Health – Continuity of care for patients seeing multiple General Practitioners

Health and Disability Commissioner Anthony Hill today released two reports which both highlight concerns with the continuity of care provided to patients seeing multiple GPs.

Anthony Hill said patients seeing multiple GPs is becoming the norm in New Zealand, and that primary care practices needed to function as a team to reflect this, in order to provide continuity of care.

“It is crucial to have processes in place to ensure that patients who require regular review and follow-up care of ongoing problems are provided with effective continuity of care,” Anthony Hill said.

“Care must be integrated and collaborative – particularly for patients who see multiple GPs. Doctors and their systems must be connected with each other intentionally. Patients will receive better care as result.”

In one case Health and Disability Commissioner Anthony Hill found the Palms Medical Centre and one of its GPs in breach of the Code of Health and Disability Services Consumers’ Rights for the care provided to a man with a history of chronic obstructive pulmonary disease (COPD).

The man visited the medical centre five times in the space of a month in 2018 with shortness of breath and chest pain. Although enrolled with a specific GP, the man saw four different doctors at the medical centre over this period, each one treating him symptomatically, failing to apply critical thinking to his presentations and putting his symptoms down to his COPD. As a consequence, there was a delay in diagnosing the man with congestive heart failure, and even when the correct diagnosis was made, its severity was greatly underestimated and the man died a short time later.

Anthony Hill said the case highlighted the importance of communication and critical thinking in the face of multiple presentations, and the need for clinicians to do the basics.

“In my view, the quality and continuity of [the man’s] care was hindered by the failure of multiple doctors to apply critical thinking, review documentation adequately, and communicate effectively with one another,” Anthony Hill said.

In finding the medical centre in breach of the Code, the Commissioner was critical that the systems in place at the centre did not facilitate co-operation between doctors, and that multiple staff members failed to think critically and diagnose the man correctly.

He also found the individual GP in breach of the Code for failing to review the man’s previous medical notes and obtain the full clinical picture before diagnosing him. While acknowledging the systems issues that put the doctor under pressure, the Commissioner reiterated the importance of clinicians doing the basics – reading the notes, asking the questions, and talking with the patient.

The Commissioner recommended that medical centre staff discuss the findings of his report, assess how the practice is implementing the Health Care Home Model and provide HDC with a summary of the assessment data, arrange for an independent review of its policies and procedures with a key focus on continuity of care, and provide a letter of apology to the man’s family. He recommended refresher training for the GP, who was also asked to apologise to the man’s family.

The full report for case 18HDC02116 is available on the HDC website.

In the second case Health and Disability Commissioner Anthony Hill found The Doctors Ti Rakau medical practice in breach of the Code of Health and Disability Services Consumers’ Rights for failures relating to the care of a man who was taking the medication lithium.

Between 2014 and 2018, the man attended the medical centre 24 times, seeing six doctors. At most of these appointments, he was prescribed his usual lithium medication to treat his bipolar affective disorder. A side effect of this treatment is lithium toxicity, which can cause permanent kidney damage, so it is recommended that lithium levels and renal function are monitored every three months. However, each doctor failed to recognise that the man’s lithium monitoring was overdue, and that his renal function was deteriorating. In June 2018 the man was admitted to hospital with acute kidney injury caused by lithium toxicity.

Anthony Hill said the case highlighted the importance of appropriate prescribing and providing adequate information to patients, as well as the need for communication between general practitioners.

“This case is both unremarkable and disturbing. It is unremarkable in that a patient presented to a series of different doctors at a single practice, which is becoming the norm in primary care practice in New Zealand. It is disturbing in that the basics were not done,” Anthony Hill said.

“Individually and collectively the doctors failed to prescribe responsibly, or to have in place systems to support them in doing the right thing reliably.”

Anthony Hill found the medical centre in breach of the Code for failing to provide services to the man with reasonable care and skill, due to the repeated failure of multiple GPs to prescribe appropriately or monitor his lithium levels or renal function. He also found poor co-ordination of care and clinical oversight reflected poor systems for continuity of care at the medical centre. The failure to inform the man of the risks of lithium and the need for associated monitoring, and therefore to obtain his informed consent, were also breaches of the Code.

Anthony Hill recommended that medical centre staff discuss the findings of his report, audit whether changes introduced since these events have resulted in regular monitoring of patients on medications that require regular blood tests to check for toxicity, and to apologise to the man.

The full report for case 19HDC00536 is available on the HDC website.