This site is intended for health professionals only

At the heart of general practice since 1960

Focus on...access versus continuity

Can the Government's push to widen access to GP services be achieved without sacrificing continuity of care?

By Nigel Praities

Can the Government's push to widen access to GP services be achieved without sacrificing continuity of care?

The tragic death of Penny Campbell in North London three years ago highlighted the potentiality disastrous consequences of overlooking the relationship between a patient and their GP.

An investigation into how the 41-year-old journalist died from septicaemia, despite seeing eight different GPs, pointed to major failures in her continuity of care between out-of-hours and in-hours primary care providers.

But concerns over continuity go far beyond out-of-hours, with the survival of the personal doctor-patient relationship under pressure as never before.

Pulse this week NHS bosses are planning a huge expansion in use of walk-in consultations in a move that promises to dramatically transform the delivery of general practice.

PCTs plan to increase walk-in capacity by 2.5-fold under the rollout of Lord Darzi's GP-led health centres, or polyclinics as they are sometimes termed.

But with the access drive now a central part of NHS policy, attempts to maintain continuity are increasingly being sidelined.

The wording of the NHS Next Stage Review by Lord Darzi himself speaks volumes.

The word ‘continuity' gets a grand total of two mentions – and only then to say it will not be affected by opening GP-led health centres. In contrast, ‘access' , the buzzword of the times, is mentioned on 50 separate occasions.

And when it comes to drawing up today's health priorities, the doctor-patient relationship fails to register on the radar of most PCTs.

GP-led health centres will be required to have 8am until 8pm opening, seven days a week - but some NHS bosses are explicitly exempting them from the need to provide continuity of care for their patients.

A report by Isle of Wight PCT says: ‘This new centre will provide a different model of primary care…The focus will be on convenience and accessibility with less emphasis on continuity of care.'

While extending access is a compulsory aim for all PCTs, less easily measured facets of general practice – among them continuity – barely feature in trusts' published lists of strategic priorities.

But there a few exceptions, with a handful of trusts deciding continuity of care is too important to leave out of the specifications for the Darzi centres.

Gateshead PCT, publishing the results of its consultation for a GP-led health centre in Blaydon, admitted concerns were raised over continuity of care and promised ‘the PCT will ensure this is included in the service specifications'.

Berkshire West PCT also says it is looking at indicators to performance-manage continuity of care for its GP-led health centre in Reading.

‘The proportion of substantive members of staff has been built into this,' says Dr David Buckle, a GP in Reading and PEC chair for the PCT, ‘meaning the provider would be penalised for having a high proportion of temporary or locum staff'.

Yet Dr Buckle admits continuity of care is ‘slipping', even in this own surgery.

‘My own practice has a branch surgery and part-time staff, but when I started it was three full-time doctors who worked six days a week. Those days have gone and I can't turn the clock back, but I recognise that as an issue for patients,' he says.

A previous Pulse investigation revealed the rising number of salaried GPs working at practices appeared to pose threat to continuity of care, with salaried doctors much less likely than partners to see the same group of patients regularly.

Our survey this week on extended hours suggests the Government's access drive may if anything make things worse – with only 11% of GPs feeling it will improve patient care, while 18% feel the money invested in keeping practices open longer will actually be detrimental for patients.

Around 27% of practices running extended hours are employing salaried GPs to cover shifts, which while a lower figure than some had predicted is still much higher than the xx% of salaried GPs nationally.

The BMA believes Government policy will damage the personalised service patients currently enjoy from their family doctor.

Yet as recently as 2006, the Government was specifically advised that more needed to be done to protect and even improve continuity of care.

A briefing paper for the Department of Health obtained by Pulse begins with the sentence: ‘Patients want both quick access and relationship continuity in their primary care consultations.'

The paper, by Professor Richard Baker, professor of quality in health care and a GP in Leicester, admits patients are willing to sacrifice continuity in short-term conditions to be seen quickly, but nevertheless recommends practices be monitored and rewarded for providing continuity.

‘The Government should revise the QOF for primary care practices so there are incentives for offering personal continuity.' says the report, which has seemingly been long-buried.

‘This is not about sustaining the profession of general practice, it is about protecting vulnerable patients who need to see a doctor they trust', Professor Baker told Pulse this week. ‘We have to decide what the NHS is for.'

