Continuity (ii)

Funny that ‘continuity’ should have two parts –

This aspect of continuity is about relationships, in particular those which exists in a clinical context, between doctor and patient; it is likely that this is relevant to all who work in health and social care, but, given that the model which still remains dominant is that of the doctor-patient dyad – the semi-mystical, secretive, occasionally inexplicable association between those who are in some sort of difficulty – physical, emotional or psychological and the individual who is committed to rooting-out the cause, determining the effect and establishing the treatment or care, I will focus on this. And, I guess, being a doctor, I am biased.

In the olden days… Say, 15 years ago, when I was a bright young thing, enthusiastically running from ward to ward, full of a sense of purpose, focus, and excitement, the world of hospital medicine was very different to that of today – in particular, and in relation to one very specific aspect (I appreciate there is a heck of a lot of other things have changed since then) – that is, the relationship between a doctor and a patient coming into hospital.

In those days, I might have been the doctor who met you in A&E, who first treated your breathlessness, palpitations or pain, I probably would have met your family, discussed first-hand, aspects of your experience that could not be conveyed in any other way; I then, would have seen you on the ward, supported you through the first days and onwards – I would have arranged tests, investigations or treatments to help establish what had gone wrong, I would have continued your care through to the day you left the hospital and went home and sometimes, I would even see you a few weeks later in the clinic, to ensure that all was still going well.

Today, this continuity of care is a rarity. The fragmented healthcare system, which has fallen victim to changing times and attitudes; to specifically name a few culprits – the European Working Time Directive, Modernising Medical Careers and now the Government’s attempt to finally hammer the nail into the coffin.

Many of the changes associated with the above initiatives have been intended to make things better – usually to reduce the silly hours we used to work, or the inconsistent training we received on our journey to be consultants, and now the tabloid-propaganda of seven-day working.

With each change, each iteration, there has been a wearing-away of continuity, a fragmenting of that relationship that used to be between hospital doctor and patient – this still exists within general practice, although it is variable and continuously threatened by guess who…

Nowadays, the doctor you meet in A&E will be different to the doctor you meet on the ward; the doctor you meet in the morning will be different to the one at night, Monday through each day of the week, the odds are that you will meet a different doctor – the consultant is likely to be a presence, but in terms of the relationships, the time spent expressing hopes, fears and anxieties, the continuity is gone; even with nursing staff, most of whom nowadays work 12-hour shifts, that is, potentially, three days-on, four off, the day by day understanding of change in those they are treating is diminished.

Over the past few years, the response to this fragmentation has been ‘handover’ a face to face, although very often written exchange of information as to which test to book, what result to chase, whether the patient is ‘medically fit’ – this process is now ritualised in hospitals across the country, and in essence, it is very often all we have – the notes scribbled on pieces or paper, or in more sophisticated organisations, transmitted electronically, yet, it can never compensate for that relationship we once had.

I try my best to ensure the continuity of care, of relationships, particularly on my ward, which is critical as so many of the patients themselves are lost – being lost within a system which is itself lost, must be terrifying.

Can we ever go back to the good old days? I doubt it, but at least, we can acknowledge that what we have now is deficient, can never convey the same level of information, of emotional capital previously invested. We can at least not pretend that we know someone because we have their name, date of birth and diagnosis.

And, if anyone is listening, and I know for a fact that many people are, this is one of the central issues of the junior doctor’s protest – they are the people who have to sit with relatives they have never before met, discussing patients they do not know, supporting them through pain and grief, they are the ones who understand the importance of this relationship, that if you stretch the rubber-band too far it will snap; the thinner the paint, the more you will cover, but that is not what we want, it is not what patients want.

So let us praise continuity, acknowledge its importance, celebrate its gift.