Continuity of care - GP's secret power
The cornerstone of General Practice in the UK has been lost over the last 10 years. How can we achieve the advantages and efficiency of continuity inspite of todays challenges.
It seems self-evident that continuity of care delivered by a patient seeing the same clinician each time they need medical input leads to a number of benefits; increased satisfaction for doctor, increased satisfaction for the patient.
It leads to increased efficiency in terms of reduced investigations or duplications of work, less repetition for the patient and less time getting up to speed for the clinician.
Continuity of care was once the standard in general practice, it used to be the norm that patients would see “their” doctor, “their” doctor would know them, know their health history and importantly their family and social circumstances.
A doctor who knows their patient well will also be better equipped to safely hold clinical risk with their patient.
The increased trust the patient may have for their known GP will also allow them to have patience in bearing a condition they are told by their doctor is to be borne.
Challenges
A number of changes over the last 10 or so years have challenged the practicalities of delivering continuity of care;
GPs increasingly having part time working patterns as they fit their work with their responsibilities at home
Increased workload pressures in primary care from the ageing population and the increased scope of work that is carried out in primary care from chronic disease management to QoF
An increased need for locums, partly from the increasing number of people choosing not to work in a regular pattern in a single practice.
With the pressures we are all under in primary care, we cannot afford to ignore the advantages gained by the patient seeing the same clinician, so it is interesting to explore options to increase continuity of care where that is possible.
Several approaches have been taken to improve this:
Strict patient lists
Cohorting patients into teams of clinicians
A total triage system
Let's look at the pros and cons of each of these approaches to consider if any of these may work for you.
Strict patient lists
This was the traditional model that allowed for continuity in general practice.
Until recently there were still a number of practices that maintained this, also some smaller single handed practices will still largely have this system.
It may well be the best system but sadly is not often practical now without some modification. Practices need to be able to look at quick enough access for patients with more urgent needs, when their named doctor may not be available for some time. As well as dealing with the challenges mentioned above.
Cohorting patients into teams of clinicians
In this scenario patients deemed to be in most clinical need - the frail, the elderly or the terminally ill have flags placed in their notes so that when they contact the surgery they are identified and seen sooner and by the same team of clinicians each time increasing the chance of continuity of care.
It requires significant organisation and identification of the appropriate patients and planning of the teams such that holidays and days off always have some members of each team present.
While this is not as powerful as the strict list system, it could well work for large and multi-sited practices as a way of keeping a degree of continuity.
The total triage system
The system of triage where all the patients requesting clinical input can be assessed by part of the clinical team and booked in with the optimal appointment first time - a balance between acuity and seeing the same clinician they normally see or have seen for this problem before. This can be a powerful way of driving continuity of care.
As the patients needs are assessed, whether that is on the fly while the patient is on the phone to the receptionist, or assessed by a clinician after the details are taken and recorded by a receptionist, the clinical triage team can look and book patients in with the same clinician where appropriate time allows or choose another clinician who has seen the patient before where continuity is needed.
Conclusions
While “the system” has certainly made continuity more difficult to achieve, as you can see above there are approaches that can help. There may be others not mentioned here and I would love to hear your thoughts - please leave any ideas you have seen or used in the comments to share with all the other “Efficient GPs”” and as ever please share this newsletter with anyone else you feel will be interested.
David