Chair speaks to conference
Publication date: 29 June 2022
Full speech from the RCGP Chair Professor Martin Marshall at the 2022 annual conference.
Welcome to the 2022 RCGP-WONCA Conference, it’s such a pleasure to see so many people here in London to celebrate our amazing specialty of general practice. We all share a great pride in what general practice achieves for the patients, communities and health systems in each of our countries. But at the same time as the need for general practice increases, inexorably, year on year, we’re seeing examples in many countries of our specialty struggling to do what we know needs to be done. That’s certainly true of the UK where we are experiencing the most worrying workload crisis we’ve seen in decades.
A time of crisis is a good time to go back to some basic principles and there’s none better in our specialty than those described by the Canadian public health researcher Barbara Starfield. Her seminal work identifies the core features of general practice-led health systems which deliver better outcomes at lower cost than those dominated by hospitals. Starfield says high quality general practice provides first contact care, a comprehensive set of services, coordination between health and care services, and lastly the principle that I’m going to talk about today, continuity of care.
I work in an amazing practice in the East End of London, just a couple of miles from here. Our team serves a highly multi-cultural and socio-economically deprived community. One of my patients, who has been registered with me for the last 8 years, reflects the joys and challenges of working in an inner city practice. Mohammed is in his early 40s, married with 2 young daughters. He was born and brought up in Iraq and has been in the UK for about 15 years. He’s obese and like nearly 15% of the local population he has type 2 diabetes, which in his case is very poorly controlled.
I spent my first 18 months as his GP doing everything I’ve been trained to do as doctor, trying to better manage his diabetes. I failed miserably.
I pride myself as a clinician who has learnt how to build relationships with patients swiftly, but Mohammed was one of a small number of patients with whom I failed to make a connection. But then I read an article by Trish Greenhalgh, a good friend and a wonderful GP academic in Oxford, in which she asked readers to think about their experience as a patient, seeing their own GP.
Did you like your GP, she asked? Did she welcome you? Did she listen to you and empathise with you? Did she remember what you’ve previously told her? Did she show interest in you and your family? Did she follow up on previous conversations? Did it feel like she was focused on your agenda rather than hers? Did she seem to have your best interests at heart?
Trish said that if the answer to these questions is yes, you have a GP who is attempting to build a relationship with you because she believes that that will make her a more effective clinician.
I have to say that I took Trish’s article as a personal criticism. Call me paranoid but it felt like she was watching me consult with Mohammed and wasn’t impressed. I realised that I wasn’t being an effective clinician because I knew much about Mohammed’s diabetes but little about Mohammed. In essence, I was behaving like a doctor but not a family doctor.
A few weeks after reading Trish’s article I seized an opportunity to visit Mohammed at home following a call from his wife saying he was unwell, coughing, vomiting and feverish. On assessment it was clear that he had a chest infection. But the home visit resulted in a more significant discovery than some crepitations in the base of his left lung. I discovered that he lived in a 2 bedroom apartment with 17 other people. I discovered he had no kitchen. His wife told me that the family ate all their meals at the local fried chicken shop – for those who don’t know East London there are many fried chicken shops in our area. Indeed a public health colleague once told me that there were 47 fried chicken shops per secondary school in our area, a killer statistic if ever there was one.
So Mohammed ate fried chicken and chips twice a day. He loved his food because he told me it was tasty, filling and very cheap. He also confided that the café was a place of refuge from the over-crowded apartment, a place to meet friends and just chat.
That one home visit transformed my approach to Mohammed. At last I could see his poor diabetic control as GPs should, in psychosocial context. Here was a man at biomedical risk because of his obesity and ethnicity but more importantly one at psychosocial risk because of overcrowding in his apartment, an inability to eat healthy food, a lack of employment and a loss of pride because he was unable to properly care for his family.
These insights at last enabled me to make a connection with Mohammed. Rather than seeing him as yet another complicated patient that I had to squeeze into a highly pressurised working day, I did what we are trained to do as GPs, I invested time in getting to know him, I reminded myself to practice what Victor Montori calls ‘unhurried consultations’. It’s easy to deliver biomedical care at pace, more difficult to deliver whole-person medicine, the defining characteristic of our specialty. I was reminded that the more disease-based specialists know about their diseases, the more effective they are, the more family physicians know about the people we are caring for, the more effective we are.
Re-energised, I worked with others in our brilliant multi-disciplinary team on a new management plan. In partnership with the local council we managed to get Mohammed and his family rehoused in less than 6 months, helped him find a job in a local supermarket, referred him to a gym using an exercise-on-prescription scheme and introduced him and his wife to a new ‘shopping and cooking’ course that was being promoted by a local Imam.
