There is little to argue against continuity of care. It is highly valued by patients and General Practitioners, improving satisfaction in both groups. It is a fundamental building block of a high-performing Primary Care service and is associated with numerous improved preventive and chronic care services, enhanced patient experience, improved care outcomes, lower hospital utilisation, lower costs and reduced mortality in elderly patients.
However, a key metric for the success of Primary Care and the first thing you often read about in the papers is around access. With ever increasing wait times for non-urgent appointments seeming to make headlines. The drive to increase access to Primary Care, may actually be having a negative affect on continuity of care.
Younger patients with acute illnesses may place more value on prompt access over continuity, preferring to see any clinician today. However, an increasingly elderly population with a high prevalence of multi-morbidity and more complex healthcare needs are more likely to require and benefit from the opposite, their usual clinician who knows them well.
Access and continuity of care are inevitably intertwined, but not necessarily inversely linked. They do not have to account for two ends of a spectrum.
In the UK continuity in primary care is in a state of decline. Attempts to create larger “super practices” threaten continuity further. The report Is bigger better? concludes with mixed feelings, which likely echos the demands of different patient groups. Some valued what larger practices can bring, while others preferred to see their usual GP, with whom they had developed a valuable relationship over time.
Continuity should regain the spotlight in Primary Care. It is important that it regains our focus. Older patients’ healthcare needs account for a large proportion of Primary Care consultations and emergency hospital admissions.
Results from numerous studies have demonstrated that greater contact with the same GP for the majority of the time results in fewer hospital admissions. Increased urgent hospital admissions, in recent years, are almost entirely due to increased numbers of patients admitted through emergency departments, most self-presenting or utilising ambulance services, and were not referred by a GP.
Primary care as a system is becoming increasingly fragmented. Patients and Doctors feel a greater disconnect from their local general practice. Compound this with increasingly difficult access due to rising demand and we have the perfect setting for patients to choose to attend an emergency department instead.
Rise in admissions, I believe was the basis of the ‘named GP’, first introduced to those patients over 75 years, with the aim of improving health and maintaining care in the community, rather than the hospital setting. Unfortunately, giving a patient a named GP, does not solve the problem, but this seems to be where the initiative ended. Giving patients a known main contact and main coordinator is only the first stage in improving continuity, actually getting recursive consultations with that main contact is the real aim.
Longitudinal or relational continuity, seeing the same doctor over time, builds trust, with patients more likely to seek their usual doctor’s advice than that of another provider. Doctors also develop a greater sense of responsibility, ensuring patients are well managed to the best their ability, avoiding unnecessary referrals into Secondary care.
Where do we start?
So I have covered, relational/longitudinal continuity here, but there are also advantages to informational continuity and management continuity, which I will cover in later posts. For now, however, I want to focus on relational continuity. The first step of improving the situation we find ourselves in is measurement.
There are two particular ways to measure relational continuity:
- patient-centric continuity measures a patients number of visits to their named clinician, divided by the total number of visits to any clinician.
- provider-centric continuity measures the number of a clinician’s assigned patients seen divided by the total number of patients seen in the same timeframe.
So lets measure our continuity, and when we have our starting figure, lets work on increasing it. That part comes next.
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