Continuity of care: still important in modern-day general practice

Continuity of care has always been at the heart of general practice. Patients who receive continuity have better healthcare outcomes, higher satisfaction rates, and the health care they receive is more cost-effective.^1,2 The Royal College of General Practitioners (RCGP) has always advocated for continuity and has previously produced a paper on the benefits of continuity of care, and subsequently the Continuity of Care Toolkit.³

In the upcoming RCGP paper Continuity of Care in Modern Day Practice (available soon at http://www.rcgp.org.uk/policy/rcgp-policy-areas/continuity-of-care.aspx) the College asks to whom continuity is most important in modern-day general practice, and how can it be realised in the face of changing demographics, work patterns, and the introduction of new models of care.

TO WHOM IS CONTINUITY MOST IMPORTANT?

The GP Patient Survey shows 52% of patients in England had a preferred GP.⁴ Seeing a preferred GP, however, is particularly beneficial for certain patient groups and a balance needs to be reached between patients who prioritise access to any GP for short-term illness, and those who would rather wait to see their preferred GP for issues they consider more serious. Those living with multimorbidities, older people, those with mental health difficulties, and patients receiving terminal care have all been shown to derive particular benefit from receiving continuity of care. According to RCGP analysis, the number of people with one long-term condition in England alone is expected to rise from 1.9 million in 2008 to 2.9 million by 2018.⁵ Alongside an ageing population, the demand for continuity is set to be greater than ever in the 21st century.

WHY IS IT DIFFICULT TO DELIVER CONTINUITY IN GENERAL PRACTICE?

The current lack of GPs and funding into general practice has obvious implications for realising continuity of care. Across the UK, all four nations are calling for an increase in the number of GPs. In England, the recent announcement of the General Practice Forward View,⁶ outlining NHS England and Health Education England’s plans to expand the GP workforce by 5000 by 2020, makes steps to address this barrier to continuity; however, this will take time to deliver. In the meantime, workload pressures in general practice remain intense. Although many GPs list their ability to develop relationships over time with a patient as an attractive aspect of general practice, current workload levels and workforce shortages impede their ability to realise this. In the UK 93% of GPs have stated that heavy workloads negatively affect the patient care they provide.⁷

Changing patterns of provision are also impacting on the ability of general practice to provide continuity of care. With more GPs choosing to work as locums, salaried GPs, or part-time, they have less opportunity to provide continuity. Similarly, the transition to new models of care and new working structures are posing new challenges for how continuity is delivered.

Lack of available GPs is also heightening the tension between continuity of care and access to care. Successive governments have prioritised access over continuity, and with 66% of patients responding to a recent RCGP survey preferring funding to be spent improving existing services, the College is pleased that General Practice Forward View clearly states that ‘no GP will be forced to work 7 days or open 7 days a week’.⁶ A combination of lack of workforce and increasing workload means general practice struggles to realise continuity due to lack of capacity and time.

HOW CAN CONTINUITY BE DELIVERED IN MODERN-DAY GENERAL PRACTICE?

Accounting for current challenges, general practice is adapting to meet the needs of modern-day patients. General Practice Forward View outlines developments that will in time aid continuity, such as: an increased workforce; greater funding for practice-based pharmacists, mental health therapists, practice-based nurses, and physician associates; a reduction in practice burdens that will release time to care for patients; and greater use of technology.

The RCGP’s paper evaluates how practices are looking at innovative ways to provide integrated health care, and reviews the implications for continuity. With limitations on the ability to provide traditional, relational continuity, it looks at how greater emphasis can be placed on managerial and informational continuity. Also, although traditional relational continuity ideally would be realised for every patient, this is impossible in the current climate, so greater emphasis should be placed on managerial and informational continuity. It explores this at GP level and practice level, and at regional and national level.

GP level

Significant evidence exists that longer consultations enhance relational continuity.⁸ Only 8% of GPs feel that the standard consultation is long enough, and 43% of GPs say that insufficient time with patients negatively impacts on their commitment to general practice;⁷ 70% state that implementing longer consultation times would resolve the pressures they were under in relation to continuity.⁸ Given that it is unlikely to be feasible within existing resourcing constraints to provide longer consultations to all, it will be important to focus their roll-out on patients for whom they will have most benefit.

