Simple Isn’t Easy – changing the way the NHS communicates with patients

This is a fantastic blog from David Gilbert – has made me very aware of how much better my own practice’s communications should be. I’ll post our new letters and guides to how we can make better use of GP appointments next.
It’s worth noting that I have a lot of nonsensical letters from private companies, e.g. about insurance, so I don’t think healthcare is uniquely bad at this!

Future Patient - musings on patient-led healthcare

All the letters I get from businesses are clear, concise and useful. I just got a letter confirming a hotel booking. It was all these things. I feel confident that when I arrive I will be welcomed and cared for. The letter told me implicitly and explicitly that I was important.

For patients, the communications they receive are practically and symbolically important. An appointment letter may be the first time they come into contact with the health service. Unlike hotel customers, they may need reassurance. Being in pain, vulnerable and uncertain, the NHS must send a letter that is extra careful with content, structure and language.

I recently got an almost incomprehensible hospital appointment letter that barked: ‘make sure you attend’ in bold letters surrounded by a red-outlined box. There was no map, no mention of how to prepare (was I going to have to undress? What sort of questions…

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Empathy and shame.

Shame – discussed in detail in a blog last year, is frequently a feature when patients consult.

How we respond to patients who are feeling, or at risk of feeling shame can make or break a therapeutic relationship. This is about how I try to respond.

Shame is a negative moral judgement about oneself. Unlike guilt or embarrassment where someone thinks that fundamentally they are a reasonable person who has done a bad thing, someone who feels shame thinks that they have done a bad thing because fundamentally, they are a bad person.

Guilt is when, for example, you feel bad that you forgot to call your mum on her birthday, but you might reasonably conclude that this doesn’t make you a bad person and so you decide to make up for it and call her the next day. Shame is when you conclude that you are (and have quite likely always been) a hopeless son or daughter who is always forgetting the important things in life and feel too despondent even to call the next day.

We should suspect shame in the following situations. A patient misses an appointment because they are afraid of being judged on the basis of their blood tests . Another fails to attend a follow-up appointment after having disclosed a history of child sexual abuse. The mother who took her child to an A&E department takes them to a different department the next day with the same feverish symptoms in order to avoid the clinician who said they were time-wasting the day before.

Situations where patients blame themselves for their perceived failure to take responsibility either for themselves or their dependents can arouse shame. Healthcare professionals have, in addition to their clinical authority, a moral authority and consciously (or more often not) and intentionally (or not) pass moral judgement on their patients’ behaviour if they do not acknowledge shame and self-blame.

There are things we can do to avoid unconsciously or unintentionally fanning the flames of shame.

Empathy

When someone gets sick, it is only natural for them to ask, “Why me? What did [I do to] cause this?” and then find something, perhaps something they did, on which they can pin the blame. This search for an explanation is not just about biology but is also a search for meaning. The study of meaning and interpretation is called ‘hermeneutics’ and for philosopher Havi Carel, who has a severe lung disease and has written about her experience of healthcare in her book, Illness, ‘hermeneutic justice’ happens when healthcare professionals give as serious consideration to their patients’ interpretations as they do to their own. Hermeneutic justice is an important aspect of empathy.

Empathy, according to Leslie Jamieson who wrote, The Empathy Exams, requires curiosity – we need to “ask the questions whose answers need to be told”. It is not enough to simply sit back and bear witness, we need to be active listeners. Empathy matters because if we recognise potential shame, and are aware of our moral significance we can say, ‘I understand how you feel, and you’re not alone in feeling like that, and it doesn’t mean you are a bad person’.  We can separate the morality of the deed from the moral character of the person. Good people do things they regret and bad things happen to good people too. Illness is indifferent to moral character.

Empathy involves connecting with something similar in yourself – recognising what it feels like when you’ve done something you regret or the need to find something to explain a tragedy.

Empathy, according to Brene Brown, “drives connection with others”, because with gentle curiosity we prove that we want to understand what they are going through. Sympathy, by contrast, may be a kind gesture, but doesn’t require understanding in the way empathy does. We might say, sincerely and sympathetically, “oh that must have been awful”, but empathy demands that we try at least to figure out just how awful it must have been and why.

 

As Brene Brown says, “Rarely can a response make something better, because what makes something better is connection”, and connection comes with understanding.

