Dis-continuity; putting 
care into context

Much is made of continuity of care, but little time is spent examining its weaknesses and exploring the alternatives. In the first of a two-part series, Dr Sara Chambers helps put continuity into context.

I was recently asked a question by an eminent GP and academic researcher: “How often does a “fresh pair of eyes” really benefit patients?” And I think it’s an interesting question on several levels. There’s so much to say that this will be a two article series. In this first article, I shall give clinical examples from day to day locum work of differences that I perceive I make as a locums to the individual patients I come across. I invite you to add your own. In the second article, coming in the New Year, I’ll look at deeper structural themes of how the “fresh pairs of eyes” of locums could be used to bring about wider system changes that could ensure greater continuity of the right type and at the right time for all patients.

The question was prompted by an article I wrote for the NASGP in 2103 - Does continuity of care need a reality check? - which explored the different types of continuity - relationship continuity vs continuity of patient management and information flow - how they are often confused; whether there might be potential disadvantages of relationship continuity and whether there might be benefits to seeing different doctors - the “fresh pair of eyes” scenario.

I was interested in these issues in 2013 as it seemed that continuity of relationship, meaning care given continuously by one doctor, was elevated as the most important tool in general practice, to the exclusion of other factors and consequent hints of a dismissive attitude to those GPs who work as locums and are typically not likely to enter into long-term therapeutic relationships. From some angles, it looked like study after study set out to prove the hypothesis that continuity of relationship is a good thing, but did not look quite so acutely at either its disadvantages, or the potentially rich seam of other modifiable factors that affect quality of care and consultations, such as access to accurate consulting room level, non-clinical information, safer systems and clear lines of communication and responsibility when managing patients of concern, and how we can improve medical records to allow better continuity of management for the many patients who now have to see different GPs.

Since my original article, the RCGP published a report in 2016, Continuity of care in modern day general practice, focusing on continuity of relationship but with recognition of the importance of informational and management continuity and how crucial this is to locums, with a small (little paragraph on page 26) but admirable mention of opening up avenues of enquiry into studying how these could be deployed to improve continuity of care where locums are involved.

So, given the lack of published data, how should I answer my questioner? On a day-to-day level, with great enjoyment and ease: all I have to do is reflect on my last few sessions and locum group meetings, and the case examples of patients benefiting from seeing a different doctor come thick and fast. It’s even been fun putting them into the following categories.

"Thank you for explaining that differently"; when patients benefit from a different doctor to check their understanding.

I find this is a common scenario, occurring at least once in most of my sessions. Patients with ongoing symptoms, or chronic or relapsing conditions, who are perhaps on multiple medications but are distressed or confused by misunderstanding the nature of their condition or the treatment aims of their medication. Or the patient is not concerned because they are unaware of a gap in understanding, but this is exposed during an interaction with a different GP; the key role of the different GP being that, having not met the patient before, we have to actively check their understanding, sometimes as we build our own understanding, and this process often reveals misunderstandings about their illness or medication. Following this process, I often find myself amending previous or repeat prescriptions with ‘indication prescribing’, so that the patient understands why they are taking the medication and the anticipated duration of treatment.

Here's a small, everyday example from a recent surgery which, once uncovered, was simple to solve and with great potential benefit to the patient:

A mother of a child with eczema had not understood the difference between emollients for ongoing use, and steroid creams for flare-ups. She was frustrated that "this rash keeps coming back" when she stopped using the emollient.

Occasionally more serious hidden misconceptions are revealed: a lady on a progestogen-only pill, who had previously been on the COCP, and so had assumed that she should continue the routine of having seven-day pill-free gaps. She had been seeing the GP partner and the practice nurse for three years at six-monthly reviews, and it took someone "going back to the beginning" to uncover the embedded error.

"I wanted to see my usual doctor, but now I'm glad I saw you"; the opportunistic second opinion.

A man in his 40s had repeatedly visited his GP with a persistent sore throat. A wait-and-see approach had initially been taken. After bloods and EBV serology had been checked and throat swabs taken, he'd been investigated by ENT who suggested a trial of PPI which didn't help. All this had taken months, and he was fed up that there seemed to be no diagnosis and relief for his discomfort. By starting from the beginning, we were able to identify that he was asthmatic and on a combination dry powder inhaler, but was not rinsing and gargling after using his inhaler.

It's possible that his usual doctor would have also “gone back to the beginning”, and I am not claiming any great clinical acumen here. But another reason I highlight this interaction was that he was initially quite angry, and I think he had almost come to vent frustration at his usual GP with whom he had "baggage" of what he perceived as months of fruitless investigation. Being a new face, I was able to bypass and diffuse his frustration by using the fact I had never met him before to say "Let's start again." His anger visibly deflated as we went through his story in detail and found a possible low-tech, simple solution. I was also able to reinforce what a diligent job his usual GP had done in carrying out investigations to rule out other causes. He was delighted and more appreciative of his usual GP by the time he left.

"I wanted to see a different doctor about this"; when patients seek a second, independent opinion

In a routine booked surgery, I saw a lady in her mid-forties who had attended a few times over the years with anxiety, depression and headaches. Reviewing her notes before calling her in, I saw that her previous consultation with her regular GP two weeks earlier had again focused on her low mood, tiredness with some mention of "generalised aches and pains". From these notes, I assumed that I would be seeing her for a follow up of her depression. However, what she really wanted to talk about was the pain and aching in her arms. So we focused on that and I was very struck by how painful and tender her muscles were to the extent that blood tests were urgently arranged.

Interestingly, at the end of the consultation, she thanked me and said that as much as she liked her usual GP who had been "very good with my depression" over the years, she had asked to see another doctor because she felt her usual doctor just wasn't picking up how painful her arms were and was attributing her pain to what he knew of her in the past. In particular, she was pleased that I was a locum as she had such a close relationship with her usual GP that she was afraid it would appear disloyal if she saw one of the other partners.

PS Her blood tests were phoned in by the lab later that day with a CK in the thousands, and was referred to rheumatology to investigate myositis.

"Please can you review this patient"; a second opinion sought by a practice-based GP

One of my GP partner friends, who works in a smaller two partner practice and has worked as a locum herself, relies on a pool of trusted locums who help out sporadically. My friend will actively seek their second opinion if she is struggling with a patient by booking an extended appointment for the patient with the locum and even writing a mini-referral letter in the notes. She finds this hugely valuable and reassuring in either confirming her diagnoses and management plans or covering new ground with the patient, and the locums enjoy being asked their opinion

When I have worked at a practice with enough regularity to become familiar with the partners, they will often thank me for seeing one of their patients and taking a different approach.

So that’s my list drawn from my experience. I am confident other locums will be able to add their own categories and cases.

To finish off my comparison of my work as a locum vs a patient’s “regular” GP, I should add that for many of my patient encounters, I find that if I am adequately equipped with an induction into practice-specific procedures, and able to safely navigate how the practice works and interacts with other services, leaving me to concentrate just on the patient's problem and building the all-important therapeutic relationship, brief though it may be, then I am an adequate stand in for the majority of patients. If being the operative word, which is where we start to dip our toe into the matter of system safety and how well systems work in supporting the wider continuity of management and information that all patients need. And that will be the theme of the next article in this series.

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