This site is intended for health professionals only


Developing continuity of care in your practice



This image has an empty alt attribute; its file name is 36d7fe1e-78fc-4699-baa5-eb9cb84e2726

Ensuring patients can see the same GP requires effort, but the rewards are worth it. Dr Simon Hodes and Dr Ben Eliad explain how it can be achieved

Continuity of care – seeing the same healthcare professional over a period of time – is shown to promote patient wellbeing, bring down referral rates and hospital admissions, reduce medication use and wastage, and improve patient and clinician satisfaction. Some studies have even shown that it improves life expectancy.1

Clinicians taking responsibility for delivering continuity of care – including dealing with their patients’ pathology results, letters, enquiries and prescriptions – are likely to work more efficiently and have higher job satisfaction. Lack of continuity could be one of many factors that contribute to burnout, and indeed to clinical errors leading to complaints.

Unfortunately, continuity is being eroded. The number of patients who were able to see their preferred GP in England fell by 27.5% between 2012 and 2017.2 This can partly be explained by the shifting workforce in primary care, with fewer full-time GPs, and the demise of singlehanded or smaller groups of GPs. These all make it harder to provide continuity.

But the direction of healthcare policy through successive governments has
also effectively made continuity more difficult to achieve, by prioritising ease of access and upscaling of general practice instead. In the past, patients always had to be registered with a specific GP, and would always talk about being on a particular GP’s ‘list’. Patients are now registered with a practice instead, and the ‘lists’ are a historical hangover. Former health secretary Jeremy Hunt made a ‘named GP’ scheme3 one of his flagship policies, but in truth, it hasn’t really worked.

Despite all these problems – and, of course, everything that Covid brings – continuity is still achievable in your practice. We suggest a five-stage process to improve continuity of care: discuss, audit and consult; design; construct; trial and review. 

1 Discuss the concept with your colleagues and team

If you think this topic might be important to consider for your practice, first find your baseline. A simple notes audit or even a team meeting will help define where you are, and promote discussion. Consultation with your patients (via a survey, a simple questionnaire or the involvement of your patient participation group) might offer further insights and suggestions. It could be that your practice workforce, demographics or demands will not allow for continuity, or mean that it is not appropriate for you.

If you are still unsure, try listing the pros and cons, which we did for our practice.

PROS

Improved patient and clinician satisfaction. Fan et al used the Seattle Outpatient Satisfaction Questionnaire (SOSQ) questionnaire with just under 22,000 patients and found that patients seeing the same clinician over time provided scores 16 points higher.4 Various studies show providing continuity improves clinician satisfaction.5

Reduced secondary care and community referrals.6 Olthof et al’s retrospective study of 19,333 patients in the Netherlands found reduced referrals when continuity was being practised and urged policymakers to invest in continuity of care as a result.

Reduced hospital admissions.7
Deeny et al investigated more than 200,000 patient records in the UK and found that if patients saw their usual
GP two more times for every 10 consultations, the admission rate could be reduced by 6%.

Probable time saving for clinicians. GPs who know their patients can provide greater insights and may not need as much time to review patient records.

Improved insight into patients issues. Having in-depth knowledge of your patients through years of close contact means you understand their health beliefs, ideas and concerns. Such insight, plus awareness of recent treatments and past medical history, will help reduce errors too.

Reduced complaints. Most complaints are caused by communication breakdowns between clinician and patient. Continuity enables a better rapport.

CONS

Possible unacceptable delay in care. Because GPs might not be working full time, or might be on leave, investigations and letters might not be reviewed immediately, leading to unacceptable delays in treatment.

Uneven workload. Clinicians could end up with differing groups of patients and differing workloads.

Reduced rapid access. There is a cohort of younger patients who simply want rapid and easy access to care, and value this over continuity. They are probably happier to use tech solutions.

Specialism. Over recent years, more
GPs have taken on extended roles. Patients may be happy to sacrifice continuity in favour of the expertise available from a GPSI, and the clinician may be more satisfied too.

2 Auditing your current process

If it is not immediately obvious whether your practice is suited to a continuity system, the starting point is to see whether the practice is already working towards it. We looked at three areas to get a greater understanding of our systems – our contacts with patients, our admin processes and time lost through lack of continuity. We also asked ourselves the following questions.

Contact with regular patients

Are you dealing with patients that you know historically – through phone, video or face to face?

Are your regular patients seeing other clinicians for administrative reasons?

Are you picking up patients who have already contacted another member of your team about the same problem?

A simple audit of activity over one or two days, or 30-40 consecutive contacts, can give valuable information. These questions around an individual consultation can be illuminating:

– Do you know this patient?

– Have they been dealing with another GP or clinician for the same problem?

– Did another GP make this referral, request this test or start this medication?

– Could this contact be better dealt with by another member of the team? If so, who and how could this happen?

