Red and swollen from mid-shin to below the ankle, Daniel’s leg was not in a good state. It looked like cellulitis, a bacterial infection of the skin and subcutaneous tissues. I can cure most cases with antibiotic tablets, but Daniel’s presentation had been unusually rapid and was uncharacteristically painful.
“I think we’d better send you in.”
There was a half-beat of hesitation before he agreed. He and his wife, Lydia, cover the childcare between her work at a nursing home and his maintaining industrial refrigeration units. Anything unanticipated necessitates a rapid ring-round of friends, and sometimes shift cancellations. Daniel didn’t question whether hospital admission was necessary, though. I’ve looked after the family for years, including, at different times, both Lydia and Daniel when their just-about-managing lives had got too much. He knows I wouldn’t admit him unless I had to.
In hospital, blood tests supported the diagnosis of a fulminant cellulitis and he was treated with powerful intravenous antibiotics. His leg failed to improve. Scans showed a possible infection in the ankle joint, a complication that would require urgent surgery. The orthopaedic team took over, but a more detailed scan failed to replicate the finding. Over the next fortnight, Daniel’s leg made some progress, though he was still on crutches when he was discharged with a carrier bag full of antibiotics. I signed him off work; at least he was home again to help Lydia with the daily juggle. I told him I was glad he seemed to be improving, even if the diagnosis remained a mystery.
In August the British Journal of General Practice published the largest ever study conducted into continuity of care. Researchers at the University of Bergen had analysed the health records of 4.5 million people – virtually the entire population of Norway – and looked at what patients derive from a long-standing relationship with their GP. After adjusting for various confounding factors, what they discovered was little short of astounding. Patients who’d had the same family doctor for many years were 30 per cent less likely to use out-of-hours services; 30 per cent less likely to be admitted to hospital as an emergency; and 25 per cent less likely to die than people registered with their GP for under a year. The risk of needing emergency care or dying began to decrease once patients had been with the same doctor for as little as two years, and continued to fall steadily thereafter. This “dose-response” relationship (in which the more you have of something, the more you benefit) strongly implies causality. Knowing and being known by your GP really is good for your health.
Continuity was widespread in UK general practice when I was growing up in the 1970s and early 1980s. Most people would have been able to name “their” doctor. Today the picture is very different. The annual GP Patient Survey conducted by Ipsos Mori since 2006 has been tracking the proportion of the population who feel they have this kind of relationship, and it has been declining every year. In 2021, the figure dropped below 50 per cent for the first time. Pressure on out-of-hours services and emergency departments has been growing for years; figures released in February 2020 showed life expectancy to have stalled, something that hadn’t occurred since records began. There are many contributing factors, not least a decade of austerity. But the Bergen study shows that these are exactly the consequences you would expect as continuity of care is eroded.
We know that continuity is strongly valued by patients. This autumn’s toxic campaigns in the Daily Mail and Daily Telegraph – singling out GPs for blame when the entire pandemic-decimated NHS is failing – have fear and abandonment at their heart. The demand for face-to-face encounters is an obvious proxy for having a relationship with a family doctor we know and, crucially, trust. Continuity also contributes substantially to GP job satisfaction. The Health and Social Care Select Committee – chaired by the former health secretary Jeremy Hunt – recently found that general practice is “in crisis… an utterly exhausted and demoralised workforce”. On 16 November the committee announced “one of our most important inquiries of the coming year” into its future. GP numbers have slumped. England alone is at least 6,000 GPs short of the government’s stated target (one that the Health Secretary, Sajid Javid, has acknowledged he will fail to meet). This amounts to a 20 per cent shortfall in total numbers, leaving fewer family doctors to deliver ever more work, and driving an exodus from the profession: burned-out GPs are retiring early while younger recruits switch to alternative careers.
For Professor Sir Denis Pereira Gray, continuity has been the focus of a lifetime’s research. A former president of the Royal College of General Practitioners (RCGP), he was the first family doctor to be elected chair of the Academy of Medical Royal Colleges. He was knighted in 1999 for his contribution to general practice, and in 2010 voted by his peers as one of the most influential GPs of his generation.
I travelled to Exeter to meet him in the summer. He collected me from the station and drove me in his hatchback to the St Leonard’s Practice where, although now retired from clinical practice, he continues to lead his research group. His two key collaborators, Professor Phil Evans and Dr Kate Sidaway-Lee, were waiting to meet me. In 2018, the trio were co-authors of a landmark review, looking at all the evidence on continuity of care published worldwide since 1996. They found that it reduced death rates across countries and cultures, in both the GP and hospital setting.
