory process

Before I help my students with their reflective writing for the first time, conscious that they might be less than enthusiastic, I ask them whether they found it useful before.  They often say that they valued time spent talking  with their tutor about what they had written, but did not appreciate handing in a piece of writing which was returned with little more than a grade and some comments in the margins. I have learned over the years to treat reflective writing as a process of supervision.

I teach second year medical students to supervise one another using a modified Balint approach [1]. They read aloud a 500 word reflective piece they have written about a patient-experience to a small group of fellow students and myself. They say why the experience mattered to them, any thoughts they had while they were reading it out, and any help they would appreciate from the group. While the writing is an example of ‘reflection on action’, that is, a retrospective view of events, thinking about the writing, whilst reading it aloud demonstrates ‘reflection in action’ [2]. While reading, students often notice things they no longer agree with, or ideas that are less clear than they were when they wrote them down. They make clarifications and comment as they go along and after they have finished reading.

I teach the group to listen. They listen for phrases, and think about why a particular phrase was used. The listen for cues – points of significance, and think about what makes them significant and for whom. They listen for contexts that are there and those that are missing, and think about how these change the significance or meaning of what they have heard. Reflective writing is full of attempts to interpret events, so they listen for examples and think about the significance of one interpretation among other possibilities. They listen to find out what role the narrator plays in the narrative – second year medical students rarely play the role of heroic doctor, but more frequently feel like an imposter playing the part of a trusted professional. They listen for the feelings and emotional content of both the writing and the reader. They listen to what needs are being expressed in the writing and reading. They listen to their own response and how that feels. For those that are keen to learn more I suggest some introductory papers on narrative medicine [3–7].

Close listening is a teachable skill and I find it extremely rewarding to join in with their discussions and share in their progress. After doing this for the last two years, I believe now that empathy can be taught, and it starts by learning how to listen [8].

After the work has been read aloud, the narrator sits back and the group discusses what they have listened to without directing their comments to the presenting student or making judgements. To show that they have listened they are encouraged to quote phrases and describe their interpretations. I help the group to identify themes and to think about areas that could be explored in more detail and to think about how they can relate to the work. Students need help to identify potential blind spots, like issues of power [9]. Reflection becomes critical reflection when it includes,

considerations of the creation by social and systemic factors of contexts that implicitly or explicitly influence one’s beliefs and behaviours [10].

After a few minutes the presenting student, who has been listening, is invited back into the group to respond. We all take turns to present our reflective writing, including myself, so that the students can see that I am willing to share my own difficulties and am interested in their responses.

The depth and quality of their conversation often shows a startling maturity and their ability to help one-another to think seriously about their work comes naturally and improves rapidly. After the first session they rewrite their piece, taking into account the discussion and then at a later session, re-present their work to the group in the same way. This gives them the opportunity to learn about trust and continuity. They learn to trust the group (or not) because of the way they handle their reflective writing. Treated sensitively they grow in confidence and their subsequent writing is deeper. Rewriting their work and re-presenting it, reveals the transformative nature of reflection and dialogue and helps them to learn how consultations can transform stories. They learn that reflective practice is an on-going social process rather than a competency or solipsistic introspection.

A reflective culture

The majority of medical students and doctors are naturally self-critical and sensitive to criticism. The aim of reflective practice should be to create a supportive culture in which all professionals are encouraged to think seriously with one-another about what is going on in every-day practice. Without a just culture clinicians will be afraid to talk about important issues for fear of criticism or recrimination [11]. In discussing their study about patient-centred behaviour in medical students, Bombeke et al. concluded that,

Raising students awareness of their personal attitudes might be a better learning goal than teaching ‘better attitudes’ because students may resist attempts to force them to be patient-centred [12].

Nobody, least of all someone who is either overly or insufficiently self-critical, likes to be told that their reflective writing is not good enough. Judgments about reflective writing may be taken as (and may well be) judgments of character, which educators and others make at their peril. Reflective capacity is a core feature of professionalism and students are unhappy with being judged on this too [14,15].