Admin processes

When you get your daily admin – results, letters, emails, phone enquiries, prescriptions – are they allocated to the clinician who requested the test or referral, the one who started the medication or the one who knows the patient?

Decide on a week to take note of all the administrative work you receive. Write down which colleague has been seeing a patient most regularly and which colleague requested a test or referral or started a new medication.

This will provide a key insight into how your practice is providing continuity of care and the necessary information to review these processes. The more clinicians who can go through this auditing practice, the more information you can gather. A suggested proforma can be found at tinyurl.com/cocaudit.

Time lost because continuity is lacking

How much time do you spend each day looking at patient notes to work out what is happening, because you are not familiar with the case?

How often do you send admin work to the patient’s usual clinician and how long does this take you?

How much time do you spend actively following up cases that could be better handled through a ‘usual doctor’ system?

You can add this to your audit.

Case study: 82-year-old gentleman with urinary symptoms

Without a continuity system

The patient sees Dr A. The urine dip shows one plus of blood. He is issued antibiotics and an MSU is sent. A week later, Dr B files a normal MSU.

Four months later, the patient sees Dr C (the GP he happens to see most often) for a routine check. Dr C notices the report and prior consultation, repeats the dip/MSU with the same result of one plus of blood noticed. Dr C makes a point to personally follow up the report. A two-week referral to urology discovers a bladder cancer (noted on cystoscopy as being around six months old).

Dr C makes a call to the patient to apologise for a belated diagnosis, discusses the issue as a duty of candour and explains the practice complaints policy. Dr C explains to the patient the situation has been discussed in a significant event analysis by the team, and the two other GPs involved are aware. Changes have been made to how apparently normal MSU results are reviewed in future, and by whom. The patient decides not to make a complaint but is grateful for the apology and explanation.

With a continuity system

The patient sees Dr C first time. Urine dip shows trace blood only, and antibiotics are given, because Dr C has previously referred the patient for BPH and treated UTIs. An MSU is sent.

A week later, Dr C sees the MSU was normal and reviews the patient, who still has mild dysuria. Noting the previous urinalysis result, Dr C arranges for this to be repeated. This shows one plus of blood again and the patient is referred via the two-week pathway. He has a small bladder TCC, which is easily treated and cured.

3 Designing a ‘usual doctor’ system

If you have decided greater continuity of care is something to explore, you can start designing the system – either manually or through your IT systems.

Manually

The slowest way is to change patients’ usual GP on an individual basis as you see them or do their admin.

e-consultations

Think about a process to ensure that non-urgent e-consultation requests go to the usual doctor. Mostly, e-consultations have a 24- to 48-hour turnaround, so as long as they are triaged they can usually wait for a named GP where appropriate, or be shared out among those working
if continuity is not necessary.

This might add a few more keystrokes to each consultation or piece of admin, but is accurate and pays dividends over time. You need to agree with your colleagues that where you are seeing repeated admin for a patient who ‘belongs’ to another GP, you can change the usual doctor on the system (or check with your colleague and ask them to).

IT solution

An article in Pulse by Dr Iain Redmill, a GP in Southampton, suggested another way to make this change. His practice merged with another in 20148 and he noted a drop in continuity that not only affected patient care, but also greatly increased paperwork for the GPs. They searched for contacts over the previous three years, then cross-mapped with the clinician seen to get a picture and allocate accordingly. It was time consuming but eventually paid dividends. There were time and cost savings from reduced paperwork, while lines of responsibility were clearer and processes were much less stressful. Dr Redmill concluded: ‘GPs appreciate receiving documents and results for a consistent group of patients, as we can co-ordinate care more effectively.’

Explain changes to patients

It will be vital to have buy-in from patients and staff to make this work. You could consider a PPG meeting, or information around the practice (notices, website, prescriptions) to help bring your patients on board with any changes.

4 Construct your admin and appointment system to aid continuity

You will need your full team on board to make this work, and there are various factors that need to be considered.

Appointments

You need a mix of appointment types in your clinics. Create a balance of pre-bookable and on-the-day slots, to allow some planned bookings, and leave spaces free for urgent care. Try to have some face-to-face slots at each clinic (if clinicians are not working from home) so GPs can see their own patients. 

You will also need a clear agreement with colleagues for what to do if urgent queries come in for your named patients when you are at work but not the duty doctor, and when you are not at work (if you’re not in the practice or are on leave).

Scanning

Admin staff who are scanning documents will need to be trained to use ‘usual GP’ where possible. There may be exceptions specific to your practice (for example, it may be best to send community scans or private referrals back to the referring clinician).

Guidance and frameworks need to be created. In our practice, we default everything to the usual GP and forward documents to each other as needed.

Hospital letters

Secretaries might add a sign-off to each letter: ‘please correspond with the GP who has made this referral’.

