Continuity of primary care matters and should be protectedBMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j373 (Published 01 February 2017) Cite this as: BMJ 2017;356:j373
- Peter Tammes, senior research associate,
- Chris Salisbury, professor of primary health care
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
- Correspondence to: P Tammes
Healthcare systems in many countries are seeking to reduce hospital admissions for patients with conditions manageable in primary care, so called ambulatory care sensitive conditions. One approach has been to seek to improve access to primary care, but this might have the unintended effect of reducing continuity of care.1
Continuity of care is an important aspect of primary care that is highly valued by patients and general practitioners and is associated with a range of improved patient outcomes.23 Recent policy in the UK has sought to achieve a balance between access and continuity by introducing a named accountable GP for each patient. This policy was first introduced for patients aged 75 and over, to provide personalised care to keep older people healthy and out of hospital.45 Therefore, the study by Barker and colleagues (doi:10.1136/bmj.j84), which examines the association between continuity of primary care and admissions for ambulatory care sensitive conditions in older patients, has implications for clinicians, patients, and policy makers.6
The authors analysed patient level data from primary and secondary care records for over 230 000 patients and concluded that elderly patients who saw the same GP a greater proportion of the time experienced fewer hospital admissions for ambulatory care sensitive conditions than other patients. This finding builds upon results from ecological studies using practice level data to explore this relationship.7891011
Barker and colleagues chose to focus on older patients (aged between 62 and 82 years) because they account for a high proportion of both primary care consultations and emergency hospital admissions. Their findings are therefore highly relevant internationally—because of demographic changes, most developed countries now have an increasingly elderly population with a high prevalence of multimorbidity. This group of patients are more likely to have complex healthcare needs and to value continuity of care than younger patients, although they are less likely to receive it.12
What might be the mechanism by which improved continuity of care leads to reduced hospital admissions? The rise in admissions in the UK in recent years is almost entirely due to an increase in the number of patients admitted following attendance at emergency departments, and most of these patients were self referred or called an ambulance and were not referred by their GP.13 Continuity of primary care is associated with reduced rates of attendance at emergency departments.314 We hypothesise that seeing the same doctor (longitudinal continuity, as measured in the new study)6 builds trust and a sense of mutual responsibility between patients and GPs. This means that patients are more likely to seek the advice of their usual doctor rather than attend elsewhere. It also means that doctors have a greater sense of responsibility in ensuring that patients are well managed and professional pride in not referring patients to hospital unnecessarily. A primary care system that is increasingly fragmented, in which neither patients nor doctors feel strongly connected to their local general practice, provides the setting for patients to choose to attend an emergency department instead. This is compounded by difficulties in accessing general practices, which are at least as overwhelmed as emergency departments by rising demand.15
Articulating potential mechanisms provides a logical basis for future research to understand the relationship between continuity of care and hospital admissions. If our hypothesis is correct, we should further explore the role of trust, a plausible key ingredient mediating the link between longitudinal continuity and reduced admissions. Researchers could usefully investigate relationships between longitudinal continuity and trust (or relational continuity),16 between trust and hospital utilisation, and between trust and other forms of continuity, such as continuity through shared records and protocols (informational and management continuity).17
Despite associated benefits, there is evidence that continuity of primary care is actually declining in the UK.17 As more general practices in the UK are merging into larger “super practices,” the threat to continuity is increasing. The recent published Nuffield Trust report “Is bigger better?” concluded that “some patients valued new forms of access offered by the larger organisation but others voiced concerns about losing the on going, trusted relationship with their own general practitioner (GP) and their own practice.”18 Access and continuity of care are inevitably intertwined,19 but they are not necessarily incompatible if both are seen as equally important. Research is needed to support the emerging super practices in finding ways to avoid losing continuity of care while also providing good access.
Given the growing body of evidence supporting the importance of continuity of primary care, we need further policy initiatives to promote it and more support for general practices to help them improve it. This would not only have benefits for patients, but would also improve job satisfaction for GPs and very likely reduce pressures on hospitals.
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.
Provenance and peer review: Commissioned; not peer reviewed.