ROWAN VICK MAEER
18 High Street
Dear Sajid Javid,
I am writing to you concerning your proposed changes to the NHS in 2022, which involves restructuring primary care to ‘join up’ healthcare (2). Whilst I agree that ‘joined up’ care between the different health and social sectors is a priority, I am concerned that an emphasis on continuity of care between health sectors will eclipse the need for continuity within relationships. Previous health policies have emphasised the importance of immediate access to healthcare which, whilst necessary, has ignored the needs of those suffering from multiple long-term conditions (7). This may have disproportionately affected socio-economically disadvantaged populations, who are more likely to be suffering with multiple, chronic conditions (10). In order to improve health services for populations suffering with chronic disease, I would like to encourage you to make continuity of care within interpersonal relationships in primary care a priority for the imminent reforms of the NHS.
As a medical student, I decided to pursue a career in medicine following my work experience with a General Practitioner. Here, I was inspired by the knowledge and rapport the doctor had developed with her patients, many of whom she had been treating for decades. However, my subsequent experiences of General Practice in medical school, taught me that these close relationships are not the norm – the current primary care model, which prioritises access to care and the management of single conditions, does not facilitate the development of a personal, therapeutic relationship between patient and practitioner (7).
Continuity of care can be defined as ‘management’ continuity, referring to integrated care between different sectors (that your plans for the NHS aspires to), or ‘relationship’ continuity, between a patient and health professional (7). Relationship continuity within primary care is a proven determinant of health (7): it is associated with better recognition of health conditions, adherence to medication, reduced hospitalisation, and increased preventative care (7) (15). A systematic review in 2018 showed that continuity of care in General Practice is associated with decreased mortality (1). Interpersonal relationships within primary care is particularly important for those suffering from complex, long-term, or multiple conditions (12) – of whom there are an increasing number, given the ageing population of today (3).
However, despite the large evidence base to support the vital role of continuity of care, policies over the last two decades have consistently undermined the relationship between patient and doctor, meaning fewer patients have access to continuous care (10). GP practices have been grouped together in increasingly large and fragmented structures, with the introduction of a private market into the NHS and restructuring of primary care in the Health and Social Act of 2012, making it harder for a patient to work with just one or two doctors (4) (13) (7). In 2004, changes in the funding structure of general practices meant patients were registered to practices, instead of individual GPs (7). Whilst patients can supposedly choose which doctor they see, this rarely occurs in practice (7).
Ironically, this devaluation of the patient-practitioner relationship has occurred at a time when this has become increasingly important. The Quality Outcomes Framework has put financial incentives and pressure on GPs to keep appointments to just 10 minutes in order to improve immediate access to care (7). However, for shorter consultations to be effective, the familiarity of a regular doctor is essential, especially for patients suffering from multiple morbidities (7).
The prioritisation of access to care, over continuity of care, may have systematically disadvantaged socio-economically deprived populations (10), who are more likely to be co-morbid (3), and less likely to have continuity of care (10). In biomedicine, multi-morbidity refers to a patient suffering from two or more chronic disorders simultaneously (3). However, anthropology has moved beyond this conception of co-morbidities, to understand the occurrence of multiple diseases as shaped by the social, economic, political and cultural environment (14). Poor health outcomes are more likely to occur in conditions of health inequality, caused by poverty, stigmatisation, stress or structural inequalities (14). This results in increased forming and spreading of disease, and makes individuals more susceptible to disease (14). Different diseases can also interact together, and with poor social conditions, to exacerbate each other and worsen health outcomes (14). In Eck’s ethnography of multi-morbidity amongst deprived populations, he found that socio-economic factors, and particularly traumatic life experiences, were related to co-existent metabolic, digestive and mental disorders (3). The co-occurrence of these diseases exacerbated each other biologically, particularly through multiple pharmaceutical treatments, but also exacerbated individuals’ socio-economic conditions (3).
Continuity within primary care can be used to mobilise resources to promote coping. Coping can be understood as the way individuals are able to manage their physical and emotional wellbeing (12). Coping is often presumed to be a process of self-management; however, this rhetoric has been criticised as hyper-individualistic, and holding moralising and blaming undertones (12). Instead, coping may be better understood as a social process, in which health services can play an active role, particularly for socio-economically disadvantaged individuals (12). In Potter’s ethnography of individuals coping with long term conditions, health practitioners play a key role in mobilising resources to help patients cope (12). For example, one care co-ordinator facilitated a call between an employer and individual (P39) struggling with chronic disease, in order to determine a strategy for her to return to work. This prevented P39’s job loss – improving her ability to cope economically, but also emotionally, by preventing the stress of job loss (12). Assistance in accessing services has become increasingly important in today’s age of austerity, where resources to promote coping have become increasingly harder to access (12). Structural and social interventions, like seen in Potter’s work, that are adapted to the lived experiences of individuals struggling with long term conditions, have been shown to be just as, or more, effective than medical interventions on health outcomes (17). However, such personalised care, I would argue, relies on a relationship between patient and clinician, which requires continuity of care.
Furthermore, continuity in primary care can provide emotional and practical support to those navigating the health system. As a biomedical system, the NHS is not designed to cope with people suffering from chronic multi-morbidities – as the vertical structure find specific therapies for specific conditions, often without looking at the individual overall (3). Continuous support in primary service can look at a patient more holistically, offering support to the patient, but also preventing the risks of the specific biomedical system (7). For example, the fragmented structure of the NHS, which means each condition is treated separately, can cause a ‘cascade’ of medication, putting individuals at risk for being prescribed too many medications, polypharmacy, adverse drug interactions, and inappropriate treatments (3). Ecks highlights this issue within his ethnography, stating “in the UK patients in poorer neighbourhoods do not lack access across healthcare. If anything, they suffer from taking too many medications, with too little integration” – of which, continuity of primary care is a fundamental component (3 pp. 507). The Royal College of GPs argues that within primary care ‘responsibility’, which involves taking control of otherwise uncoordinated care, is often more important than immediate access to primary care (7). In the current context of co-existent epidemics of increasing multi-morbidities, with an ageing population, and iatrogenesis, primary care is under increasing pressure to provide such ‘responsibility’ (3).
Continuity of care within General Practice is vital in enabling patients and doctors to build therapeutic relationships where illness, in a broader sense, can be understood and treated. Relationship continuity is also valued by GPs and has been shown to improve job satisfaction (5) (6) (8). Therefore, I am encouraging you to prioritise continuity of care in General Practice within your restructuring of health services in 2022.
Whilst some efforts have been made to improve relationship continuity in recent years these have been largely administrative changes, such as requiring patients to have a named GP again in 2015, and limited in their impacts (10). In order for real and sustained improvements to be made to continuity of care, the primary care sector needs to be restructured. One of the ways this can be done is through organisational changes within General Practice – making consultation times longer, which is vital for creating and maintaining relationships between a patient and their doctor, and practices smaller, meaning patients see the same health practitioners regularly (19). Whilst these structural changes to primary care may be time consuming and expensive, I hope that this letter has highlighted the value relationship continuity with GPs will have on patient health outcomes. These organisational changes should first be carried out in socio-economically disadvantaged areas due to the unequal burden of chronic disease and a lack of relationship continuity in these areas.
Rowan Vick Maeer
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1. Jeffers H, Baker M. Continuity of care: still important in modern-day general practice. British Journal of General Practice. 2016;66(649):3