Empathy also requires staying out of judgement. We may not like patients who are ashamed, for example, because  they abused their children, or stole to fund their addiction. Empathy does require us to try to understand them, what they did, and why, but does not demand that we like them. Likewise although empathy requires hermeneutic justice, it does not demand that we agree with our patients’ interpretations. We can, for example, travel a long way towards understanding the lived-experience of illness without sharing our patients’ belief that it is a punishment from God. But our understanding of their experience of illness would be incomplete without also knowing something of their explanations.

After 2 years in an academic post, I have little material (publications) to show for my time, but I have managed to nurture a curiosity about my patients and the nature of suffering that is transforming my practice on a daily basis. And for that much I am very grateful.

 

 

Critical Reflection

There are strong currents of suspicion, scepticism and downright cynicism about reflection in medical practice and medical education. In part this is because we are pressured for time and also evidence/ outcomes oriented and so naturally ask – ‘what difference is this going to make?’ Without a clear and compelling answer, many people conclude that it is not worth the time and effort.

There is another common reason for resistance to reflective practices, whether they take the form of Schwartz rounds, Balint groups, supervision sessions or reflective writing.

Emotions.

When people enthuse about reflective practices, they typically recall a case that was really emotional. People involved were moved to tears, the story was really powerful, shocking and so on. Stories about being distressed by the death of a child or a terrible mistake, a vexatious complaint or some other traumatic experience are shared – often to great empathic effect with others responding, ‘yes, I too know how you feel’.

There are risks with this. One of competitive trauma, where people bring increasingly distressing cases, which exclude or alienate people whose experiences are, by comparison mundane. Another risk is that people who are less emotionally bruised by their work, feel excluded because they have so little in common or because their issues are not emotionally charged.

More likely though is that quite simply, even for healthcare professionals, talking about or admitting that our work affects us, or even hearing about how it affects our colleagues, makes us feel very uncomfortable. We feel safer in the belief that we are clinically engaged, but emotionally detached.

People who feel like this need to be reassured that reflective practices do not have to involve emotions.

Steven Brookfield – who has written a great deal about reflection in education thinks that most importantly, reflection should be critical.

 

Reflection is not, by definition critical. And if it happens that it is not critical, it doesn’t mean that it’s not important. Put briefly, reflection becomes critical when it has two distinctive purposes. The first is to understand how considerations of power undergird, frame and distort so many educational processes and interactions. The second is to question assumptions and practices that seem to make our teaching lives easier but that actually end up working against our own best long term interests – in other words, those that are hegemonic.

 

Power

 

In my experience of Schwartz rounds, for example, hierarchies are replicated as more senior and more confident people speak out in large groups. Brookfield would have us reflect critically on whether the physical structure (large room with a panel and an audience) reinforces hierarchies. Power is ever present and a force for good as well as harm as I have tried to illustrate in two previous blogs –Medical Power and Power in the Consultation. Critical reflection should pay attention to the way power is used by clinicians, managers, politicians, patients, organisations etc.

 

We should reflect on statements like,

 

We are empowering our patients

Giving patients more responsibility is empowering

Patients should take more responsibility

Doctors are powerless these days

Managers have too much power

Nurses have too little power

I feel powerless/ afraid/ intimidated/ bullied

 

Questioning assumptions

 

Brookfield says we should question different types of assumptions, first and foremost, ‘paradigmatic assumption’. These are the facts that we take for granted about what we do. Examples include,

 

We practice evidence-based medicine

Medicine is a science

Medicine is a vocation

Doctors should be objective

Empathy cannot be taught

It is better to be clinically excellent than a good communicator

Patients’ needs are what matters, not what they want

I know what my patients want and need

Patient-centered care means giving them what they want

Surgeons don’t do compassion/ shared-decision making

Palliative care doctors are lovely

Patient-feedback improves the quality of care

 

Brookfield concludes with six reasons why critical reflection is important,

 

  1. It helps us take informed actions
  2. It helps us develop a rationale for practice
  3. It helps us avoid self-laceration
  4. It grounds us emotionally
  5. It enlivens our classrooms
  6. It increases democratic trust

 

It may not be obvious that these follow from analyses of power and assumptions, but when I read his work the conclusions make a lot of sense.

