Imagine if we had a polypill with a strong evidence base for reduced morbidity and mortality, improved patient satisfaction, reduced outpatient referrals, safer prescribing, and lower hospital admission rates. [1,2] Imagine if it was easy to provide and distribute, and largely free from side effects.
Continuity of care is that polypill. But we seem to be undervaluing it. In recent years, health policy is eroding continuity, is pushing GP teams into larger groups with extended team members, and continuity has increasingly been sacrificed in favour of immediate access to “any” healthcare professional, in any setting.
Continuity of care, defined as “receiving care from the same healthcare professional over a period of time”, promotes patient wellbeing and reduces medication use. It is associated with improved outcomes, and there is growing evidence that it improves life expectancy. [3-5] Continuity creates trust and builds up a therapeutic relationship. [6]
It also improves professional satisfaction, which may in turn reduce burnout and contributes to a sustainable healthcare system, not least by reducing the time taken to process pathology results, prescriptions, and patient correspondence. [7,8] With levels of stress and burnout at an all time high, anything that improves working life, efficiency and job satisfaction should be embraced.
Continuity may not be as important to some patient groups. [9] For example, it is likely that for minor illnesses and in younger age groups there is less patient demand or clinical need for continuity. And yet it is often only possible through multiple, straightforward interactions with patients that we get to know them, develop their trust, and can then appreciate their context when they come to us with an acute or chronic illness.
As John Launer states, skilled clinicians need to learn to “weave tapestries” rather than “dig holes,” and this is far easier where there is an ongoing therapeutic relationship, which includes not only a relationship with the patient over time, but also a wider, holistic knowledge of their family history, background, and social setting. [10]
Jennifer Richards, carer, “I would like to see the concept of the family doctor valued”
In my experience, not all patients want same day care. What is far more important is continuity of knowledge—both the doctor’s knowledge of the patient and, seldom mentioned, the patient’s knowledge of the doctor. But continuity of personnel on its own doesn’t guarantee continuity of care—the culture of the healthcare system needs to support it.
I feel that the approach generated by the Quality and Outcomes Framework in 2003/4 has had a lot to do with the lack of continuity of care in general practice, as appointments can feel transactional and there isn’t time or scope to build rapport and mutual understanding. I have found that part-time GPs have been able to provide excellent continuity.
I would like to see the concept of the family doctor valued. I care for my husband, who has dementia, yet we don’t seem to be seen as a family unit and I’ve had to employ various stratagems to be able to discuss my husband’s health. It’s taken a very long time to get recognition of the impact of his worsening dementia and I don’t believe that would have happened if I had enjoyed greater continuity of care from the team.
The move to remote consultation during the pandemic has been necessary, but it concerns me that it may be overused in the future. If there is no rapport in person, it is unlikely to develop by phone.
Ben Eliad, GP registrar, “continuity of care is essential to providing holistic care in the age of telemedicine”
For me, continuity of care underpins everything that I want from a career in general practice. Medicine is not about science or disease, but about people and their stories. We choose general practice to provide holistic care to our patients. Access is important, but not to the detriment of continuity.
Observing the personal relationships that my trainers have developed over years is inspiring. From just one name they can provide an in-depth story of their patient. Medical ethics is underpinned by autonomy and we, as clinicians, require an intricate understanding of our patients’ beliefs and values to honour this. The fragmentation caused by easy access to care loses these intricate details of someone’s personal narrative.
Remote consultations are a critical facet of healthcare provision in light of the covid-19 pandemic, but concerns about the loss of the human element of care are valid, especially given an ageing population with increasingly complex health needs. [11]
As a GP registrar, just beginning my career in family medicine, I believe that placing emphasis on continuity of care is essential if we are to fulfil our desire to provide holistic care in the age of telemedicine.
Covid-19 and continuity in telemedicine
The coronavirus pandemic has necessitated rapid, sweeping changes to healthcare, with a massive shift to digital solutions. All patients in general practice are currently screened by a phone call or web form before being triaged and booked into a phone or video call, with face-to-face consultations only as needed. For many this has improved access, and when used well can in fact improve continuity of care. However, many patients have struggled to navigate the new ways of accessing GP care, and it is likely that for many patients continuity has suffered as a result of the pandemic, especially for those with poor digital literacy and complex medical problems. This may further exacerbate health inequalities and the digital divide, both highlighted as a major health risk factors.
