The secret of the care of the patient is in caring for the patient—Francis Peabody, 1927
Francis Peabody's famous comment, above, is nowadays questionable. Few of us would choose to consult a doctor whose judgements are ruled by emotion. And what about technical performance? Mistakes may be forgiven but incompetence, no. We have come a long way since 1927. A new contract being offered to UK general practitioners this year subdivides their work into 130 indicators of quality that will determine how much they are paid. In this revolutionary deal, GPs will be allowed to shed some of the responsibilities they find burdensome, but the shift towards a consumer model does not include patient choice of doctor: in future, patients will register with the practice rather than a doctor, though ‘they will still retain the choice, where appropriate, to request to see an individual GP’. Already, some GPs are looking aghast at the prospect of recording consultations in the manner of a supermarket checkout; and a pervasive worry is that primary care will become focused on the aspects that are being measured. The ‘personal doctor’ is threatened with extinction in the UK, and those who worry about the implications for doctor—patient relationships must seek comfort in such phrases as ‘Holistic care will be incentivized through holistic care payments under the quality framework’.
How important are long-term personal relationships in primary care? By chance, two papers in the current JRSM deal with this issue. Both come from the Exeter team led by Sir Denis Pereira Gray, whose interest in the subject goes back more than 30 years. The first paper, headed by Pam Lings, reports a qualitative study conducted to determine the factors important in doctor—patient relationships (p. 180). After preliminary work in the UK, the group examined views from staff and patients in a primary care centre in the USA (where the consumer model is more fully developed). A striking observation was that, on both sides of the divide, patient and doctor, much weight was put upon ‘liking’. Trust was also important, and a third observation concerned an ‘asymmetry of perceptions’ that spoke against the consumerist notion of a partnership of equals.
Lings and her co-workers suggest that liking and trust are products of continuous relationships—of the kind now under threat—and this brings us to the review article on p. 160. In a massive endeavour, Pereira Gray and his colleagues have reviewed the published evidence for and against their ‘Exeter theory of continuity’ whereby a primary-care doctor with ‘accumulating knowledge of the patient's history, values, hopes and fears will provide better care than a similar doctor who lacks such knowledge’. Their conclusion from this review is that, although there are a few aspects in which continuous relationships seem detrimental, and although some groups of patients actually prefer an impersonal service, general practice would be much impoverished by a move away from continuity.
So that brings us back to today. The proposed new contract offers solutions to several of the discontents among GPs, while providing a hopeful route to better quality control in primary care. However, good indices are no guarantee of happiness on either side. A point in the Exeter review is that doctors as well as patients have much to gain from a relationship that is working well. The challenge for GPs now is to find ways of adapting to the new contract without losing the their old valued function as trusted adviser—the doctor who, as well as possessing good knowledge of what can be done, is familiar with the circumstances and has good judgment on what should be done.