Against assessment

In their paper about Assessment as Practice, Jordan and Putz describe inherent, discursive and formal types of assessment [16]. We make inherent assessments all the time, as I did by recognising the progress my students made with their reflective writing in our sessions together,

Fundamental is the fact that in-a-glance, on-the-fly mutual assessments underlie all of human sociality and, in fact, the solidarity of all social species. They occur routinely, effortlessly, and unavoidably as part of any non-solitary human activity where people rely on a shared sense of purpose. It is how newcomers become full members of communities of practice.

Formal assessments of reflective writing risk transforming a social process into a finished product, but it is obvious to my students that reflection is always open-ended.

In their narrative review of supervision in medical education, Ng et al. ask, rhetorically,

What difference might it make to consider reflection as more than tool or technique? Reflective practice as a way of being transcends traditional assessment; it is an orientation through which one practices, continually challenges one’s own assumptions, and builds new knowledge [10].

Rita Charon [17], in A Sense of Story, or Why Teach Reflective Writing, says,

The duty of the teacher is not to judge and rate but rather to read and tell what is seen.  Reflection fulfills difficult missions of medical education in teamwork, peer learning, trust and care.

In learning to listen, reflect and respond to each other, students learn how to listen empathically and interact not only with one-another, but with patients. It helps students develop not just self-critical faculties, but social and political awareness. They learn a little of what it is like to reveal their vulnerabilities and have someone else respond with skill and empathy.

Charon continues,

We worry that in our commitment to bring reflective writing to our students we might hurry to provide our schools with what we think they want, like quantified markers of individual learner’s achievements. This impulse perhaps distorts and squanders the potential deep dividends of the work of reflective writing. We might remember that it is a profound achievement to equip our students – and ourselves – with the capacity to tell and listen to stories.

We should pay more attention to nurturing reflective practices instead of devising formal assessments of reflective writing. Medicine might be more humane for doing so.


 References and further reading

1         Launer J. Moving on from Balint : embracing clinical supervision. Br J Gen Pract 2007;45:182–3.

2         Schön DA. The Reflective Practitioner: How Professionals Think in Action. Basic Books 1983. (accessed 7 Aug2014).

3         Greenhalgh T. What Seems to be the Trouble?: Stories in Illness and Healthcare. Radcliffe Publishing 2006. (accessed 2 Dec2014).

4         Greenhalgh T, Hurwitz B. Narrative based medicine: Why study narrative? BMJ 1999;318:48–50. doi:10.1136/bmj.318.7175.48

5         Charon R. Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust. JAMA 2001;286:1897. doi:10.1001/jama.286.15.1897

6         DasGupta S. Stories Matter: Narrative, Health and Social Justice. 2012;5:1–4.

7         Launer J. Patient choice and narrative ethics. Postgrad Med J 2014;90:484. doi:10.1136/postgradmedj-2014-132866

8         Afghani B, Besimanto S, Amin A, et al. Medical students’ perspectives on clinical empathy training. Educ Health (Abingdon) 2011;24:544.;year=2011;volume=24;issue=1;spage=544;epage=544;aulast=Afghan (accessed 22 Sep2014).

9         Donetto S. Medical students’ views of power in doctor-patient interactions: the value of teacher-learner relationships. Med Educ 2010;44:187–96. doi:10.1111/j.1365-2923.2009.03579.x

10      Ng SL, Kinsella EA, Friesen F, et al. Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review. Med Educ 2015;49:461–75. doi:10.1111/medu.12680

11      Dekker PS. Just Culture: Balancing Safety and Accountability. Ashgate Publishing, Ltd. 2012. (accessed 7 Aug2014).

