Is continuity of care truly possible?

Dr Jeremy Carter, Pulse PCN editorial board member and clinical director of Herne Bay PCN in Kent, discusses the challenges around continuity

Continuity. A concept so important, it is now included as a contractual requirement for us. The new GMS core contract requirements explicitly require continuity of care to be considered when determining the appropriate response when a patient contacts their practice. In addition, it is specified in the PCN DES requirements for the investment and impact fund (IIF) conditional funding, requiring active consideration of offering the same clinician for continuity.

I read these requirements with mixed feelings; as a firm believer in the merits of continuity in principle, yet, constrained by numerous challenges to being able to deliver on this.

Evidence for the benefits of continuity is plentiful in the literature. Benefits for patient outcomes and for the system in terms of efficiencies. However, much of this literature is based on the premise of continuity specifically with a GP. A single continuous generalist doctor. Not a Practice, a group of doctors, and not a wider team of health professionals.

And therein lies the challenge. In the same breath as championing continuity, we are also actively pursuing strategies to diversify, triage and stream primary care provision. We have built a huge workforce of highly capable additional roles, each dealing with specified aspects of the patient care journey.

Patient triage

 In many places we filter access to General Practice care through triage systems, to ensure the ‘right’ professional sees the patient. If having a medication query our patients may be streamed to our highly skilled pharmacy workforce. For social care needs, perhaps a social prescriber. And if mental health is the presentation, or musculoskeletal symptoms, we have mental health practitioners, and musculoskeletal first contact practitioners.

And that is just the wide tapestry of diversification internally we have directly overseen and implemented over the past five years. We have also actively promoted the use of our pharmacy colleagues, now scaled greater than ever before with Pharmacy First, to deal with minor ailments.

These varied presentations, however, are the same presentations that are referenced when citing the benefits of building continuity with one GP. Continuity is a product of action over time, not a statement on paper. It can only be built by seeing the same patient. It is in the continuum of learning and understanding of our patient, through the presentations of medication queries, the minor illness management, and the social care request, which we know, rarely present in isolation, that the holistic picture emerges and becomes apparent to the continuum GP.

 It appears that we are happy to champion continuity of care with a doctor, but seemingly also spin a narrative that large swathes of presentations should not, in fact, be seen by doctors at all. Only at such time as a patients care needs have become so complex and demanding, that we would triage them to necessitate a doctor’s opinion, do we then feel that continuity is of value.

And this is probably well after the true benefits of continuity would have been reaped; seeing a complex and in-need patient, where there is no history of prior understanding, nor an established relationship, is not, in my opinion, the definition of continuity of the family doctor.

Of course, the reality is there is too much demand on a diminished GP workforce. The expansion of the additional roles reimbursement scheme (ARRS), and other avenues of management of primary care issues, such as through community pharmacy, and walk-in minor illness/minor injury centres, are what has maintained our ability as a system to deliver care.  

As for our GP workforce, even if accepting the challenges in continuity outlined already, we have several constraints in providing continuity, even for those cases for whom we, or our patients, deem a doctor’s input necessary.

Portfolio careers

We have a workforce that is in large numbers working only part-time in general practice. Even if full-time, many of us have diversified to some extent, with portfolio roles, and special interests. If clinicians are working for example only one day a week in practice, what is the realistic prospect of us as contract holders honestly saying to our patients that we will meaningfully be able to offer continuity.

If we value the portfolio career, and teams of GP’s with different specialty interests and knowledge, and stream patients by their choice, or by our triaging systems to the doctors in the Practice specialising in the condition of presentation, which could fit with getting the ‘best’, or ‘most experienced’ clinical opinion, we have to recognise, and be honest, that this is a barrier to any concept of the same GP seeing their own patients regardless, for the development of continuity.

Complex consultation

I would add to this constraint other factors that limit the number of patients GPs can offer a continuous service to. Due to a host of reasons, we are finding consultations becoming more complex. There is pressure to extend the time we spend with patients, and to limit the numbers of contacts per day. We operate in a system that still knowingly creates systemic duplication of work; if for example our consultant colleagues are consulting remotely, we find ourselves being tasked with taking actions on their behalf that previously they would have done.  This takes time away from seeing a patient and offering continuity.

Without being honest with our patients around the constraints of our GP workforce, and the systemic factors that are creating unnecessary additional workload, taking doctors away from seeing patients at their point of need, then the ‘sell’ of continuity as not only something to aspire to, but a contractual obligation, is unrealistic and unachievable.

Estates

Aside from the human factors or workforce structure, we have to contend with other structural challenges to providing continuity.  Estates are a constant challenge. Finding room for clinicians to operate from is a challenge we will all be familiar with. Over time, we have moved from smaller Practices, to larger combined groups covering larger populations. We find a workforce often employed over a reasonably sized geography, with multiple physical sites of delivery, and staff often moving between sites. So, unless a patient is going to follow the clinician, this possibly amplifies the restriction of continuous access.

IT

Interestingly, IT may hinder continuity. While an absolute saviour during the challenges of covid restrictions in allowing ongoing safe care, we now have elements of workforce working remotely at times. As expectations and clinical thresholds have evolved since covid regards the appropriateness of remote consulting, trying to ensure appropriate continuous consultation with a GP is made harder if not able to offer the appropriate consultation method at point of need.

Therefore, I remain challenged by the contractual ask of us. Yes, I value continuity. But I also admire and respect the diversity of our workforce, across multiple specialty roles, and I see the huge benefits for us, and our patients, in triaging care appropriately.  However, this multi-role provision means no one clinician, GP or not, will be able to build up a truly continuous relationship with our patients. Being honest with ourselves as a healthcare system, and our patients, in what is achievable is vital to avoid the risk of General Practice being accused of failing to deliver.