Personal Care

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AIM: To promote critical engagement and discussion with questions related to the delivery evaluation and impact of personal care

CONTACT: Prof George Freeman

Report of session at SAPC ASM in Norwich on 9^th July 2010.

This year, the Personal Care SIG was again successful in its submission for a peer-reviewed panel session with four linked papers and extensive discussion. This well-attended and enjoyable parallel session was chaired by Chris Salisbury.

Our title was Unpacking the consultation: the importance of context. The unifying idea was to contrast papers reporting apparent threats to our shared belief in a person centered style of practice with a paper which closely studied how patient-doctor relationships actually develop and contribute to good care.

Two papers from Frede Olesen’s group in Århus, Denmark, questioned our conviction that primary medical care is best delivered in the context of a registered list of patients who, as far as possible, normally consult the same practitioner.

Rikke Sand Andersen had interviewed 32 patients and their families about their care-seeking decisions leading up to a diagnosis of cancer. Some patients implied that they felt their problem was not serious enough to overcome the bar of restricted referral to specialists. Others perceived pressure to concentrate on their relationship with their doctor rather than to transact symptom-related business. Some even said that previous encounters with a known doctor caused them to delay the presentation of new and possibly serious symptoms or to be embarrassed about returning with previous symptoms which had not resolved in spite of earlier re-assurance. Thus a patient’s assumptions about their GP’s gatekeeping role could modify their presentation of their story. In conclusion Rikke reminded us of wider issues such as the organisation of services and the imbalance of power in doctor-patient relationships. Their effect is not necessarily minimised by the patient knowing the doctor well.

Peter Vedsted ended the presentations by challenging us with a slide showing poor Danish and British performance figures in a European ‘league table’ of cancer survival statistics. They had associated this finding with three features of 19 European countries’ primary care systems: the GP as gatekeeper, a list system of registration, and the GP as the first point of contact in the service. A low position in the cancer survival table was associated with these features. And Rikke’s findings might begin to explain the mechanism!

Simon de Lusignan could not present his paper owing to a sudden bereavement, but luckily he was able to forward his slides which George Freeman shared with the audience[1]. He challenged the moral standing of personal care from another tack. He had compared GPs’ consulting behaviour in the period before with that of the same GPs in the period after the annual QOF data deadline. He was investigating how GPs use their computers, using a four channel video system which records actual computer use alongside audio-visual consultation recording. His serendipitous finding was that GPs paid far more attention to the patient’s agenda relative to their own when the QOF deadline was not looming!

So it was a nice contrast to hear from Marta Buszewicz about a tape assisted recall study where patients and doctors independently reported their experiences of consultations where mental health problems were presented or discussed. Half of the sample of 14 patients reported that their consultations with the GP had helped in their developing an understanding of their mental health problems. On examining the content of these consultations in more detail it appeared that the GPs mainly helped patients understand their mental health problems by recognising patients’ own attempts at explanation and helping to shape and develop these. GP led explanations were the exception. There were, however, also some examples given where the patients or GPs appeared to block the development of a discussion about things from a psychological perspective. This might be, for example, because of embarrassment on the side of the patient or the GP not feeling sufficiently skilled.

George Freeman opened discussion by reminding us that the presentations suggest some potential downsides as well as the more familiar advantages of our systems of primary care in Denmark and in the UK. He then made three points:

1. What about The Netherlands? The Dutch came near the top in Vedsted et al’s cross-tabulation of cancer survival by country, yet we usually quote them as having the primary care system most like our own. (Vedsted suggested it was easier to refer in the Netherlands).
2. Clearly we need to look more closely at the process of cancer diagnosis in general practice. Fortunately Rubin et al are doing just this. Greg Rubin responded to this point suggesting consultation behaviour may be country specific.
3. We are a meeting of the Personal Care Special Interest Group. Clearly we would be interested in specific study of the effects of patient-practitioner relationships on cancer diagnosis, accepting that these may not all be positive. Meanwhile we can remember that for at least the last 25 years, many patients in general practice do not in fact know their practitioner very well, relationship continuity often being hard for patients to get.

Wider discussion raised some good questions for further study including:

• what features of secondary care encourage or inhibit referral? In particular what about the two-week referral criteria?
• availability of diagnostic aids may be crucial, e.g. being much better in France.
• is the effect of the ‘watchkeeper’ (i.e. NICE) to raise perceived referral barriers too high? Vedsted suggested that we should have a much higher index of suspicion.
• how about comparing countries according to their use of investigations? what is the NNI (Number Needed to Investigate) for common cancers?
• what happens after an initial referral draws a blank? Are we then too reluctant to re-refer when problems persist?
• there are different types of gatekeeper – think of facilitators and then of bouncers! What kind are we?
• do our consultation models veer too much towards the ‘assessment model’ in MRCGP? Maybe MRCGP criteria for success do not emphasise diagnosis of serious conditions sufficiently?
• how does the medical paradigm bear down on patients? what effect may it have on presentation and formulation of symptoms?
• a participant using student videos in an MSc project remarked how students struggled with simultaneous computers and patients!
• discussion ended by turning more directly to Buszewicz’s presentation. While some participants speculated that the scope of mental health diagnosis might require contrasting skills to those needed for spotting cancer early, the consensus was that her findings would also apply very much for patients consulting with symptoms which could mean a diagnosis of cancer.

Informal initial feedback was very positive about this meeting – and we were very fortunate in having such stimulating material. Freeman and Salisbury’s initial response is to aim for a further panel presentation in Bristol next year but hope to have a more discursive and informal breakfast meeting as well on the Thursday morning.

George Freeman 31^st July 2010

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