Continuity of care

Continuity of care. Does it matter?

In Primary Care, bloggers have been vocal for over a year, raising awareness that government policy is to shift Primary Care away from an established GP practice with GPs looking after you (and other staff supporting this) to a new style of clinic. In these (often private) clinics, access is easy but the consultation is usually not with a doctor. When medical input is necessary, it's with who ever is working in the clinic that day, so there's no continuity of care.

You speak with a doctor about your problems. Tests are arranged, there's uncertainty over diagnosis, there's sensible safety netting and a review is arranged for a month to see what the clinical course has been. But when you're reviewed it's by a different person. So how can they compare if things are better or worse? How can they tell if the chest auscultation is clearer, or the heart murmur is harsher, or the skin is more icthyotic, or the dyspnoea more intense?
Much badness.

Patient surveys have consistently shown that patients would prefer to see the same doctor. In psychiatry, surveys have shown that this is also true. Who wants to give a frank account of their life to a doctor, start to develop a relationship and perhaps feel some trust, to then see some random soul and pick up consultations with a stranger? Much better to work with someone who knows your medical history but more (and this to my mind is the crunch) with someone who knows something of you. You can't get that in medical notes. It's about rapport, about relationships, about a shared understanding and shared confidence and shared trust.

Patients will trust me and I will trust them. That develops over time, it's generated through honest dialogue and evidenced actions that we undertake together over a period of time. Then, if I'm suggesting something they're sceptical about, they know it's because I genuinely feel it's the right thing to offer, knowing and having experienced appropriate care over time, so having a degree of trust.

I know colleagues who work in other hospitals/mental health Trusts, in other regions. Mental health isn't a huge field. Some colleagues work in systems where patients see a different team for different stages of their illness.
First you see an Early Intervention team.
Then, if things aren't great, you see a Crisis Reolution or Home Treatment team.
Then, if you need support within a hospital, you are transferred to the Inpatient team.
You're then discharged to the Community team.
Not cured? Then let's transfer you to the Rehab team.
A patient has been bounced through 5 teams before they've even entertained specific teams that might add in to care pathways (lithium clinics, drug/alcohol services, clozapine services, early onset dementia teams).

5 different teams, 5 different Consultant Psychiatrists. What if one is very much a community psychosocial medic who likes holistic interventions and minimum use of medication and another is a very biomedical medic who like the medical model and drugs? Care is ghastly. You get no drugs in one part of the service, you're admitted and given oodles of drugs, then discharged to the community where you're picked up by someone who doesn't think you should be on lots of drugs, but now you are. What to do, what to do.

As well as a lack of consistency of approach, there's then the tension of boundaries. The community team feels risks are significant and treatment isn't working and the patient and family aren't coping, so arrange for a hospital admission. The inpatient Consultant hasn't experienced what it's like for the patient and family at home so can't see what's so bad that hospital in-patient care is necessary, so promptly discharges the patient back to the frazzled community team, bitter that community folk are always turfing work to the in-patient wards whenever they're stressed or busy or have real work to do. The community team is bitter that the in-patient team never sorts problems out and only's interested if a patient needs detaining or needs ECT and sees everything else as something the community team should manage outside of hospital.

Speaking with folk from 3 areas who do work in this way, this scenario sadly isn't fiction but is the world that some folk now live in. Mental health services are already like this, in some parts of the country.
Much badness.

I don't work in this system. I cover a geographical area and manage all the patient's care where ever they may be. There's no tension over what area should be doing what, it's still my work whether they're an in-patient or in the community or in a care home or whatever. There's no tension with me having one philosophy of care and another psychiatrist with different views giving conflicting care. There's no problems of patients and families seeing a different person each time (only I do an out-patient clinic, there isn't even a junior doctor's clinic list, so I see follow-up patients myself).

I would be driven to burn out if shackled to out-patient clinics all week. Or in-patient wards all week, without seeing the follow up and positive results in the community.

Polyclincs in Primary Care. Fragmented services in Secondary Care. It's worth speaking up about them, and speaking up about them now, before things change for the worse. It may not feel immediate or directly and personally relevant. It's still an issue that should be fervently opposed.

"When the Nazis came for the communists,
I remained silent;
I was not a communist.

When they locked up the social democrats,
I remained silent;
I was not a social democrat.

When they came for the trade unionists,
I did not speak out;
I was not a trade unionist.

When they came for the Jews,
I remained silent;
I wasn't a Jew.

When they came for me,
there was no one left to speak out."

- Pastor Martin Niemöller (1892–1984)