Can GPs restore continuity of care?

Allowing GPs to opt out of out-of-hours and the erosion of links between individual doctors and their patients has undermined continuity of care, a report commissioned by the RCGP has found.

RCGP-commissioned report urges GPs to maintain a personal relationship with their patients (Photograph: Getty Images)
RCGP-commissioned report urges GPs to maintain a personal relationship with their patients (Photograph: Getty Images)

The 'continuity of responsibility' must be restored or GPs risk 'surrendering relations with most patients', it warned.

The report, from a 'commission on generalism' set up by the RCGP and charity the Health Foundation, makes clear that it is not attempting to recreate 'a romantic vision' of the generalist as Dr Finlay - a TV doctor famed for knowing his patients from birth to death.

Old-fashioned care

So how can modern GPs provide continuity of care and improve the doctor-patient relationship, without returning to a more 'old-fashioned' type of general practice?

The report makes a number of suggestions on how general practice could resuscitate continuity of care. It says:

  • 'Named teams' could take responsibility for registered patients seven days a week.
  • Care should be available 24 hours a day and general practice should recognise the value of home visits and treatment.
  • Generalists should make better use of new information and communication technologies.
  • GPs and hospital consultants should liaise directly and personally.
  • GPs should incorporate ongoing patient feedback into their work as a matter of routine.
  • A dedicated generalist healthcare service for patients in care homes should be examined.

The key element required to meet the recommendations is more GPs, says RCGP chairwoman Dr Clare Gerada.

'The more GPs you have, the better the outcomes. If the health service is going to move into the 21st century we have to have more GPs,' she says.

Wessex LMCs chief executive Dr Nigel Watson agrees. 'Ultimately we need more GPs and larger teams, so you're not having to manage so many individuals,' he says.

Multidisciplinary teams

Londonwide LMCs chief executive Dr Michelle Drage agrees that creating practice-based multidisciplinary teams could improve continuity of care, drive down inappropriate referrals and reduce costs.

But this would all depend on taking resources out of secondary care and putting them into primary care, she says.

'It's about fundamentally looking at the 15-85 per cent (NHS budget split) equation,' Dr Drage says.

Out-of-hours care is a key factor in the report. It criticises the 2004 GMS contract for removing GPs from out-of-hours and fragmenting care.

But Dr Drage says blaming the contract is a 'red herring'. 'The splitting of the contract sent a very clear message to the government that if they could split it in one area they could do it in others,' she says.

The report argues that 'illness does not strike during office hours only' and therefore general practice should not be limited to those hours either.

Dr Watson warns that providing care around the clock would be extremely difficult in modern general practice.

'You can't deliver everything, it's always a compromise,' he says.

But this is not what the report demands, Dr Gerada argues.

Rather than providing their own out-of-hours, GPs will in future take control of the service through commissioning.

'GPs should be commissioning out-of-hours alongside ambulance services and A&E and social services,' she says.

Self-management

Nevertheless, GPs believe patients will also need to self-manage more. Northumberland LMC secretary Dr Jane Lothian says: 'With the working-age population, it's much more about self-management rather than face-to-face contact.'

The report urges GPs to promote self-care and improve out-of-hours, but also to maintain a personal relationship with their patients.

It goes so far as to liken a GP to a 'local priest', who could offer advice 'on a range of issues including healthcare'.

Dr Gerada says this is not a comparison she would have made, but she agrees that GP practices are 'pillars of society', along with institutions such as local primary schools.

But other GPs are unsure whether they should offer advice on matters outside their clinical expertise.

Dr Watson says GPs are often 'treated as the priest'. But he says: 'As the workload is increasing we need to try to stop people saying "your GP can sort this out".'

Dr Lothian adds: 'I don't think GPs should in any way set out to be the old-style pillar of the community any more.'

Fundamentally the report is about what patients really want, Dr Drage says.

General practice has changed a great deal over the past 50 years, but the 'one thing that hasn't changed is the patients', she points out.

Dr Gerada agrees: 'Patients want access, they want continuity of care, ideally with a named doctor. They want someone who cares.'

This may be true, but demands on the NHS have changed and with budgets increasingly restricted, GPs will wonder if they will ever see the workforce to give patients what they really want.

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