How crucial is continuity of care to helping GPs spot domestic violence?

‘I think it’s possible to tell a GP about domestic violence as long as you see one GP all the time.’¹

The quote is from a study into the experiences of women who had experienced domestic violence - something I was not taught about in medical school. Perhaps it was not seen as a medical problem, although the evidence refutes this.

Domestic abuse is common, particularly among patients accessing primary care. A study of women attending general practices in east London found that 41% had experienced physical or sexual violence in their lifetime and 17% in the past year.²

Domestic abuse is associated with poor physical and mental health. An Australian study found that domestic abuse was the biggest predictor of disease burden in young women, overshadowing smoking and alcohol.³

Survivors

Survivors of domestic abuse identify doctors as someone they would trust to disclose to, and doctors can make a difference by asking, referring and supporting. Sadly, most patients affected by domestic abuse are not identified in primary care. I strongly suspect that discontinuity of care is contributing to under-detection.

As a junior doctor, I am part of the problem. Junior doctors change jobs frequently, getting to know a service and its patients, and then leaving. Some of my patients are wise to this.

I frequently get asked how long I will be around for. The question often comes from patients who are struggling with difficult lives and sadness. I am floored by the personal things they tell me sometimes, particularly about domestic abuse.

This rarely happens the first time we meet, or even the first time they are asked. I’ve been told how difficult it is telling different professionals the same emotive story. I think continuity of care matters to survivors of domestic abuse, both for disclosure and ongoing support.

Continuity

On the face of it, I think I know what continuity of care means - but a deeper look reveals a concept that is complex and multifaceted. Take, for example, the idea of ‘relational continuity’. Objectively, this is the repeated contact between an individual patient and a doctor. Subjectively, it involves trust and responsibility.

Like any human relationship, there can be difficulties. Seeing the same doctor repeatedly does not necessarily lead to a trusting relationship. I am often relieved when another doctor sees ‘my’ patient, because they provide a fresh perspective on a problem that I have begun to normalise.

I have also learned, the hard way, that persistently following up vulnerable patients does not always help them, and risks burnout.

Despite the complexity, there is hard evidence that relational continuity improves outcomes for patients. A systematic review published this year revealed that better relational continuity is associated with lower patient mortality.

Patient satisfaction

This was a powerful addition to the evidence for the benefits of continuity, which includes increased patient satisfaction, greater adherence to medical advice and decreased use of hospital services. The authors argued that medical research has focused on the technical aspects of medicine, while research into the human aspects of medical care has lagged behind.⁴

When a patient discloses domestic abuse to a doctor, the human relationship could not be more relevant. Continuity is in decline in primary care, despite the growing evidence of its value. The proportion of patients who only see their preferred GP some of the time, never or almost never rose from 35.2% in 2012 to 40.3% in 2015.⁵

Disproportionately, it is deprived and vulnerable patients that receive fragmented care.⁶ The causes include government policy, service re-organisation and changing working patterns. Policy initiatives have favoured access over continuity. General practitioners are increasingly embracing portfolio careers, including myself.

Relational continuity matters to patients, particularly to those affected by domestic abuse. We cannot afford to take for granted that continuity of care will remain a defining feature of general practice. It needs to be protected.

• Dr Kate Pitt is a GP registrar and academic clinical fellow based in Bristol

References

1. Bacchus L, Mezey G, Bewley S. Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health Soc Care Community 2003; 11(1): 10-18.
2. Richardson J et al. Identifying domestic violence: cross sectional study in primary care. BMJ 2002: 324.
3. VicHealth. The health costs of violence: measuring the burden of disease caused by intimate partner violence. A summary of findings. Victorian Health Promotion Foundation. 2004.
4. Pereira Gray D et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open. 2018.
5. Baker M, Jeffers H. Continuity in modern day general practice. RCGP 2016.
6. Sweeney K, Gray D. Patients who do not receive continuity of care from their general practitioner – are they a vulnerable group? Br J Gen Pract 1995; 45: 133-135.