Professor Hay articulates the opposite arguments from those I advanced in a previous article in the BJGP. 1,2 This vision has, unfortunately, from the first sentence, rested on fallacies and untested hypotheses.
Access, continuity of care, and low cost are not competing objectives. Achieving one tends to improve achievement of the others.
Continuity and access are correlated at the level of general practice: those that achieve high continuity also achieve good access. This is easily observable in General Practice Patient Survey data. The Pearson correlation coefficient is 0.65 between the ‘continuity’ question (how often do you see your preferred clinician?) and the ‘access’ question (what was your experience of contacting your GP practice?). Higher continuity with an individual GP reduces demand for appointments (workload in general practice). 3 It also results in lower antibiotic prescribing and reduced admissions to hospital. 4,5 Therefore, it reduces costs in both primary and secondary care.
One of the key issues in general practice sustainability is staff retention. Low continuity is associated with higher staff turnover. 6 Qualitative research identifies relational continuity as providing doctors with a sense of joy in their work. 7 This is echoed in letters from GPs responding to the article.
In other words, practices that provide low-cost care tend to have good access and high continuity. Exactly the opposite of what is suggested.
These benefits appear to be linked to an individual relationship with an individual doctor. We have no evidence to support alternative models, such as GPs as leaders of a team of clinicians. From the responses to the article, the evidence is not appealing to many GPs. The article proposes something that would continue the current tendency towards fragmentation in general practice. But no evidence is advanced as to why this model would be superior. Existing evidence suggests this would increase demand for appointments, likely reduce access, and increase costs, while contributing to staff turnover. Proponents of such an approach should provide evidence to support the view that it would not.
References
- 1.Marshall T, Scholtes S, Wyatt S, et al. What makes general practice work: the role of continuity in efficient and sustainable primary care. Br J Gen Pract. 2025 doi: 10.3399/BJGP.2025.0038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Hay AD. Consultant GP-led team-based continuity: a vision for sustainable primary care. Br J Gen Pract. 2026 doi: 10.3399/BJGP.2026.0255. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kajaria-Montag H, Freeman M, Scholtes S. Continuity of care increases physician productivity in primary care. 2024. [DOI]
- 4.El Turabi A. Unintended consequences: empirical studies of continuity of care and financial incentive gaming in primary care. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences; 2019. [Google Scholar]
- 5.Hetlevik Ø, Holmås TH, Monstad K. Continuity of care, measurement and association with hospital admission and mortality: a registry-based longitudinal cohort study. BMJ Open. 2021;11(12):e051958. doi: 10.1136/bmjopen-2021-051958. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Parisi R, Lau Y-S, Bower P, et al. Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study. BMJ Qual Saf. 2023;32(7):394–403. doi: 10.1136/bmjqs-2022-015353. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Nowak DA, Sheikhan NY, Naidu SC, et al. Why does continuity of care with family doctors matter? Review and qualitative synthesis of patient and physician perspectives. Can Fam Physician. 2021;67(9):679–688. doi: 10.46747/cfp.6709679. [DOI] [PMC free article] [PubMed] [Google Scholar]