Continuity of care is believed to be the cornerstone of general practice. It is associated with higher patient satisfaction, lower health care costs and even lower mortality. While there may be generational differences in patient attitudes towards continuity, in the wake of overnight adoption of digital and remote consulting at the start of the pandemic, this fundamental aspect of care has been thrown into sharp focus.
In this context, we carried out a survey from January to March 2021 exploring clinician attitudes towards continuity. We received responses from sixty-four clinicians encompassing GP partners, sessional colleagues, GP registrars and nurse practitioners based predominantly within the North-East of England.
Does continuity still matter?
Overwhelmingly, the survey results indicate that all respondents value continuity of care, with 85% suggesting it as a ‘very important’ element of general practice. Key reasons cited include its role in reducing the need for unnecessary investigations and promoting holistic and safer care. One respondent suggested that ‘it is the mainstay of general practice as we know it’.
The remaining 15% suggested that continuity was ‘somewhat important’.
Though there appears to be some evidence that seeing the same clinician may affect clinical outcomes it is clear that continuity remains a widely valued part of general practice.
How has COVID-19 impacted continuity?
About 60% of those who responded indicated that COVID-19 has had a negative impact on continuity, principally due to increased use of telephone triage and some shift away from face-to-face consulting which typically characterises continuity of care.
Perhaps surprisingly, nearly 25% did not feel that continuity has been affected adversely. Whilst 15% of respondents reported no change in continuity, one-fourth of respondents reported improvement with the use of technology such as AccuRx.
Some respondents highlighted the benefits of telephone review appointments which have made it ‘easier for patients to speak to the same doctor than otherwise would be to get a face-to-face appointment’, respondents also said it is ‘easy to follow up patients virtually’.’ Similarly, practices with ‘personal list’ systems reported continued positive impact on continuity.
How can continuity be enhanced in future models?
It is important to emphasise that the views of patients will be a vital area to explore further. The more transactional, ‘on the day’ system is likely to have been valued by some patients especially around acute presentations but disliked by those who place greater value on relational continuity.
The following themes emerged in the ideas from the respondents in addressing continuity for the future.
The use of personal lists and micro-teams, more streamlined care navigation and the role of receptionists can help enhance continuity of care. Other ideas included priority lists’ for complex patients (for example, palliative care, those with severe mental health problems and learning disability) and increased appointment flexibility (mix of telephone, face-to-face, and variation in appointment length). Use of other members of the team such as advanced nurse practitioners dealing with same day problems, and clinicians proactively arranging follow up and pre-booking appointments were also suggested.
Wider systemic changes
Respondents to the survey also felt there was a need for more GPs (especially partners) and retaining existing clinicians. Centrally funded technology and greater funding to support the amount of work carried out in general practice would also allow longer appointments , often described as the limiting factor to more robust relationships and a major cause of stress.
What does the future hold?
Our survey has shown that most clinicians believe that COVID-19 has led to a notable change to care continuity. A substantial proportion felt that there have been opportunities to improve continuity of care. The findings also revealed that there were either systems in place that have been resilient or adaptive changes that are now being widely used that can help to enhance care continuity.
The effects of the pandemic will bring significant long-term change to access in primary care. Although not favoured by all, care delivery may become more flexible and could provide a blueprint for new ways of working.
We believe that one of the most important challenges will be to ensure that the increased use of telephone triaging and video and text consultations can adapt to effectively managing long-term conditions and be inclusive of those who are vulnerable.
In an increasingly remote digital age, it is important to ensure that recent changes to access continue to support optimal care pathways for all patients and that continuity of care is available for those who value it the most.
General practice is busier than ever. We have a responsibility to adapt to meet this challenge and the evolving needs of the populations we serve.
- Dr Jessica Farrell is an ST3 GP trainee and Dr Kamal Sidhu is a GP partner in County Durham