Written evidence submitted by Professor Mark Rickenbach (FGP0249)

 

Summary

 

 

1.0 Continuity of care and good relationship based care between patients and healthcare workers saves life, improves heath, saves NHS time and costs and increases patient, staff and doctor satisfaction with retention of staff

 

2.0 A Doctors Assistants model of direct personal help with administration of patient care is needed with direct funding.

Administrative workload exceeds time spent on direct patient care, is a waste of doctor’s time, demoralises doctors and encourages doctors to leave healthcare.

 

3.0 The Primary Care Network model is good when it supports integrated work between GP Practices as well as links with the community.

However, the current shift to top down directives enacted through the Primary Care Network is in direct opposition to effective local team work and co-operation

 

4.0 A Vision for primary care is needed which is positive, has buy in from those working on the coalface and fully supported by NHS managers and government.

 

5.0 Remaining Select Committee questions and responses

 

 

Introduction

 

I am Prof Dr Mark Rickenbach and have been a GP for thirty years at Park and St Francis Surgery near Southampton.

I am a Professor of Healthcare at Winchester University, a lead for Education in Primary Care Research for Wessex Clinical Research Network and the Clinical Champion for Continuity of Care at the Royal College of General Practitioners. I have been an Associate Dean for Quality of Education in Health Education England.

I am submitting evidence as a member of these organisations and as the national lead for continuity of care.

 

 

Evidence

 

1.0  Continuity of care and good relationship based care between patients and healthcare workers saves life, improves heath, saves NHS time and costs and increases patient, staff and doctor satisfaction with retention of staff

 

1.1 A recent study in Norway has shown that there is a 25% reduction in mortality with 15yrs of continuity of care between a doctor and their patient (Sandvik et al. 2021). This is likely to be cause and effect as there is a dose response relationship with a fall in mortality as the duration of continuous relationship increases from one year up to fifteen years.

This is also support by previous reported evidence.

 

1.2 The literature consistently showing the benefits for continuity of care between a doctor and their patient. Despite there being few randomised trials, showing benefits in midwifery care, the weight of evidence in favour of continuity of care is extensive. (see appendix at the end or follow this link at References for Continuity of Care Impact | DocRick).

For example for every two additional consultations with the same doctor over time there is an associated 6% reduction in urgent care service use (Barker et al 2017)

 

1.3 Reports of disadvantages are mainly anecdotal and considerably outweighed by the benefits. Any disadvantages of seeing the same patient over time can be overcome by using a range of good consultation techniques.

 

1.4 Research shows continuity of care leads to increased satisfaction for patients, as well as healthcare staff including doctors.

This leads to investment in the healthcare relationship by both patients and doctors. There is increased compliance with treatment, less duplication of work, less overtreatment, and fewer inappropriate referrals as a result.

 

1.5 The economics of continuity of care suggest there is likely to be a significant saving of healthcare costs at the same time as clear improvements in safety of patients and reduced litigation. Further economic evaluation is urgently needed to raise awareness of the extensive benefits of continuity of care to government and healthcare leaders.

 

1.6 Healthcare computer record systems need to be funded to provide feedback on continuity of care in local general practices. To help identify which doctor and /or nurse is actually providing continuity for a particular patient, and to batch transfer to the correct GP at regular intervals.

This is a simple, local, low cost step that has been researched as part of the Healthcare Foundation continuity of care programme.

 

1.7 The Healthcare Foundation continuity of care programme was designed to demonstrate how to increase continuity of care across half a million people and five sites in England between 2019 and 2021. See Continuity of Care (rcgp.org.uk)

 

Continuity of care has been shown to be “Important, Achievable, and can be done by all. It merits national incentives and support to increase continuity.

 

1.8 Continuity of care enables good “Relationship based care” as proposed by the Royal College of General Practitioners. It has been show to help reduce workload and improve access to healthcare by making healthcare more efficient.

What role does having a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?

1.9 Having a named GP is the first step to continuity and an essential step. However this alone is not enough (reference on request). It needs incentives and advice on how to put continuity in place. These approaches are identified in the Health Foundation programme on continuity of care that ran from 2019 to 2021.

 

1.9 Every day, as a working general practitioner, I appreciate the value continuity of care. Every patient I see it saves time and provider safer healthcare. I start knowing my patients history and preferences, saving minutes in every consultation.

