CLINICAL MANAGEMENT

Published: 18/08/2005, Volume II5, No. 5969 Page 25

Leaving general practice can be a disturbing experience. Some of your patients get quite upset, some implore you to stay, others feel betrayed and become quite angry.

Having been through the process myself twice it seems that at the heart of all this distress is a break in the patient's continuing care. Patients do not consult me for 10 minutes; it is actually nearly four hours but spread over the course of five years.

Recently, in my current practice, I encountered a patient who was seeking to maintain his registration despite having moved over 60 miles away.

This is not uncommon and in the past I have 'flushed out patients' who have apparently moved into their next-door-neighbour's house (ie a 'proxy' address) while others have pleaded that they would never request a visit if they could just remain on my list.

I have also been offered (and refused) money, antique furniture and even a free holiday to keep a patient registered.

At the end of last year a critical review of the health effects of continuity of care was published (Journal of Family Practice, December 2004). This demonstrated that continuity of care increased patient satisfaction, reduced hospitalisations, emergency department use, inappropriate prescribing and inappropriate diagnostic testing, and improved the receipt of preventative services.

All these improvements were particularly marked for patients with chronic disease. From the health service's perspective, costs were also significantly reduced.

In the light of all this I find it somewhat perplexing that politicians and health service managers seem to attach so little importance to continuity.

Over the last 20 years I have seen continuity marginalised within the hospital setting and the focus is clearly now on care outside hospitals.

Policy initiatives such as supersurgeries, drop-in centres, dual registration and 48-hour access targets all undermine continuity of care.

NHS Direct is the only exception as it seems that virtually every encounter my patients have with this service generates a GP consultation anyway.

General practice itself has been defined as the continuous and comprehensive care of individuals and families. If we lose continuity and, in parallel, we also metamorphose into practitioners with special interests, what will the future hold for primary medical care?

I believe patients should continue to be offered the option of traditional general practice, and I would even suggest the term 'general practice plus' to make the idea more palatable to my political and managerial masters.

But then, continuity is hardly a feature of NHS management. In endeavouring to work with colleagues at all levels of the NHS it seems that individuals change more rapidly than the seasons.

Only last month HSJ reported yet another bout of restructuring, intended to slash the number of PCTs by half and management and administrative costs by 15 per cent in just over a year (news, page 5, 28 July).

Perhaps here lies the fundamental problem: it could be that continuity is difficult for organisations or individuals to consider when they are so transient themselves.