12      Bombeke K, Symons L, Debaene L, et al. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ 2010;44:662–73. doi:10.1111/j.1365-2923.2010.03627.x

13      Birden H, Glass N, Wilson I, et al. Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach 2013;35:e1252–66. doi:10.3109/0142159X.2013.789132

14      Finn G, Garner J, Sawdon M. ‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study. Med Educ 2010;44:814–25. doi:10.1111/j.1365-2923.2010.03743.x

15      Brainard AH, Brislen HC. Viewpoint: learning professionalism: a view from the trenches. Acad Med 2007;82:1010–4. doi:10.1097/01.ACM.0000285343.95826.94

16      JORDAN B, PUTZ P. Assessment as practice: Notes on measures, tests, and targets. Hum Organ;63:346–58. (accessed 9 Feb2015).

17      Charon R, Hermann MN. A Sense of Story, or Why Teach Reflective Writing? Acad Med 2013;87:5–7. doi:10.1097/ACM.0b013e31823a59c7.A

Relationship-centred care


The best book I’ve read this year, by a long way, is Forgiveness, Stories for a Vengeful age. In her introductory essay, “As mysterious as love”, Maria Cantacuzino explains why she has chosen not to define forgiveness,

The only thing I know for sure is that the act of forgiving is fluid and active and can change from day to day, hour to hour, depending on how you feel when you wake in the morning or what triggers you encounter during the day.

Following her essay are forty personal narratives about forgiveness written by people who have forgiven, have been forgiven and are struggling with forgiveness. It is a hard read because every story begins with pain and describes a struggle that may or may not be resolved. Forgiveness is a process that helps to relieve the pain of broken relationships, with others and oneself. Forgiveness is both social and intensely personal and the stories that range from childhood abuse to people involved in genocide demonstrate the importance of allowing people to tell their own personal stories of forgiveness.

Like forgiveness, patient-centred care means different things to different people and can change from day to day. It involves suffering, and is a process, which is also a struggle. It means very different things to the parents of a new-born baby on a neonatal ward, an athlete with a broken ankle, the husband of an elderly woman with moderate dementia, and a fifty year old businessman with seven different medical conditions and fourteen daily medications.

Forgiveness can be hard for those who are giving and receiving, for example one story is told by someone who accidentally ran over and killed an elderly woman and was unable to forgive herself. Healthcare professionals who harm patients in the course of their practice sometimes find it very hard to forgive themselves and are known as ‘second victims’. While there is a widespread and growing recognition that patients suffer from a lack of patient-centred care, it is less often recognised that it is deeply frustrating for those of us who want to give patient-centred care, but cannot.  One contributing factor to burnout among health professionals is when we are moved by another’s suffering and recognise what needs be done to help, but are prevented from doing so, usually by time and resources or organisational factors out of our control.

Some of the conflicts felt by doctors and medical students who are unable to provide patient-centred care were revealed in a study by Katrien Bombeke titled, “Help I’m losing paitent-centredness!” In common with other studies showing a loss of empathy through the years of medical education, she showed that medical students found it increasingly hard to sustain the patient-centred practice they aspired to because there was so much more than their patients to attend to as their responsibilities increased.

It is easier to be patient-centred when as a second year medical student based in general practice, you are given an hour with a patient to take a comprehensive history, especially if you are taught to pay attention to narrative, meaning, values and experiences. Many students and patients find this time together mutually therapeutic. There is no pressure to make a diagnosis, formulate a management plan, undertake a medication review, organise a referral, discuss weight loss or smoking cessation or any of the other demands of an average ten-minute GP consultation. By the fourth year of their training, students find themselves attached to a specialist firm, expected in twenty minutes to take a focussed gynaecological or neurological history, examine the patient and formulate a management plan. Time spent exploring their patient’s palpitations, colitis, depression and financial insecurity might mean there is not have enough time to find out the cause of their menstrual bleeding or seizures. Once the patient has presented their story to the student, the student has to represent it as a case to their supervisor,

All case presentations seek to turn an individual physician’s interpretation of the patients subjective and private experience of illness into an objective, scientific – or from another viewpoint, a reliably inter-subjective and medically recognizable – account of disease. Tierney

There are inescapable conflicts between the need to take a focussed history and make an accurate diagnosis in a timely manner in a busy clinic and the need to be more patient or person-centred. We have to be at the same time objectively diagnostic and subjectively therapeutic, often combining both in a single consultation, for example, when faced with a patient presenting with new symptoms on the background of complex, chronic multi-morbidity.