Patients have often said “because you know me /them it has made all the difference” I recall taking more action for patients who looked different to previous consultations with no other indication of illness. One had a carcinoma of colon and one had breast cancer.

 

 

2.0  A Doctors Assistants model of direct personal help with administration of patient care is needed with direct funding.

Administrative workload exceeds time spent on direct patient care, is a waste of doctor’s time, demoralises doctors and encourages doctors to leave healthcare.

What can be done to reduce bureaucracy and burnout, and improve morale, in general practice? 

2.1 The NHS should Promote and fund a national model of a Doctors assistant. To make this available through the Additional Roles funding via the Primary Care Network or via direct funding.

 

2.3 A more experienced member of the reception staff or nursing staff to sit alongside a GP without other roles so they can tackle routine GP tasks like checking normal blood results against normal ranges, phoning patients to rebook them, informing patients of results, checking patients have recovered on treatment, or acting on GP advice to alter their treatments .

2.4 The model of a doctor’s assistant can release a GP from the majority of their administrative work to speed up decision making by the GP, allow a quicker response to patient care, improve GP morale and increase GP retention in the healthcare service.

 

 

3.0 The Primary Care Network (PCN) model is good when it supports integrated work between GP Practices as well as links with the community.

The shift to top down directives enacted through the Primary Care Network is in direct opposition to effective local team work and co-operation. This will stifle local innovation if it continues.

Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

Yes because of the increased funding for staff. However the administrative burden has remained similar and increased where staff management has been required.

3.1 Social prescriber / linker workers have enhanced social care and helped reduce the impact of this on the GP consultation.

3.2 MSK physiotherapists have moved MSK consultations away from the GP and often handled them effectively

To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

3.3 The key to effective working with other professionals is having them in the same building working alongside. This is the reason care improves

 

The danger is that other professions like midwives, community nurses and health visitors have been underfunded and moved away from their primary care based disrupting healthcare.

 

The gain in social prescribing and MSK physiotherapy has been offset by a loss of midwives, community nurses and health visitors to the local primary care team

 

GP time has been freed up by direct access physiotherapy and social prescribing.

 

 

4.0 A Vision for primary care is needed which is positive, has buy in from those working on the coalface and fully supported by NHS managers and government.

 

Directives tend to be top down without ground level collation of knowledge and experience. Healthcare staff and GPs are forced into having to put forward what they do not want healthcare service rather than sharing what is wanted.

 

4.1 The big unifying “why” is to improve and safe lives. All NHS staff want to help others and feel valued in doing so (this is significantly missing at present and is more important than pay). Keep the focus on the patient as it is a common language and currency we all aspire to help

 

4.2 The NHS needs to focus on quality of care or quality of access to holistic proactive care rather than the speed of access to basic transactional care. The former is more cost effective and safer.

 

4.3 Future vision – a workforce supported to improve healthcare and able to do so. Supported as trusted professionals, as all of them are committed to safer patient care.

What are the main challenges facing general practice in the next 5 years?

4.4 GPs are too few, underfunded and demoralised. This creates a downward spiral. Look at improving morale, support and direct funding to empower GPs to improve healthcare

4.5 Healthcare is funded on what is easy to measure rather than what matters most. The NHS needs to reduce box ticking on things that are simple to measure but only a proxy for what is important. This just forces organisations to design systems to tick the box without improving quality of care.

 

4.6 The Government does not appear to trust GPs so funding is provided indirectly or tied into easy to measure records. Provide funding to coalface general practice to do what is required locally.

 

4.7 Home visits take significantly greater time and are more complex. Having a visiting service provided for each surgery will allow GPs time to sort out healthcare in the surgery. A visiting service that is proactive, gives continuity of care and links well with the primary care team, so that those providing home visiting care invest in doing it well.

4.8 There is insufficient funding for reception staff. Direct funding for more receptionists to handle phone calls and administration which a doctor does not need to do.

4.9 Community nurses, health visitors and midwives are all underfunded, pressurised and have been pulled out of primary care into pooled brief contact groups of frustrated technicians. Management support and funding to bring back key services into the primary care team is required.

4.91 There is a lack of space in primary care settings. Funding is required for rental of nearby rooms or property space to enable the primary care team to work alongside each other more effectively.

