Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
Nuffield Department of Primary Care Health Sciences, University of Oxford, UK.
Soc Sci Med. 2023 Sep;332:116112. doi: 10.1016/j.socscimed.2023.116112. Epub 2023 Jul 27.
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.
连续性是初级保健中一个由来已久且备受捍卫的价值。基于医患一对一关系的传统连续性近年来有所下降。当代全科医学在组织和技术上都非常复杂，有多种员工角色和技术支持患者就诊（例如电子和电话分诊）和临床接触（例如电话、视频和电子咨询）。因此，重新评估连续性的关系、组织、社会技术和专业特征是及时的。我们在收集和分析英国 11 家全科诊所的数据的同时发展理论，这些诊所从 2021 年到 2023 年进行了案例研究，这些诊所引入（或选择不引入）远程和数字服务。我们使用了战略沉浸式民族志、访谈和对技术（例如数字透视）的材料分析。连续性几乎在所有情况下都受到重视，但在不同的实践中定义不同。它始终是有位置和需要努力的，受到当地、组织、技术基础设施、更广泛的系统以及参与行为者的价值观和工作方式的影响，并且通常需要员工进行表达和“修补”。远程和数字模式提供了跨越时间和空间扩展连续性的机会，并在一定程度上实现了数字记录的连续性和对患者和疾病发作的共同理解，这些记录和理解跨越了临床团队。为最脆弱的患者提供连续性有时需要大量的劳动，并且需要一次性的适应。在 Haggerty 等人的早期工作基础上，我们提出了一个新颖的本体论，该本体论分析了四种不同但在经验上重叠的连续性——治疗关系的连续性（基于心理动力学和叙事范式）、疾病发作的连续性（生物医学-解释范式）、分布式工作的连续性（社会技术范式），以及实践对社区的承诺的连续性（政治经济学和关怀伦理范式）。这个本体论使我们能够对我们的数据集中的成功（连续性的实现）和失败（连续性的中断和护理的碎片化）进行理论化和批判。
