For decades, patients had a family doctor who knew them, their parents and their medical history, but this backbone of British general practice has collapsed, GPs warn, to the detriment of patient care.
Now, patients are more likely to see a new doctor every time. According to GPs Francesca Frame, Peter Tate and Phil Whitaker in The Doctor’s Communication Handbook, the shift from relationship-based medicine to fragmented and transactional care is undermining good healthcare.
The reasons for this are varied and have been mounting in the last ten years – including workforce shortages, reduced appointment times and a proliferation of remote consultation methods.
“The UK system of general practice used to be an international benchmark of high-quality, low-cost healthcare centred on longitudinal relationship-based medicine, but this is in sharp decline,” the authors explain to their peers in the book, now in its ninth edition and considered by many in the medical community as an industry must-have.
“The loss of continuity of care has not only had an impact on a patient’s experience and outcome, but on our ability to consult effectively. For those of us who have had the opportunity to experience continuity with our patients, we know the value of it.”
Why does it matter?
There is empirical evidence that suggests continuity of care leads to better patient outcomes. A systematic review in the BMJ, for example, found that increased continuity with a doctor was associated with lower patient mortality – meaning the more time spent with the same clinician, the greater the benefits. In fact, a large-scale Norwegian study found up to 25% reduction in mortality and 30% reduction in emergency hospital visits.
“Imagine if this level of benefit was seen with a new drug or treatment,” Drs Frame and Whitaker say, “it would be on newspaper front pages as the new miracle-cure.”
Besides the data, they say trust built over time makes difficult conversations easier and uncertainty more bearable.
“Difficult conversations become so much easier when trust has already been earned and established. Patients are more likely to follow our advice because they know it worked last time, and so they have confidence it will again. Patients also better understand the thorny issues of medical uncertainty when discussed with a trusted clinician, and they more easily accept the fact that sometimes we are not right and we will make the wrong treatment choices, or a mistake, because they know us as people and individuals in our own right,” they explain.
And the benefits run in both directions, Drs Frame and Whitaker argue. For clinicians, continuity saves time and crucial brainpower – rather than starting from scratch each visit.
“For us as clinicians, there are obvious benefits; we already know our patients, we are not having to establish a new rapport and relationship in every consult, and we can use our previously learned knowledge of a patient’s situation, background, medical history alongside their previously elicited ideas, concerns and expectations,” Drs Frame and Whitaker say.
What is behind the shift?
General practice is undergoing what the authors call ‘something of a seismic shift’, as small, independent practices are absorbed into larger organisations. At the same time, patients increasingly consult a wider range of healthcare professionals, sometimes instead of a doctor, further fracturing any single point of care.
Remote consultation technology further compounds the problem, they suggest. The convenience of reaching a clinician through a few clicks of a smartphone screen lowers the barrier to seeking care, but the authors warn this can also encourage ‘doctor-shopping’ – patients consulting multiple clinicians to avoid continuity altogether, sometimes guided by online forums where doctors are negatively portrayed.
Artificial intelligence adds yet another layer of complexity. In fact, England’s chief medical officer, Chris Whitty, raised concerns earlier this year that GPs are spending consultation time ‘undoing’ misinformation confidently delivered by large language models such as ChatGPT.
However, the authors tell colleagues not to be unduly alarmed, and suggest AI is simply the latest source feeding into patients’ pre-existing ideas, concerns and expectations, such as family anecdotes, things they’ve read or advice from a well-meaning neighbour. Understanding these influences is a concept, they argue, that has always been central to good consulting.
“Any clinician who wants to be effective must be interested in people and not merely diseases. They must be committed to their patients’ welfare, willing to search out their patients’ beliefs, and it follows that they must also be willing to listen to whatever problems their patients bring to them. This is an intensely personal form of healthcare, which is under increasing pressure in the resource-squeezed NHS of today. The treatment of a disease can be largely impersonal, but the care of a patient is entirely personal. We have an ethical duty to keep it that way.”
What are the stakes?
All this amounts to a healthcare system that is fractured and patients who are often lost on how to navigate it, they suggest.
While individual clinicians must work within the systems, Drs Frame and Whittaker argue strongly that continuity should be championed at any opportunity before it disappears for good.
“Continuity can exist in many shapes and forms, but we must protect and promote the ability for a patient to have continuity with their clinician. We have seen throughout this book how continuity improves patient outcomes, and how it also makes our job more effective,” they say.
“If we lose that continuity, we will lose much more than most people realise. Healthcare that shifts to a transactional, access-first, one-size-fits-all approach will be an infinitely poorer place to be cared for and to work in. We can only hope that those who wield power and control within the NHS recognise this before it is lost.”
These doctors suggest that continuity of care is not just for nostalgia’s sake, it is a measurable feature of good medicine that modern healthcare systems are pulling apart.
“We all have various opinions on the direction of travel in the current NHS system. The inevitable fallout of a collapsing social care system is wreaking havoc with community services and hospital capacity alike. Resources are scarce and often misdirected, and policy changes on political whim and agenda. Politics is far outside our remit here, but to ignore the impact of major large-scale and system-wide change on the dynamics of the clinician-patient consultation would be both wishful thinking and naïve.”