Continuity of care - again

We all know that continuity is good for patients - well in theory we do, there's a growing name-checking of the subject in the official looking documents I read which is welcome but precious little actual implementation of policies designed, let alone monitored, to achieve it.

But what you may not realise is it's very good for clinicians too.
A patient I saw a while back brought this home, as seeing real people usually does; it is the point of medicine after all.

But starting where we are...
The NHS abcess that is access obsession (the ineluctable policy focus for an under-resourced service) seems to me to be tacitly supported by a number of false, vague but widely held assumptions, which I have not seen explicitly expressed, but which seem to sit in the background of NHS documents aimed at 'increasing access'.

So at the risk of setting up a straw man, they are:-
1) Clinical work is essentially mechanical. Particular symptoms inevitably mean a particular diagnosis which inevitably means a particular treatment. Ok so I'm over-stating it but an underlying bias in that direction appears to be the logic behind the current penchant for online consulting via apps and questionnaires (as a soft excuse for the real financial one) and the prevailing simplistic approaches to screening and health checks. A scan will sort you out.

2) Following from 1: An adequately trained clinician can follow the mechanics and so all adequately trained clinicians are essentially interchangeable. ie experience does not count so what's the point of seniority payments to GPs for example. (Nod is given to 'complex patients' but still the assumption is that all GPs are equally up to the task, so again why bother with seniority)

3) A shared electronic health record and the generic clinician render personal continuity unnecessary

This to me is the politically-chosen-NHS-poverty-necessity / corporate-commodification-of-medical-time tail wagging the workforce philosophy dog. Reality seems to be ignored in the drive for access; after all, if the above 3 are true, continuity is an irrelevance and the greatest happiness will follow from the greatest access.

Wrong

So how does my patient's experience illuminate this? A lady in her late 20s develops a nagging intermittent abdominal pain over several months, which she puts down to a muscular cause and, as she is otherwise well, is none too bothered by. However after another mention to her partner it becomes a 'thing' and once a symptom-set becomes a 'thing' it materialises as solid as a snooker ball. It must be dealt with by the system, preferably by being expertly pocketed first time into either 'Normal range, no worries', 'Spot diagnosis, no worries', 'More thought needed, clear management plan, no worries'. Any response that doesn't have the 'no worries' element will result in the ball bouncing around the cushions until it meets a clinician who can pot it because these 'things' crave 'no worries'.

Unfortunately this lady met a centrally driven scheme to improve access, often staffed by inexperienced doctors where there is no continuity or mentor-ship in their role. But hey the doctor was straight out of the GP sausage factory with a fresh MRCGP label and expiry date 5 years hence and had access to my lady's GP record, so all criteria 1, 2 & 3 met - sorted, yes?

No.

When I saw her for her test results a few weeks later she related how she had become progressively more anxious in the consultation as the doctor's inexperience manifested in doctor anxiety as potting this one with 'no worries' was clearly outside their capacity. She began to doubt her own reassuring self-diagnosis; doubts that were confirmed when the doctor ordered FBC, U+E, LFT, TFT, Bone, HbA1c, Coeliac disease screen, Vitamin D, CA-125, abdominal ultrasound and a chest x-ray!

So I saw her on the sixth NHS contact after her initial appointment request (1 Dr, 1 phlebotomy, 1 USS, 1 X-ray, 1 call to book me). We had a chat; she was well, and funnily enough the pain had gone away. I went through her 26 test results (some of the above tests have multiple readings). There were two abnormal results - one of the bloods was slightly out of normal range and a minor benign finding on the scan (which the patient already knew about). But as in a battery of 26 tests with a 5% abnormal cut-off, it's 3 times more likely that at least one of the results will be falsely 'abnormal' than none abnormal and as my clinical assessment put her pre-test probability as extremely low, I was happy to reassure her on that 'abnormal' result. Pocket made 'Patient diagnosis likely correct, natural resolution, tests unhelpful... no worries'.

