Much is changing but much stays the same

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The traditional view of general practice is one in which patients see “their” doctor and establish a relationship over time through effective communication between doctor and patient. Continuity of care is maintained by a patient having visited the same doctor over time. That model is changing and, at an increasing number of medical centres, a patient may see many different doctors as well as other clinicians such as practice nurses. Commonly, patients are offered the choice of being seen by the first doctor available on the day or booking an appointment at a later time with their preferred doctor.

In 2019, General Practice New Zealand issued a discussion paper, “Workforce and Resources for future General Practice”. The aim of the discussion paper was to describe what a widespread new normal for general practice could look like. It states that new technology has enabled a shift from the traditional episodic doctor-based consultation to different modes of delivering care, meaning that first contact care is no longer always conducted in person. Examples were email consultations, use of patient portals, or delivering consultations by video conferences. The paper states that effective and easily accessible universal primary care can reduce inequalities, but primary care has to be responsive, more comprehensive, and multidisciplinary. Similarly, the World Health Organization recommends inter-professional, collaborative practice in the provision of care for chronic and complex conditions.[1]

However, with lesser exclusive focus on individual doctor consultations and the involvement of a multidisciplinary team, attention must be paid to the need to ensure continuity of care, and to the issues that can arise when no single clinician takes overall responsibility for the patient.[2]

Research in Canada regarding patients’ perception of team care[3] found that for most measures of care, patients reported no change, and they appeared to value team-based care because of the benefits of having other health professionals involved in their care, such as increased education and knowledge about their condition and how to manage it, and improved psychological well-being and health-care independence. Patients felt that their access to primary care improved with team-based care in that it was easier to schedule appointments, and there was a decrease in appointment wait times. There was also a perceived decrease in emergency visits and hospital admissions. Almost all patients preferred to receive care from a doctor, rather than any other health professional within the family practice clinics. The patients appeared to identify doctors as the team leaders who had overall clinical decision-making responsibility, with other health professionals functioning in a supportive role.

The Health and Disability Commissioner (HDC) recently issued two opinions related to the continuity of care provided to patients seeing multiple GPs. In 18HDC02116, a man had a history of chronic obstructive pulmonary disease (COPD). He visited a medical centre five times in the space of a month with shortness of breath and chest pain. Although he was enrolled with a specific GP, he saw four different doctors at the medical centre over this period. Each treated him symptomatically, and did not think critically about his presentations, and consequently put his symptoms down to his COPD. There was a delay in diagnosing the man with congestive heart failure and, even when the correct diagnosis was made, its severity was underestimated and, sadly, the man died a short time later. The Commissioner noted that multiple doctors failed to apply critical thinking, review documentation adequately, and communicate effectively with one another. He found the medical centre in breach of the Code, because its systems did not facilitate cooperation between doctors. He also found an individual GP in breach of the Code, for failing to review the man’s previous medical notes and obtain the full clinical picture before diagnosing him.

In the second case (19HDC00536), the patient was taking lithium for his bipolar affective disorder. He attended a medical centre 24 times between 2014 and 2018 and saw six doctors. At most appointments he was prescribed lithium. However, as lithium toxicity can cause permanent kidney damage, his lithium levels and renal function should have been monitored every three months. Each doctor failed to recognise that the lithium monitoring was overdue and that the man’s renal function was deteriorating. In June 2018, he was admitted to hospital with acute kidney injury caused by lithium toxicity.

The Commissioner pointed to a failure to do the basics. There was a repeated failure of multiple GPs to prescribe appropriately or monitor the man’s lithium levels or renal function. There was also poor coordination of care, and clinical oversight reflected poor systems for continuity of care at the medical centre. The man was not informed of the risks of lithium and the need for associated monitoring, and so his informed consent was not obtained.

It is undoubtedly true that New Zealand primary care is facing challenges. These are complex problems but it appears that at least part of the solution lies in the use of multidisciplinary teams with processes being put in place to ensure continuity of care if patients are seen by multiple clinicians. In addition, particularly with complex patients, one clinician should be responsible for the overall management and coordination of the patient’s care.

New Zealand Doctor, 25 March 2020
Associate Commissioner Dr Cordelia Thomas

 

[1] World Health Organization. Framework for action on interprofessional education & collaborative practice. Geneva, Switzerland: WHO Press; 2010. [cited 2018 February 6]. Available from: http://www.who.int/hrh/resources/framework_action/en/.

[2] Opinion 08HDC06359.

[3] Olga Szafran, Sandra L. Kennett , Neil R. Bell, and Lee Green, 4 “Patients’ perceptions of team-based care in family practice: access, benefits and team roles”, Journal of Primary Health Care 10(3) 248–257 https://doi.org/10.1071/HC18018 Published: 4 October 2018.