Yet GPs were left in little doubt about what the new NHS is for, at least as the Government sees it, when primary care tsar Dr David Colin Thome addressed the Primary Care Live conference two weeks ago.

He told GPs they must be far more active and entrepreneurial about bidding for Lord Darzi's new centres, which he predicted could see another wave if successful.

Yet these centres will, in some cases, be run by companies, or groups of GPs, who come from many miles away.

Pulse revealed last week that some groups of GPs are bidding for tenders up to 150 miles from their traditional base, with fears they may run centres remotely through employing teams of salaried GPs.

Dulwich Medical Centre, in South London, has just been chosen as preferred bidder for a GP-led health centre and an APMS practice in Kent, and is also bidding for contracts as far afield as Somerset.

Business manager Anil Gupta says it is ‘about general practice metamorphosising into a new type of structure' that will improve care.

Dr David Portnoy, a GP in Ilkeston, Derbyshire, where a contract has been awarded to GP-led company Intergral Healthcare Partnership based in Yorkshire, Great Manchester and the North East, does not agree.

‘A Darzi clinic in Ilkeston, staffed often by transient salaried doctors, will provide neither the same continuity of care or standard of care that we have locally grown to accept,' he says.

The Government claims the QOF, NICE guidance and electronic care records are all offering improvements to managerial and information continuity.

But Professor Bruce Guthrie, professor of primary care medicine at the University of Dundee, says policy has overlooked the crucial importance of personal continuity, especially in patients with complex comorbidities.

‘There is an assumption continuity can be maintained with guidelines and by writing everything down, but this breaks down when you have people with multiple conditions when you are balancing one condition against another. It is very hard to write this kind of information down.'

Professor Guthrie claims the Government's obsession with access could permanently damage continuity. ‘There is a risk by focusing on the well who have acute problems, you lose something for the sick who have long-term health problems,' he adds.

Professor Steve Field, chair of the RCGP, says the political wrangling over access has ‘done more harm than good' and warns the profession to focus more on influencing the way access is provided.

‘The political turbulence at the moment is detracting from the discussion about having the appropriate number of GPs. What we have got to do is get GPs into leadership positions so continuity of care is not forgotten,' he says.

Yet with Labour and the Conservatives competing on who can place access to GPs higher on the policy agenda, it appears politicians may not be listening.

The debate over continuity of care

Polyclinics:
FOR: The Government says most patients will get continue of care from their own GP, with centres aimed particularly at young patients, and non-bread and butter patients ranging from the homeless to airport workers.
AGAINST: Anyone will be able to visit their Darzi centre, which look set to be manned by large numbers of salaried doctors, with nurses outnumbering GPs three to one

Out-of-hours:
FOR: Making it easier to sustain smaller practices by removing the grind of on-call rotas
AGAINST: With the huge range of different out of hours providers more mistakes will be made

Workforce changes:
FOR: Enables a greater choice of GP for patients
AGAINST: Increasing numbers of part-time staff and work shared between doctors and nurses will further reduce continuity

Electronic care records:
FOR: Roll-out will allows greater transfer of information between doctors
AGAINST: It is impossible to write everything down and should not be a replacement fro seeing the same doctor every time

Extended hours:
FOR: You cannot get continuity of care without access
AGAINST: Wastes money that could be put into ensuring continuity of care for the majority of patients

FAQs

What is continuity of care?
Often defined as patients seeing the same doctor at each visit, others say the transfer of information and the way healthcare systems work together to manage patients' care are equally important. The RCGP use the rather motherhood and apple pie definition of ‘the experience of a co-ordinated and smooth progression of care from the patient's point of view.'

How important is it?
It is a priority for patients and doctors, but evidence varies about its affect on outcomes. But there is likely to be some association with compliance, accuracy of diagnosis and possibly reduced hospitalization.

Do patients want continuity of care?
Without doubt yes, according to Department of Health funded research. But as patients get older and feel more vulnerable they place even more importance on continuity, and will wait to see a GP they know and trust even with new and unexplained symptoms.

Professor Richard Baker Professor Richard Baker

This is about protecting vulnerable patients

NHS bosses are exempting GP-led health centres from the need to provide continuity of care NHS bosses are exempting GP-led health centres from the need to provide continuity of care

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say