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Is continuity of care an outdated ideal?

Dr Richard Fieldhouse says there is no evidence that continuity of care makes any difference, but Professor Roger Jones argues it is a core value of general practice and - if lost in the rush to modernise - will be gone forever

Dr Richard Fieldhouse says there is no evidence that continuity of care makes any difference, but Professor Roger Jones argues it is a core value of general practice and - if lost in the rush to modernise - will be gone forever


Continuity of care has long been the holy grail of general practice.Like the holy grail, it is the stuff of legends, harking back to the bygone age of Dr Finlay, housekeepers and 24-hour cover 365 days a year. Computer records were still a twinkle in Bill Gates' eye and notes were handwritten in glorious serif script with only the word 'Amoxil' being faintly legible. But that was an age ago, and times have changed. No more golf in the afternoon - we're living in post-Thatcher Britain, with time a commodity and, thankfully, patient care foremost in our minds.

All we know about continuity is patients like it and doctors like it. There is no evidence it's actually good for the patient, yet our profession continues to bleat on about it being the backbone of general practice. The continuity argument is even being used to malign Lord Darzi's polyclinics - not that I'm the least bit in favour of these, it's just that the main argument we're using against polyclinics is baseless. It's a romantic notion that needs challenging.

The argument for continuity is that the GP can slowly come to know patients well and develop insights into their social and psychological welfare. For a list size of several thousand, a GP can hope to do this for a few hundred of their most frequent attenders.

There is a point, though, where too good a relationship with a patient is a bad thing. When treating a family member or friend, for example, we start to impinge on the uncomfortable territory where familiarity adversely affects our judgement. The BMA ethics department advises against treating patients who are close to us. So, what of those patients with whom we have developed a significant relationship? We strive to build that friendly relationship, yet at that point can our professional relationship still exist? Do we not regularly and unconsciously make assumptions about people we think we know well?

The logic that suggests no patient should see the same GP more than three times in a row is much stronger than patients only ever seeing the same GP.

Middle ground

There is obviously a healthy middle ground between clinical objectivity and social familiarity, with us locums treading on the side of impartiality. But isn't overfamiliarity the flip side of this continuity, leading to potential complacency and maybe even contempt in our dealings with heartsink patients?

Certainly as locums, where just about every patient is a new patient, we often come across a case where our second opinion will alter the direction of the patient's care. We also come across instances, as the incumbent GP that day, where the patient is so familiar to their usual GP that a clinical record isn't even needed!

None of this is to say that we can't aspire to our original values of patient continuity, but just that we should approach it in a different way. With so many of our GPs working part-time, and anything up to 28% of GPs in the UK being locums, we simply can't keep deluding ourselves or our patients that traditional continuity is an option open to all. Instead, what we need to aspire to, rather than continuity of care, is continuing care - making sure the record of the patient's care allows every professional to carry on from where the last one left off.

Continuity of care doesn't matter much to many patients. And for the patients for whom it does matter - such as the elderly or those with chronic diseases - they probably get it. If they have an urgent problem they can see a locum, the important thing being continuity of record. The locum can then reassure the patient that the information will be relayed back to their regular doctor.

Dr Richard Fieldhouse is vice chair of the National Association of Sessional GPs


I recognise that the research evidence for the value of continuity is fairly thin, and that this is a difficult topic to research.

But it would be a mistake not to make the achievement of continuity a key part of planning primary care services.

Continuity can be looked at in a number of ways, perhaps most usefully as continuity of information, continuity of management and continuity of the doctor-patient relationship. The need to provide continuity of information and management is unarguable. From every perspective - not least patient safety - it's critical that continuity of information about patients is maintained as they move through the health system, with implications for information technology in primary and secondary care. We still have a long way to go (I'm thinking of Connecting for Health), but it's worth the effort.

Closely linked to this is the importance of continuity of management, particularly in patients with complex medical problems, who are often looked after by different specialists and community-based agencies. GPs are at the centre of this web of care, and remain best-placed to ensure co-ordination of care and that patients don't fall through the cracks in the system.

I recognise that continuity of the doctor-patient relationship is more contentious. It implies a long-term relationship between one doctor and one patient, with the doctor accumulating knowledge of the patient's medical problems and their social background. It's this aspect of continuity that is most threatened by fragmentation of the medical workforce and new configurations of general practice.

It has also been argued that the box-ticking requirements of the QOF are a potential distraction from concentrating on more important aspects of building a meaningful relationship with patients.

Complex problems

But picture the scene when a patient with diabetes, cardiovascular disease, eye problems, mobility difficulties and a disabled spouse is unable to see a doctor who knows about all of these problems, and has to explain everything from scratch each time they consult a new GP. This cannot be efficient, it is certainly frustrating for the professionals concerned and seems unlikely to lead to the quality of care that could be achieved, more quickly and efficiently, in consultations where the doctor and patient are already familiar with each other.

Patients must, of course, be in a position to make an informed choice about continuity, and it may well be that for certain problems seeing their usual doctor isn't what they want or even what they need - the GP specialist in the practice with a particular skill in one medical area may be a better port of call. We are all aware of the kind of collusive relationship that can develop over time when doctor and patient are only prepared to discuss 'safe' areas, and do not wish to rock the professional or social boat by exploring or declaring uncomfortable problems.

Conversely, some patients seem to insist on continuity with doctors who find it difficult to meet all of their needs.

But these are important times for general practice and the NHS. If continuity of care becomes a casualty of the rush for modernisation and reform it may be something we will never be able to regain. Our patients would not thank us for that.

Professor Roger Jones is Wolfson professor and head of general practice at King's College London School of Medicine

Is continuity of care an outdated ideal?

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