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...

Suppose we do actually need GPs?

Suppose it turns out we do actually need GPs after all? And we find out 5 years too late...

Everyone seems to be trying different ways of delivering primary care with fewer trained GPs per head of population. We have the appointment of pharmacists, physiotherapists, advanced nurse practitioners, paramedics, physician assistants and community matrons. We have techno solutions aplenty; virtual appointments, email, online booking, telehealth, skype, health apps, text, pre-doctor questionnaires, algorithms, on-line consultations. All this is being driven much more forcibly now by, amongst other things, one problem; a failure to invest in the GP workforce over the last ten years to match population growth and the multimorbidity associated with successful ageing.

All this activity makes me anxious.

As I tell my patients, if there are lots of treatments for a condition viz cough remedies, it almost certainly means none of them work very well, if at all (unless they are all merely me-toos of one treatment that does). ie if there are lots of treatments you are probably best advised to have none. The fact that there are so many things being tried in GP land tells me that no one actually has yet hit upon something that is really effective, or we would all be doing it already.

The other reason for thinking this is the simple observation that GPs have always had an incentive to get someone else to do their job, pay them less and pocket the difference. So why after 60 years of the NHS has it not happened to a great extent?

The answer must either be that GPs are all wonderfully altruistic, forgoing monetary reward en masse to absorb the work themselves (no, I didn't think you would buy that) or that it is a hard problem or that GPs are what patients actually want or both. On the face of it there are lots of studies purporting to show that X% of GP work could be done by a physiotherapist, and Y% by a minor illness nurse and Z% by a pharmacist where X+Y+Z+... >100! So why am I still here?

I have no problem with exploring these options. Indeed my own practice is taking part in the pharmacy pilot and actively looking at developing practice sub-teams. It will be great if we can get it to work but it isn't going to be easy.

Evidence is mounting that some of these approaches are not going to work as well as hoped. Trials have been done looking at minor illness nurses in primary care showing reasonable outcomes and good patient satisfaction but, and here's the rub, not a lot of cost saving once you factor in the fact that they are less time efficient and need supervision. There is a cultural block too, not the false 'nurses don't make diagnoses' one but that nurses (and other HCPs) have been trained to be risk averse; that's what doctors are for. The trials also were not powered to detect possible adverse outcomes when rarer but serious problems presented to nurses. Recent reports of increasing claims and complaints against nurse practitioners suggest these concerns may have been justified.

Technology too is begining to take a hit with concerns being raised about the algorithms and medically untrained staff used by NHS 111 in assessing patients.

However the real reasons for a lack of diversion from GPs is less to do with safety concerns and more to do with practicalities. It may be true that 15% of GP workload could be handled by a physiotherapist but the problem is knowing that for sure in advance of the consultation. And even if you can discover it by triage or on-line questionaires that is going to be scuppered frequently by the real world of patients wanting advice on more than one thing at a time. It's the multiple presentation of multi-morbidities torpedo that holes these one-dimensional solutions.

Take the common example of a young mum presenting with back pain, low mood and needing contraception. To be sure a physiotherapist could deal with the back pain and a therapist with the low mood and a family planning nurse with the contraception, but they would need at least an hour and three appointments! And each would deal with their aspect of the problem and the patient might not think to mention the other issues. Now the FP nurse, like a GP, might make the diagnosis that it is the irregular periods caused by the progesterone only contraception that is contributing to the low mood and back pain and suggest an IUS say, but however good the FP nurse is under this system the patient still has to see two other HCPs to get to that point of integrated care.

No doubt too that a practice nurse could have sorted the 8yo I saw with ear wax (well, assuming their protocol allowed ear syringing in children), but would the PN have had the experience necessary to diagnose and manage the molluscum contagiosum and viral warts that also presented? Maybe, but not reliably.

I could go on to enumerate many thousands of combinations of presentations that are routinely dealt with by generalists in one consultation in under 15 minutes but could only be managed by many more thousands of consultations by non-GPs. There is a good reason why GPs exist - most people, most of the time present with multiple cross-speciality problems that are most effectively dealt with by a generalist with GP-like training. Most patients recognise this but also value being able to see someone they know and trust. So it seems that the GP solution could turn out in the end to be the most practical, safe, holistic and cost effective one as well as being the option most desired by patients. Let's hope there are enough of us left when NHS England comes to its senses and decides to properly fund the evidence on primary care.