Why is the value of continuity of care never articulated in any of the statistics describing the performance of general practice, asks Dr Liz Marles?
Two weeks ago my registrar called me about an adolescent he was seeing with severe neck pain.
While she had no neck stiffness, nausea, fever, or neurological signs, her pain was quite disabling for her, and her mother was requesting an MRI and possible referral.
The registrar wasn’t sure what was causing the pain and was also uncertain about whether we could order an MRI.
As soon as he told me the patient’s name I was able to fill him in – I knew Alex (not her real name) and her family extremely well.
Alex had a long history of unexplained pain, which first appeared after her parents separated. Her mother had re-partnered and her little brother needed lots of attention for ADHD.
Interestingly Alex’s severe headaches, back pain and knee pains had not interfered with her ability to play in rep basketball, and the symptoms totally disappeared when she went on a holiday with her dad in Hawaii.
Nonetheless, she had been thoroughly investigated previously, chiefly at her mother’s request. She had been reviewed by two paediatricians and managed at the Sydney Children’s Hospital pain clinic without any definitive cause for her pain ever having been discovered. A change of schools a couple of years ago and an improvement in her home life had seemed to coincide with an improvement in her symptoms of late. She was much happier.
This family had been coming to our practice for a long time. I was aware that her mother, Jenny, was struggling with her own health issues and her stepfather Max had just been diagnosed with diabetes.
Jenny had lots of feelings of guilt about the family situation and always wanted to make sure she was doing the right thing by her daughter.
She and Alex were very happy to talk to me briefly and to be reassured that the current neck pain had no features of any more serious underlying pathology, with the understanding we could review her if her symptoms didn’t resolve.
The value for the patient and the healthcare system here was knowing the history and having the patient’s trust – a result of continuity of care.
Having spent many consultations talking to her mother Jenny, discussing Alex’s case with the paediatricians, as well as also caring for other family members, I had an in-depth knowledge of the current medical, family and social history.
The 15 minutes of this consultation built upon hours of previous consultations conducted at different points in Alex’s life.
History and trust were also fundamental in knowing the most appropriate way to proceed and which words were most likely to resonate with both Alex and her mother.
Although it is early days, Alex’s symptoms appear to have resolved and she has not required further review. We have avoided the time, effort and expense of unnecessary investigations, referrals and consultations. A win-win for everybody, especially Alex and her family.
While every GP understands the value of continuity of care, it is never articulated in any of the statistics that are used when authorities are describing the performance of general practice.
Apart from the chronic disease item numbers, (where it is meant to be the usual GP who constructs the care plan) there is no specific financial incentive to provide continuity of care.
Politicians remain focused on the bulk-billing rate as a measure of how well primary care is serving the population, while the real economic value of general practice is completely missed.
In our current system, GPs are, in fact, financially penalised for spending more time with their patients, particularly those who have the least capacity to pay, who often are the most in need.
While no longer providing home visits to palliative care patients, and restricting time spent with the homeless, the mentally ill and other high need disadvantaged individuals will definitely improve the practice bottom line, it potentially shifts the care and costs to other areas of the health system such as the hospital sector.
In this environment, where every consult is likely to be conducted by a doctor who has never seen the patient before, and has little, if any, knowledge of the patient’s history or context – care is destined to be much more expensive and less appropriate.
As the recommendations of the MBS review and healthcare home trials come through, there needs to be discussion about the value of continuity of care and how it can be promoted.
Strategies such as voluntary patient enrolment may need to be explored again.
Fears that it will restrict freedom of choice need to be addressed and the concept accepted by the community as well as general practice.
Evidence will help. There already exists a body of work by American paediatrician and primary healthcare advocate, Barbara Starfield which shows countries with strong primary care, as defined by, among other factors, the promotion of the GP’s role as first contact, and continuity of care, have lower costs with better health outcomes.
From a personal perspective, I feel that my greatest satisfaction in general practice comes from having longstanding, trusting relationships with my patients.
In an era where there is unprecedented access to health information via the internet and epidemic levels of health anxiety, the value of the doctor-patient relationship and continuity of care has never been higher.
Dr Liz Marles is director of Hornsby-Brooklyn GP unit in NSW and a past President of the RACGP
