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Written on 1st December 2023 by Susan Brown

A new investigation report by healthcare watchdog, HSSIB, has called for GPs to provide continuity of care for their patients. The report, Continuity of care: delayed diagnosis in GP practices, calls for changes to the contract which GPs have with the NHS, and to standards governing the electronic records systems used by GPs, to improve patient safety, particularly for patients with unresolved symptoms.

The investigation followed the experience of a patient with complex health conditions, who suffered a delay in diagnosis of metastatic cancer which had spread to his spine, after the importance of his unresolved back pain symptoms was not recognised by multiple healthcare staff at his GP surgery over many months. 

Poor communication, incomplete patient information or handover, and other failings in continuity of patient care are common features in serious injury negligence claims against GP practices, and other primary and emergency healthcare organisations. HSSIB’s findings and recommendations are both timely and important, particularly given the increasing numbers of patients who now rely on their GPs for management of multiple and complex medical conditions.

What is continuity of care?

HSSIB define continuity of care as where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient.

Serious health conditions, such as cancer, spinal cord compression or cauda equina syndrome (CES) can develop over time with a gradual onset of apparently minor symptoms. A doctor is more likely to suspect an underlying cause for a patient’s unexplained symptoms if they know the patient’s medical history, their current condition and background, see them regularly and have a relationship of trust between the doctor and patient. However, when a patient visits their GP practice with an unresolved or persistent health problem and is seen by different GPs or practice staff each time they visit, their safety depends on reliable systems being in place to ensure continuity of care.

HSSIB’s reference event – the patient’s experience

HSSIB’s report highlights the experience of a male patient with a history of breast cancer, alongside other conditions including learning disability.  Two years after he was discharged following treatment for his cancer, he developed severe back pain. He was seen at his local A&E department, and was discharged with pain relief and advice to contact his GP. A month later, he called his GP surgery and saw his named GP who requested a blood test, which the patient failed to attend and was never followed up. His GP also referred him to the practice’s physiotherapist, who advised him about exercises, but these did not relieve his pain. Over the next eight months he saw two out-of-hours GPs, six practice GPs, a nurse and a physiotherapist at the GP practice, as well as attending other consultations about unrelated issues.  At the end of the eight month period, he saw a GP who found a lump on his spine and advised him to go to his local A&E. At the emergency department, a CT scan revealed a lump on his spine, which was later diagnosed as metastatic breast cancer which had spread to his spine.

HSSIB’s investigation found that at every visit to the GP practice his back pain had been considered as a new symptom, because he was seen by different doctors. The overall picture was not recognised because, in isolation, the symptom that each doctor saw during his individual consultation with the patient did not justify referral to hospital for further investigation.

The patient’s GP practice told HSSIB that they understood the challenges caused by patients seeing several different GPs, and recognised that a robust system was needed to support continuity of care through the electronic patient record system, linking patients’ attendances for the same symptoms. As there was no system in place for continuity of care, the way that information was displayed to GPs in the electronic patient record system became more important. The GPs did not have enough time during consultations to complete all the necessary tasks required of them, leaving tasks to be carried out in their own time, which in turn was negatively affecting their wellbeing and their ability to deliver the service that they wanted to give their patients.

HSSIB’s investigation into GP continuity of care

In looking at the wider healthcare system, HSSIB recognised that continuity of care is not always necessary for all patients in all circumstances. Patients who need advice or treatment for acute (sudden or short-term) conditions, may simply want to see the next available GP. Continuity of care is more important for patients whose GP manages their long-term condition or whose acute condition could develop into something more serious. In these situations, patients told HSSIB they were prepared to wait longer to see their regular GP rather than have to explain their condition to a new GP.

GPs told HSSIB that having their own regular patients was beneficial to the patient but also helped the efficiency of the GP practice, because additional time was not wasted in establishing the patient’s history at every appointment. GPs also said that personal patient lists led to patients being more forgiving of their regular doctor when minor errors were made, and they felt more able to have ‘difficult conversations’ with patients about taking responsibility for their own health, such as by losing weight or stopping smoking. Seeing the same doctor also prevented retraumatising patients by making them retell their health ‘story’.

Patients told HSSIB that seeing their regular GP, meant that they had a relationship with their GP, often over many years, which allowed the GP to know them, their health and personal circumstances, and made it easier to talk openly, respectfully disagree, and trust their GP, even after mistakes. They did not have to re-explain long-term conditions, so their appointments made better use of the time. They were willing to wait longer for important appointments with their own GP, but if they booked an appointment with another for an acute problem, their own GP often moved them to their own appointment list for the day.

Despite these benefits, many GP practices which used a personal list system to deliver continuity of care to their patients told HSSIB that they did not receive funding for this service. Many GPs had, nevertheless, invested in the system outside of their contracted services.

HSSIB noted that GP practices which ran a personal list system for GPs to see their own patients achieved significantly higher scores from patients in the 2022 national GP satisfaction survey.  In contrast, practices that did not operate a continuity of care system scored significantly lower than the national average in terms of patient satisfaction.

What are the findings of HSSIB’s continuity of GP care report?

Both GP practice staff and patients told HSSIB’s investigation that continuity of care plays a vital role in delivering safe GP services. However, HSSIB’s findings included that:

  • the GP contract governing NHS GP services does not specifically require GP practices to provide continuity of care;
  • many GP practices do not operate a formalised system of continuity of care;
  • there is no standard framework for continuity of care in GP practices, so different practices do it differently across the country;
  • some GPs believe it is not possible to deliver continuity of care, even when they recognise its potential benefits;
  • there is no requirement for GP IT systems to consider continuity of care or to identify and flag patient information to GPs when they see a patient with unresolving symptoms.

Where continuity of care exists within GP services:

  • patients find it beneficial to see their named GP for long-term health conditions;
  • GPs have more time to process information during consultations and to take action to ensure patients receive the care that they need;
  • GP practices that have a system of continuity of care have better staff welfare and retention, and fewer recruitment issues, than practices that do not.

HSSIB found that GPs have limited time to read notes before and during consultations, making system identification and flagging of red flags essential.  GP IT systems do not currently present information in a way that enables GPs quickly to see whether a patient is returning with unresolving symptoms.

GPs told HSSIB that they are currently only seeing patients with the most complex needs. Other practice staff are dealing with patients with minor ailments or in specialty areas such as pharmacy and physiotherapy. In addition, GPs have no time between appointments to process emotionally or technically difficult conversations or issues with patients, before seeing the next patient, with cumulative effects as the day progresses. They feel unable to complete all the tasks that are required of them during a consultation, so work reduces their quality of life on days off and weekends. HSSIB noted that many GPs were visibly upset when talking about their workload and working environment, and many were planning to take early retirement, reduce their hours, or leave their practices.

HSSIB’s recommendations included changes to the NHS GP contract to explicitly include and support the need for GP practices to deliver continuity of care, and updating of GP IT standards, including the flagging of priority information to healthcare professionals when patients visit GP practices multiple times with unresolving symptoms.

If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.