General practice

What future for continuity of care in general practice?

^a Department of Public Health and Primary Care, Charing Cross and Westminster Medical School, University of London, London SW10 9NH, ^b Department of General Practice and Community Medicine, University of Oslo, N-0317 Oslo, Norway

Correspondence to: Professor Freeman

	Introduction

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

Continuity of care has had many definitions,¹ but in the context of general practice it is still virtually synonymous with care from one doctor, usually spanning an extended time and more than one episode of illness.² Although this longitudinal continuity, with its implied personal relationship, is seen by many as a core feature of the discipline, there is little supporting evidence. Seeing the same doctor does not guarantee a good patient-doctor relationship, and in any case such continuity can no longer be taken for granted. In many countries it is being abandoned under pressure from modern developments in medicine, in organisation of practices, and in society generally. A recent report from the British General Medical Services Committee suggested that it is being replaced by continuity within the primary care team.³

The practical question is whether patients should be enabled as far as possible to see the doctor of their choice or whether to go further and state that they should normally see only one general practitioner because this is better for them. We think that current evidence does not support this last view. Instead general practitioners, primary care teams, managers, politicians, and the public need to develop a shared understanding of the strengths and drawbacks of continuity, which when allied with good communication we call personal continuity (box).

	Longitudinal versus personal continuity

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

Longitudinal continuity is a simple concept with strong face validity. It is easy to measure quantitatively,⁴ but it says little about the patient-doctor relationship and quality of care. Its value rests on the assumption that any doctor can relate well to any patient provided that there is sufficient opportunity. Sometimes, though, a patient may find it easier to communicate with, and hence trust, a different doctor. Longitudinal continuity tends to be used as a proxy for the desired quality of personal continuity.

Personal continuity implies both empathy and personal responsibility according to McWhinney and others.^{5 6} It is harder to measure but is clinically more relevant and important. It implies a commitment from patients as well as from doctors, and this may be reflected in the patient's willingness to wait for a particular doctor. It is hard to assess the importance of personal continuity without looking at the content of the consultations as well as counting them. Thus assessment demands qualitative methods, often involving face to face questioning.

Of course, some longitudinal continuity is necessary for personal continuity, but quite low longitudinal continuity may be enough. Interviews in both pilot and published studies have found some patients with a clear identity of their personal doctor even though they had not consulted him or her for a long time.^{7 8} Likewise in Norway some patients reported the feeling of personal doctoring after only a few consultations with a new general practitioner, while others had not attained this after several years of contact with the same doctor.⁹

	What sort of continuity of care?

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

Continuity of care can be understood in various ways. It can mean care in one place or from one person, coordinated care, or a common medical record.^{5 10 11 12 13} Literally, the phrase implies that care received by the patient should be continuous and hence presumably consistent. This is particularly relevant now that care is becoming increasingly complex and often shared between teams in primary and secondary care. However, medicine remains highly personal, and continuity of carer is often sought in order to get better continuity of care.^{2 10}

View larger version (86K): [in this window] [in a new window]   Patients like to have a personal doctor, but it can put extra pressure on general practitioners ULRIKE PREUSS/SOUTHAMPTON COMMUNITY TRUST

Most research has studied longitudinal continuity. It has been associated with various benefits including compliance with therapeutic regimens,¹⁴ reduced number and duration of hospital admissions,¹⁵ saving time and tests in primary care,¹⁶ patient satisfaction,^{15 17} doctor satisfaction,^{18 19} reporting of emotional problems by patients,²⁰ and reduction of inappropriate attribution of symptoms by outpatients with functional abdominal complaints.²¹ Breslau pointed out that continuity may be much more important for patients with a chronic or serious illness.²² However, other aspects of care have shown no improved outcome. These include care of pregnancy,²³ hypertension,²⁴ gonorrhoea in teenagers,²⁵ and epilepsy.⁷

Some studies highlight the personal element of continuity. Ettlinger and Freeman studied compliance with short term regimens of antibiotics in two general practices and found a highly significant association between good compliance and patients feeling that they knew the doctor well.²⁶ The association of longitudinal continuity with compliance was less strong, though still significant. This suggests that personal continuity can be achieved with relatively few contacts. Hjortdahl and Laerum studied the relation between the personal (qualitative) and longitudinal aspects of continuity more directly. They found a significant sevenfold rise in patient satisfaction associated with the patient seeing "my personal doctor for all my health problems." ⁹ The equivalent odds ratio for how long the patient and doctor had known each other was less strong (1.85 for five years or more (95% confidence interval 1.07 to 3.19)) while increased frequency of contacts in the past 12 months had no significant effect on patient satisfaction. Thus the concept of a personal doctor seems to have added value compared with repeated contact alone.

	Costs of continuity

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

Few studies report increased costs or negative effects of longitudinal continuity, possibly because of publication bias. However, Miller reported late referral²⁷ and two studies found reduced conformity with professional standards.^{28 29} The most comprehensive European study published to date showed savings in time and tests associated with an increased use of wait and see policies but more prescribing, referrals, and sickness certification.¹⁶ This suggests that the influence of personal continuity of care on a doctor's decisions in a consultation is complex and multidimensional. One possibility is that knowing the patient limits diagnostic costs but encourages spending on managing disease. Another is that patients who know their doctors well persuade them to do more, perhaps by feeling more empowered. Thirdly, doctors who know their patients better may wish to do more. Finally, less familiar general practitioners may defer positive action (except for tests) until patients see their usual doctors.

