Kieran Sweeney

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 It is increasingly being superseded by other principles—notably, accessibility and plurality of provision.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

A comparison of professionals' and patients' understanding of asthma: evidence of emerging dualities?

Despite an increase in the provision of services to patients with asthma, morbidity from the disease remains high. Recent research (outside asthma) has raised the possibility that patients may develop a conceptualisation of illnesses which is not entirely compatible with the prevailing biomedical view. This paper compares the way in which health care professionals and patients with asthma described various aspects of the illness, using an approach which considered the type of knowledge which might be used to construct the respective conceptualisations of asthma. A qualitative method is empliyed, using focus groups. Eight focus groups were convened, four of professionals and four of patients with asthma. Following the initial data analysis, the results were reviewed linguistically, with particular attention to the use of metaphor. The health care professionals and patients participating in this study agreed broadly in their explanations of the aetiology and drug treatment of asthma. The data suggest lack of congruence in the development of treatment strategies and locus of control. Health care professionals and patients in this study used linguistically different metaphors to represent the disease: the former more frequently used metaphors evoking on-going processes, the latter visualising the chest (in their use of metaphor) as a static container, emptying and filling throughout the course of the disease. Two commentaries from philosophical and anthropological literature are considered in order to offer theoretical accounts relevant to this interpretation. The data suggest an emerging duality in the approach to treatment plans, in the roles played by professionals and patients with asthma, and in the different types of knowledge used by professionals and patients to construct their respective working models of asthma.

Clinical practice: when things go wrong.

High-profi le scandals are disturbingly commonplace in modern health systems, and their consequences are as predictable as they are distressing. A spate of media outrage triggers hasty government action. Employment terminations or suspensions are followed, rather than preceded, by calls for in-depth inquiries into what went wrong. With almost equal predictability, senior professionals join policy makers in calling for a strengthened focus on quality and a renewed commitment to excellence. Reports from the subsequent inquiries off er a repetitive liturgy of criticism: lack of leadership, failure to respond to obvious warning signs, dismissal of concerns raised by members of the public, and preoccupation with fi nancial imperatives and targets at the expense of high-quality care. Individual managers and clinicians are publicly censured, and, collectively, both groups are described as being part of a malign managerial or professional culture. The role of the medical profession becomes the subject of responses ranging from disappointment to outrage. In the UK, we have witnessed scandals surrounding paediatric cardiac surgery in Bristol in the 1990s, mass murder by Harold Shipman in Hyde up until his arrest in 1998, and, most recently, unusually high mortality rates in patients admitted to Mid Staff ordshire National Health Service (NHS) Foundation Trust, and the death of Baby Peter. So why does the profession seem to be so passive in the face of obvious defi ciencies? Concerns about serious failings in health care at Birmingham’s Children’s Hospital, due to understaffi ng and poor management, led to an aggressive response by local doctors and national professional leaders, but why was this response the exception rather than the norm? The conventional answer is that standards are slipping, and the medical profession is losing its moral compass and prioritising its own vested interests above those of the people whom it is supposed to serve. There seems to be a growing belief that, rather than striving for the best, many doctors are willing to tolerate mediocrity, to normalise failure, and to abdicate their leadership role. Such criticisms of the medical profession are not new; the spotlight has been on the profession’s responsibility for how the health service works for some time. More than 35 years ago, Keith Joseph, the Secretary of State who was responsible for the Department of Health, commented: “Doctors can be remarkably selective about choosing the ills they see worthy of treatment. No one can see better than doctors the needs of the public and the shortcomings of the service. I am not aware that there has been steady, powerful medical pressure to remedy the really worst shortcomings.” Evidently the medical profession needs to be reminded of its responsibilities. If internal professional motivation is not driving eff ective practice then, logically, external leverage needs to be applied. But, as a consequence, professional autonomy is being eroded; employment contracts increasingly codify what doctors should do, and how and when they should do it. Performance management and economic levers for change—such as targets, fi nancial incentives, and, evermore, prescriptive guidance—are replacing reliance on the moral motivation that is traditionally associated with being a member of a profession. Furthermore, clinicians are increasingly expected to take on managerial roles, thereby explicitly putting them in positions with widened responsibility for the running of the health system. Are these accusations of poor leadership, complacency, or lack of competence justifi ed? Why do highly trained, committed professionals sometimes tolerate a quality of care for their patients that they know to be inadequate and which they would not want for their own families? Without seeking to excuse the inexcusable, we off er two alternative and synergistic explanations for this apparent failure of professionalism: the fi rst related to perspective, and the second to the necessity of compromise. Front-line clinicians are working to make the system function at the micro level. But from this perspective, the system as a whole is obscured. Consider the evolution of the Bristol heart scandal. Individual surgeons began to push at the boundaries of their competence and experience: one child suff ered, then a second, a third, and so on. However, clinicians working prospectively as the system evolves, can never be sure at what point a bad outcome becomes a systematic rather than a personal issue. After the event, inquiry reports describe causation as linear, and use a misleading binary taxonomy to identify what was right or wrong, and which person is to blame. The situation and the explanation seem clear after the event, but for an individual clinician working in the system, the warning signs can be diffi cult to recognise. The situation exemplifi es Donald Schon’s insight: “In the varied topography of professional practice, there is a high, hard ground where practitioners can make eff ective use of research-based theory and technique, and there is a swampy lowland where situations are confusing ‘messes’ incapable of technical solution.” All medical personnel should aspire to excellence across the dimensions of quality: clinical eff ectiveness, safety, patients’ responsiveness, access, equity, and effi cient use of resources. However, in practice, this aspiration soon becomes a pragmatic exercise in making compromises. Donald Schon reminds us: “There are Lancet 2010; 375: 1491–93

Diagnosis of type 2 diabetes in primary care

Little is known about the impact of case-finding and protocol-driven screening at a practice level on the increasing prevalence of type 2 diabetes. This cross-sectional study investigated the diagnostic process in 154 patients with diabetes in a single practice with protocol-led screening for diabetes. A large proportion (87%) were diagnosed in primary care and of the 116 (86.6%) patients with type 2 diabetes the majority (58.6%) were also asymptomatic at the time of diagnosis. The commonest reason for screening was the presence of hypertension. Br J Diabetes Vasc Dis 2003;3:342‐4

Evidence‐Based Practice: Can This Help Joint Working?

This article presents a qualitative analysis of three focus groups convened during a study day for health and social care professionals, which reveals a strong perception of a philosophical difference in approaches to professional practice. The prospect of health and social care professionals working more closely together is welcomed, and evidence‐based practice should be encouraged and financially supported. While established educational strategies can be deployed to respond to the conventional perceived barriers to working together, more innovative models are needed. The authors commend the model of Significant Event Auditing.