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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