“And it’s not just in medicine,” Pereira Gray explained. “It applies equally to midwifery, where continuity reduces perinatal mortality [the death of babies] by 16 per cent.”
There are other benefits: patients are more likely to follow lifestyle advice, attend screening and vaccination appointments and stick with treatment. Continuity reduces prescribing costs, results in fewer referrals and protects the health service against litigation costs.
“And it doesn’t take long to build,” Pereira Gray added. He cited research showing that patients’ relationships with their doctors typically deepened over their first eight meetings, while a doctor’s sense of responsibility for a patient was increased after two consultations. These appointments may be over minor complaints, too – a viral infection, a contraception query, a skin concern. “None of us know when some serious health problem will strike,” Pereira Gray said. “But the apparently unimportant everyday stuff lays the foundations of the relationship for when it does.”
A common counterargument is that continuity is no longer attainable. Practices are ever larger, and the trend towards less-than-full-time (LTFT) working means that fewer GPs are physically there every day of the week. But Pereira Gray’s research shows that even practices staffed entirely by LTFT doctors can achieve impressive rates of continuity.
“General practice is quietly splitting into two factions,” Pereira Gray told me. There are the surgeries for whom continuity remains an important goal, which he places in the minority. The majority regard all doctors as equivalent and provide “taxi-rank medicine”, with each patient contact representing a fresh episode to be picked up by the next available clinician. Pereira Gray is clear that as practices merge and expand, the default is for continuity to be lost unless careful steps are taken to preserve it, but he knows of several large surgeries that have successfully done exactly that.
It ought to be a high priority for politicians and health leaders. If continuity were a pharmaceutical product, the National Institute for Health and Care Excellence (Nice) would be mandating its deployment (a 25 per cent reduction in mortality is far greater than virtually any drug that Nice advocates). The Care Quality Commission should be assessing continuity as a critical aspect of its inspections. The Department of Health should be devising policies to incentivise its provision.
None of these things is happening. At the end of my visit to St Leonard’s, I signed the visitors’ book. Mine was the first entry after a Covid-enforced gap of 18 months, but earlier pages were a roll call of everyone who has learned first-hand from this elder statesman. Pereira Gray’s group has been highlighting the importance of continuity for decades, and seen scant attention paid by those running the NHS. As he told me, “We’ve been a lone voice for a very long time.”
A couple of weeks after discharge, and while still taking oral antibiotics, Daniel’s leg deteriorated. I took urgent bloods which painted the same picture. I got on the phone to the orthopaedic team; they reviewed him immediately, but couldn’t arrive at a diagnosis. The next stop was an urgent rheumatology appointment, where the consultant ordered a battery of tests. What had looked like a simple if refractory leg infection had become a bewildering maze of rare diagnostic possibilities, some of them potentially life-altering.
The weeks off work turned into months. Daniel’s sick-pay provision dropped. The family’s savings exhausted, Lydia took on extra shifts to keep them afloat. In chronic pain, Daniel sank into depression. We’d been here before, he and I, several years ago, at a time of comparable life difficulty. I prescribed the antidepressants that had been effective then, and referred him for counselling.
Lydia came to see me, experiencing chest pain and palpitations. A careful evaluation and a listening ear enabled her to understand them not as the heart problem she feared, but manifestations of the strain she was under. And when Claire, their seven-year-old, began to suffer abdominal pain and nausea, I was able to put it into context – not a “grumbling appendix”, urine infection, nor a life-threatening cancer, but a child reacting to the stresses permeating the family home.
Dr Chris Garrett agreed to speak to me on the understanding that I change his name and not identify the large practice where he works. This is one of a new breed that has grown up over the past 15 years, the result of government policy to push general practices to work “at scale” (bigger being more cost-efficient), coupled with contractual changes that have created a type of doctor that didn’t exist 20 years ago: the salaried GP.
The organisation that employs Garrett is an amalgamation of three smaller surgeries, with close to 30,000 patients. Prior to the merger there were 16 GP partners working across three practices, and each doctor had a long-term commitment to their surgery and its patients. The new super-practice is run by just four partners, with most of the clinical work done by salaried GPs like Garrett, who have no control over how services are designed and delivered. If they find them intolerable, their only option is to move on.
Garrett is typical of many of his generation. In his mid-thirties, he operates a portfolio career, working two days a week at the practice and another two in his local hospital’s stroke service. On Wednesdays, he is involved in a research project looking at falls among the elderly. “In some respects, you could say I’m part of the problem – another one of those part-time GPs,” he told me. “But I need to have a balance just to survive.”
