Following on from her previous article Dis-continuity; putting care into context, Dr Sara Chambers explores the idea that sometimes continuity of care is deployed to paper over the cracks where 'continuity of management' and 'information' is lacking or even absent, and why the locum's perspective needs to be part of a future solution.
None of the value that I believe locums can bring detracts from the evidence that continuity of relationship is a vital tool in the armoury of general practice. Indeed, for some patients it will be the most important factor in their care. But it is not the only tool, and it favours no-one to over-emphasise relationship continuity as the key aspiration in general practice to the neglect of other factors, most importantly the systems that ensure continuity of management and information, which are the true backbone of good care for all patients, including the many who see different GPs.
And again, the experience of locums “being a fresh pair of eyes” has something to teach us about how we can improve our systems to ensure that all patients get the continuity they need.
Too often, as a locum, I see evidence of a dysfunctional over-reliance on relationship continuity, which is then used to paper over serious cracks in a system that lacks continuity of management and information, so that a patient’s management and safety becomes dependent on the cognitive energy and memory of a GP. Since most GPs are diligent and competent, this can work adequately most of the time. But as Lucian Leape, the pioneer in patient safety identified in his 1999 landmark report, most errors in healthcare arise from faulty systems, and this places immense individual responsibility and demand on GPs who are often blind to the fact that they are overloaded and propping up a weak system.
"A common response to a lapse in care involving a locum is to personalise blame rather than questioning the system that contributed to the error, feeding into the narrative that continuity and quality of care is disproportionately based around individual practitioners."
Locum GPs, being outsiders, a “fresh pair of eyes”, and often working when the ‘lynchpin’ GPs are away, are ideally placed and experienced at identifying these weak systems of management and informational continuity. From my own experience, these weaknesses include unclear channels of communication and responsibility for care within a practice, inadequate medical records which do not capture the nuances or soft information about patients, and bewildering variations and lack of clarity in referral procedures, result handling procedures and repeat prescribing systems.
Sadly, at the moment, instead of tapping into this unique perspective of locums, a common response to a lapse in care involving a locum is to personalise blame, rather than questioning the system that contributed to the error, feeding into the narrative that continuity and quality of care is disproportionately based around individual practitioners.
A rewarding area of work would be to foster a positive and open-learning, Black Box thinking culture, and build mechanisms for allowing feedback from locums on these weaknesses. Let’s move the narrative away from only focusing on the performance of individual GPs, and instead use this expertise to build systems that support all doctors to work at their best and enable every GP consultation to be as effective as possible: a system that is so reliable and transparent that if disaster struck, a team of locum staff could step in and safely hold the fort. Not ideal, and in no way a desirable replacement in the long term for those patients that need relationship continuity, but a backstop of safety for the majority and a good way of conceptualising what a safe system should look like.
Such a robust, reliable system would also bring day-to-day benefits of supporting practices in providing core general practice, making them safer and more efficient for their own staff and GPs, but also helping them attract GP locums to aid them in this, or even recruit for permanent posts.
Practices now face competition from the various flavours of local overflow demand management clinics, as GP locums are starting to report that they are being attracted away from core general practice to work instead in from the various locality centres offering extended access e.g. MIAMI, overflow hub clinics or urgent care centres. Even when earning less and often working at unsociable times, many locums nonetheless prefer this work because they feel better supported by working within a more standardised system where they are part of a team, getting support from their colleagues as needed. In comparison, it just feels too unsafe and difficult to face the numerous obstacles that arise in working in practices who can vary enormously in their processes and level of induction and engagement and support.
Systems to improve engagement between GP locums and practices could attract more GP cover back into providing core general practice. There are many marginal gains that could be made by implementing standardised induction procedures for all new and visiting staff in practices, and improved consulting room level information management. I can state from my personal experience as a locum that a welcome induction tour, a concise locum induction pack and a point of contact during a locum session can bring unstinting loyalty and goodwill from a locum towards a practice. And this key area is why NASGP has worked so hard to develop LocumDeck and Spip as tools to promote this co-operative working between locums and practices in all their great variety.
So what’s the real, perhaps more difficult, answer to my original questioner on how often as a locum I found a fresh pair of eyes to be valuable? Well, I am now middle-aged; I have twins who are becoming young adults, and ageing parents. I want them all to have safe, timely access to GPs who are equipped and supported by a reliable system that allows them to work seamlessly in a practice, understanding how it operates and how it interacts with other vital services, so the GP is freed to concentrate on the most important job in the NHS; being a GP, focusing on the patient’s problems and building a therapeutic relationship, however brief that might be. And for my parent’s generation, or any patient with complexity or long term illnesses, I hope for a system that supports and nurtures continuity of relationship with a named GP when it is needed.
How do we achieve this? Alongside the goal and the studies and the statements about how important continuity of relationship is in general practice, I want my profession to declare that the goal of a “disaster-proof, locum-ready” safe system, that facilitates true continuity of management for all patients, should have equal parity. And then I hope that new questions will start to be asked of GP locums about how, with our unique perspective as a “fresh pair of eyes”, we can be involved in building and improving those systems.
Sara was a salaried GP for 4 years, and has worked as a locum GP since 2001 in over sixty different GP practices. As well as NASGP’s appraisal and revalidation lead, and mother to twins, she is also the brains behind NASGP’s Practeus platform.
Sara’s an avid reader, especially fiction, history and trains (yes, trains); loves walking, pilates and beans on toast with cheese.