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Should the QOF incentivise continuity of care?

QOF targets for continuity might be tricky to arrange, but would rebalance the framework in favour of the doctor-patient relationship, says Dr Matthew Ridd. But Dr Carolyn Tarrant believes they would do exactly the opposite, by eroding trust in a GP's motivations for developing that relationship.

Continuity of patient care has traditionally been one of the hallmarks of general practice. However, many changes in the way that GPs and their practices work mean patients are now less likely to see the same doctor than they once were.

This is significant because research has shown that continuity continues to be valued by patients1 and doctors2 alike and that it has been linked to markers of quality of care.3;4

GPs have been encouraged by the QOF to achieve certain targets on chronic disease management and appointment availability.

While the principles behind these goals are laudable, the importance of continuity has not been given the same recognition and indeed these initiatives may have contributed to the erosion of the longitudinal patient-doctor relationship.

Whereas previously a patient may have seen the same doctor for all of their care, they may now see a nurse practitioner for minor illnesses, a practice nurse for their asthma and perhaps a different doctor with a specialist interest for their diabetes care.

In some situations this may be no bad thing, but the more complex the person's situation, particularly where psychological or social factors influence their health, the greater the potential benefit from seeing the same practitioner.

Rewarding practices who provide continuity by including it in a future version of the QOF fits in with its original aims, which were ‘to improve quality of care delivered in general practice, to help recruitment and retention and to reward practices for the delivery of existing high quality care'.5

Recent systematic reviews have linked continuity to higher levels of patient satisfaction,3 improved care processes and outcomes4 and cost-effectiveness.4 Continuity of patient care is a reason that many doctors cite for choosing a career in general practice.6

The measurement of continuity presents methodological and practical challenges.7 Continuity is a complex concept which comprises many different elements.8;9

It is closely related to access because the value of patient-doctor continuity will vary according to the characteristics of the patient and their problem.

GPs are rewarded through QOF on patients' reporting of appointment availability in the GP Patient Survey but not on responses to a question that asks whether patients can see a preferred doctor. Although conceptualising patient-doctor continuity by means of this single item is simplistic, rewarding GPs on this aspect of patient experience would serve three purposes.

First, it would redress the balance between financial inducements to improve access and continuity. Second, it would at least acknowledge that continuity leads to improved care for many patients.

Third, it is entirely compatible with a national healthcare policy that advocates choice: the patient choosing to see the same doctor where preferred.

The QOF is not without its critics, and I have sympathy with the argument that not everything that counts can be counted.

For those GPs who were already providing good quality care to their patients before the new contract, the tick-box mentality may have harmed the consultation more than it has benefited it.

However, it does seem to have reduced inequalities10 and for as long as the QOF stays in place, GPs would do well to argue the case for the inclusion of markers that they believe fairly reflect quality of care: continuity is a prime candidate.

Dr Matthew Ridd is clinical lecturer in primary healthcare at the University of Bristol and a GP in the city

A recent study provided worrying evidence that the QOF has had a negative impact on continuity of care in general practice.

Continuity in primary care is already under threat from sweeping changes in how primary care services are organised and delivered.

These changes are driven by policy imperatives that promote access, choice and efficiency as the core values of modern primary care, rather than personal GP-patient relationships.

Adding continuity of care to the list of indicators incentivised by the QOF might seem to be the obvious solution. But incentivising continuity is problematic and may ultimately be counterproductive.

The practical problems are the first among many. If continuity of care were to be included in the QOF, we would need to be sure we know what it means.

And we would want to be assured that success in meeting it could be reliably measured. At the moment we are a long way from either of these, making the idea of promoting continuity through QOF points untenable.

A more fundamental question is whether continuity of personal relationships is something that can be promoted through incentives.

The GP-patient relationship is built on a foundation of trust. Patients want to believe that their GP is motivated by professional values, caring and empathy, and has a genuine drive to act in the patient's best interests.

If they suspect the GP's efforts to build a relationship are motivated instead by financial gain, then surely this will undermine the very thing it is designed to promote.

The more general problem with incentives applied to something as complex and nuanced as continuity is their tendency to provoke pathological and unhelpful forms of behaviour.

These include rigid behaviour aimed towards achieving targets, rather than responsiveness to patients' needs.

The introduction of incentives for quick access to primary care saw practices chasing targets of appointments within 24 or 48 hours for all patients, despite the fact that not all patients wanted or needed to be seen quickly.

Incentives for continuity could act in the same way, pushing patient to see their ‘usual' GP, rather than ensuring they could get the type of appointment they wanted, with whom they wanted, and at an appropriate time.

It's important to recognise that continuity can be what patients and GPs want some – maybe most – of the time, but not all.

When patients see the same GP, we know that generally they tend to be more satisfied, feel more enabled, and are more likely to adhere to treatment.

With continuity, GPs feel better able to discern patient agendas, make diagnoses, and manage patients more effectively. There is some (less conclusive) evidence that continuity can lead to improved health outcomes and lower cost healthcare.

If continuity continues to decline this has real potential to have a negative impact on quality of care

But this doesn't mean that seeing the same GP is always best. People want and need different things at different times.

For example, younger working people with minor health problems tend to want quick access rather than continuity of care.

And in some cases discontinuity can be a good thing - a different GP can give a new perspective on an old problem. Good-quality primary care requires practices to be able to respond flexibly and provide care that's appropriate for each patient as an individual.

Incentives have their place. But they are a blunt tool for improving quality of care. We need start from an understanding of the role and value of continuity of care in primary care.

Then we need to design services so that different priorities – access, choice, continuity – can be optimally balanced. Financial incentives too easily disrupt this delicate balance.

Dr Carolyn Tarrant is a lecturer in health psychology at the University of Leicester who has specialised in GP-patient interaction

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