Abstract
In the last issue of this journal, our editor, Richard Draper, highlighted the worldwide shortage of primary care physicians. This shortage has been well documented in the UK and is keenly felt by patients, GP trainers and their trainees up and down the country. Access to care has become not only the subject of a multitude of headlines, but the battle ground for annual contract negotiations. The range of clinicians working in primary care settings has become more diverse, in large part to meet this challenge. Practices have merged and expanded, with bigger list sizes and more complex telephone and triage systems.
Whether or not a GP was accessible often grabs headlines too. Demoralising as this may be, remember that even under the weight of enormous lists of patients to be seen, for primary care to be useful, patients need access reliably. This might be at odds with the pervading emotions experienced on a daily basis by GPs and their teams as they try to meet the growth in demand for appointments.
GP trainees finding themselves in this environment for the first time may feel understandably daunted. Your first experience of access as an issue may be with a patient who grumbles (or even complains) about how difficult it was to get to see you. Even in the maelstrom of appointments, it can be helpful in those early consultations to reflect specifically on how access affects consultations. Thinking about, reflecting and even studying how marginalised groups can gain access to appointments may make consultations more effective and perhaps form the basis for some quality improvement projects.
While access remains a red-hot political issue, it will become a bigger distraction from looking at what happens in consultations when they do happen. For many commentators (increasingly obsessed with the importance of access) the GP consultation is a simple transaction or perhaps an algorithm built on medical facts. There is insidious pressure for the consultation to stand alone; a transactional episode within which all is done and dusted in one go. Look no further than the medical model that teaches us that by the end of this process, diagnosis and management are achieved. In my experience this is a notion increasingly prevalent in hospital medicine, where a shift-based system of care provision means patient interactions are one-off episodes. When GP trainees make the switch into general practice, such an approach can lead to a sense that we have ‘to do it all in one consultation’. Anecdotally this sense can be heightened by the pressure of exams and a guideline-driven outlook making us think there is some kind of ‘pathway’ for every patient.
Taking all this into account it is no great surprise that continuity of care gets forgotten. In many ways, provision of continuity of care is general practice’s superpower. By carefully planning who is followed-up and when, we can improve a whole host of outcomes, including patient mortality and patient satisfaction. Ironically, given the well documented queues outside hospitals, provision of continuity also reduces the risk of admission. Yet for some reason, even with the established evidence of benefit, the value of continuity is consistently and systemically marginalised. For GP trainees, planning how to provide continuity to the right patients is rewarding and improves consultations. It allows us to reduce the harm created by over investigation and to reduce costs. Building relationships with our patients improves the chances of them telling us about key symptoms and following our advice.
Of course, in general practice, as in life, you can have too much of a good thing. There is no need to follow everyone up and if you do, pretty quickly you will become inaccessible to many patients and unpopular with your colleagues. Herein lies the leadership challenge for the next generation of GPs. Access and continuity are key functions of primary care and they must be kept in balance. Systems need to be developed that enhance or maintain access and promote continuity of care. For trainees and trainers interested in improving how their practice deals with this conundrum, the RCGP continuity of care toolkit provides a great starting point.
