Continuity of Care: Why we need to build services around therapeutic relationships

This month’s British Journal of Psychiatry includes a lovely qualitative study by Bilderbeck et al on how patients experience being assessed for a mood disorder.

I think we can learn so much more from a good qualitative study than we ever could from a study on genetics or a drug RCT, both as professionals and as mere members of the human endeavour, so it was great to see a high-impact journal publishing the paper.

One of the recurring themes that Bilderbeck et al identified in their interviews with patients really leapt off the page at me. As well as wanting an explanation for their feelings, wanting to feel listened to and involved, the patients wanted consistent and continuous care. 

In short, the patients wanted to meet the same doctor each time they attended. In the trade we call this continuity of care.

Continuity of care

Bilderbeck et al noticed that patients felt more comfortable and able to discuss sensitive, personal events if they’d met the doctor before. Conversely, if the doctor they were meeting was new, they felt more anxious and were generally less able to use the relationship to heal:

‘There’s never any consistency. It really bothered me… Virtually a different doctor every time I went back… it’s just like going back to a stranger and I don’t really, it’s not helping me at all.’ 

In fact, one quote illustrates how seeing a new doctor at each visit can be nothing more than a waste of time, like a clinical Groundhog Day:

‘I’d like to see the same doctor all the time. See one, than have to explain myself again and again and again.’

 

Widespread problem 

This is by no means a chance finding in a small group of participants. A lack of continuity is raised again and again by patients who feel let down by the system.

This is because getting to know a mental health professional, and letting them get to know you back, is the most powerful treatment we have. The therapeutic bond formed between the professional and the patient is taught to be worth more than the effect of any tablet, and responsible for the majority of the effect of any talking therapy.

In most other medical specialities, meeting a patient for the first time and taking a history (asking them all about their main problem, past problems, personal life and family history) is largely nothing more than a simple transfer of information. The patient gives the doctors facts about his life and current state, and the doctor uses these facts to decide on a treatment. If the same doctor turns up again the next time then that’s nice, and saves a bit of time, but if a different doctor turns up they can just read the notes the carry on fairly easily where the previous doctor left off.

In mental health, however, talking to a patient about their problems for the first time is more than just an exercise in gathering facts. It is the foundation for a lasting and potentially healing relationship, built on the trust that the patient’s disclosures imply. It isn’t always easy but it’s the first part of recovery.

Later meetings between the professional and the patient continue this healing – building on the previous meetings and delving deeper and wider into the problems, with growing nuance and understanding. To meet a different doctor at this point would be, in a way, to restart the largest aspect of the whole healing process and risk the patient feeling rejected.

What’s more, a doctor who already knows you is far less likely to make a mistake, like misdiagnosing you or sectioning you when you’re actually no worse than you usually are.

Stifling continuity

Often a lack of continuity is unavoidable – doctors have to take it in turns to cover the hospital at night, for example – but often we build services in such a way that continuity is stifled from the start.

We’ve brought in Triage wards, to which patients are admitted for a few days before either being discharged or admitted to a longer stay ward. Triage wards have their own team of doctors and nurses, with whom patients somehow have to miraculously form a relationship in just a few days, when seriously unwell, before being moved on to tell their story again elsewhere.

If the patient is admitted to a longer stay ward, the chances are that their consultant won’t be the same consultant that they see in the community. These days, consultants are moving towards solely doing either inpatient or outpatient work for the sake of “specialisation”. Therefore, another person to tell your story to.

Even on discharge, you might not end up under the care of your old consultant. Depending on your diagnosis you might end up under an Early Intervention team, or any number of other crisis resolution or brief treatment teams. They might be specialists, but they’re not mind readers – it’s time to tell your story again. 

And don’t forget that you might have to see a Home Treatment Team in the meantime (tell your story) and even a separate Drug and Alcohol team, because your own team can’t deal with that (tell your story).