Where they exist, any therapeutic relationships that clinicians already have with patients arguably make telemedicine safer, at least in the short term. However, we need to understand how this shift to virtual consultations may affect established relationships in the longer term, and also how we can build up a therapeutic relationship while working remotely.
Continuity of care contributes greatly to GP teams’ knowledge of their community. During the early days of the pandemic, when patients at highest risk were advised to “shield”, it would have been more efficient and personalised to ask GP teams to identify these patients, rather than relying on the centrally generated lists which were used initially. The success of the vaccine rollout, 75% driven via Primary Care Networks, highlighted the power of local knowledge in reaching out to vulnerable, at risk and hard to reach patients. Many GP teams simply called the patients they know, using the therapeutic trusted relationship to book in the early vaccine appointments.
What are the hurdles to achieving continuity, and how can these be overcome?
Despite evidence of a strong association between continuity of care and lower mortality rates, the number of patients able to see their preferred GP in England fell by 27.5% between 2012 and 2017. [12, 13]
Health policy has consistently offered increased choice of access to patients, and pushed GPs into larger groups, the latest iteration being primary care networks (PCNs). [14] While it might be possible to provide a wider range of staff and services through larger groups and federations, and to offer population health at local scale, there is no doubt that continuity of care is likely to be further fragmented and compromised unless we take steps to support it.
In recent years we have seen a shift to a workforce of salaried, locum, portfolio and sessional GPs. They are more likely to work part time or across several practices, which means they may not be able to provide the same level of continuity to their patients. [7] The importance of the partnership model in supporting continuity of care has been highlighted by a formal review, yet is not promoted by healthcare policy. [15]
However, there may be other ways in which continuity could be supported. Perhaps as GPs are forced into PCNs, there will be an opportunity to provide “organisational continuity?” [16] This would require particularly strong communication between members of the team, and there are precedents for this way of working which appear to be successful in creating good outcomes and high levels of patient satisfaction, as this recent article outlines. Perhaps we can also harness some of the convenience and potential of new health technologies to improve continuity of care.
Whatever happens, with GP teams at breaking point, we need a clear recognition of the benefits of continuity of care from senior policymakers, with sustained political backing.
Simon Hodes (@DrSimonHodes) has worked as a GP partner in the same Watford practice since 2001 and is also a GP trainer, appraiser and LMC rep. The views expressed above are his own.
Sally Lewis, National Clinical Lead for Value-Based and Prudent Healthcare and Honorary Professor at Swansea School of Medicine Twitter: @RslewisSally
Ben Eliad, GP registrar, based in Watford, Hertfordshire. Twitter: @BenEliad
Jennifer Richards is a carer for her husband who has dementia.
Competing interests: none declared
References:
1] Pereira Gray DJ, Sidaway-Lee K, White E, et al. Continuity of care with doctors—a matter of life and death? A systematic review of continuity of care and mortality. British Medical Journal, 2017. https://bmjopen.bmj.com/content/8/6/e021161
2] https://www.kingsfund.org.uk/projects/gp-inquiry/therapeutic-relationship
3] https://www.nhs.uk/news/medical-practice/seeing-same-doctor-every-time-reduces-risk-death/
4] Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract 2020. https://bjgp.org/content/early/2020/08/10/bjgp20X712289
5] Mortality rates are lower with higher continuity of care, review finds https://www.bmj.com/content/370/bmj.m3184
6] Murphy M, Salisbury C. Relational continuity and patients’ perception of GP trust and respect: a qualitative study. British Journal of General Practice 2020. https://bjgp.org/content/early/2020/08/10/bjgp20X712349
7] https://www.kingsfund.org.uk/projects/gp-inquiry/continuity-of-care
9] https://www.annfammed.org/content/1/3/149?ijkey=7a4a826cd56e7b85f7972b0e9416b6703aa69f8c&keytype2=tf_ipsecsha
10] https://pmj.bmj.com/content/96/1135/307
11] https://bjgplife.com/2020/05/15/video-consulting-not-just-a-consultation-plus-tech/
12] Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. British Journal of General Practice 2020. https://bjgp.org/content/early/2020/08/10/bjgp20X712289
13] Levene LS, Baker R, Walker N et al, Predicting declines in perceived relationship continuity using practice deprivation scores: a longitudinal study in primary care, British Journal of General Practice, 2018.
14] https://www.kingsfund.org.uk/publications/primary-care-networks-explained
16] https://www.rcgp.org.uk/policy/fit-for-the-future.aspx