His hospital role is comparatively “civilised”, he says: fixed clinics with adequate appointment lengths and a ceiling on the number of patients; a half-hour lunch break; and a reliable 5pm finish. But in general practice, “I’m working 13-hour days, at the end of which I’m just broken.”
When Garrett joined the practice, virtually every ten-minute appointment was reserved for booking on the day. The partners had done this in response to government pressure to prioritise ease of access; the practice’s figures for the proportion of patients dealt with on the same day look exemplary. But the price that patients pay is the daily 8am dogfight for an appointment; this can involve up to an hour spent pressing redial to get through. When they do, some patients find that all the slots are gone. They will have to do it all again tomorrow.
It’s a system that precludes continuity. “If I want a patient to follow up with me,” Garrett explained, “I have to tell them to ring in on a specific day. Hopefully, they’ll get through. Hopefully, I’ll still have a slot.” It is such an unreliable system that Garrett ends up contacting those he feels most need his ongoing care. These consultations are in addition to his contracted appointments, lengthening an already punishing day.
At one point he approached the partners. “I said, ‘When did GPs stop seeing continuity of care as integral to what we provide?’” They grudgingly agreed to convert a few of his on-day appointments into follow-up consultations. This helps, Garrett said, but it is nowhere near enough.
Not all of his salaried colleagues are as conscientious. Some GPs, Garrett told me, will simply do whatever is necessary to close a consultation within the allotted ten minutes, avoiding engaging thoroughly because they know that, next time the patient calls, they are likely to be someone else’s problem. He doesn’t blame them. “There’s a lot of firefighting, people just trying to get through that day.”
This experience of primary care – a sense of being fobbed off, and of no one taking ongoing responsibility – will be familiar to many patients of large-scale practices, particularly those who have any degree of complexity to their case. As well as being dispiriting and damaging, it is highly inefficient, as Garrett explained: “People end up having five appointments with a succession of different doctors – where one thorough consultation, maybe 20 minutes long, would have got to grips with it all.”
While this new breed of super-surgery is the product of government policy, many within the medical profession have colluded. The “industrial” practice, where clinical work is largely undertaken by salaried (and cheaper) colleagues, has in many instances been lucrative for the handful of partners who own and manage them. To politicians with no background in healthcare – and doctors willing to don blinkers – it doesn’t matter who a patient sees. All they need is to connect with someone, anyone.
The Bourn Surgery in Cambridgeshire operates a personal list system – one where each patient knows which GP is responsible for their care and is encouraged, but not compelled, to consult with them. I spoke to Dr Francesca Frame, who joined as a salaried GP seven years ago. She’d experienced “industrial”-style general practice, but when she came to the Bourn during the final year of her postgraduate training it was an epiphany: “I thought, ‘This is what I have always envisaged – this is what I’ve always wanted to do.’” Frame became a partner two years ago, and like every other doctor there she works less than full-time, maintaining an external role with her Local Medical Committee, a body which advises practices in their dealings with NHS commissioners. Frame and her partners are proof that traditional general practice values can still be offered to patients: it just takes intention and care.
The gabapentin I’d started some weeks back was at last kicking in; Daniel’s pain was coming under control.
“Yeah, it’s a lot better,” he told me.
His leg was still red but much less florid. He was following orders, using the crutches to take the load off.
“Six months, then we’ll see,” he said.
I asked how he felt about that.
“At least I know what’s what.”
The rheumatologist had finally arrived at a diagnosis: a rare form of destructive joint disease that usually only affects patients with diabetes, a condition Daniel doesn’t have. He needed to keep his weight off the leg for half a year, by which stage the limb would have improved as much as it ever would. After that, another team of orthopaedic surgeons would decide what might help any residual disability.
We sorted a further sick note, this one to facilitate benefits claims. With no prospect that Daniel could return to his former role, his boss had let him go. I talked him through the staged increases in gabapentin dose that I hoped, over the coming weeks, would manage his pain.
“How are things at home?” I asked.
“Yeah, good, thanks.”
He was in noticeably better form. After months of uncertainty, he knew what he had to contend with. His boss’s decision had crystallised the family’s financial circumstances; he could now apply for support. The gaba-pentin must also have been playing its part: continual pain is debilitating. The prospect of respite was at last tangible.
I started to draw the consultation to a close. But a thought intruded from nowhere: ask him about depression. It seemed incongruous; it was obvious Daniel was in a better place. I even felt irritated by it: what was the point in prolonging the consultation? But despite the internal tussle, I asked him: “And you. How are you, in yourself?”
He didn’t say, “I’m fine, thanks, yeah.” He didn’t say anything. Instead, his eyes flicked down and he stayed like that for a long time.