Of course, you might not see any of these teams – they might all be burnt out and hideously understaffed because getting to know new patients all the time is hard work. Treating patients you know can be thoroughly fulfilling, and building on those relationships can make your job worthwhile, but a constant turnover of new and subsequently worrying cases can be enough to wear anyone out.

Where from here? 

So how do we bring continuity of care back to the forefront of psychiatric practice?

Sometimes it’s easy. We need to make sure that when a patient is re-referred to a service, someone who already knows them takes their case again. If a patient is readmitted to hospital, they need to go back to the ward where the staff know them best. It sounds obvious but so often, it doesn’t happen.

Of course, this also means keeping enough beds open so patients don’t need to be transferred hundreds of miles away when they need an admission, and paying for enough staff to be available to cater for all the patients on a long term basis.

But how do we ensure continuity past the obvious?

For me, the first step seems to be proving that it’s important. That means more qualitative studies on patient experience in high-quality journals. In general, we need to listen to what patients feel is important more often – we need to judge quality of care not just by abstract outcome markers like “readmission rate”, “medication adherence” and “employment” but by what patients think about how much we helped.

Ideally, we need to prove that continuity of care is somehow cost effective too. This is certainly true, but also certainly difficult to demonstrate. If different doctors see the same patient three times, they’ll each repeat a lot of the work, generally take longer and make more mistakes – all costing time and money.

Next, we need to use that evidence to design services with continuity in mind. Ideas could include:

  • switching consultant posts back to a mix of community and inpatient work
  • cutting down on unnecessary or unproven specialist teams
  • developing service policies on continuity on an individual and service level
  • turning Triage wards back into longer stay wards, or linking them better with the patient’s long term consultant
  • being more flexible about keeping a patient under a team’s care when they change GP or move house

Continuity of care is at the core of every positive change we make in mental health and we need to protect it at all costs. As always, I’m eager to hear your thoughts.

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About Alex Langford
I am a psychiatry trainee based in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

11 Responses to Continuity of Care: Why we need to build services around therapeutic relationships

  1. Thank you for a very sensible yet so important issue in psychiatry. Ask any psychotherapist why their clients value the work they do it is because of the therapeutic alliance. In fact many studies have shown that often it isn’t the model of therapy but the relationship between therapist and client that is the main important factor in “movement” for the client. Certain specialties do offer the continuity and consistency as we know that is what is needed through ev base of treatment. ie PD where patients will feel rejected or not worthy if they cannot be contained. However these feelings are not exclusive to this client group and therefore all patients should be offered continuity of care,

  2. ashakura21 says:

    Adding to Fenella’s post about the therapeutic relationship being the most important factor in patient recovery, I find it mind boggling why services are set up to change the teams so often. Even for admission, the poor guy/gal being admitted may have to tell their story 4-5 times (A&E, then assessment team, the admitting nurse, then admitting doctors, then day team). It’s akin to making them relive the trauma. Having a community post now and having to effectively “lose control” of input patients receive when admitted is really frustrating, both for myself and patient. Obviously no details here, but both myself and the patient involved found the whole experience rather harrowing and exceptionally unhelpful. In a more dynamic service, I could have popped over and saved number of bed days, consultations, a mis-diagnosis (I hope, not saying I have it right myself!) and a bad prescription.

    In summary, yes, agree. Services should allow in-patient/out-patient to cross-over.

  3. Em says:

    I’m an academic qualitative researcher (recovering statistician/clinician!) in the field of mental health, and also a patient. I couldn’t agree more with this post. i wish more people understood the impacts of the lack of continuity of care in mental health, both, the long term harder to define issues around trust and hope, as well as the immediate fears and frustrations of ‘can I speak to this stranger?’ or ‘do I have to explain myself yet again’.

  4. bookwormthings says:

    Trust, I have huge problems with and huge fears as well. Telling the same story again and again doesn’t make it any better. To insulate myself against the pain I crack jokes about it sounding like a plot from a 2nd rate soap opera. I drop into very matter of fact and sound like I’m coping, when actually I’m emotionally in pieces inside.

