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Improving continuity of care



My interest in continuity of care started in the 1970s, working in what was then an ‘unusual’ practice in Southampton. We were all salaried academics and so worked part-time in the practice, and continuity of care suffered. I wrote a small piece of research that showed patients were far more likely to complete their course of antibiotics if they felt they knew the prescribing doctor well, the publication of which launched my research career.

Now, in 2012, continuity is more topical than ever and for the same reason as it was when I worked in Southampton – levels of continuity are poor and care is suffering as a result. Continuity got a particular nudge downwards with the 2004 contract, with the end of 24-hour responsibility and registration with individual GPs, as well as the introduction of the QOF, and it has not recovered.¹ The question now is whether GPs can do anything about it.

Why continuity matters

There is a wealth of evidence that better continuity (seeing the doctor of choice over time) is associated with better and less costly outcomes, enhanced patient enablement and more satisfaction for both patients and staff.

So far, the outcomes evidence is more by association than by proving cause and effect.2,3

No one has carried out any trials randomly allocating patients to better or worse continuity for many years, thought when this was done (in the USA) the results were very convincing).

But new British evidence this year has shown meaningful reductions in both emergency and elective admissions in practices where patients report they are more able to consult a particular GP.4,5 A recent paper even shows better cancer mortality for such patients.6

Researching continuity over the years, I have been impressed that, while all practices say continuity is important, few can show what they actually do to encourage it. Of a range of tactics likely to improve continuity, some practices manage one or two but none does them all.

Instead other priorities tend to dominate practice policies, particularly workload-sharing issues and the perceived need to prioritise access at the expense of continuity. Good access encourages continuity because the patient is more likely to wait for their chosen doctor. At the same time, better continuity reduces the need for repeat effective consultations, reducing pressure on new appointments and freeing up access.

Of course not all patients want to see a particular doctor, and in many cases where a technical service is required for a straightforward problem this gives no immediate advantage. One benefit of larger practices is more chance to sample different clinicians informally without having to re-register, and also to have easy access to alternative opinions when wanted.

Professionally it is not always best for patients to see the same clinician. Professional isolation is undesirable, and too exclusive a relationship can make it tempting for either party to collude in avoiding both unpalatable diagnoses and necessary but unwelcome therapeutic regimens. There are reports of diagnoses delayed by seeing the same doctor; however the opposite problem – missed diagnosis due to care by too many clinicians – is distressingly common and has as much potential for damage.

We are left with the evidence that patients in England want more scope to choose whom they see than they currently get. Results from the NGPPS over recent years clearly show that the majority of patients still wish to see a particular doctor; and while many are able to do so, a substantial minority want but cannot get continuity.7

How to measure continuity

Some argue that practices should be financially rewarded for achieving high continuity, raising the question of how to measure it. ‘Usual provider continuity’ (UPC) is the simplest method. It records how much of the time a patient sees the same person and is expressed as the proportion of contacts over a given time period (such as a year) with the GP most often seen (though not necessarily their first-choice doctor). UPC is highest in small practices (up to 85%) and with so-called ‘personal lists’ – both of these limit choice. With larger practices, the UPC can be less than 50%. Even back in 1985, when I looked at large Southampton practices, some children were seeing a different GP for each of 12 consultations. Such a service can be expected to increase inappropriate A&E attendance.

While UPC is relatively easily derived from computer records, it does not of itself imply a good therapeutic relationship. The effectiveness of relationship continuity is better assessed by asking the patients directly. The patient survey (NGPPS) does this to a useful degree (particularly questions 15 and 16) and enables practices to compare their performance over successive years and also with rivals in their area.

Before taking any of these steps, practices need to want to improve. It may be best to start by assessing how much continuity patients are getting. The NGPPS results make a good starting point, but these can be very usefully supplemented by studying critical incidents – which we are all required to do. In larger practices it will be found that continuity problems keep cropping up.

Some fairly obvious simple changes would focus practices more clearly on continuity and make it easier for patients to get it. Results from the NGPPS over recent years clearly show that the majority of patients still wish to see a particular doctor. But while many are able to do so, a substantial minority want but cannot get continuity. Many of us can probably think of patients who might benefit from continuity who may not think of asking for it – for example those who don’t speak English as a first language, have a learning disability, suffer from mental illness, or lack social skills or self-confidence.

