Continuity of care

 It has always been a given that one of the advantages of the British system of General Practice has been that it has allowed for continuity of care. This has been for a number of reasons:

• The registration system – unlike the private sector where the doctor only has a duty of care to the patient for the current illness episode, the system of registering with a doctor who then has an ongoing duty of care tends to encourage patients to consult the same doctor for sequential illness episodes, and for a relatively complete patient medical record to develop.
• The gatekeeper function of the GP – unlike many countries where you can self refer yourself to a consultant, in our system you have to go through the gatekeeper – the GP, and this also encourages a long term doctor-patient relationship to develop.
• The difficulty of changing doctors – easier now than it was 12 years ago (when you had to get your previous GP to sign your medical card before you could change doctors!) relatively few people change GP (unless moving house etc) even when they are dissatisfied. Oddly enough, complaints from patients, if well-handled, can have the effect of fostering the relationship between doctor and patient.
• 24-hour-care – the old (GMS) GP contract (recently re-written – see the freebies) and all PMS contracts state that GPs have to provide 24 hour cover. In most practices this involves delegating on-call to other partners for some nights of the week, and more recently to GP co-ops. But the responsibility has been on the GP to organise the round-the-clock cover.
• Relatively small practices – the average practice in Britain is still only 3-4 GPs. Inevitably this will foster greater continuity than in practices of, say 12-15. See below for more on the way practices organise themselves.

Why is continuity so important, anyway?

It is not always easy for a different doctor to pick up the thread of what has been happening with any particular patient, and to continue with the management of a problem in the same way that their usual doctor would. This might lead to under- or over-investigation, delayed referral, conflicting advice, and for some patients, over-medicalisation and over-treatment of their problems.

• Can you think of examples to discuss?
• What patients particularly do need continuity of doctor?

What are the drawbacks to patients always seeing the same doctor?

• A patient may have to wait longer to see their own GP, who may only be available at times inconvenient for the patient. The current emphasis on speed of access (48 hour targets etc) and Walk-in centres is a response to these concerns.
• Sometimes a fresh pair of eyes can pick up something obvious that the usual doctor has missed (hypothyroidism, Parkinsonism etc)
• It is quite a strain on the individual GP if all his/her regulars wait for him to come back off holiday…

The personal list system

Some practices (although this is becoming less common) try to enforce the continuity of doctor principle even more rigorously and insist that unless it is a dire emergency a patient sees their usual doctor – known as the personal list system. 

Records, co-ops etc

One solution to the problem of availability vs continuity is to aspire to continuity of care rather than continuity of doctor. This can be achieved if a practice is committed to maintaining good records. With much of out-of-hours care being provided by co-ops, it will necessitate good quality information being made available to and fro between practice and co-op.

To find out before next week

Does your practice operate a personal list system?

If so:

• How well does it work?
• What problems does it cause?
• Do patients like it? Why/why not?

If not:

• How does the practice encourage continuity of care?
• Does it have a written policy?
• What instructions do the receptionists have about making appointments for patients to see the most appropriate doctor?

Written by: Bill Irish

Last update: 29 August 2007