Sunday, 31 August 2008

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)


Sara said...

I am quite jealous of your style of practice. Here, all care is equally fragmented as you describe.

madsadgirl said...

I have to agree with all that you have said in this post. I have been lucky with my GPs over the last 15 years (two different practices, the change being necessary because I moved from Cambridgeshire to London; three GPs in total). I feel that continuity of care is important for all, but particularly those with chronic problems, and especially those with mental health problems. I have also been lucky with the two members of staff who I have seen at my local Mental Health Trust.
I need to feel comfortable with the person that I am talking to about my problems, that is not possible if I have to see a different person every time. There would be no opportunity for the doctor to get to know me and to be able to properly determine my state of mind. He would be unable to determine whether I was entering a period of depression, coming out of it, or just muddling along from day to day. More importantly he would not know what signs to look for in me, to ascertain whether I was suicidal or not.
I have in the past had a nasty encounter with a locum, whose only suggestion was that I be admitted to hospital. Fortunately, the practice nurse who was familiar with me and my depression saw me as I was making a hasty exit from the consulting room, and was able to tell me to come to the surgery on the following morning (this was in the days of regular Saturday morning surgeries at the local GP's) when my GP would be on duty and he would know how to deal with me. She even left a note for my GP telling him what had happened so that he knew what sort of state I would be in when I came to see him the next day. She also phoned some friends of mine, explained to them that I was in a bad way, and asked if it would be possible for them to take care of me that evening, so that I didn't do anything silly.
Hospital would have been totally wrong for me; my problem was caused by the fact that in a few days it would have been my 25th wedding anniversary, so what I needed was a bit of company and TLC. Familiarity with me and my problems meant that I could be cared for in a way that did not make me feel worse than I already was. Polyclinics wouldn't allow this to happen and that is why I will fight against them in any way that I can.

cellar_door said...

Can I come and work for you when I'm a nurse pretty please?

Anonymous said...

I couldn't disagree with you!

Continuity of care both helps the patient and the physician.

Socrates said...

Cellar Door, that would probably worked better as "I'm a pretty nurse, please". Point taken Shrink, heading over to the PCT's website to look for signs of malignancy...

InEx said...

This is for the most part true - where I live there are community MHT and then there is the hospital team - I don't think they talk very much. My Psychiatrist is a Community Psych when I was admitted I had a different one (God complex he had) and when I saw the Crisis Team it was a different Psych (pompous pratt) again. Now I won't see anyone but the Community Psych (who is brilliant) and the Social Worker (also brilliant) and guess what they actually talk to each other.
My GP is brilliant (salaried partner) too as in the Nurse Practitioner (salaried partner) and the Practice Nurse.

Ill be there on the barricades not for Doctors but for me and the care I want.

Socrates said...

It appears I'm too late. Following what appears to have been a sham public consultation, loaded with tendentious "Would you like a really nice, new place, full of loads of doctors and nurses so you won't have to trek all the way to hospital" type questions, OldPoshshire PCT is about to open its first "Extended Hours Health Centre". But diplomatically not calling it a Polyclinic.

Cat said...

It certainly seems a better way of working. We have currently, a unified system of care for older people (and probably in CAMHS too but I don't know about them too much) but that's mostly come about because our community consultants have their 'own' wards and the crisis team doesn't work with over 65s.. I think there are far more different services in 18-65s that need to meld together - but I don't think anyone can argue that continuity of care is a good think all round.

Quacktitioner said...

I agree with your post but thought I'd add a few ramblings, I think the idea of a hospital and community consultant system is awful and ghastly, but in some areas this is the way the consultants wanted to work. Personally, I much prefer the mixture of both so that consultants retain skills for both inpatient and community work and the obvious continuity for the patient.

Which brings me on to my other point. Apart from early intervention, other teams, eg crisis resolution teams etc should be an addition to the existing care package. In areas I've worked in, the existing consultant, CPN, SW etc remain involved and a short term plan is agreed with a crisis team to provide additional support, for example to try and support patients at home rather than in hospital. If admission to hospital proves necessary the care co-ordinator (who may be a SW, CPN or the RMO) and team remains involved again to provide continuity.

The point that screams through your whole post is that sometimes none of these different parts of mental health services communicate with each other, which is a problem highlighted in many mental health inquiries.

I think the other contributing problem in acute psychiatry is that in some areas staff turnover is rapid and the use of locums and agency staff is high, this really hinders any continuity for patients. The other difference in adult secondary care as opposed to primary care is that much of the follow on care for relatively settled patients falls on junior doctors, so if you have a review every six months you will never see the same doctor each time.

Anna O. said...

As I said in my blog - I think that is a better way of working for everyone, patients and staff. Gives us doctors a sense of knowing our patients a lot better and I think a better therapeutic relationship is achieved. I know most psychiatry teams working with older people still work in the geographical model - as I said before, kicking myself for not having got a SpR post in your field! Have decided to harrass deanery and try and dual train....

Ms-Ellisa said...

(is there an e-mail where I can reach you?)

David said...

Excellent post. Absolutely spot on bang the nail bullseye.

I remember your positive input when I bemoaned this situation:

The thing about the "therapeutic relationship" is that it often takes months for people to open up, and blimey, I for one still haven't told any of the professionals any of the worst stuff, and the same goes for blogging. You have to feel you know and trust a person, and that they have a feel for you, and a trust in you and your own judgement. Otherwise it is all stone-walling and misery.

David said...

Hmm, I ballsed up the link. Sorry about that. :-)

Anonymous said...

Perhaps the answer lies in patients actually choosing their psychiatrist - like they do their GP or their mechanic - rather than having one foisted upon them.

Anonymous said...

Oh Shrink, please can I come work with you?!

The BIGGEST complaint I have from my patients is that they just get used to one Dr then they are off and they have someone new. Our Consultant sees patients once in a bright pink with purple spots on moon.

Your example about inpatient wards was spot on - I've had patients admitted in teh past and the wards discharge them with no consulattion with the community team...

The only continuity of care patients in our team get is from the CPN's, and I'm not saying that with a big head, it's the truth.