How to improve continuity in general practice?

For some patients, continuity in general practice is becoming harder to achieve. With many GPs working part time, a scarcity of appointments and booking systems that don’t always make it easy to see the same GP twice, those who don’t value continuity may question why we even bother talking about it.

But individual accounts of how continuity shapes people’s relationship with general practice, such as the four views presented in this accompanying piece, show how important it can be. Whether for a complex and enduring illness or a new condition that changes how other people perceive us, there are times when a deep knowledge of an individual and a trusting relationship between a GP and their patient are central to the therapeutic impact of general practice. 

The recent Nuffield report, Improving access and continuity in general practice, describes the positive impact of continuity on various patient outcomes and on the use of NHS services. It also identifies reasons why some patients do not seek continuity. Some might not be aware that it is possible, while others don’t trust their usual doctor and/or want a second opinion. The report concludes that we need to get better at knowing who does want continuity and who might benefit from it.

Long-term gains

At present, we do not have systematic ways of identifying patients for continuity. From looking at those four views, the experience of Kathryn suggests that one criterion should be reaching some threshold of complexity. But Jasmin and Liz’s stories highlight the importance of their GPs knowing who they are and what they were like before illness kicked in. 

Tech enthusiasts who advocate for online services like GP at Hand argue that generally healthy adults with acute symptoms don’t need continuity – just somebody with the clinical skills to address their immediate clinical problem. This transactional view of the role of general practice may work well until things change (as these four views describe), by when it’s too late to build the relationship that enables a GP to know the original ‘you’. Or, as in Rachel’s account, for the GP to have demonstrated a level of caring about her and built the trust needed to believe it was worth stepping back from a cliff edge.

The Nuka Health System described in a previous Nuffield publication, Divided we fall, sees this long-term relationship as central to good primary care. It goes some way to ‘segmenting populations’ and tailoring its services to the needs of different groups. But it still seeks to build and sustain an ongoing relationship between doctor and patient, which comes into its own when serious health problems emerge.

Three ways forward

Recognising that not everybody wants such a relationship and that it cannot be forced upon people, Improving access and continuity in general practice highlights three broad ways to both enable and improve continuity when it is needed.

Service and organisational design

Services are most likely to succeed at delivering both convenient access and continuity for selected patients when they are organised in a way that enables them to:

• preserve the detailed knowledge held by staff (both clinicians and receptionists) of patients with complex needs
• take advantage of scale, such as investing in technology and developing specific care pathways for access and continuity
• ensure staff know enough about clinicians’ skills and special interests to steer patients to the right professional for their clinical problem, through appropriate booking systems.

The report’s case studies suggest that current policy to develop primary care networks would result in organisations of a scale where it’s still possible to maintain the relationships and local knowledge that support continuity.

As clinical commissioning groups (CCGs) commission extended access appointments, many are increasing the scale of the services they commission, which may make it harder to maintain the characteristics we’ve described. CCGs should encourage providers to organise access hubs at the scale of primary care networks, in order to combine improved access with characteristics that support continuity. Whatever the size, the key message is that how clinics and appointments are arranged will influence their ability to provide continuity.

Practices can also help within their own organisations by analysing who currently struggles to get continuity and who may benefit from it. Their challenge is to use booking systems, receptionists’ advice and care navigators to ensure continuity is prioritised where appropriate.

Workforce redesign and professional behaviours

Practices or groups of practices can broaden their skill mix and introduce micro-teams (small groups of clinicians) to promote continuity. To do this, they will need support for training, role development, and operational systems and processes. The use of micro-teams to take responsibility for an allocated list of patients, and of receptionists to appropriately direct patients and manage clinicians’ appointments, are widely suggested to have the potential to support continuity.

Digital and health care technologies

GPs generally recognise that electronic medical records are an essential clinical tool and enabler of continuity of care. The use of email, video and telephone consultations has the potential to improve access, better supporting the whole pathway of care and helping to maintain the relationship between patient and clinician.

However, the effect of these technologies on continuity in practice has yet to be sufficiently well researched, and may result in duplication and some additional workload. To maximise the potential of new digital technology, continuity of care will need to be an explicit goal of implementation.