We have done this for some time now as hospital letters often were addressed to retired GPs rather than the doctor making the referral. Though it is not perfect, it has proven effective. Private specialists now always write back to the referring GP.

Prescriptions

If you have access to in-house pharmacists, local policies should require that queries are forwarded to the usual GP unless they are urgent.

We have implemented this system and it is effective for medicine management and helps with prescribing incentives. Urgent requests go via our pharmacists now. However, all queries default to the usual GP.

QOF, enhanced services

We allocate work by usual GP and have found it to be personal and efficient. Over time there is a snowball effect on efficiency and job satisfaction.

The more you see your own chronic patients and manage their care, the more familiar you become with them – and vice versa.

Flexibility

This is always important. Patients do change GPs, or prefer to see certain GPs for specific problems, perhaps due to clinical expertise or personal reasons. We always respect this where possible.

Sometimes we see patients through an acute illness spotted while on a duty session, then pass them back to their usual GP for ongoing care once it is resolved.

Flexibility is also useful when GPs have days off or take holidays. All GPs will inevitably leave or move practices at some stage, at which time an incoming GP can inherit that GP’s list, or it can be divided out.

5 Trial and re-audit

As with any new system, it is important to trial it and review it after six months, with a repeat audit, patient survey, PPG or team meeting.

Key learning points

  • Continuity has been shown to lead to improved patient and clinician satisfaction, reduced referrals and admissions, potential time savings and fewer errors and complaints
  • A simple audit of activity over one or two days or 30-40 consecutive contacts can demonstrate whether patients are being dealt with the correct member of staff in your practice
  • You can assign a ‘usual GP’ to patients either manually – by processing the changes as you see the patient or do their admin – or automatically, by searching contacts over the past few years to determine their usual GP
  • Design a system that creates a balance of bookable and on-the-day slots, to allow some planned bookings and leave space for urgent care
  • Admin staff who are scanning documents will need to be trained to use ‘usual GP’ where possible

Dr Simon Hodes is a GP partner and trainer and Dr Ben Eliad is a GPST1, in Watford, Hertfordshire

References

1
Maarsingh O, et al. Continuity of care in primary care and association with survival in older people: a 17-year prospective cohort study. BJGP 2016;66:e531-9

2
Levene L, et al. Predicting declines in perceived relationship continuity using practice deprivation scores: a longitudinal study in primary care. BJGP 2018;68: e420-e426

3
Marshall D. Q&A: Named GP scheme for the over-75s. Pulse Today, April 2014. tinyurl.com/NamedGP-QA

4
Fan V, et al. Continuity of care and other determinants of patient satisfaction with primary care. J Gen Intern Med 2005;20:226-33.

5
Cook R, et al. Gaps in the continuity of care and progress on patient safety. BMJ 2000; 320:791-4

6
Olthof M, et al. Continuity of care and referral rate: challenges for the future of health care. Family Practice 2019;2:162-5

7
Deeny S, et al. Reducing hospital admissions by improving continuity of care in general practice. The Health Foundation 2017. tinyurl.com/HF-continuity

8
Redmill I. How we launched a ‘named GP’ system for all our patients. Pulse Today 2014. tinyurl.com/coc-it-systems

READERS' COMMENTS [3]

Dave Haddock 18 November, 2020 10:55 am

Not recruiting part-time doctors helps.

Patrufini Duffy 18 November, 2020 11:07 pm

Important article. The new snowflake generation (which the NHS has to worry about funding to old age) couldn’t care less for continuity. Nor show an iotre of respect for it when available. NHSE and the RCGP conjured this complex myth of “continuity” – while actively deterring it with manager-led private providers to app companies and mega-practices with Partnership decimation, locum structuring and community and social care which is knowingly fractured. The DoH and CQC persecuted and neglected smaller holygrail practices and single handers over the decade, with a disregard for the essence and lessons of true family practice medicine, whilst permitting critical errors of poor access, clinical ambivalence and fragmentation from certain profiteering care providers. Primary Care at scale needs a descaling. There’s a difference between Harrods and Tesco. And looking at the workforce structure, GMC shadow, demoralisation, portfolio-isation, locum numbers and general lethargy, truthfully, does “it” really care for continuity anymore, or understandably let’s pass the buck, like lessons learned from the impenetrable hospital.

Andrew Jackson 19 November, 2020 7:52 am

You shouldn’t be able to earn more for a session of GP related medical work than you do for a F2F session of General Practice as this will always be the hardest part of the week.
We also have no mechanism that rewards repetitive and consistent work in the same practice on a regular basis.
Seniority was the closest we had as at least there was a semblance of increased pay linked to numbers of patients seen over many years but it was scrapped.

I have no friends that don’t work Monday to Friday consistently over their careers yet we have a situation where the offer to a GP is not a sustainable model of full time work hence we attract part time workers.