There are five main ways to improve continuity in practices:

  1. Better management of personal lists Practices can build up a list system if they help patients identify their ‘own’ doctor, prioritise appointments with the named doctor, and ensure that reviews of medication and test results are carried out by this doctor too. Emerging workload can be dealt with by reallocation of uncommitted patients and by guiding new patients to those least busy.
  2. More choice beyond face-to-face contact Relationship continuity is much easier to deliver by encouraging cheaper, less formal alternatives. Telephone follow-up has an impressive evidence base and greatly encourages continuity.8 Email also offers the great advantage of avoiding the opportunity cost of ‘real-time’ contact. Clinicians are understandably apprehensive of uncontrollable workload and wary of medico-legal issues. This area cries out for experiment.
  3. Smaller teams The 1966 GP ‘charter’ improved standards by ending professional isolation, but numerous studies show that patients prefer smaller practices, and doctors and managers prefer larger ones. An obvious answer lies in the creation of smaller teams in a practice cluster. See if local practices want to help establish a system of this kind.
  4. More emphasis on certain patient groups Anyone less able to take control of their own health – in other words needing more care – potentially gains from better continuity. While it is important to improve the system for all patients, some groups arguably merit particular priority, as discussed previously. It should be possible to tag their records to help receptionists. For some patients, it may even be best to use IT systems to limit appointments to selected clinicians.
  5. Wider concept of care Continuity targets based on UPC risk creating unforeseen perverse outcomes. However, both patients and GPs seem to prefer higher rates of UPC. To make continuity a strategic aim, we need more feedback from our patients via the NGPPS and patient participation groups. We should ask GPs to describe exactly how their practice maximises relationship continuity during appraisals.  It may help make continuity a priority if GPs can show commissioners how continuity reduces usage of secondary care, and thus healthcare costs.

The next steps

More work and advice is urgently needed from professional negotiators and IT experts. Email is potentially a very useful tool for enhancing relationship continuity. The profession needs to establish medico-legal ground-rules for use, and GPs, perceiving extra unpaid workload, are naturally wary. We need both proper experiments and negotiation of appropriate checks and rewards to prevent excessive use and reward any extra professional time.

Practice IT systems need extra programming and perhaps software in order to routinely measure UPC, highlight each patient’s usual or preferred doctor, prioritise usual doctor appointment offers, and allow arrangement of patients and staff in smaller units within a large practice.

Implementation of continuity improvement programmes needs action research, in order to establish what works best and at what cost. Those not persuaded by the case for immediate action should press for randomised trials – offering patients the ‘complex intervention’ of an enhanced continuity package compared with unchanged or ‘usual’ care. Such a trial would be of world-wide interest. Even designing a useful trial requires preparation. For example:

  • We still have remarkably little evidence about receptionists – how do they work and what motivates them?
  • What would an effective continuity training programme look like?
  • Is email a valuable extension of our range or an uncontrollable explosion of workload?
  • How can we best harness patient power – through practice patient groups or otherwise – to maximise continuity?
  • How can we motivate doctors and nurses? We need such evidence to design the best possible intervention.

But simple steps are ready to be taken straightaway. There’s no excuse for making it too difficult to achieve relationship continuity. For further reading I recommend the RCGP Policy statement, which explains things in far more depth, with a lot of real life quotes.9

Professor George Freeman is a retired GP and an academic at Imperial College London. He worked as a commissioner on the RCGP’s Medical Generalism (2012) report

References

1 Campbell SM, Reeves D, Kontopantelis E, et al. Effects of Pay for Performance on the Quality of Primary Care in England. New England J Med. 2009;361(14):368-78.

2 Cabana  MD, Jee SH. Does Continuity of Care improve Patient Outcomes? The Journal of Family Practice 2004;53(12):974-80.

3 Freeman GK. Progress with Relationship Continuity 2012: A British Perspective. International Journal of Integrated Care June 2012.

4 Bankart MJG, Baker R, Rashid A, Habiba M, Banerjee J, Hsu R, et al. Characteristics of general practices associated with emergency admission rates to hospital: a cross-sectional study. Emergency Medicine Journal 2011;28:558-63. DOI.10:1136/emj.2010.108548.

5 Chauhan M, Bankart MJ, Labeit A, Baker R. Characteristics of general practices associated with numbers of elective admissions. Journal of Public Health 2012:1-7. DOI:10.1093/pubmed/fds024.

6 Levene LS, Bankart J, Khunti K, Baker R. Association of Primary Care Characteristics with Variations in Mortality Rates in England: An Observational Study. PLoS ONE 7(10):e47800. doi:10.1371/journal.pone.047800.

7 Roland M et al. Do English patients want continuity of care, and do they receive it? Br J Gen Prac 2012;DOI: 10.3399/bjgp12X653624.

8 McKinstry B, Watson P, Pinnock H, Heaney D, Sheikh A. Telephone consulting in primary care: a triangulated qualitative study of patients and providers’. BJGP 2009;59(563):e209–18.

9 Hill AP, Freeman GK. Promoting Continuity of Care in General Practice. RCGP London March 2011.
http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z%20policy/RCGP_Continuity_of_Care.ashx
(accessed 07.11.12)