My previous post outlined how continuity of care is in a state of decline, at a time when there is a growing need for more co-ordinated care. Co-morbid long-term conditions, frailty and older age emphasise the need for greater coordination and personalised care.
Why is Continuity declining?
- There has been a shift in the standard GP working pattern and also an increase in locum and sessional GPs. Less GPs now work the entire week in the clinical setting. Either developing specialisms, taking on other responsibilities or creating portfolio careers. There has been a lot of media attention recently around “part-time GPs”, I refrain from using this phrase for many reasons outlined here.
- Government mandates to improve access to primary care, with guaranteed GP appointments within 48 hours, NHS walk-in centres, and wrap-around out-of-hours care have fragmented the system. Whilst reduced continuity is not an inevitable consequence of increased access, it may have contributed to its fall.
- With decreasing budgets and problems with recruitment of GPs and other healthcare staff, general practices have responded by increasing in size and scale to achieve efficiencies and absorb some of the financial and staffing deficits. Whilst larger practices are better at maintaining good quality care, it raises concern we are losing the relationship of a trusted GP established by smaller practices.
How does continuity improve?
There are four main facets to improving continuity for patients and GPs:
Measure continuity, as outlined in my first post. It is important to understand how the practice is currently performing. Once a baseline is established, this information can be used to set goals or aims on what continuity level should be strived for. Making this information available for all staff will aid reflection and development of innovative ideas to improve this number.
Increase clinician coverage through the week, i.e. the number of sessions the clinician is seeing patients. Demanding clinicians merely work extra days in a system which already demands so much is unlikely to deliver fruitful results. Increasing continuity but ultimately sacrificing staff to burnout is not a viable long-term solution. There are two main approaches to solving the problem of continuity:
- the first is to improve the working environment, to make working a clinical day less demanding in terms of cognitive fatigue and administrative burden, so that 10 clinical sessions feels like 6 sessions now.
- the second is to develop the buddy-system or team-based approach, where continuity is measured by contact with the team. Imperative to this approach is communication within the team to ensure informational and managerial continuity is maintained.
Appointment system adaptation - improvements must be made to increase same-day or next-day access for all clinicians - urgent care appointments being maintained, but with a re-focus on improving access to the patient’s named team when they require urgent assessment. An additional aid to this could be the use of additional ‘discretionary appointment slots’. If all appointment slots are booked, the clinician could agree to see their own patients requiring urgent care within these slots, but this is a discretionary decision made by the clinician.
Change practice and patient policy, encourage continuity over access and emphasise this to patients and staff. A scheme or campaign could be employed to encourage patients to “ask for your GP” or “ask for your team”. A new approach to offering appointments could follow the script: “Your doctor’s next appointment is …, should I book this for you?” If this is not appropriate for the patient and they need to be seen sooner, then either the clinician’s discretionary appointment slot can be used or standard practice is employed.
Use your data
Interrogation of electronic health records (EHRs) will allow current levels of continuity to be measured, as outlined in the first part of this series. It also provides a valuable resource to measure improvements in continuity rates with different interventions.
EHRs also provide a valuable resource to identify the patterns in consultation and re-consultation rates, referred admissions, readmissions and direct emergency admissions. Assessment of patient’s diagnosis, reason for encounter with service, last visit date with the practice, and most recent communication with your practice—even the time of day and day of the week could highlight potential areas where improvements to continuity could be focused. What is the problem, is there a common factor? If there is, can it be rectified?
Many studies have focused on the improvements shown with a single Clinician for continuity, however, benefit can also be demonstrated when a patients visits are concentrated within a small group of healthcare providers or team.
Given that most GPs no longer conduct clinical sessions that cover the entire week a buddy system could be employed to ensure that patients have a common GP / GP partnership for their care. However, the current application of Primary Care is now in the form of teams, including GPs, nurses, healthcare assistants, physics, pharmacists, community psychiatric nurses.
Larger practices may benefit from the application of the micro-team, which brings these people together to form common groups or micro-teams, providing care for a specific patient cohort, thus improving continuity for the patient and their team. The GP could act as coordinator, with individuals in the team having specific roles defined, so care becomes the responsibility of the whole team not the individual.
There are specific groups of patients that would invariably benefit from a focused effort towards increasing continuity. These groups include:
- Care home & Nursing home residents
- Housebound patients
- Frequent attenders - high care utilisers
- Significant disease burden - those patients with multiple co-morbid conditions
- High care needs - those patients with mental health problems, drug and alcohol problems who are prone to sudden crises.
Focused initiatives on these groups of patients, devising joint plans and also practice-based plans may provide a better approach to caring for these groups. There are certain groups of patients who invariably access services late on a Friday afternoon. This often creates problems with providing adequate provision of care. Common patients seen at this time are the lost controlled drug script or the Care home requiring reviews of patients “because it is the weekend”.
Giving these groups a more coordinated approach and clear action plans if such events occur and also education of these patients and care homes may improve healthcare utilisation. This focused approach can extend to the other groups as well. A GP who has seen the patient through previous acute episodes will be aware of the features leading to another episode and may be able to intervene before that point is reached again.
Certain conditions also deteriorate with each exacerbation, however this deterioration can be difficult to identify if patients are seen ad-hoc by multiple different clinicians. An obvious advantage of having a team or individual providing continuity is observing decline in performance of a patient and being able to plan care.
Public engagement and self care
Promoting the ethos of continuity to patients and staff will encourage appointments with a usual GP or team. The benefits of seeing their team can be explained through posters, leaflets and during consultations.
Whilst it is important that patients and the first point of engagement with the practice are aware of the benefits of continuity, the ethos must extend throughout the organisation. GPs, nurses, HCAs and all other providers of care must understand the benefits and invest significantly in its application for it to work fully. The idea of discretionary appointments above will only work if there is an understanding of why continuity should be sought.
The benefits of continuity are likely to be imperceptible at first as the system beds-in. Unfortunately this is often the time when new innovations are assessed. It is important to highlight, to staff and patients, any improvements that the new approach has achieved as it improvements will often be difficult to measure on a day-to-day basis.
The side effect of having a clear point of access is the central role the care plan takes and the patient’s understanding of this plan. Worsening signs or symptoms of a condition, explicit instructions about follow-up care, and the resources to contact with questions and concerns should promote patient empowerment and self-care.
With the success of initial continuity plans, the scheme should be expanded to cover all patients in a practice. The benefit of applying a continuity approach to everyone is the power of ownership. No longer is a GP’s actions of no perceivable benefit, their work and efforts directly affect their level of work moving forwards. If patients can be encouraged to seek other appropriate means of health advice, then future consultation rates should reduce. Having your own cohort of patients means that those patients you educate and the reduction in consultation rates should directly affect you as a GP and the rest of your team.
Trust your teams
A crucial component to the success of this culture change is to give GPs, the whole practice team, as well as patients, the skills and opportunities to identify where improvement is required. Once identified, it is imperative to give them the support to implement and evaluate changes. Being in touch with the data and results at the bleeding-edge of their improvement changes, returns the agility to Primary Care that was lost with the creation of larger practices.
Coming soon, part 3 of this series -understand the key role technology can play in improving continuity.
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