Continuity of care is the key principle which runs through everything doctors do at the Elmswood surgery in Sherwood, Nottingham.
During the course of one morning in January, Irfan Malik – one of the six partners at the practice – sees patients he has been treating for decades, families whose stories he knows like his own, and even one young adult he first assessed during her baby check 22 years ago.
That continuity is not just a relic of the profession’s past fortunately preserved here – it has been carefully cultivated with partners.
The 9,000-patient practice is solely doctored by the six partners and registrars in training, who fight to prioritise a culture led by staff wellbeing and the relationship between patients and doctors.
‘We call it an old school method,’ Dr Malik says. ‘We are probably atypical because we’ve got no vacancies – so many places are under-recruited. We are very lucky and over the years we’ve built up an excellent rapport with the patient population.’
The results of continuity are clear in this residential area, just north of the city centre: rates of admission to hospital are relatively low, even though the population here is ageing and patients are managed in primary care for longer with low referral rates because each partner specialises in interventions which would often be carried out in secondary care.
Beyond that, Dr Malik says doctors here are rarely abused and relationships with patients are excellent, despite concerning trends elsewhere in the country. The mainstream media – and government – narratives about general practice could not feel any further from the truth in Dr Malik’s consultation room.
‘I know we are losing that continuity around the country, but luckily we’ve got it here. And as well as the medical side of things I enjoy the banter and the conversation, too… Talking to them about the football or the cricket is why I’m here as well.’
We’ve built up an excellent rapport with the patient populationDr Malik
Dr Malik adds: ‘We hardly get any people kicking off here. The receptionists may have a slightly harder time because they have to put people into appointments but generally the patients are lovely.’
Evidence for the benefits of continuity of care is not difficult to come by, but anecdotally the effect is clear here, too. During the course of 16 patient consultations in one morning Dr Malik is able to deal with incredibly complex patient stories efficiently, but also with great humanity – his understanding of the histories and characters of his patients combined with a genuinely caring and inquisitive disposition, ensures discussion around, and reassurance over, a number of issues to take place in the space of just 10 precious minutes.
Breadth of expertise
On this freezing January morning the breadth and complexity of the patient caseload is astounding to the lay person.
Dr Malik sees an older couple wanting to discuss the husband’s Parkinson’s, potential DNAR instruction, recent bout of COVID, and potential palliative care for a cancer diagnosis.
Another patient needs help deciphering the results of a number of tests relating to a recent stroke and support with wider agencies such as the DVLA. Some patients are less complicated – coughs and colds dealt with over the phone and in person, a likely golf-related knee injury and blood pressure reviews among others – but each is clearly left feeling more empowered and less anxious.
I enjoy the banter and the conversation. Talking to them about the football or the cricket is why I’m here as wellDr Malik
These patients would be much worse off without this continuity of care, and the wider system is already struggling to cope – it is not in a position to take further responsibility for people in this area.
In February, Nottingham’s hospitals stood down a critical incident not because pressure had eased but because the crisis was so consistent and prolonged they could no longer have a significant effect by escalating to the most severe alert level.
Hanging by a thread
The model in Sherwood clearly works, but the truth is that continuity, and the successes it brings, are fragile concepts.
Dr Malik says the winter of 2022/23 has been easily the toughest in his three decades in the profession - and each urgent, same-day, appointment required means the management of longer-term issues is pushed back.
On top of that, punitive pensions taxes means doctors such as Dr Malik are actively considering their futures in the short and medium-term and just one or two GPs leaving this surgery could destabilise everything.
He says that continuity would instantly ‘begin to wobble’. Dr Malik is clear this is a crucial year for his surgery and for the wider profession and system.
Ministers, he says, need to show ‘real political will’ and a genuine commitment to both general practice and wider issues like social care, or patients will suffer the consequences.