I distinctly remember Mohammed’s incredulous response to this flurry of activity. ‘You’re a doctor’ he said ‘and you want to teach me how to cook?’. The word sceptical would be an understatement. But over time, as we got to know each other better, built mutual trust and confidence, he opened up more to me. I learnt that he was the middle of 3 sons, always regarded by his father as a disappointment. He coped by being the joker, the life and soul. I learnt how sceptical he was about doctors and how he believed that since his father and grandfather died in their early 50s, he was pre-ordained to do so as well.
Four years after Mohammed first registered with me, we had what felt like a break-through moment. In one of our increasingly frequent conversations he made clear that wouldn’t have engaged with any of my crazy ideas if he hadn’t trusted me. It took time to develop that trust – years in fact. But the investment - by both of us – helped me to be a better clinician. I felt like I had risen to Trish’s challenge.
As GPs you’ll all know that my personal experience with Mohammed is strongly supported by empirical research evidence. Mohammed is one of millions of patients who benefit from the simple fact that their family doctor has got to know them over time and has built mutual trust. A body of research evidence conducted over many decades in many different countries tells us that continuity of care is associated with better patient experience, fewer patient complaints, a stronger focus on prevention and health promotion activities, increased patient adherence to their medication and their willingness to follow expert advice, better clinical outcomes, a reduction in the use of hospital and Emergency Department services and lower overall costs.
Remarkably, a study published in the BMJ in 2018 by Professor Sir Denis Pereira Gray, our former College Chair and President, showed that continuity of care is even associated with lower mortality, not only in general practice but also in hospital settings and most notable in midwifery where, according to a Cochrane systematic review, it’s associated with a reduction in the perinatal death rate of 19%.
These conclusions, drawn from a highly diverse set of studies, were beautifully reinforced in an article by Sandvik and colleagues in the British Journal of General Practice in August last year, based on an observational study of 4.5 million patients in Norway. Having the same family doctor for 15 years was associated with a 30% reduction in the use of out-of-hours services, a 30% reduction in hospital admissions, and a 25% reduction in mortality rates, in comparison with having the same family doctor for less than 1 year. The impact of continuity on these outcomes was realised after less than 2 years of registration and there was a clear dose-response relationship over time.
So how does this drug ‘Continuity’ work? There are a number of possible mechanisms including biological explanations relating to neuro-endocrine-mediated immune function. The most plausible mechanism, I think, is the concept of ‘accumulated knowledge’, first described by Hjortdahl, 30 years ago. Based on a cross sectional study carried out in Norway, he describes how GPs build their knowledge and understanding of their patients’ medical history, personality, social and family networks, their work and interests, their values, hopes and fears.
Hjortdahl claimed that it took 1-5 years and 4-5 visits per year to create an extensive knowledge base. This accumulated knowledge increases the sense of responsibility that the doctor has for their patients and therefore their desire to sort problems out. Using a self-rating scale, Hjortdahl demonstrated a 5-fold increase in ‘sense of responsibility’ after just 12 months of continuity and a 16-fold increase after 5 years.
These remarkable figures will come as no surprise to experienced family doctors. Every day we experience how mutual trust makes it easier to avoid prescribing unnecessary antibiotics, easier to avoid requesting a clinically unnecessary MRI scan for headaches, easier to manage pressure from a patient for a dermatology referral for a simple skin rash. We know that patients who know and trust us are more likely to disclose that they are victims of domestic violence and more likely to provide a truthful assessment of their alcohol consumption.
So, I have to say, what’s not to like about continuity of care?
There’s no arguing with the facts that knowing and being known by your GP is good for your health. I’ve even argued that developing a trusting relationship between a patient and their doctor is the most powerful intervention that GPs have at their disposal. If relationships were drugs then clinical guidance would mandate their use.
I’ve provided a heart-warming account of continuity so far but now I’m going to introduce a reality check. If I can stereotype the traditional model of relational continuity of care for our specialty, it’s one GP, one patient, for 40 years. Sometimes it’s generations of GPs serving generations of families. My first GP trainer when I was a medical student was a fifth generation GP in the same practice in a market town in Wiltshire. He described how the first patient he saw when he joined the practice was a very old gentleman who opened the consultation by saying ‘your grandfather brought me into the world, your father looked after me as I was growing up and I want you to see me to my grave’. He did - after several years of care I’m happy to say.
I don’t doubt that there are some family doctors who want to continue with that model, but there are more clinicians who say, with some sadness, that it’s undeliverable. More than that, they say that advocates of the traditional model are clinging to the past. I speak to young family physicians who for a range of reasons are unable to deliver a high level of continuity and feel like they aren’t ‘proper GPs’.
There are legitimate threats to the traditional model of continuity. We live in a more mobile, more transitory, more transactional society than in the past, Doctors have different constraints on and expectations of their careers. General practice is changing too in many countries, in particular larger practices, a wider range of health professionals delivering care and greater use of technology.