Costs for patients
Any policy encouraging or imposing longitudinal continuity may reduce choice for patients. It may also increase waiting times by discouraging doctors from sharing the workload.³⁰ However, this may not necessarily dissatisfy patients. Patients in the strict personal list practice in Freeman and Richards' study had little opportunity to see another of the six general practitioners and showed little wish to do so when asked.⁸ Their contentment was strikingly different from that of patients in two shared list practices with much less longitudinal continuity where the patients seemed both better informed and more willing to criticise individual doctors.

Costs for doctors
The main costs of offering high longitudinal continuity through a personal list system are the personal commitment and high personal availability, which result in doctors being more tied to the practice with less scope for outside interests and for personal or professional development.¹⁰ This lack of flexibility may mean more doctors are needed to maintain a given level of service, but there is no firm evidence for this.

	What do patients want?

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

The evidence about patients' views on quality care in general practice has recently been reviewed by Rees Lewis.³¹ He refers to a study which found that longitudinal continuity was patients' third priority after a doctor who listens and a doctor who sorts out problems.³² Patient satisfaction is said to be the only one of four outcomes that can be influenced by quality primary care (the other three are self reported health, disability, and medical costs).³³ The key factors associated with patient satisfaction are providing information, medical skills, and interpersonal skills, none of which is directly linked to longitudinal continuity of care.³⁴

Hjortdahl and Laerum point out that personal continuity and satisfaction are bidirectionally related.⁹ Not only does continuity lead to increased satisfaction but satisfaction ratings predict what patients will do next time they need health services: "Incompatibility problems may cause the patient to use their `exit' option and change doctors." This conclusion was shared by Freeman and Richards, who found that patients appreciated choice in shared list practices but then felt frustrated if unable to see their chosen doctor when they wished.⁸

In the same study patients in the personal list practice were more satisfied and made fewer suggestions for change than those in the combined list practices. This point was reinforced in a study of 89 practices in southwest England where a full personal list system, rather than a partly personal or a pooled system, was strongly correlated with general satisfaction³⁵ and with satisfaction with consultations.³⁶

	What do general practitioners want?

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

General practitioners in countries with a well developed primary medical care system such as Britain,³⁷ Norway,¹⁰ and Australia³⁸ seem caught between the rhetoric and tradition of longitudinal continuity and the often conflicting pressures of patients' expectations and society's demands. To be in demand is a yardstick of success in any profession.³⁹ To be asked for personally by patients is much more satisfying than seeing a succession of patients who just want any doctor. A personal following, whether formalised by a personal list or as a result of demand from patients on a shared list, is a considerable investment and an assurance for general practitioners. Although general practitioners often feel overworked, it may be worse to feel unwanted.

Seeing the same patients is also vital for feedback on the efficacy of diagnosis and treatment. Observation over time makes an important contribution to education of general practitioners, particularly in encouraging a wait and see policy and being aware of the natural course of disease. Reflective practitioners⁴⁰ wish to review the outcomes of their professional work, and seeing the patient in person powerfully enhances this form of continuing medical education.⁴¹

All over the world governments struggle to contain the costs of medical care against technological advances and rising patient expectations. Often they turn to primary care to act as gatekeeper. However, over hasty development of primary care may risk steeply rising costs. Hjortdahl and Borchgrevink's evidence of increased testing and reduced expectant management (wait and see) among less well known patients deserves further study.¹⁶

Traditionally, appointment as a general practitioner was seen as a full time job for life associated with a stable place in the community. Today young graduates hesitate to commit themselves to a professional lifetime in one community; there is more demand for part time work in general practice from men as well as women. This increasingly threatens longitudinal continuity and the personal list. One solution may be more emphasis on continuity with the whole team, as advocated by Pratt.⁴² Another is to be more explicit about shared responsibility between individuals as in job sharing or in nomination of a first and alternative choice by patients.

The future: encouraging personal continuity
People seek a general practice consultation to find out what is happening to them, what it means, what might be done, and to what effect.⁴³ Providing a response to these concerns is what most general practitioners feel they are best at and are happiest doing. If we think personal continuity is valuable then our clinical and administrative actions must constantly encourage it; we must be far more positive but stop short of compulsion. Our aim should be to maximise personal continuity while maintaining an element of choice (see box). This will sometimes mean hard decisions, particularly in balancing short term workload and adequate personal availability. Longitudinal continuity will generally rise but not perhaps to the levels found in practices maintaining a strict personal list for each general practitioner. Personal continuity is an essential attribute of general practice enabling us to deliver care that is both individual and cost effective. Longitudinal continuity provides just one element of the framework supporting this personal continuity, along with excellent communication skills and good teamwork and records. There remains another vital and intuitive element which has been described as mysterious.⁴⁴ We must try to help our students learn this element for the benefit of future patients.

	Acknowledgements

We thank colleagues, both inside and outside our departments, who have constructively criticised this paper.

Funding: None.

Conflict of interest: None.

	References

Top Introduction Longitudinal versus personal... What sort of continuity... Costs of continuity What do patients want? What do general practitioners... References

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