Professor Martin Marshall has been in the media far more than he might have liked over recent months. As current chair of the RCGP, he has given countless interviews, written for newspapers and appeared before the Commons Health and Social Care Select Committee, all to defend the profession against a sustained assault over the question of face-to-face GP appointments, as the pandemic grinds on.
In spite of this, Marshall was upbeat during our video conversation. I first met him in December 2019, a month after he’d taken office. Then, a key aim for his three-year term was to advance understanding among politicians of the pivotal role GPs play in the NHS – what he has dubbed “relationship-based medicine”. This has much in common with continuity of care, but also emphasises the particular expertise that family doctors have in interpreting the complex interplay between patients’ emotions, psychology, life circumstances and physical health (known as biopsychosocial medicine).
How would he rate his progress on that score, I asked him? Marshall shook his head and laughed. Just a few months into his tenure the world had been upended by Covid. “I think the whole health service has become more transactional, less person-centred,” he told me. “It’s had to be, to even begin to cope. Surgeries that are still providing traditional continuity are very much in the minority – perhaps as few as 10 per cent.”
It is the consequences of this transactional shift that look likely to push continuity of care centre-stage. Francesca Frame told me that her relationship with her patients had played a vital part in being able to manage their problems remotely, where appropriate, during the first waves of the pandemic. Patients at “industrial” surgeries like Chris Garrett’s will have had a very different experience, battling to get a call from a doctor they may never have spoken to before.
“I’m not very popular [in political circles] for saying this,” Marshall said, “but 80 per cent of the answer to the current crisis lies in recruiting more doctors.”
The responsibility for that lies with the government: sustained cuts during the decade of austerity have made general practice a decreasingly attractive career. Politicians have banked on plugging the gaps left with less expensive, non-medical professionals, with remaining GPs increasingly reliant on IT “solutions” to increase their productivity. (Prior to the pandemic, and up until the point he resigned, the former health secretary Matt Hancock was a passionate advocate of remote consulting and artificial intelligence apps.) Jeremy Hunt’s select committee inquiry must also address the discredited 2004 Carr-Hill formula – a funding settlement that leaves some practices so disadvantaged that they are unable to recruit.
A reinvigoration of continuity of care does not depend on the return of outdated working practices, when surgeries were run by full-time, mostly male partners. Pereira Gray’s research, and Francesca Frame’s lived experience, show that continuity can be delivered by modern practices staffed by portfolio GPs – both salaried and partners. But the government needs to dispense with the micromanagement of clinical activity and the fetishisation of guidelines; it needs to recreate an environment in which GPs have the time to manage each patient according to their needs.
Corresponding with Pereira Gray after we met in Exeter, I asked him if we might be in the throes of a battle for the soul of general practice. He readily agreed. I asked Martin Marshall the same question. “The battle for the soul of general practice will never cease,” he said. “Any more than the battle for other glorious institutions.” Institutions, I understood him to mean, such as the NHS itself.
I still can’t say what prompted me to ask Daniel about depression. When he finally spoke, he haltingly told me how worthless he felt now that his working life was at an end. How he’d been researching methods of suicide, and had stored in his garage the things he would need. No, he hadn’t said anything to Lydia. I was the only person he’d told.
In the field of suicide risk assessment, this constituted a huge red flag billowing in the wind. I referred Daniel urgently to the mental health team, who scooped him up the same day. A few months later, a card turned up in my in-tray from Daniel, handwritten in block capitals: “YOU KNOW I’M NO GOOD AT SAYING THINGS IN WORDS BUT THANK YOU FOR SAVING MY LIFE.”
My belief is that, having known him for years, and having seen him in adversity before, a warning bell had been set clanging in my subconscious. And, trusting me, he’d felt able to reveal his darkest thoughts. I don’t know how any of Daniel’s family would have fared in an “industrial” surgery, under a taxi-rank system. Lydia with her chest pains and palpitations: an emergency admission, perhaps; certainly a cardiology referral. Claire with her abdominal pain and nausea: a surgical admission or a paediatric review. As for Daniel, I take no special credit; I was just doing what I have been trained – and what I had the opportunity – to do.
Daniel is now back in full-time employment, albeit in a more sedentary role, and needs hardly any pain relief for the residual symptoms in his leg. I am currently helping Lydia with symptoms of the menopause. I have not seen Claire for some time, but I trust she is thriving at school. Without continuity of care I believe their stories would have ended very differently. But there are no counterfactuals in life; we have to be guided by the objective evidence, which, when it comes to continuity of care, is overwhelming. Sajid Javid, please take note.
This article appears in the 09 Dec 2021 issue of the New Statesman, Christmas Special