Had she seen an experienced doctor first off, the pot would have been a swerve around the black of inherent clinical uncertainty putting the mildly anxious red straight into the 'Spot diagnosis - muscular pain, no worries' pocket in such a convincing way that it would have become a self-fulfilling prophecy, even if not quite correct. (The endorphins generated in the patient (and Dr!) by such a shot boost the immune system & sense of well being that ill-ness often just melts away - that's the pharmacology of the 'drug doctor'.) That's one consultation, no tests, no follow-up, same result. Yes experience is literally worth every penny of seniority. (And yes, I do feel sore about this.)

Now, I'm not getting at the doctor; the problem here is a system that de-prioritises continuity. And further, our health system simply cannot afford this way of doing medicine! This doctor may have seen the results but they didn't see the patient again and are very unlikely to in an access-prioritising system. So this doctor has lost out on one of the main tools for effective continuing professional education in the real world - the patient feedback loop. 

But supposing my patient had first seen a doctor in a context where the doctor could call upon experience or could see her again? They might have ordered the tests, if experience hadn't intervened, but when they saw her again they would learn they will never need to order those tests in that situation again, as they will naturally re-calibrate their response to that symptom-set. Further they will learn a bit more too about the bit of history they didn't take first time; that the patient wasn't actually very worried - which for this sort of person means they don't need to be either.

As it is, NONE of this learning will occur and the anxious doctor will continue to make the same decisions and the costs to the NHS will mount...
(I did toy with giving my feedback but I don't know the doctor and have no formal professional responsibility there, can't do it face to face & have no idea how it would be received, although I do feedback to members of my own practice & staff I know. But this is my point; we don't rely on people doing a good turn to make sure the aircraft engines are ok - it's there by design.)

Back to the assumptions.
1) is just plain wrong. The technical stuff of history and diagnosis exists within an intensely personal and complex context which modulates it. Inexperience focuses on the technical but as you get more experienced the technical just becomes incidental to the personal, which is where real medicine is really at, or at least should be.
2) is plain wrong. Most newly minted GPs mainly know that they don't know that much; experience counts - it's called 'practise' after all.
3) is plain wrong. Ironically because personal continuity is much, much more information rich than any current IT system and it uses intuitive real-time data retrieval and application.

If the assumptions are wrong then this obsession with access is harmful to both patients, doctors and NHS finances!

My advice to young doctors. Yes you may want to avoid partnership just now, but get a job in a place that values continuity, training and offers mentor-ship or, at the very least, the chance to chat to colleagues about your work at work. It's how you learn and get more confident. Spurn access-only; it won't develop you.
Please yes we need access but we need continuity for the benefit of all concerned and policies that actually make continuity work.

PS I have changed details so neither patient nor doctor are identifiable

Continuity of care - who needs it!

Ladies and Gentlemen I have some good news and some bad news and then some better news!
Good news the NHS is set up to cope with anything: If you were Tim Peake, Britain's Astronaut, hurtling towards the earth in a Soyuz capsule to land in Kazakhstan and you were injured during that landing the NHS was already prepared. Yes if Tim had been injured his GP would have been able to add the Read Code T55z0 'Spacecraft accident NOS, occupant of spacecraft injured' to his medical record. Had, heaven forbid, his parachute failed, the NHS was ready for that too, the code is X711Z Failure of parachute on descent. Indeed the NHS would have been code ready if the Soyuz capsule re-entry motors had failed or they had suffered a loss of air supply or even if they had been hit by a passing passenger jet or meteorite. Yes we have spacecraft accidents covered - there are 57 varieties of code for spacecraft accidents. Or maybe you have been bitten by a hippoptamus - we have a code for that too X717Z. Or maybe your GP wants to record your pasta intake Ub0A3.

