If the covid-19 pandemic has taught us all one thing, it is the value of human relationships. More than ever before, doctors, nurses, and all allied healthcare professionals are working virtually via telephone and video consultations, changing the way that we relate to our patients. Guidelines have sprung up telling us how to do this better, but something fundamental is missing: continuity of care. [1]
The importance of continuity of care has been amplified for me during the pandemic, both as a patient with type 1 diabetes for 35 years, and as a paediatric diabetologist. As a patient, I don’t want to have to repeat my story every time I see a new doctor, especially the difficult things that need discussing. As a doctor, how do I learn whether the advice I gave was correct, and how do I find out what my patient really wants from me, or when to gently nudge them in a different direction or provide reassurance? Knowledge of the patient allows me to be a better doctor, to give an individual approach, rather than responding to a blood glucose value.
Plenty of evidence exists about the benefits of continuity of care across many health conditions and ages. It improves satisfaction, reduces unnecessary referrals, and lowers mortality. [2,3] Continuity will matter more to some patients (and doctors) and more in certain conditions, than others. Some will sacrifice continuity if it means a long wait. Others who find the relationship therapeutic as much as the medicine, will rank continuity more highly. Managing and understanding that must be central to the discussion.
A snapshot online survey of 80 paediatric diabetes consultants in the UK, collected for a debate on continuity of care, during the British Society of Paediatric Endocrinology annual conference, identified that only 47% of consultants are able to practise continuity of care, despite the acknowledgement that it was important for their continued professional development and job satisfaction, and for their patients.
So if continuity is known to be beneficial, why is it not practised more often? One barrier is infrastructure and training: how do junior doctors get experience without moving to different specialties and clinics? If consultants need to be elsewhere, like a ward round or on holiday, should the clinic be cancelled? All this needs to be worked out and there isn’t a one-size-fits-all solution.
Many healthcare professionals have had to set up virtual clinics overnight. This drive towards innovation is a good thing: it has cut bureaucratic processes, can save money for the health system, and save time for the patient. As we hopefully start to emerge from the pandemic, the NHS and other healthcare systems will need to redefine how we function. Virtual working will be on the table, but before setting it up indiscriminately, we need to pause, and consider how it can best be used. The patient should remain at the centre, and be offered choice, to maintain and improve patient satisfaction and outcomes. Patient continuity, especially for chronic conditions, should not be unwittingly sacrificed: forming a healthy attachment between doctor and patient is at the core of how we relate and trust.
If the pandemic has taught us about the importance of human relationships, it has also taught us that if there is enough will, a solution can be found.
Rachel Besser is a consultant paediatric diabetologist at Oxford University Hospitals NHS Foundation Trust and author of Diabetes Through the Looking Glass – seeing diabetes from your child’s perspective. @BesserBesser
Competing interests: none declared.
References:
- Car J, Choon G, Koh H, Foong PS, Wang CJ. Video consultations in primary and specialist care during the covid-19 pandemic and beyond BMJ 2020; 20;371:m3945.
- Pereira Gray DJ, Sidaway-Lee K, White E, Thorne A, Evans PH. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018;8:e021161.
- Helen Salisbury H: Measuring continuity of care BMJ 2019;3;367:l6567. doi: 10.1136/bmj.l6567.