Continuity, myths and maths

“I can’t get to see my doctor any more” is one of the commonest patient complaints we hear.  The sense of loss of the family doctor echoes as much in Whitehall as in suburbia as Hunt attempts to recognise the value of continuity (though only so far for over 75s).

Continuity matters to GPs and patients

My doctor, not just any doctor

At the same time structural forces are working against the special doctor – patient relationship, which has been shown in study after study to reduce secondary care costs and improve outcomes.  Practices are getting larger, and part timers are increasing.  If the doctor you normally see isn’t in today, or is one of 8 and with other patients today, continuity is bound to be lost isn’t it?

With the PM Challenge Fund calling for general practice to be open 7 days a week from 8 to 8, the situation could worsen. Professor Martin Roland of Cambridge Centre for Health Services Research is calling it the wrong direction.

Let’s look at the maths.  Perfect continuity is achieved if every patient has a personal physician on call 24 hours a day, 168 hours a week.  Oligarchs excepted, I don’t think you want to pay enough tax to think about this.  But what if your doctor were available 12 hours a day, 84 hours a week?  Do you want your doctor to work 84 hours a week, even if you could find a way to pay?  It doesn’t really matter because doctors won’t do it.  No one in their right mind would build a career at the call of their patients for 84 hours a week.  12-7 working in general practice simply cannot improve continuity, it can only destroy it if the same GPs spread themselves across the required time.

Get real with the numbers

Halving the hours again to 42 starts to look reasonable.  With part time flexibility, not many GPs offer 42 hours clinical time per week, but it would at least seem possible.  The problem is, to offer a choice of doctor you need to have availability at convenient times and soon.  The traditional system falls down because

  • a choice of doctor means a longer wait, often 2-3 weeks
  • most patients want to see the doctor the same day they call
  • most patients want to be seen in core hours, not evenings and weekends
  • many then accept a different doctor with a shorter wait, and rebook
  • doctors offering pre-booked slots find their availability is scarce.

The premise of 8-8 working, 7 days a week is that availability should be higher.  Given the limitations of the working week above, this would mean

  • doctors available OOH would not be prebookable, as this thwarts availability
  • they would be less available in core hours, for working time reasons
  • the choice of doctor for patients is therefore reduced

What could meet demand?

There is a need for access to primary care out of hours.  Patients sometimes have urgent or emergency needs, which can be very well addressed by GPs in primary care.  Continuity might be beneficial, but you can’t have it all the time.  Our data shows that 60-70% of presentations to GPs are acute, but only 20-25% are urgent, and in the GPs view, continuity is important in a little under half.

There is no affordable and “perfect” answer, but there are practical and affordable solutions which can do much better than a singular focus on access and hours.  The secret is to have excellent access and availability in core hours, offering a choice of doctor.  Patients will then manage their own continuity, they call when the doctor they want is available.  We measure the effect of this and often see a 10-15% rise in continuity.  Out of hours, responsiveness matters in the same way, but without a choice.  That way patients will wait if choice matters.

Access and continuity go hand in hand.  Both can be improved at the same time.  An exclusive focus on either will be a costly mistake for the NHS, at just the time when UK general practice should be properly valued.

 

Harry Longman

 

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