Bad news: But suppose you are in that highly unusual situation of being an older person with multiple chronic diseases and needing the personal continuity of being seen by the same clinician each time, not only for your own safety but your sanity too. 'If I have to tell another doctor the same story again I shall go mad!' Supposing your healthcare record needs to flag that up? We don't have a code for that!!! No not one. Typing 'continuity' into a read code search engine will give you codes for 'disorders in continuity of bone or heart valves' but nothing on continuity of personal care! The nearest you can get is the code XaKZN Provision of continuing care, but even this is more about Continuing Healthcare Funding than continuity of care. Our coding system has evolved to reflect successive governments' obsession with access to appointments to the exclusion of continuity despite a wealth of evidence that continuity delivers on quality, cost, safety and patient satisfaction. There are hundreds of codes about getting, making, attending, not attending or cancelling appointments by any number of different providers! So if you are a politican remember patients love continuity and those patients tend to be older and those older patients turn out at elections. #justsaying If you are an NHS Finance person remember patients who get good continuity take their medications better and tend to choose cheaper less invasive Rx options when discussing risks with their trusted GP. #justsaying If you are a clinician out there we know that Drs or nurses with good continuity show better job satisfaction #justsaying. If you are a patient well you know all this we just need to listen to you! #justsaying

Better news: It doesn't have to be like that. Continuity at last features in our CCG plan. The new Snomed coding system that will eventually come into NHS actually as about 4 codes relating to continuity of care. Practices can use the Usual Doctor system to help direct patients to the best person to see them. But sometimes with teh additonal pressures we face that needs a bit of extra help. Two years ago we introduced a system whereby, using that one sort of continuity code, we flag certain patients who really do need to see the same GP as far as possible. Using that flag reception staff are then able to ensure as far as possible that when those patients need attention we direct it to the same person each time, whether its getting that doctor to ring back or booking them in to be seen or handling a medication enquiry or call from an outside agency. We have been able to show that in addition to using the usual doctor system for assigning doctors to patients and vice versa, this provides an additional improvement in continuity of care on top. Yes you can measure continuity of care - it's just that those who set the rules have chosen not to. In addition we are experimenting with developing virtual teams to help prevent patients getting lost in what is now a bigger organisation. So let's start organising and commissioning and regulating and funding for continuity of personal care...

A plan comes together

Don't you love it when you can deliver healthcare with an efficiency and quality even the 'A' Team would struggle to match?

My patient booked an appointment on line to see me about their thumb. He/she put in the free text 'I think I need an injection. :-( '

This text appeared on my screen under their appointment booking so I had the needles / steroid ready on arrival. Yes -  typical osteoarthritis of the 1st carpo-metacarpal joint. I did the injection clean into what can be a small joint to get into. My patient went away happy and left me with the feeling of a job well done.

Appointment on-line booking time by patient three minutes.
Consultation time eight minutes.
Reception time 0.
Admin time 0.
Medical record coding time 0 (part of my 8 minutes)
Invoice processing time 0.
Insurance assessment time 0.
Patient wait 0 (first appointment of session)
Time to claim minor operation fee 0 (integrated into our EPR)

I challenge you to find another healthcare system within Pluto's orbit that could come anywhere close to diagnosing and treating this condition from a standing start in 11 minutes total. Compared to the NHS most other systems would still be in the blocks by the time we'd finished the race and completed our third lap of honour.

Private medicine? You are having a laugh - 15 minutes to complete the first tranche of bloody paperwork!

So how do we do it?
No denying it, the technology is great and primary care IT like this is world class.

But here is a formula to note
Technology + Continuity = Quality + Efficiency

This could not have worked without continuity.

I had previously injected this patient's plantar fasciitis about 7 years ago and it worked a treat. So they knew I did injections and so knew to book with me.  They also knew my injections were 'ok' - reading on NHS Choices that someone else thinks you inject ok is not the same as knowing it (almost literally!) in your bones. It means patient anxiety pre-injection is minimal and I can get on with the procedure quickly without lots of explanation, consent forms, reassurance or medico-legal worry. All this makes the procedure itself less painful by eliminating nocebo effects.

An APMS contract (NB NHS England) could not have delivered this as with 5 year contracts it's highly unlikely the same doctor would still be around. This is only possible under GMS or PMS which NHSE very, very stupidly is not actively newly commissioning.

Technology alone could not have delivered this because technology cannot manufacture the trust that comes from long term personal care.

So Mr Hunt if you have a 25 year vision, make long term personal continuity part of the plan and stop wrecking GMS/PMS!

Stop blathering on about technology - I've been using computers in General Practice since 1989. I got it 26 years ago! We all get it in GP land, that's why we lead the planet.

You can have it all but only if you get and promote continuity of personal care...