PROFESSOR ROB GALLOWAY: How my patient proved how important it is to see the same doctor every time

Would you like to know how valuable it is to have your own GP who knows you and whom you see at every appointment? Yesterday the Mail reported that almost a third of patients ‘rarely’ saw the same GP, and only half ‘always’ or sometimes’ saw the same GP.

Let me show you what happens if you don’t have this, because we pick up the pieces of this every day in the emergency room.

Last week, an 84-year-old gentleman presented to the emergency room with difficulty breathing due to complications from his heart failure. He had almost survived until then, but a recent respiratory infection had tipped him over the edge.

But when he called his GP for an appointment, someone wasn’t available quickly enough, so he was told to call 911.

If he had seen his usual – and experienced – GP, and knew him as they did, they would have done everything they could to keep him out of the hospital and would most likely have given him antibiotics and increased his dose of heart failure medication.

Instead, the 911 call handler typed his symptoms into the computer and the algorithm decided that an ambulance should be called. Three hours later the paramedics arrived; they are highly skilled essential members of the NHS – but their training is focused on treating acutely ill patients.

My patient was not acutely unwell, but chronically unwell, with a chest infection that was the straw that broke the proverbial camel’s back. The paramedics could not do what the patient needed: adjust his medication and prescribe antibiotics.

Instead, they took him to the emergency room; When he arrived late at night, he was – yes, you guessed it – placed in a hallway and given a battery of tests, many of which he didn’t necessarily need, like an EKG and a chest X-ray, but who required the protocol because he had a breathing problem.

One of these tests, a d-dimer test, revealed a problem. This test checks for a clot in the lung, but it’s not a great test; the test rises under a number of other conditions. Including chest infections.

The test was ordered by an inexperienced employee because the patient was short of breath. When a junior doctor saw the results, they were understandably concerned.

Because they had spent most of their training in hospitals – and had never worked in a general practice – they responded according to their training: they had to rule out a potentially life-threatening lung clot.

And so an expensive CT scan was ordered – not only was this normal, but it also delayed the scans of patients who really needed one.

By the time I was asked to assess this patient, it was 3am.

And while I would have otherwise fired him, I couldn’t because it was too late and there was no transportation available to take him home.

The only thing I could do was admit him to a ward. Outside his usual environment, he lost his self-confidence, fell and ended up staying in the hospital for over a week.

What could have been handled in a ten-minute personal consultation with his own GP, ​​who knew him well, ended in an unnecessary hospital admission that was many times more expensive than a GP appointment.

This is not an isolated case. And as someone who has dedicated his entire career to working in the NHS, it pains me to write this – but the NHS is really failing.

No wonder the public has lost confidence in it, as the latest annual British Society Attitudes Survey shows.

The results showed that although the public still supports the principles of the NHS, satisfaction with healthcare is now only 24 percent; in 2010 that was still 70 percent.

While there are many problems with our healthcare system, at the heart of it is the lack of continuity of care with your primary care physician.

If patients were treated differently, outcomes would be better and in a more cost-effective way – and the data supports this.

And yet the government is not trying to retain GPs, especially experienced GPs: although there is some extra money for GP practices, they are specifically not allowed to spend it on GPs, but must spend it on other (cheaper) doctors. staff who do not have the level of expertise, such as physician assistants. This will further undermine patient satisfaction.

But back to why seeing the same doctor matters. In a new study in the journal Management Science, researchers from the University of Cambridge analyzed data from ten million GP consultations.

They found that when patients saw the same doctor, their care was better (evidenced by the fact that the time between their appointments was 18 percent longer compared to patients who saw different doctors), which reduced demand.

This echoes a 2017 study in the BMJ that reviewed the medical notes of 230,472 older adults in England: continuity of care reduced hospital admissions.

Another review of 42 studies, published in 2021 in the journal BMC Primary Care, found that continuity of care for patients with diabetes or hypertension reduced their risk of premature death and the need for hospital care.

But for me the most important study is one from 2022, which showed that the longer you had the same GP, the less you used the GP post and the emergency department, the fewer hospital admissions you had and the lower the risk of disease. dying early, the British Journal of General Practice reported. This was based on data from more than 4.5 million patients in Norway, so this is research we should take seriously.

What all these studies have in common is that continuity of care is the key to improving outcomes – and more importantly, making the healthcare system affordable. However, experience is crucial.

Experience – and the autonomy doctors have – allows them to become a ‘risk taker’, which is necessary to help the NHS survive.

Riskatician is my word for making decisions in the best interest of the patient, but knowing that there is a risk in that you could miss a diagnosis because you don’t do all the possible tests.

The other thing all these studies have in common is that they are being ignored by those who run our NHS – who have chosen to waste money on initiatives to improve access, but not by the healthcare professionals who know the patients or have the experience to to do this. these risk-based decisions: GPs, of course.

This is where that extra funding comes in. To cope with the number of GPs retiring or leaving their jobs, practices will receive a further £1.4 billion in funding.

But the catch is that they are not allowed to spend the money on general practitioners who can provide the perceived continuity of care that is so necessary. Instead, they should spend it on support staff such as physician assistants, health coaches, musculoskeletal specialists, pharmacists and paramedics.

They are all good at the role they have been trained for, but they are often asked to see patients that a senior GP would normally see.

Without the same level of expertise, training and autonomy, the decisions they make are often risky and not good for the patient.

During a recent shift I saw a patient who had been seen by a paramedic in a GP surgery.

This patient died of pneumonia. The paramedic had referred them to hospital for fluids and antibiotics: this was safe care, but the patient was in a nursing home and had dementia. What was really needed was a conversation with their families about how to stay home and feel comfortable while nature took its course.

This is what GPs are experts in. Furthermore, some people without the experience of primary care physicians but who do fill that role – such as physician assistants – literally do not have the experience to recognize how sick some patients are, and unlike that paramedic, they may not refer the patient to the hospital when necessary. It. But that’s a topic for another day.

As physicians, we use evidence-based medicine to treat our patients. NHS leaders must do the same.

Evidence suggests that the most cost-effective use of NHS money is to ensure that GP practices have the resources to provide continuity of care from an experienced doctor. Only then will public perception of how well the NHS is doing really start to recover.

@DrRobgalloway