Denis Pereira Gray

Towards a theory of continuity of care

As a principle of healthcare planning, continuity of care is losing ground. It is increasingly being superseded by other principles—notably, accessibility and plurality of provision. Baker1 has identified the pressures and Hjortdahl2 writes of continuity ‘going out of style’. National Health Service (NHS) walk-in centres provide open-access primary care on sites separate from general practices and staffed by different people. For the first time, it is possible that continuity of care will be phased out of NHS planning. If this happens, what will be the consequences for patients and doctors? Over many years a research group in Exeter, including all the authors of this paper, has been developing a theory of continuity, based partly on clinical experience and partly on published evidence. The essence of the Exeter theory is that, in primary care, a ‘personal doctor’ with accumulating knowledge of the patient’s history, values, hopes and fears will provide better care than a similarly qualified doctor who lacks such knowledge; and that the benefits of such continuity will include not only greater satisfaction for the patient but also more efficient consultations, better preventive care and lower costs. When we assess continuity in primary care, the duration of registration with the general practitioner (GP) is only one background factor. A more important consideration is the total time the patient and doctor have been in direct communication; and this will include contacts about third parties, such as a child, or an elderly relative during a home visit. We recognize that continuity can have disadvantages; for example, a fresh eye may see what the familiar eye has missed. In this paper we examine the published evidence for and against continuity in primary care.

Personal significance: the third dimension

1–3 Using this model, clinicians try to turn the patient’s story into a clinical question, and to answer that question by searching for the best relevant evidence, applied in an appropriate manner. We rank that evidence, by convention, according to a hierarchy of study designs and criteria that relate to internal strengths of a study. By definition, such evidence comes from population studies, and the results relate to what happens in groups of people, rather than in an individual. Decisions are based on interpretation of the evidence by objective criteria, distant from the patient and the consultation. Subjective evidence is anathema. In this context, evidence-based medicine is almost always doctor centred; it focuses on the doctor’s objective interpretation of the evidence, and diminishes the importance of human relationships and the role of the other partner in the

The influence of general practitioner community hospitals on the place of death of cancer patients

All deaths from cancer were identified from death certificates in the Exeter Health District for a period of one year. Place of death, age, cancer type and access to general practitioner community hospital beds and the domiciliary hospice service were recorded. There were 1022 deaths attributable to cancer (parts 1 a, 1 b or 1 c of the death certificate) who were patients of general practitioners in the health district. The place of death for patients with access to community hospital beds were: home 173/590(29%), community hospital 232/590 (39%), specialist services unit 102/590 (17%), nursing or residential home 32/590 (5%), Marie Curie hospice 51/590 (9%). For patients without access to community hospital beds the place of death was: home 177/427 (41 %), specialist services unit 165/427 (39%), nursing or residential home 42/427 (10%), Marie Curie hospice 43/427 (10%). The presence of community hospital beds was associated with a significant reduction of deaths in the specialist service unit (p<0.001) and with a smaller reduction in home deaths (p<0.01). Access to the domiciliary hospice services in areas with community beds was not associated with any significant change in the place of death. General practitioners cared for 74% of cases at the time of death in areas with access to community hospital beds and for 51 % of cases without such access, which was a significant difference (p <0.001). It therefore appears that community hospitals play a major role in the terminal care of cancer patients and access to such beds is associated with a decrease in cancer deaths occurring in specialist services beds.

Provision of medical student teaching in UK general practices: a cross-sectional questionnaire study

BACKGROUND Health care is increasingly provided in general practice. To meet this demand, the English Department of Health recommends that 50% of all medical students should train for general practice after qualification. Currently 19% of medical students express general practice as their first career choice. Undergraduate exposure to general practice positively influences future career choice. Appropriate undergraduate exposure to general practice is therefore highly relevant to workforce planning AIM This study seeks to quantify current exposure of medical students to general practice and compare it with past provision and also with postgraduate provision. DESIGN AND SETTING A cross-sectional questionnaire in the UK. METHOD A questionnaire regarding provision of undergraduate teaching was sent to the general practice teaching leads in all UK medical schools. Information was gathered on the amount of undergraduate teaching, how this was supported financially, and whether there was an integrated department of general practice. The data were then compared with results from previous studies of teaching provision. The provision of postgraduate teaching in general practice was also examined. RESULTS General practice teaching for medical students increased from <1.0% of clinical teaching in 1968 to 13.0% by 2008; since then, the percentage has plateaued. The total amount of general practice teaching per student has fallen by 2 weeks since 2002. Medical schools providing financial data delivered 14.6% of the clinical curriculum and received 7.1% of clinical teaching funding. The number of departments of general practice has halved since 2002. Provision of postgraduate teaching has tripled since 2000. CONCLUSION Current levels of undergraduate teaching in general practice are too low to fulfil future workforce requirements and may be falling. Financial support for current teaching is disproportionately low and the mechanism counterproductive. Central intervention may be required to solve this.