Reflective practice must be founded on trust which is supported by confidentiality, respect, curiosity and non-judgement. It is a skill that like playing an instrument, improves with practice and fades with neglect and sounds better with company.

Brookfield concludes,

Critical reflection is inherently ideological. It is also morally grounded. It springs from a concern to create the conditions under which people can learn to love one another, and it alerts them to the forces that prevent this. Being anchored in values of justice, fairness and compassion, critical reflection finds its political representation in the democratic process. Since it is difficult to show love to others when we are divided, suspicious and scrambling for advantage, critical reflection urges us to create conditions under which each person is respected, valued and heard. In pedagogic terms this means the creation of democratic classrooms. In terms of professional development it means an engagement in critical conversation.

By highlighting that reflective practice need not be all about emotions, but is also an intellectual challenge that has potential to improve professional relationships and patient care, I hope that some sceptical colleagues may be tempted back.

Related post: “Don’t judge me!” Reflections on reflection

 

Guideline centred care

Doreen, Ahmed and Henry have recently had their medication changed in response to a new guideline for prescribing Statins, cholesterol-lowering drugs.

None of them came to ask for a change in their medication. In each case the change was recommended by a clinician in response to a new guideline against which our practice will be judged and financially rewarded or penalised.

Here are the NICE guidelines 2015:

The NICE guideline on lipid modification recommends that the decision whether to start statin therapy should be made after an informed discussion between the clinician and the person about the risks and benefits of statin treatment, taking into account additional factors such as potential benefits from lifestyle modifications, informed patient preference, comorbidities, polypharmacy, general frailty and life expectancy.

and

NICE recommends that statin treatment for people with CVD [Cardio–vascular disease] (secondary prevention) should usually start with atorvastatin 80 mg daily.

It is very easy to judge whether or not people with CVD are on Atorvastatin 80mg, but almost impossible to judge whether the decision to start therapy has been made as a result of thoughtful deliberation between the patient and the clinician. Thoughtful deliberation is at the heart of patient-centred care (not doing whatever the patient wants, as is often confusingly assumed).

Increasingly, financial incentives are being used to ‘improve quality’ in healthcare, which usually means that payment depends on the proportion of patients with condition ‘a’, receiving treatment ‘z’.

The assumption is that good quality medicine is about drugs like ‘z’ treating conditions like ‘a’. It says very little about Doreen, Ahmed or Henry.

Doreen is 67 and has CVD, chronic pain, depression, COPD, and recurrent vertigo. She lives alone, is socially anxious and isolated, frequently misses appointments, hates going to hospital, forgets to take her medication less often than she chooses not to take it – which is very often. She smokes about 30 roll-ups a day and has never exercised, and is very thin.

Ahmed is 47, has had two heart attacks, has type 2 diabetes with complications affecting his eyesight and his kidneys, he is overweight and cannot exercise because of chronic gouty arthritis. He has high blood pressure and cares for his wife who has schizophrenia, doesn’t speak any English and is frequently admitted to hospital.

Henry is 91, he has had a series of strokes and moderately severe Dementia – a mix of Alzheimer’s disease and stroke disease. He has metastatic prostate cancer and pain in his back from where the cancer has spread. He cannot speak and needs nursing assistance for all his needs.

Doreen, Ahmed and Henry are not the kinds of patients who are going to object when the doctor they know and trust, or even the expert they have never met before, changes their medication to include Atorvastatin 80mg. Dozens of people like them are my patients. I have no desire to impose an unnecessary burden of treatment upon them. I have every desire to practice with wisdom and compassion, to understand what matters most to them, what they want to get out of their treatment, to know how much is enough and how much is too much, to know which risks are worth taking and which are not. I want to know, in the context of their lives and their complex multiple conditions how much, and in what ways they are likely to benefit from changing their medication to include Atorvastatin 80mg. It is almost impossible to answer these questions without time. Guidelines do not, and cannot possibly take into account the characteristics of every patient. They generalise and we attempt to contextualise. Guidelines are rarely ever put together with or even for, patients. They rarely ever have any shared-decision making support and are not written in a way that is easily accessible to patients. Guidelines recommend that we are patient-centred, but they are not.

