Continuity of care is the bedrock of general practice, but its foundations have been steadily eroded over the past few years. Patients are registered with a practice rather than a specific GP, there are more part-time GPs and targets for access have often been chased at the expense of continuity.
This has happened despite a rise in the number of patients with long-term conditions being treated in general practice – the people who most value the continuity of care GP practices should provide.
Continuity can be achieved without sacrificing good access for those patients presenting with less serious conditions or hiring more staff, and this article will show you different ways you can make it happen.
1. Assess the current situation
GP practices vary a lot and so do the demands of their patients, so it is important to find out what your patients think.
Survey your patients to see what they think of your current systems and what could be improved – you may be surprised at what they say. For example, ask them how much they value seeing the same doctor for their ongoing care. Do they mind seeing a different doctor or nurse if it is an urgent or new problem? Or would they still rather wait to see their usual GP?
Surveys can be done in a variety of ways, from simply handing out paper questionnaires in reception, to using online services such as SurveyMonkey.1 If you have a patient participation group, talk to them about how they think continuity could be improved. Practice staff may also have valuable ideas about how to improve systems within the practice that affect continuity of care.
2. Divide up the workload
Based on the feedback you receive from your patients, decide what balance of access versus continuity is right for your practice. For instance, give patients a particular ‘usual' or ‘registered' GP, or let them choose their preferred GP and set up systems to direct that patient's workload to that person. In an ideal world, patients should be allowed to choose who they see and given the choice of whether to wait to see a particular GP, or to see someone else straight away for an urgent problem. However, this may become more difficult in larger practices with lots of GPs and part-time staff.
Try as much as possible to divide workload within a practice equally between GPs and nurses. This should help free up GP time to achieve continuity. Don't forget that the division of workload also extends to non-patient contact workload – for example, repeat prescriptions, blood results, hospital letters and medical reports. Continuity and patient safety will be improved if the doctor who knows the patient best can deal with these matters.
3. Use buddy groups
Continuity of care can be adversely affected by GPs being on annual or study leave, and with increased part-time or portfolio working, a GP may not be in the practice for the whole week.
Buddy groups are a way around this and can work in different ways to suit different practices. At its simplest, GPs can be paired and protocols within the practice agreed to ensure only one of a pair is on leave at any time. The buddy will then deal with all paperwork, prescriptions and so on.
In a practice with strict patient lists, the system can be extended so that the buddies see each other's patients when the other is on leave, thereby giving an improved level of continuity for patients who can get to know their usual GP's buddy.
For part-time GPs, this can be further extended so that buddies cover each other's work on their buddy's day off. This requires the rota to be organised so that regular days off do not clash, which can be a challenge.
4. Set up remote working
The ability to log into practice computer systems remotely improves continuity by allowing GPs to check results and read scanned letters from home on days off.
While GPs may initially not be keen to work from home on their days off, it may mean they don't have to stay late at the practice to catch up and it should be more efficient for them to deal with patients they know rather than other GPs' patients.
5. Improve ease of access
Improvements in continuity will only occur if patients are able to access their usual GP when they need to. Buddy systems as above can ensure there is cover, but it is important to ensure the appointments system works well and there is sufficient capacity for patient demand when buddies are not covering. Patient demand may vary between individual GPs depending on their consultation style and patient list profile, so it is important to assess the current situation with regard to appointments before making any changes. If appointment capacity is a problem, consider using nurses and healthcare assistants to free up GP time.
Nurse practitioners commonly deal with acute minor illness and evidence suggests patients worry less about continuity for these sorts of problems. Healthcare assistants can be used for many tasks previously done by nurses, freeing up nurses to take on more chronic disease management and other protocol-driven jobs from the GP.
It is also important to mix appointment types so all GPs have some same day and some pre-bookable appointments. Their usual patients will then be able to see them for more acute problems (or acute exacerbations of chronic problems) as well as the more routine complaints.
Alternative consultation methods such as by telephone and email also have a place as some patients may find it difficult to come to the surgery even if appointments are available, and many problems can be dealt with in this way.
6. Train staff
Once appropriate systems have been set up, it is important to make all staff aware that continuity of care is important to patients and to the practice. Reception staff are key, so make sure they can quickly and clearly identify a patient's usual GP using your practice system. Encourage receptionists to direct patients towards their usual GP, and if they're not available then to the buddy GP. Patients may be happier to wait to speak to their usual GP than to see an unfamiliar one immediately, so reception can suggest this if it is appropriate.
7. Train patients
Many older patients will be used to the idea of having their own GP, but younger patients may not be aware who their usual GP is. It may take time for these patients to become aware that continuity is important to the practice, so staff and GPs need to continue encouraging patients to see their usual GP wherever possible and for follow-up of ongoing problems.
Patient trust of their GP is important, so GPs need to be aware if a patient has problems with their usual GP and have systems in place to address these issues.
As with any change, it is important to communicate clearly with patients. Use of both online and more traditional methods is important to reach different patient groups. Continuity of care will not improve overnight, so it is important to keep making patients aware that the practice encourages continuity and help patients to know who their usual GP is.
8. Instruct receptionists to review records
Continuity of care is not just about clinical staff – receptionists should also be encouraged to take ownership of a patient's care, and good record keeping will facilitate this. For example, if a receptionist speaks to a patient about a particular issue but needs further information before dealing with it, this should be recorded.
If the patient then phones back about the same problem, they can be passed back to the same receptionist to ensure continuity and to prevent the patient having to explain their problem twice. This also makes it clear for any GPs reviewing records what has been done so far.
Receptionists should also be encouraged to look at the patient records if a patient has an ongoing problem to see which GP is dealing with it. Accurate recording also extends to failed encounters so that if a patient is phoned but is not there, everyone is aware an attempt has been made.
9. Review progress
Finally, when any changes are made, it is important to monitor the situation and resurvey patients to see if things have improved.
Continue to adjust systems based on the results and if you've got things right, patient satisfaction should start to improve.
Dr Mark Kelsey is a GP in Southampton
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