It is interesting that (in general but not exclusively) the patients represented in the policy oriented literature usually have a number of established conditions. These patients are used to demonstrate the need for better coordination of services. The healthcare professional literature features more patients with greater uncertainty and is used to demonstrate the need for better communication and shared-decision making. Both organisational and relational aspects of patient-centred care matter to patients. Kieran Sweeny, in describing his experience of being diagnosed with cancer highlights this clearly,

Medicine is not solely a technical activity and pursuit, medicine is about understanding and being with people at the edge of the human predicament. Caring for somebody is a transactional activity, where they do things to me. Everything I’ve had done to me has been excellent; there hasn’t been a single mistake, I’ve been seen on time, transactionally the place has been outstanding. It’s the relational care where I think the experience has been less than satisfactory.

It is clear from clinical practice that doctors need to be both diagnostic and therapeutic at the same time. A urinary tract infection might be easy to diagnose, but patient-centred care requires doctors to recognise and respond appropriately to their patients’ concerns, ‘Could it be something I caught from my boyfriend? Could I give it to my daughter? Is it because of something I’ve done? Will it damage my kidneys? Could it make me incontinent or harm my baby?’ ‘Do I really need to take antibiotics?’ Recognising that concerns like this even exist requires that we establish a relationship of trust so that our patients can ask the kinds of questions they are afraid to ask because they might feel embarrassed or guilty. The potentially confessional nature of even the simplest consultation demonstrates doctors’ pastoral power in which we bear witness to what may be guilty secrets. Handled respectfully and skilfully this can transform a simple consultation into something genuinely empowering for patients and satisfying for doctors.

Patient-centred education

It is easier to be patient-centred when you are trained that way. I wasn’t. Patient-centred care was not a phrase I heard at medical-school in the 1990s and I suspect that the majority of medical professionals have had no specific training in patient-centred care. In medical education in the UK basic attempts are made in communication-skills training. Bombeke found that medical students were able to draw on their communication skills training, but it did not translate well between medical education and clinical contexts. In the post-graduate GP curriculum, communication skills may be treated by strategically minded students as hoops to jump through or tricks to perform to get through an exam, rather than a core value that underpins their practice. They conflict with other necessities, like diagnostic-skills, time-keeping and the demands of guidelines, targets and incentives. Patient-centred care may be reduced to rote questions, “what are the patient’s ideas, concerns and expectations?” and ‘shared decision making’ becomes a matter of telling the patient everything we know, and asking them what they want to do. After a while, so many so many patients reply, “I don’t know, what do you think?” that we sink back into a benevolent paternalism. The benevolence shouldn’t be underestimated. In my experience, the vast majority of doctors who have little idea about patient-centred care lack neither kindness nor competence. Patient-centred skills of narrative humility, epistemic justice, values based care and shared decision-making can be taught, but they take time, patience and expertise. Atul Gawande’s four questions are a simple and useful start; What do you understand? What matters most to you? What are you most afraid of? And what compromises or risks are you willing to take? Time required to teach sophisticated communication skills is contested by many who think time would be better spent on teaching statistics or anatomy.

Patient, person or relationship-centred care?

Good health depends on us having healthy relationships in three areas; with people (including carers, family, colleagues etc.), materials (including the built environment and the ‘stuff’ around us) and organisations (including systems, pathways, lines of communication etc.) The importance of healthy relationships has been highlighted by a recent report from Relate, a short book called Humanising Healthcare and longer book called Intelligent Kindness, Reforming the Culture of Healthcare. What they share with a growing literature on empathy and compassion in healthcare is the understanding that the way we treat patients is a reflection of the way we, ourselves are treated. In Bomeke’s study, she discovered that medical students who sustained patient-centredness were those who experienced student-centred relationships with supervisors who spent long enough with them to get to know them.