I am not sure that shared-decision making tools aren’t heading down a blind alley. They assume that people making decisions are rational and interested in abstractions like statistical tools and flow-charts, when the way my patients usually talk about healthcare is in personal narratives with significant events, characters, aspirations and moral negotiations. Compare Richard Lehman’s description of a shared decision making process or Paul Haidet’s description of a consultation with the NHS shared decision making website.

There is another, perhaps more important issue that this case highlights. GP appointments are a valuable and scarce resource. If the agenda for discussion is to be determined by neither the patient nor the doctor, but by the guideline, then there is less time to discuss other issues that may be of far greater importance and potential benefit. One important question to ask before administering any guideline is, “are there more important issues or interventions to discuss with your patient?”

Thousands of doctors and nurses struggle all day, every day to share difficult decisions with their patients. Making the right decision in the face of the natural complexity of medical practice and our patients’ lives, requires ‘phronesis’ or practical wisdom, informed by guidelines, but not led by them. Thousands more clinicians, caught in a trap with too little time and too much pressure to prescribe will skip the deliberation and simply default to the bit of the guideline that tells them what to prescribe.

When our patients look at the league tables and the accountants look at our books, will they be able to tell us apart?

 

 

Recording consultations

Recording consultations

Oasis

In a recent Guardian article a photograph of the audience at an Oasis gig in 1996 is remarkably dated because everyone in the crowd is watching the band instead of staring at their mobile phone while they record the action on stage. The author of the piece has written a lament to a time when people could be fully present and immersed in an event as it takes place.

No moments are too sacred to be recorded these days and that includes doctor-patient consultations.

Two facts need to be set out from the start. Firstly, as a recent article in GP magazine, Pulse explains, patients are fully within their rights to record a consultation. Secondly, where patients suspect that doctors will refuse or object, rather than arguing for their legal rights they may be covertly recording consultations.

Recording consultations, overtly or covertly may not be very prevalent, but one way or another there is nothing we can do to stop it. Like chronic pain or diabetes we have to find ways to live with it.

Opportunities

A study by Glyn Elwyn et al. surveyed views from 130 respondents following an interview about the subject on BBC Radio 4. A majority 98 (77%) said that they would like their GP to allow them to record consultations. The primary motivations for recording were to help recall and understanding and to share the recording with others, especially when the issues were complex. They sometimes recorded consultations to share with someone who could not attend the appointment. In cases like this, patients, professionals and others benefit. Like doctors, but more so, patients struggle to remember what is said in a consultation. It is especially hard when they are anxious, less literate and older.

Cyril is 81 years old and in remarkably good health considering his diabetes, peripheral vascular disease and ischaemic heart disease. He also has worsening breathlessness and mild dementia. He asks if he could record the consultation. Ideally he would like his son to come with him, but his son lives and works in Devon. Cyril thinks it would be useful to have a recording because he easily forgets what we have been talking about by the time he gets home. He appreciates the written information I supply him with, but says he likes the way I explain things. Recording the consultation seems like a good idea.

In Elwyn’s study patients wishing to record covertly had already experienced poor care or were afraid that a request to record a consultation would be refused, but most patients felt that asking permission would improve relationships with their doctor. As one interviewee said, acting covertly would lead to ‘only getting half the benefit out of the recording’. Elwyn’s study concurred with a 2014 review that concluded that patients value and benefit from recording consultations. Elwyn’s patients’ proposed solution was for recording consultations to be normalised, encouraged and facilitated by professionals.

Threats

In some cases patients have previously experienced, or fear poor quality care and wish to hold the professional to account, or have a record. One patient with mental health difficulties was told by her GP to kill herself. Unknown to the doctor, she was covertly recording the consultation and he was later struck off the medical register for three months. The doctor’s behaviour was clearly reprehensible, and it seems likely that without the recording the patient’s complaint would not have got very far.

Once or twice in a day of 40 or more consultations  I think, ‘that was a great consultation!’ Most of the time they are OK, and sometimes they are really not very good at all. According to my patient feedback around 90% of patients are satisfied with their consultations, which suggests that about 10 consultations a week are unsatisfactory, any of which could be recorded and replayed by a patient. I have, like most doctors, been subject to complaints from patients, including one that recently concluded unsatisfactorily for both parties after nearly two years of dispute. I’m pretty confident that recordings of the consultations would not have helped and might very well have made things worse. An inexperienced, stressed GP seeing upwards of 150 patients a week has a lot more to fear than a confident professor of General Practice seeing barely 20 patients a week.