Some people say we should just accept these changes and give up on any pretense that continuity is still deliverable. I think this would be a big mistake. What is general practice, if not a relational medical specialty? But I do agree that the nature of continuity, and how we deliver it, needs to evolve so that it feels relevant to patients, feels deliverable by clinicians and is seen as essential by health service leaders and policy makers.
What needs to change?
First, the building of relationships requires time and space. The current environment in British general practice is not conducive – on average 3 problems are presented in a 9.8 minute consultation – the second shortest consultations in Europe after Germany. British GPs are regularly working 11 hour days and seeing or speaking to over 40 patients in that time. Most GPs are working well beyond their capacity to deliver person-centred care and their relationships with their patients are suffering as a consequence. We need to be seeing fewer patients for longer if we are to realise the benefits of continuity of care. At a time when workload is going up and the size of the GP workforce is reducing, as it is in the UK, this may require a redesign of how we work, with a shift from GP-as-all-things-to-all-people to a more focused approach, where we add value as members of a wider professional team – and continuity of care is one of those areas. Last week our College launched a new campaign, Fit for the Future, highlighting these issues and promoting our solutions.
Second, the importance of relationship-based care needs to be made more explicit and perhaps less mysterious for the people who have the greatest influence on the design of our health systems - policy makers and system leaders. Politicians may never understand our passionate commitment to continuity but they will understand the hard-headed language of ‘value’ – better outcomes at lower cost. That is the argument which will most likely encourage them to think about the impact of their policies on the ability of frontline clinicians to maintain trusting relationships. And the evidence that I cited earlier makes a strong case for the cost-effectiveness of continuity of care.
Third, early career general practitioners in particular need to be reassured that whilst the traditional model of longitudinal relations with patients over many years remains the gold-standard of relationship-based care, it is possible for well-trained clinicians to build trust over a much shorter period of time. Highly trained generalists, using their understanding of the social sciences of psychology and sociology, are able to make useful connections with patients, quickly. We’ve all experienced these quick connections, how even in a single consultation you can see in a patient’s eyes whether they have confidence in you. The concept of ‘speed relationships’ will reassure and empower the growing number of practitioners who work part time or who are geographically mobile. I accept we’re compromising on the Hjortdahl model that I described earlier but compromise is necessary otherwise we risk losing all.
Fourth, we need to better understand the implications of remote consulting for relationship-based care, particularly in this post-pandemic era when a higher proportion of our consultations are tech-enabled, in particular using the telephone. Old research studies into telephone consultations in general practice suggest that they tend to be shorter and are characterised by less data gathering, less advice and less rapport building than face to face ones. But this evidence was created at a time when we weren’t using telephones much. As both training and experience in consulting remotely increases, digital interactions between patients and clinicians have become more substantive and more sophisticated. In addition, effective triage could improve continuity of care by directing patients in large practices to the clinician who best knows them.
Finally, more than half of the consultations which take place in general practice in the UK are delivered by members of the primary healthcare team other than doctors and we’re seeing similar trends in other European countries. The increasing multi-disciplinarity of general practice is viewed by some as an impediment to realising the benefits of the traditional relationship between a patient and their GP. But continuity of care is well-delivered by primary care nurses providing care for patients with long term conditions and there are increasing examples of micro-team based care in which relationships are held by more than one clinician. Continuity of care is a defining feature of family practice but doctors shouldn’t have a monopoly on its delivery.
So, I will conclude. As general practice in each of our countries responds to massive political and societal pressures and evolves, we need to remember that the essence of our speciality is our use of the bio-psycho-social model to deliver whole person care. Building and utilising trusting relations is the most effective way of delivering high quality care and in the absence of these relationships general practice is less effective.
If you happen to bump into Mohammed as you explore the lively communities of East London over the next few days, you wouldn’t recognise him from the man who registered with me eight years ago. I’m not claiming any miracles, life’s not like that. He still pops into the fried chicken shop occasionally. But he’s lost weight and his diabetes is under control. And he has a smile on his face and a bounce in his step. He’s not only re-found his health, he’s re-found his pride in being a husband, a father and an active member of his community.
Mohammed’s story reminds us all of what we do as general practitioners. The word ‘physician’ comes from the Greek word phuo which means ‘to grow’. And the word ‘doctor’ comes from the Latin word docere meaning to guide. Our job as a general practice team in East London has been, over years, to use our trusting relationships to guide Mohammed and to help him to grow. I’m pleased to say he thinks we’ve done a pretty job and he thinks general practice is amazing. So do I.
Thanks for listening and enjoy your conference.
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Notes to editor
The Royal College of General Practitioners is a network of more than 53,000 family doctors working to improve care for patients. We work to encourage and maintain the highest standards of general medical practice and act as the voice of GPs on education, training, research and clinical standards.