The politics of patient centred care

There is a simplistic, politically useful conception of power as something akin to a football that can be passed between patients, professionals and organisations. According to this view, professionals and organisations refuse to share power with patients because of vested interests. The policy implications that follow from this are that professionals and public healthcare institutions need to be disempowered. One problem with this view is that by any measure the NHS is not centred on the needs of professionals. A lack of time even to attend to basic bodily functions combined with a culture of bullying and fear, rising levels of staff sickness with stress and mental illness, all point to an organisation that is anything but centred on the needs of its staff. If there is any validity in the conception of power as a football on which attention is centred, it is that a great deal of damage is done fighting for possession.

A more sophisticated and realistic conception of power is,

as a productive network which runs through the whole social body, much more than as a negative instance whose function is repression. Foucault: Power/Knowledge: Selected Interviews & Other Writings 1972-1977

There is no avoiding the power differential between someone rendered vulnerable by illness and a healthcare professional who is there to provide care and support. Those who would use patient-centred care as a political tool to undermine professionals are often driven by their own vested interests.

In a carefully argued paper from 1995, retired GP Dr Julian Tudor Hart explains that,

Optimally efficient health production depends on a general shift of patients from their traditional role as passive or adversarial consumers, to become producers of health jointly with their health professionals, in an essentially co-operative rather than competitive public service.

Patient-centred care and continuity

It is easier to be patient-centred when I know my patients. Continuity of care enables me to learn about my patients’ lives and gives my patients time to discover how I think, what I care about and what I know. For patients with long-term conditions, especially with a troubled history, it is upsetting to have to tell their story to a never ending series of strangers. Continuity of care allows trust to develop. Max has been my patient for the best part of a decade. I know his wife and children and I looked after his father during his final illness and his wife during her pregnancies. After about two years of careful negotiating he decided to have his kids vaccinated. Caring for patients as ‘persons’ – people with a history and a social network, takes time over which relationships can develop. It is possible to do a lot more in the NHS to facilitate continuity of care, but factors like shorter, more intense shift work, militate against this.

Patient-centred care and incentives

The vast majority of NHS staff are salaried employees, including now, the majority of GPs. We cannot subvert medical care for our own financial gain by over-treating the wealthy and excluding the impoverished as often happens when healthcare is a business. This is one reason why so many of us are anxious about the direction of reforms that are encouraging patient consumerism and profession entrepreneurialism. Nevertheless the financial security of the institutions on which both we and our patients depend is tied to incentives that are not patient-centred. Dr Margaret McCartney has tirelessly campaigned for an end to work being forced upon us that is of no proven benefit to patients. This includes health-checks, dementia screening, advance care plans, most QoF, referral management schemes and CQC inspections. Many doctors and nurses find the demands of the electronic patient record an unwelcome distraction. National Voices a UK patient involvement charity, suggest that,

Although professionals and commissioners are increasingly discussing how to be ‘person centred’, service delivery remains dominated by regulatory, financial and organisational priorities – which regularly trump other considerations. This often results in staff doing the right things “despite the system”

International patient safety expert, Don Berwick was commissioned by the UK government to write a report after Mid Staffs and concluded that we should,

‘Abandon blame as a tool, NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and circumstances they face that lead to patient safety problems.’


The vast majority of healthcare professionals long to be rewarded for finding out what matters to their patients and helping them. If what patients need lies outside their professional expertise, they want the people and the organisations around them to be competent, efficient and patient-centred and they share their patients’ frustrations when they are not. In these very stressful times, patients and professionals are in great danger of blaming each other for being indifferent to each-others’ needs. I believe that what patients and professionals want, and need is surprisingly similar. It is possible for NHS care to be much more patient-centred if we pay much closer attention to what we have in common and work on the healthy relationships and therapeutic partnerships that are good for us all.