A consultation is not a TED talk. It is not a carefully rehearsed performance or a public lecture. Haidet’s seminal paper, Jazz and the Art of Medicine compares a consultation to jazz improvisation. He quotes trumpeter Wynton Marsalis,

The real power and innovation of jazz is that a group of people can come together and create art—improvised art—and can negotiate their agendas with each other. And that negotiation is the art. 

My ‘great consultations’ are like this. They are psychodynamic, creative acts, performed in partnership, developing trust and understanding together. Like all improvisations we take turns to change the tempo, the tune and the allow for quiet spaces between the notes. There are moments of harmony and bum notes too, which in the context of the consultation are understandable, but on record may take on a different significance.

Emanuel and Emanuel’s classic paper describes four models of the doctor patient relationship: Paternalistic, Informative, Interpretive and Deliberative. The good doctor evolves their consulting style from primitive paternalism to an enlightened deliberative model. The premise underlying the enthusiasm for recording consultations appears to assume that the doctor has not progressed beyond the rather basic, Dr Informative stage of development. Different consultations call for differences in emphasis, with some involving more information delivery than others. As I get more experienced and confident I talk less, listen more and spend less time in the consultation delivering information that will probably be forgotten and will often be better on-line or elsewhere. Records of my consultations may not reveal all that much useful information.

Doctors recording consultations

Many GP consultations are already recorded. GPs in training video consultations with patients and watch them again with their trainers and other trainees. The RCGP guide to assessing consultations reflects the rather jazzy nature of consulting with criteria for, ‘encouraging patient contributions’, ‘responding to patient’s cues’, ‘putting information into the social context’, ‘seeking to confirm the patient’s understanding’ and so on.

At our practice and at our out of hours organisation, all phone calls are recorded in case of any mistakes or complaints. About six months ago, I took a call from a nurse at a nursing home who was worried about a breathless patient. I listened to the breathing (the patient couldn’t talk) and sent a doctor round to see them. Unfortunately the patient died shortly after the doctor arrived. It was not clear after I had listened again to the call with the director of the service and the clinical governance lead, whether, based on the phone call, I should have arranged an ambulance, so we played the recording to an educational meeting of about a dozen of the regular out of hours doctors. It was a difficult case that led to a really valuable discussion and was a powerful learning event. Doctors (like most of us) cringe at hearing our own voices, the words and phrases we come out with and so on, no matter how much we practice. Worrying a lot, and feeling guilty about the patient’s death I had also imagined that I had been less thorough in my assessment than I was. It was a relief to listen to the call again with a group of other experienced GPs. I offered to share my own case first, in part to demonstrate the importance of sharing our fallibility.

Power, professionalism and trust

It is claimed, rather uncritically by Elwyn, that allowing patients to record consultations is empowering. Firstly it is important to remember that serious illness and the associated anxiety, fear and uncertainty is dis-empowering and secondly that social deprivation, lack of education, and insecurity of housing and employment are profoundly dis-empowering. A great deal of what doctors do such as treating disease, relieving suffering and anxiety, giving confidence and reassurance, advocating and supporting patients with housing, benefits and employment, etc. empowers patients. Patients may be empowered by recording their consultations, but in the larger scheme of things, it’s pretty small fry.

One of the biggest fears that doctors have of patients recording consultations, especially if they do so covertly, is that it represents a loss of trust on which their symbolic healing power depends. This implicit trust based on social difference, professional expertise and symbolic mysticism is important and used responsibly is a potent power for good.

But implicit trust is not enough. It must be also be explicit and earned through actions that demonstrate openness and humility, a willingness to take risks with patients and manage the consequences.

We may feel very uncomfortable with our consultations being recording (myself included) but we will have to find ways to live with it, rather than fight against it.

Sign of the times: Be careful what you say in the operating theatre. Lancet Feb 2016

First impressions

Roy sat on the chair in front of me puffing and panting struggling even to hold his head up and make eye contact. I was, as usual running late, but had no desire to hurry him. It was at least a minute before he could string words together to make a sentence.

