A few years ago, when I was boarding a plane I picked up The Times newspaper and noticed a big headline stating: ‘The family doctor is going out of fashion’. In the article journalist Matthew Parris explained why young people prefer to go to the emergency department. I kept the article as I thought it would be a great blog topic, but for some reason I forgot about it – until something jolted my memory.
Last month I had the pleasure of meeting with the Board of Health Consumers Queensland. I enjoy conversations with consumer representatives as I always learn something, even though these exchanges are usually slightly confronting. One of the topics we touched on was continuity of care, or better, the perceived lack thereof in general practice by consumers. During the drive back home to the Sunshine Coast I suddenly remembered the article in The Times.
In 2013 Parris wrote: “Very gradually the era of the personal physician is drawing to a close.” He said he noticed a trend in the UK where younger, busier people were going directly to specialist accident & emergency departments and argued that they don’t want a local GP because working men and women in a hurry will be attracted to a place where they can walk from one room to another and access the specialism they need.
So, I wondered, is the family doctor who provides ongoing care a thing of the past? Am I really a dying breed – the last of the Mohicans?
What exactly is continuity of care?
In primary care literature continuity is often described as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. To confuse the situation other terms are used synonymously, such as ‘care coordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’. On top of that the experience of continuity may be different for the patient and the health practitioner, adding to even more misunderstandings.
Continuity is how individual patients experience integration and coordination of care.
The authors of an article in the BMJ titled ‘Continuity of care: a multidisciplinary review’ said that continuity is not an attribute of practitioners or organisations. They defined continuity as the way in which individual patients experience integration of services and coordination. And also: “In family medicine, continuity is different from coordination of care, although better coordination follows from continuity. By contrast, a trade-off is required between accessibility of healthcare providers and continuity.”
There are three types of continuity of care:
- Informational continuity: The use of information on past events and personal circumstances to make current care appropriate for each individual
- Management continuity: A consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs
- Relational continuity: An ongoing therapeutic relationship between a patient and one or more providers.
Continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database. Understanding of individual patients’ preferences, values, background and circumstances cannot always be captured in health records; health providers who have a longstanding relationship with their patients often have this information in their heads.
“Poor continuity gives rise to high risk medicine
In 2010 Dr Frank Jones wrote in Medicus: “Poor continuity gives rise to high risk medicine. Ideally continuity should be personal and longitudinal – the essence of the traditional general practitioner. However the very concept of continuity gets more complicated nowadays. How does it apply to single-handed GPs or to group practices?”
Indeed, continuity of care exceeds disciplinary and organisational boundaries. The Royal Australian College of General Practitioners describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers.”
The benefits of continuity
There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction. Evidence also indicates that primary care (in contrast to specialty care) is associated with a more equitable distribution of health.
GPs often manage up to 4 problems per visit, which is of course more efficient than walking ‘from one room to another’ in an emergency department or hospital outpatient department. Overall, primary care is associated with lower total costs of health services.
Looking at the primary care reform processes that are under way in Australia, it is not unlikely that the multidisciplinary general practice team will be the key component in the care for people with chronic and complex health conditions.
In part 2 I will discuss the six methods GPs use to improve our health, according to world-renowned primary care researcher Professor Barbara Starfield, and why primary care plays an important role in a sustainable health system.