Over a million consultations take place in general practice each day in the UK and many of us – one in two people (52%) – have a particular doctor we prefer to see. But, according to the latest results from a survey of 750,000 patients across England, it’s getting harder for people to see ‘their’ GP.
For the first time, fewer than half of those who responded to the latest General Practice Patient Survey and have a preferred GP say they are actually able to make an appointment to see them.
This change is not so much a seismic shift in the landscape of primary care as a slow landslide.
Evidence shows relational continuity in England has been declining for many years now: according to the Royal College of General Practitioners, the number of patients able to see their preferred GP in England fell by 27.5% between 2012 and 2017.
Does seeing the same doctor over time make a difference to patient health?
Research has shown that people who see the same doctor over time benefit from this. Relational continuity is associated with reductions in mortality, higher patient satisfaction and fewer hospital admissions, according to our recent NHS England-funded Nuffield Trust report into access and continuity.
We don’t really know why being able to see the same GP over time confers these kinds of health benefits. But part of the answer might lie in the power of personalised care and a high-trust relationship.
It can be hard for any GP to deliver personalised, holistic care to a stranger they’ve only known for nine minutes. Building longer-term relationships – based on trust and a shared understanding of ‘what really matters to you’ – can make a real difference to quality of care. The accounts from patients we recently published describing what seeing their own GP meant to them illustrate this powerfully.
In a study based on survey data from two million patients in England, continuity of care was found to be particularly important for those with poor health and patients with long-term health problems.
“Continuity of care over years with the same GP has the same kind of survival advantage as many drugs and complex interventions”, according to Professor Trish Greenhalgh from the University of Oxford, “but nobody has taken this on and sought to protect this crucial aspect of our health care system.”
Continuity is important to doctors, too.
For many GPs, a focus on relationships, including the doctor-patient relationship, is part of what brings joy to their work.
This is not just about efficiency, and the advantage of avoiding the time needed to take a patient history for someone you have never met before who has four long-term conditions, 12 different medications, and is currently caring for a spouse with terminal cancer.
Being able to provide care, tailored to what is important to a patient and informed by a deep understanding of their personal, psychological and emotional context, really matters to doctors.
What impact might this have on the NHS as a wider system?
Losing relational continuity may have unintended consequences for the NHS more widely.
In a study of more than one million Medicare patients in the USA, multiple measures of continuity of care were shown be associated with lower health care expenditure and hospitalisation rates.
Estimates by the Health Foundation suggest that if patients saw their most frequently seen GP two more times out of every 10 consultations, this would be associated with a 6% decrease in hospital admissions. In the US, the value associated with high continuity is approximately $US1,000 per patient each year, a calculation based on evidence of a 14% reduction in costs among physicians in the top quintile for providing continuity of care.
Is the erosion of relational continuity inevitable?
With tremendous pressure on GP surgeries and the number of doctors per head of population falling, is it simply a hard fact that something has to give? In order to see a doctor at all, will patients have to accept it won’t necessarily be the one they want?
Perhaps. But recent work by the Nuffield Trust shows there are many things that practices can do continue to offer relational continuity for patients who need it.
This includes booking systems that allow patients or clinicians to prioritise continuity; a role for receptionists in ‘signposting’ patients towards the usual GP at the time of booking an appointment; data-driven approaches to identify those within a practice population who will likely benefit most from continuity; and the use of clinical ‘micro-teams’.
Building continuity into new ways of delivering general practice has implications for digital technologies, workforce redesign, and service organisation.
The erosion of relational continuity is not inevitable, but its benefits to patients and the NHS will continue to wither without attention to these issues. Turning things around will require a concerted effort on the part of policy-makers, clinical leaders and GP practices alike.
Paddison C (2019) “Patients are finding it harder and harder to see their preferred GP – does it matter?” Nuffield Trust comment.