Should we be concerned about declining continuity of primary care?




by Peter Tammes, Mairead Murphy and Chris Salisbury, Centre for Academic Primary Care, University of Bristol

Decreasing trend of continuity of care

Seeing the same GP over time is highly valued by most patients and GPs in the UK. This is known as ‘continuity of care’ and it is linked with lower healthcare costs, more satisfied patients, fewer emergency hospital admissions and even with reduced mortality.

Given these multiple benefits, one would expect it to be highly prioritised. However, our recently published study in the British Journal of General Practice shows that continuity of care declined steadily between 2012 and 2017. On average, the percentage of patients who reported to have a preferred GP declined by nine percentage points and the percentage who can usually see their preferred GP declined by 10 percentage points.

Is decreasing continuity of care a concern?

Decreasing continuity is a concern for several reasons. Poor continuity of care is associated with higher emergency hospital admissions, so further declines in continuity of care could result in increasing pressure on A&E departments.

Although certain patients, especially younger and healthier patients, are less interested in continuity of care some patients prefer seeing their own GP as it helps them to deal better with their healthcare problems, particularly if they have long-term health conditions.

The decline in continuity of care might result in worsening health in these patient groups and a consequently greater workload for doctors and nurses in GP practices and hospitals. This might eventually lead to less satisfied patients, pressured healthcare professionals, and increased healthcare costs.

Which factors might have resulted in decreasing continuity of care?

Recent healthcare policies and reorganisations might have failed to support continuity of care. In 2014, the government required older patients to be assigned a named GP, but this did not necessarily reflect which GP the patient had seen most often or preferred to see. This could well have resulted in confusion about which GP to consult, as many older patients already had a preferred GP but may have been assigned a different GP as their named GP.

GP practices in some places have merged into super GP practices which might have improved access to primary care but worsened continuity of care. The recent introduction of Primary Care Networks might have a similar effect. Furthermore, a shortage of primary care workforce and increased GP workload might have negatively affected the delivery of continuity of care. The above factors could have limited the ability to see a preferred GP.

Our research revealed a steady decline in the percentage of patients who reported to have a preferred GP as well as the percentage who could usually see their preferred GP. This suggests that the problems with continuity of care might have demotivated patients from having a preferred GP in the first place.

This is only one possible reason; it is true that there may be a genuine shift among patients in preference for seeing the same or a preferred GP. But we should also recognise that the attitudes expressed in surveys reflect patients’ expectations and experiences. If they have not had the experience of being able to see a doctor that they know, they are not likely to value it.

Rethinking continuity of care

In the context of a changing patient population and a rapidly evolving healthcare system we should rethink what we understand as continuity of care within healthcare.

Accelerated by the COVID-19 pandemic, traditional face-to-face consultations are being replaced by telephone, video, and e-consultations. When a face-to-face consultation is needed, appointments are increasingly triaged via algorithms or receptionists, which sometimes directs patients to a range of different health professionals including practice-based nurses, pharmacists, case managers and counsellors. Besides, patients might prefer to see different doctors or different types of staff for different health problems. None of the usual ways of measuring continuity of care take account of these complications.

From the patient’s point of view, we need to understand more about which types of patients want continuity of care, why they value continuity and under what circumstances. From a health service perspective, we need to reconsider how to ensure that patients receive the type of continuity that most improves patients’ health outcomes and maximises value for money.

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