  5. Nell Munro says:

    The other argument for continuity of care is patient, professional and community safety. This case used to be made a lot see: http://www.tandfonline.com/doi/abs/10.1080/09585180110056786#.Ux-YqYXbDWE. I’ve not seen it discussed so much lately as risk has slipped off everyone’s agenda as an inconvenient truth. But in the inquiry reports of the 1990s the perpetrators all demonstrated effective therapeutic relationships at points during their contact with services, and in those cases where the homicide was found to be preventable it was typically the case that the relationship had broken down at the point when the individual’s mental state led them to committing homicide.

    As an extreme alternative data point I had a family member born in 1949 who had severe learning disabilities and epilepsy. When he died of complications related to a seizure in 1981 the social worker who had been assigned his case in the early 1950s and worked with his family throughout childhood and adulthood attended his funeral. That was some serious continuity.

  6. Pingback: The Smallest Gestures Mean The Most - Parenting And Mental Health

  7. Judy says:

    Wouldn’t that be good! Instead total disconnect between hospital teams and community teams, rarely the same people in crisis teams, locum psychiatrists, regular turnover of care coordinaters, different assessment teams……….. and the patient is somehow expected to tell their story over and over again – and professionals comment that you don’t seem very emotional about it…….

  8. K hallas says:

    Continuity of care to aid the therapeutic relationship is useful in most areas of medicine and not just psychiatry. It is not true to say that continuity of care is not as useful in other areas of medicine. Psychosocial factors are important in all types of disease and illness. I have worked in diabetes clinics before and we found patients were more likely to attend follow up appointments if they saw the same clinician. It was also easier for patients to broach subjects such as erectile dysfunction.

    During rheumatology clinics I worked with patients who had severe levels of disease which limited their quality of life. Patients reported that a consistent relationship with treating doctors made it easier for them to ask for help between clinic appointments. Many patients felt that they did not ‘want to make a fuss’ or ‘bother us’. This became easier when they knew the team.

    The doctor patient relationship is fundamental to all aspects of medicine and not just psychiatry. Medical conditions inherently make people vulnerable. Medical conditions impact on social/family life, work, activity, aspirations and finances. It is not easy to talk about these things with a stranger. Nor is it easy to bring forth all symptoms when first meeting someone ( ‘that blood coming from the back passage doctor’). Many symptoms can be embarrassing or just too intimate to reveal. As a GP now I regularly see patients attend to ‘check out the doctor’. Then the following week they will present again with the real problem they are worried about.

    • Those are some really valuable insights, thank you.

      Perhaps I was being conveniently reducing of the benefits of continuity of care in general medicine. I still stand by my opinion that the importance is greater in MH, as getting to know someone is inherent to getting to know their illness, but you make a great case.

    • Continuity is very important in psychiatry however important too in medical specialties. I agree that in MH it perhaps is somewhat more important as it takes real effort to get to know each other and how one ticks. In diabetes you can ask a patient what triggered a hypo or review meds based on last bloods and patient experience. In MH you need to take alonger view as changing diabetes meds or pain meds is easier but still disruptive. CNS med are more difficult as have withdrawal effects etc Plus the whole issue of working as a partnership of two adults not just doctor/patient. The quality of experience is crucial as is the actual treatment.

      • KHallas says:

        It may be worth reading Roger Neighbour, The Inner Consultation and Michael Balint The Doctor, his patient and the Illness. Both of these talk about the Doctor as being the most effective ‘drug’. This view and the techniques advocated by Neighbour and Balint can be extrapolated for effective consultations throughout all medical specialities. My Colleagues and I in General Practice use use the doctor patient relationship and continuity of care for almost all ‘presenting complaints’. I would say that the relationship and continuity of care is more important to get spot on than the factual medicine itself.

        I think it is important to get away from this view that there are types of medicine that can be reduced down to mere facts and robotic questioning (for example fenella mentioned about diabetics and hypos). It is never that simplistic.

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