The end of general practice as we know it

Keywords: continuity of care, general practice, health outcomes, patient satisfaction.

I have heard the title phrase many times in my career. I heard it when District Health Board and Primary Health Organisation structures were formed, I heard it when capitation was introduced, and I heard it as maternity care shifted to midwives and physiotherapists were allowed to complete ACC forms. Yet general practitioners (GPs) are still seeing patients in much the same way as 30 years ago. Change has occurred, and some changes have been excellent, such as electronic medical records, the ability to access hospital records from our practices and health pathways. But not all of it has been good. Most people will remember a time when everyone knew exactly who their family doctor was. Continuity of relationship for both them and their family with their GP was expected and normal. Today, if people are asked who their GP is, the answer is likely to be that they see whichever doctor is available at the medical centre. In the United Kingdom, Australia and Canada, concern over the erosion of continuity of relationship is growing.^1–3 In New Zealand, this transition has been slow but relentless and its implications are considerable. Worse, it has occurred without deliberation, without consultation and therefore with scant regard for the consequences to the profession or patients who come to see us.

A useful definition of continuity of care distinguishes between informational continuity, management continuity and relational continuity.⁴ Electronic medical records have made possible remarkable advances in both informational and management continuity. Increasingly, shared care plans are being built into such systems with considerable benefits to management of chronic and complex disease. It is relational continuity that is the subject of this paper. Relational continuity can be defined as the relationship between a single practitioner and a patient that extends beyond specific episodes of illness or disease. It implies that a patient will preferentially or exclusively see the healthcare professional with whom they have an established relationship, and there is an expectation that the healthcare professional will take some degree of responsibility for, and interest in, the patient’s health and wellbeing outside of specific episodes of illness. While research on continuity of relationship has focused on GPs, now in New Zealand the conclusions will most probably apply to nurse practitioners and registered nurses in nurse-led clinics.

Relational continuity results in accumulated knowledge of the patient and care consistent with the patient’s needs. It facilitates improved communication and a sustained sense of responsibility.⁵ It brings an increased sense of trust between patients and clinicians.⁶ In turn, this increases patients’ readiness to believe in and accept medical advice and adhere to long-term preventive treatments.⁷ Relational continuity of care is of value to young and marginalised populations.⁸ Lack of such a relationship results in increased psychological distress, suicide and mental health presentations to emergency departments.^9–11 Hospitalisation rates for the elderly increase when relational continuity is not a feature of their healthcare.¹²

Aside from better health outcomes, the effect of relational continuity on primary health practitioners is that job satisfaction improves and efficiency is increased.^13–15 It is also considered valuable by patients.^16,17 If we accept that patients want continuity of relationship with a primary health practitioner, that the practitioner also wants this and that health care outcomes (particularly for disadvantaged communities) are improved by continuity of relationship, why is it becoming increasingly rare in general practice? There are undoubtedly many reasons behind this change that include lifestyle and the pressure of work, but the financial incentives at both an organisational and individual level need close examination.

Relational continuity is co-constructed or co-produced through interaction between patients and clinicians and is facilitated or obstructed by how services are organised and managed.⁷ It is how and why general practice management has evolved that gives insight to declining relational continuity. Neoliberal market logic has predominated the political climate in New Zealand for the last 35 years. The policy characteristics of neoliberalism focus on privatisation, limiting public expenditure and promotion of individual responsibility.¹⁸ Its effect on healthcare has included a focus on employee productivity and flexibility, the use of ‘measurable deliverables’, loss of professional autonomy and a tacit acceptance of the health practitioner as a replaceable unit of production. The shift to employed positions rather than owner-operator arrangements has brought many practices and practitioners into a corporate framework.

While there always have been both relational and transactional elements in providing care in general practice, the wider economic environment and corporate intent may change the focus to be predominantly transactional. As noted in a recent paper from the United States, the shift in family medicine from relational to transactional ways of relating to patients is more typical of secondary care: ‘… there is another reason, more insidious and harder to defend: we have been pulled into the orbit of mainstream medicine’ implying capture of family medicine by the culture of secondary medical services.¹⁹

Alongside the impact on health care workforce, the last 35 years has also brought increased income inequality that particularly affects Māori and Pacific peoples.²⁰ The inevitable consequences of poverty are health and social problems, such as chronic disease and mental illness. With negative impacts on health for a sizable proportion of the population, healthcare funding has remained essentially stagnant and many of the social determinants of poor health go unanswered. The perceptive criticism of personal responsibility in neoliberalism is that in health care, it places the burden of poor systemic outcomes on individuals rather than inadequate systems driven by political ideology.

Demand-side factors, such as increased complexity of patient management, devolution of work from secondary to primary care and greater patient expectations have increased the work of GPs. Simultaneously, supply side issues of workforce shortages and an increasing trend to part-time work have resulted in increased reliance on temporary workers and fragmentation of care. Part-time work complicates the concept of continuity of care but does not negate it. Excessive workload applies pressure on general practice’s ability to provide continuity of relationship.²¹

There are pockets of organised general practice that appear to run counter to the prevailing trend of reduced relational continuity. For example, the Healthcare Home Collaborative has as one of their quality indicators, ‘patients are encouraged and supported to see their preferred GP and practice team’.²² Just over 200 general practices are involved in the Collaborative and on a journey towards their concept of excellence in care. Smaller and independent practices where there is meaningful professional input to management structures and culture may be more immune to loss of continuity of relationship. The correct organisational culture is necessary if people working in primary healthcare are to trust the organisation and can, in turn, create trusting relationships with patients.²³

There are many competing imperatives in general practice and the pace of change is fast. It is easy under such circumstances for soft issues such as values to be relegated to the ‘when I get time’ basket while burgeoning in-boxes, workforce shortages and Covid related issues take precedence. Yet values provide focus, purpose, and a sense of identity for an organisation and are a critical building block for organisational culture. Not appropriately prioritising continuity of relationships with patients will result in a fundamental shift in what general practice is. The current trend is not in our patients’ interest, not in our interest and results in worse health outcomes. There has been little professional discussion about the changes that have happened. If we wish to preserve continuity of relationship, the concept must be built into our management structures, our job descriptions, and the culture of general practice. We need to think carefully about how the concept is taught and modelled in our universities and vocational training schemes. We must eliminate perverse incentives and ensure that health funders both understand and will act to preserve continuity of relationship. We should not lightly discard one of the pillars of our profession or we will end up with a very different home.

Data sharing is not applicable as no new data were generated or analysed during this study.

The author declares no conflicts of interest.

This article did not receive any specific funding.