Supervision for all

Clinical supervision: The key to patient safety, quality care and professional resilience. BMC Medical Education

“The performance of the NHS is only as good as the support we give to the staff”

So said the Secretary of State for Health, Jeremy Hunt at a conference at the King’s Fund this week. In doing so he echoed the conclusions of Professor Don Berwick who was asked to review the findings of the Francis report into failures of NHS care in 2013. He concluded, The most powerful foundation for advancing patient safety in the NHS lies much more in its potential to be a learning organisation, than in the top down mechanistic imposition of rules, incentives and regulations.

Missing from these political statements and grand reports are suggestions about how to make the NHS a more supportive, learning organisation. Clinical supervision has been long established as the way that healthcare professionals provide education and support in their working environment and has patient-safety and the quality of patient care as its primary purposes. Whilst clinical supervision is mandatory for trainees, it not routine for those of us who have completed our training and we may spend the majority of our working lives unsupervised. Consequently we become isolated, uncomfortable with having our work scrutinised, and out of the habit of reflecting on our practice with others.

Clinical supervision has many different forms though its functions always include education and support. The flexibility of its forms means that it can be adapted to suit the needs and resources of different groups, small or large, specialist or interdisciplinary. In recent weeks I have attended large group clinical supervision in the form of Schwartz rounds, where senior clinicians presenting have modelled clinical uncertainty, ethical difficulty and emotional engagement with their work that prompted a young nurse to respond, I used to think it was only the most junior members of staff that felt like this.

Narrative-based supervision is particularly suited to the needs of professionals whose challenges have less to do with technical knowledge than relationships with colleagues, administrators, managers, patients and relatives. It facilitates teamwork, open discourse and reflective practices on which a just culture and patient safety depend. It relies on the quality of the questioning rather than expert-knowledge, so that junior staff-members can supervise their seniors, nurses can supervise doctors and hierarchies can be flattened. Its emphasis on identifying and exploring problems reveals medicine’s underlying moral conflicts and helps create habits of ethical thinking on which safe, compassionate care depends.

Professional isolation, stress and burnout are widespread and worsening across many healthcare systems.  Regular clinical supervision ensures that health professionals connect with their peers in safe, serious and supportive ways. It has been shown to reduce burnout and compassion fatigue in GPs and improve engagement in hospital doctors and help nurses connect emotionally with their patients.

Stopping us from providing clinical supervision for all professionals are problems of acceptance and access. Some professionals think that they have no need once they have completed their training. They see supervision as a slight on their independence, in spite of the increasingly team-based nature of modern healthcare. Others find that their previous experiences of supervision have not been all that supportive, and prefer other ways of achieving similar goals. Individuals and organisations my not value supervision enough to protect time required for it to take place. Access depends on a culture that embeds supervisory skills throughout the healthcare professions. This is not that difficult. I teach second year medical students to supervise one another using a modified Balint approach. They read aloud a 500 word reflective piece they have written about a patient experience to a small group including myself. The say why this experience mattered to them, any thoughts they had while they were reading it out, and any help they would appreciate from the group. They then sit back and the group discusses the issues raised without directing their comments to the presenting student or making judgements. After a few minutes the presenting student, who has been listening, is invited back into the group to respond. We all take turns to present, including myself, so that the students can see that I am willing to share my own difficulties and am interested in their responses. The depth and quality of their conversation often shows a startling maturity and their ability to help one-another to think seriously about their work comes naturally and improves rapidly. In only a couple of sessions they are able to facilitate themselves.

I hope my paper for this special BMC collection, which brings together theory and evidence in support of clinical supervision, will help create a culture where regular clinical supervision is normal practice for all health professionals. I have little doubt that patient safety, quality care and professional resilience depend on it.