New forms of access such as video consultations may also assist GPs in delivering continuity. Manchester Medical has utilised Skype consultations for face-to-face contact with patients without them attending the practice. By increasing a patient’s access to their preferred GP, these can support the delivery of relational continuity. They can be especially beneficial to those receiving palliative care, or during winter months when travel may be difficult. But their impact on all forms of continuity needs further evaluation and they will never be able to replace GP–patient consultations within the practice.

Practice level

At practice level micro-teams are an innovative method of delivering relational, informational, and managerial continuity where practices have staff working part-time or on annual leave. They comprise a small number of GPs, and sometimes a nurse, working together to cover care for groups of patients. Where patients cannot book with their preferred doctor, an appointment with another doctor from their micro-team will be booked. In order for micro-teams to be successful, informational and management continuity need to be prioritised in addition to relational continuity. However, micro-teams are still in their infancy and their current prevalence across the UK is unknown. They have potential to work within federations and combine with skill-mix but greater research is needed into their impact.

In addition to seeing doctors from a team, practices are increasingly adopting telephone triage. The ESTEEM study saw the number of patients in contact with their GP increase, while the number of patients attending the practice fell.⁹ This may have resulted in an increase in relational continuity. However, the study also found that telephone triage may lead to workload simply being redistributed from face-to-face to phone consultations.

Making greater use of the general practice team’s skill-mix can assist in delivering greater relational and managerial continuity; for example, practice nurses have a vital role in delivering continuity when managing chronic illness. By performing medicine reviews and answering medicine-related enquiries, pharmacists have great potential to free up GP time to provide continuity for those who need it most. RCGP’s collaboration with the Royal Pharmaceutical Society and Health Education England has introduced a £31 million 3-year scheme funding pharmacists to work in practices across England,⁶ and as part of General Practice Forward View this will now be supplemented by new central investment of £112 million. But risk of discontinuity, with patients interacting with a greater number of professionals, should not be overlooked.

The RCGP’s paper emphasises that the role of non-clinical staff in delivering continuity should not be underestimated. Receptionists are paramount in realising continuity by understanding the needs of patients and identifying those who would benefit most from receiving continuity, as well as encouraging patients without a preferred GP to book with clinicians who are less in demand.

Practices are also working to reduce unnecessary workload in the 21st century; 91% of patients registered with practices in January 2015 had the option of online booking,¹⁰ adapting to the increased use of technology in general practice. The opportunity to book an appointment online with a preferred GP increases access and therefore continuity, but also frees up phone lines for those without access to the internet.

Regional and national level

On a regional and national level, GP federations, despite being in early development stages, are an example of how modern-day general practice is developing. They enable practices to share back-office functions, reduce cost, and broaden skill-mix while retaining the local nature of general practice, which has obvious implications for all forms of continuity. The development of multispecialty community providers will also impact how continuity is realised. Although bringing all aspects of patient care into one easily accessible place has the potential to improve continuity, there is also the risk that increased specialism could detract from it. However, pioneering multispecialty community provider Lakeside Surgeries is successfully delivering continuity to patients by identifying patient groups for whom it should be prioritised for by mapping out their care pathways. As GP federations and multispecialty community providers continue to evolve within UK regions, all forms of continuity should remain at the heart of their development.

CONTINUITY IN THE FUTURE

Continuity in the NHS is vital to meeting the needs of 21st century patients, but much of current policy is not designed to promote this goal. General Practice Forward View aims to address this and ensure that the future NHS takes a holistic approach to patient care that retains a GP–patient relationship focus during the transition into new ways of working, as well as understanding the importance of informational and managerial continuity. New models of working in general practice should be evaluated and monitored, and their effects on patient health care robustly evaluated.

Clinical models, information technology, and governance structures all need to align to support the delivery of continuity of all types in the 21st century. In addition to clinical staff, non-clinical staff have a significant role to play in realising this goal and should be trained to enable them to do so.

However, as general practice finds ways to retain the values that underpin continuity of care it will never be possible for a patient to see the same GP for every consultation. Relational continuity needs to be prioritised for patients who will benefit from it most, and be supported by improved informational and managerial continuity for all patients.

Provenance

Commissioned; externally peer reviewed.