Maria had my medical students entranced. She had come to teach them about living with COPD, a chronic lung disease, but in the context of her life of destitution, homelessness, alcoholism, depression, domestic violence and epilepsy – caused by a violent head injury – it soon became clear that COPD was the least of her problems.

Simon answered the entry-phone when I buzzed and then let me in. He works front-of-house at up-market bicycle shop, Cyclefit. He smiled, introduced himself, looked me in the eye and shook hands, “Very nice to meet you”. “You too” I replied, slightly taken aback. Unlike anyone I had ever met in a bike shop (and I have visited far more bikes shops than I can remember) he was wearing a freshly ironed shirt, waistcoat and silk tie, knotted in a perfect half-Windsor. His sleeves were rolled up, ready for hard graft if necessary, his tie was tucked out of the way so as not to get tangled in a chain. He was smart and prepared for physical work.

Simon

Barely 2 weeks later I walked into the reception area at 8am wearing wool trousers, a silk tie from the Alhambra, a woollen waistcoat from Oldtown and a fitted shirt from Thomas Pink that I had bought for a wedding a year before, but not worn since. ‘What is going on?’, I had been wondering, ‘when someone who works in a bike shop, looks smarter than a GP?’

The receptionists stopped in shock. “Wow! Look at you! What’s all this for?” I said it was for the CQC visit, which handily coincided with my new look, but then I explained about Simon and said that I wanted to make more of an effort because I thought it would make me, my patients and the people I work with feel better. The feedback from the receptionists was clear – they liked it.

Patients immediately began to comment, it seemed to lift their spirits, many commented – because I have such good continuity of care, most of my patients noticed the change, and they liked it too. I felt good, and so did they. Sartorial therapy.

What of Roy and Maria?

Roy was wearing old army boots, but the toes were so bright, you could see your reflection in them. His trousers were perfectly creased, his shirt ironed, his tie straight and his old sheepskin jacket as smart as it could be. “How long does it take you to get shaved and dressed every morning, Roy?” I asked. He looked at me and laughed. “Doc, this is the first time I’ve been out in nearly three weeks. Most days I don’t get out of my pyjamas.”

“So how long did it take you to get ready today?”

“Oh, it’s, what 7pm now… most of the afternoon, but mentally… a couple of days.”

Maria was wearing patent leather shoes, old and clearly uncomfortable and unsuitable for the cold weather. Her jeans were stiff from being recently washed and a nylon jumper with snowflakes covered a crumpled blouse. Her hair was sprayed up and her make-up thick , but carefully applied. At the end of our teaching session I tried to give her a £10 Marks and Spencer voucher – which we give to all our patients who come in to help teach, but she firmly refused. “This blouse was from M&S, but I don’t have an iron, so I have to find something to cover it up,” she told us. “I’d never get to M&S these days”. I wanted to offer her cash instead, worried about it for a bit, not wanting to embarrass her, offered it, she got embarrassed and refused, I got embarrassed. The students watched, embarrassed.

I helped Roy stand up, it seemed to take him the whole consultation to catch his breath. “You know, Roy – I’ve got to say this, but I really appreciate how much effort it must have taken for you to come here today, all that for barely 10 minutes, and all we’ve really done is chat and fine tune your medication. You look terrific, I mean, what I mean is, I can really appreciate what it must have taken for you to look as good as you do, and, well, I just wanted to say I’ve noticed”.

“Thanks doc” he said.

Patients frequently make enormous efforts when they come to see us. If we focus too narrowly on the disease there is a danger that overlook the context of their lives and the sheer effort involved in overcoming breathlessness, destitution, mental and physical exhaustion so severe that even the simplest of tasks, like washing and dressing have to be saved for special occasions.

Dressing up for my patients has made a difference, I don’t wear a suit, but I do look smart: I cycle to work, shower and dress with sartorial intent. Perhaps most patients don’t care or don’t notice, but for those that do it matters, and it is one way to show respect for my patients whose efforts, in comparison are extraordinary and humbling.

Further Reading:

Understanding the role of physician attire on patient perceptions: BMJ Open 2015

The Clothes Make the Doctor. Atlantic 2014

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. A recent blog shows how amazingly efficient continuity of care can be.

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.

card

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.