4.92 There is a pointless negative use of the media and public opinion as a stick to herd on GPs. Positive messaging of the benefits of our primary care service to attract more staff, nurses and GPs is required. Primary care covers everyone, is very efficient for money, high benefit and responsive.

 

 

5.0 Remaining Select Committee questions and responses

 

5.1 What are the main barriers to accessing general practice and how can these be tackled?

The main barrier is lack of time and resources for a GP to provide care. The number of patients per GP is too high and the payment model favours high numbers of patients with short contact

5.2 To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

The government focus appears to be on raising patient’s expectations for rapid access irrespective of the problem and its true medical urgency.

5.3 What are the impacts when patients are unable to access general practice using their preferred method?

The seriously sick patients have reduced access because those worried well who are familiar with routes of access utilise the limited time of GPs.

There is a significant group of patients who only have landline phoned and struggle with GP access by any other methods.

5.4 How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

There is a risk policies and approaches for general practice are based on or set by a limited number of regions or cities. They may not be relevant to all areas therefore or appear not to be.

5.5 What part should general practice play in the prevention agenda?

General practice is well placed to motivate and encourage individuals but it needs professional support for prevention alongside GPs, in funded space, next door to the GP and their team

5.6 How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

Minimise QoF, relate QoF more to quality of care and continuity of care, increase direct general practice funding and help the local GP leaders to decide how to allocate resources

5.7 Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

Yes. There is a lack of understanding about the significant benefits to the NHS of GP partnerships which are highly productive cost effective units of care when compared to salaried services. This needs further research to demonstrate the benefits.

5.8 Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

No they encourage data collection to meeting demands for recording measurable elements of care. The NHS needs to shift its focus to incentives for proactive, personalised, coordinated and integrated care.

 

REFERENCES FOR CONTINUITY OF CARE IMPACT

When they receive continuity of doctor care, patients:

Are more satisfied  *

Baker and Streatfield (1995)

Baker et al (2003)

Adler et al (2010)

 

Are more likely to follow medical advice (adherence)

Warren et al (2015)​

Chen et al (2013)​

 

Are more likely to take up offers of personal preventive medicine

O’Malley et al (1997)​

Christiakis et al (2003)​

 

Are more likely to have a good doctor patient relationship with their GP

Mainous et al (2001)​

Ridd et al (2011)  

 

Are more likely to receive good quality of care

O’Connor et al (1998)​

Romano and Segal (2015)​

 

Are less likely to need to go to A&E *

Brousseau  et al (2004)​

Van den Berg et al (2016)

 

Are less likely to need a hospital admission, ** particularly for ambulatory care sensitive conditions

Barker et al (2017)​

Bankart et al (2011)​

 

Are likely to live longer *

Maarsingh et al (2016)​

Pereira Gray et al (2018)​

 

Have more cost effective healthcare (including meaning funding available for other things)

Starfield (1994)​

Weiss and Blustein (1996)​

When continuity of doctor care is provided, doctors:

Have an ‘accumulated knowledge’ about the patient.  Doctors use such accumulated knowledge both for diagnosis and to tailor their advice.

Hjortdahl & Borchgrevink (1991)

Hjortdahl (1992)

Ridd et al (2011)

 

Report that continuity enables them to provide a ‘higher-quality’ care.  GPs are then rewarded with more professional satisfaction through doing a better job.

Ridd, Shaw, & Salisbury (2006)​

 

Have improved problem recognition and quality of management for long term conditions

Saultz and Lochner (2005)​

Baird et al (2018​)

 

Have reduced conflicts of responsibility , particularly reducing the ‘collusion of anonymity’ where succession of clinicians only deal with what is immediately most pressing

Freeman and Hughes (2010)​

 

Contribute to the reduced the use of specialist care, A&E, emergency admissions and outpatient appointments *

Hansen et al (2013)​

Katz et al (2015​)

 

Reduce costs e.g. prescriptions and tests

Weiss and Blustein (1996)​

Saultz and Lochner (2005)​

 

Reduce cases of avoidable significant harm

Avery et al (2020)

A good introduction to continuity is shared by Sir Denis Pereira Gray in the Improving Continuity: The Clinical Challenge (2016

Dec 2021