Patient Perspective - (2003) Volume 11, Issue 1
Social Scientist and Patient Representative, Woking, UK
Accepted date: January 2003
In the last 30 years there have been many changes in the organisation of general practice. There has been a decline in smaller practices and a movement to multidisciplinary group practices often working from purpose built health centres. General practitioners (GPs) now work in teams and some of the work previously always carried out by doctors is now undertaken by nurses or other professionals allied to medicine. But have these changes helped to maintain and provide the quality of general practice that patients seek
In the last 30 years there have been many changes in the organisation of general practice. There has been a decline in smaller practices and a movement to multidisciplinary group practices often working from purpose built health centres. General practitioners (GPs) now work in teams and some of the work previously always carried out by doctors is now undertaken by nurses or other professionals allied to medicine. But have these changes helped to maintain and provide the quality of general practice that patients seek?
Martin Roland in his 1998 Mackenzie lecture identified the following as aspects of general practice that patients now hope to find:[1]
• availability and accessibility
• technical competence
• communication skills including providing time for exploring patients needs, listening, explaining, giving information and sharing decisions
• humaneness, caring, supportiveness and trust
• continuity of care.
It is often suggested that there is an increase in patient expectations. However it is interesting to note that thirty years earlier in 1968, Richard Titmuss in a paper to the BMA suggested that patients will increasingly be looking for:[2]
• scientific expertise
• personal interest and psychological understanding
• continuity of care
• the right to choose whether to be treated at home or in hospital.
It would appear that patients have been remarkably consistent in their identification of the important attributes of GP care. For patients, quality in a GP, is a technically competent, caring and supportive doctor who provides continuity of care.
What does continuity of care mean? The New Dictionary of Medical Ethics defines continuity of care as: ‘vital in caring for any long-term illness’.[3] Continuity of care is indeed extremely important for patients and their families living with chronic illness but it is also appreciated by those not su¡ering from long-term illness. Fleming describes continuity of care as a concept that has been a fundamental principle of general practice over the last 50 years and rooted in personalised one-to-one GP to patient care.[4] He argues that two of the most important benefits of continuity of care are the quality of communication between patient and doctor and the quality and accessibility of the clinical records.
Patients, on the other hand, are likely to describe continuity of care as being cared for by a competent practitioner who knows the patient and their medical problem and who takes an interest in the whole person.[5] This definition applies to all categories of patients including those consulting for relatively simple and self-limiting conditions as well as patients su¡ering from chronic conditions.
Patients now have more choices of whom to consult and where to go for medical help. In 2003, patients may have a choice of whether to go to a walk-in centre, a minor injuries unit or to consult whichever practitioner in a practice is available. These choices may o¡er convenience but they do not necessarily provide the patient description of continuity of care. Walk-in centres and minor injuries units are unlikely to know the patient, nor do they have ready access to the patient’s records.
Patient standards of continuity of care can be, and are currently, o¡ered by many group practices rather than being the responsibility of an individual doctor. For example, while a patient with a chronic condition may prefer to see a particular doctor that doctor may not be the ‘expert’ in the practice for the particular disorder. The patient attends a nurse-led clinic in the practice and gets to know the nurse and the partner with responsibility for that clinic.[6] Continuity of care is thus maintained.
There are, however, factors that mitigate against the provision of continuity of care in the present organisation of general practice. For example there is the problem of size. The bigger the practice, the greater the tendency for an impersonal approach to creep in. Larger practices also need to work hard to maintain good communications within the practice, and the training of receptionist sta¡ in how to communicate with patients becomes even more important as they too are part of the team o¡ering continuity of care. How challenging it will be to provide continuity of care in ‘big centres probably also providing as well x-ray, pathology and health promotion’ if these were to become the norm.[7] The appointment system adopted by some practices where appointments cannot be made more than 48 hours in advance may help patients to see a doctor more quickly but this system can make it di¤cult for some patients to see the doctor of their choice. It can also be di¤cult to provide continuity of care for the increasing numbers of elderly housebound patients dependent on home visits where the system in the practice is for doctors to take turns in doing home visits.
Continuity of care provides satisfaction for both doctors and patients. To continue to provide continuity of care as a patient marker of quality is not impossible but will be a challenge for doctors and their colleagues in general practice. Without con-tinuity of care as defined by patients, the relationship between patients and their GPs is likely to change.
