Continuity of GP care: using personal lists in general practice

The hidden work of general practitioners: An ethnography

High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity.

Primary care micro-teams: an international systematic review of patient and healthcare professional perspectives

BACKGROUND

International trends have shifted to creating large general practices. There is an assumption that interdisciplinary teams will increase patient accessibility and provide more cost-effective, efficient services. Micro-teams have been proposed to mitigate for some potential challenges of practice expansion, including continuity of care.

AIM

To review available literature and examine how micro-teams are described, and identify opportunities and limitations for patients and practice staff.

DESIGN AND SETTING

This was an international systematic review of studies published in English.

METHOD

Databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, and Scopus) and grey literature were searched. Studies were included if they provided evidence about implementation of primary care micro-teams. Framework analysis was used to synthesise identified literature. The research team included a public contributor co-applicant. The authors conducted stakeholder discussions with those with and without experience of micro-team implementation.

RESULTS

Of the 462 studies identified, 24 documents met the inclusion criteria. Most included empirical data from healthcare professionals, describing micro-team implementation. Results included characteristics of the literature; micro-team description; range of ways micro-teams have been implemented; reported outcomes; and experiences of patients and staff.

CONCLUSION

The organisation of primary care has potential impact on the nature and quality of patient care, safety, and outcomes. This review contributes to current debate about care delivery and how this can impact on the experiences and outcomes of patients and staff. This analysis identifies several key opportunities and challenges for future research, policy, and practice.

A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age

Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and 'tinkering' by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving-to a greater or lesser extent-continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity-of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.