Diagnosing Type 2 diabetes before patients complain of diabetic symptoms—clinical opportunistic screening in a single general practice

In the UK, patients normally see their general practitioner first and 86% of the health needs of the population are managed in general practice, with 14% being referred to specialist/hospital care. Early diagnosis is the privilege of general practice since general practitioners make most medical diagnoses in the NHS. Their historic aim has been to diagnose as early as possible and if possible before patients are aware of symptoms. Over time, diagnoses are being made earlier in the trajectory of chronic diseases and pre-symptomatic diagnoses through tests like cervical screening. Earlier diagnosis benefits patients and allows earlier treatment. In diabetes, the presence of lower HbA1c levels correlates with fewer complications. Methodologically, single practice research means smaller populations but greater ability to track patients and ask clinicians about missing data. All diagnoses of type 2 diabetes, wherever made, were tracked until death or transfer out. Clinical opportunistic screening has been undervalued and is more cost-effective than population screening. It works best in generalist practice. Over 19 consecutive years, all 429 patients with type 2 diabetes in one NHS general practice were analysed. The prevalence of type 2 diabetes rose from 1.1% to 3.0% of the registered population. Since 2000, 95.9% were diagnosed within the general practice and the majority (70/121 = 57.9%) of diagnoses were made before the patients reported any diabetes-related symptom. These patients had median HbA1c levels 1.1% lower than patients diagnosed after reporting symptoms, a clinically and statistically significant difference (P = 0.01).

Value of screening for secondary causes of hyperlipidaemia in general practice.

The number of estimations of serum cholesterol concentrations being performed has risen dramatically in the past few years. The reason for the rise is partly that general practitioners are increasingly realising the importance of cholesterol and partly that authoritative reports - notably that of the Royal College of General Practitioners1 and the European Atherosclerosis Society2 - have encouraged general practitioners to screen for raised cholesterol concentrations. Leading lipidologists and all the major textbooks emphasise the association between a raised serum cholesterol concentration and diabetes, hypothyroidism, excessive alcohol consumption, and renal failure,3, 4 and virtually all authorities advise general practitioners to make sure that when hyperlipidaemia is present no treatable cause exists. All patients with hyperlipidaemia should therefore have at least …

Involvement in multiprofessional continuing education: a local survey of 24 health care professions

Multipmfessional education is becoming recognised increasingly widely as the way forward for the health professions. A survey was conducted within one English health authority, namely North and East Devon, to determine how much of it was actually taking place at post-qualifying level. Unlike previous survyes, which have mostly been addressed to educational providers, this was sent to individual workers in all the established health professions and sought to measure the extent of actual involvement within each profession, along with attitudes towards learning in a multiprofessional context. Nearly threequarters of those who replied had been involved in some form of multiprofessional education during a specified 12-month period, although levels of involvement varied greatly between professions, with some professions having markedly better access to opportunities than others. A key finding was that a number of professions are effectively excluded from multiprofessional education. Considerable interest in lea...

Role reversal between primary and secondary care

Through medical education, medical students become doctors. Medical school staff have to ensure students prepare for the future, but futurology is difficult and the leaders of nations and industries have often been wrong. Some trends, like increased technology, more effective drugs, more informed patients, enhanced roles for other health professionals, government involvement and financial pressures are relatively easy to foresee. Profound trends are harder to determine. Great advances have been made by progressive specialization, culminating in one-operation surgeons and one-disease doctors. However, narrowing the field of practice may not enhance vision.

Status incongruence and serum cholesterol in an english general practice

The relationship between status incongruence and serum cholesterol was examined in a case-control study carried out in an English general practice population. Patients (n = 54) with elevated serum cholesterols (greater than or equal to 7.0 mmol/l) were compared to age and sex matched controls (n = 54). A specific type of status incongruence--lifestyle incongruity--was measured as the degree to which style of life (material consumption and status-enhancing behaviors) exceeded occupational status. Lifestyle incongruity was associated with higher serum cholesterol and an increased odds of being a case. This association was independent of age, sex, the body mass index, family history of cardiovascular disease, alcohol use, and, for women, menopausal status. Implications of these results for research on social inequality and the risk of cardiovascular disease are discussed.

Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality

Objective Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality. Design Systematic review without meta-analysis. Data sources MEDLINE, Embase and the Web of Science, from 1996 to 2017. Eligibility criteria for selecting studies Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients. Results Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors. Conclusions This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important. PROSPERO registration number CRD42016042091.